Expert Commentary

VULVAR PAIN SYNDROMES A bounty of treatments—but not all of them are proven

OBG Manag. 2011 October;23(10):29-41

	Neal M. Lonky, MD, MPH, moderator of this discussion, is Clinical Professor of Obstetrics and Gynecology at the University of California–Irvine and a member of the Board of Directors of Southern California Permanente Medical Group. He serves as an OBG Management Contributing Editor.
	Libby Edwards, MD, is Adjunct Clinical Associate Professor of Dermatology at the University of North Carolina in Chapel Hill, NC, and Chief of Dermatology at Carolinas Medical Center in Charlotte, NC. Dr. Edwards is a Past President and Past Secretary General of the International Society for the Study of Vulvovaginal Disease.
	Jennifer Gunter, MD, is Director of Pelvic Pain and Vulvovaginal Disorders for Kaiser Permanente in San Francisco, Calif.
	Hope K. Haefner, MD, is Professor of Obstetrics and Gynecology at the University of Michigan Hospitals and Co-Director of the University of Michigan Center for Vulvar Diseases in Ann Arbor, Mich.
*The authors report no financial relationships relevant to this article.*

References

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All patients should receive counseling. And clinicians who lack expertise should refer the patient to a vulvodynia specialist.

Dr. Haefner: This type of patient may benefit from physical therapy. Bupivacaine steroid injections could also be considered. A sacral nerve stimulator should be considered if the other measures fail to provide adequate relief.

I agree that counseling is extremely helpful in the patient who has vulvodynia. Sexual counseling, with tips on positions for intercourse, lubricants, and control of uncomfortable situations, is of utmost importance.

Dr. Gunter: I offer oral medications and nerve blocks (typically, ganglion impar blocks), and many patients do well.

I also highly recommend advanced programs for mind-body techniques.

Patients who fail all therapies may be candidates for a nerve stimulator, depending on psychiatric comorbidities and response to selective diagnostic nerve blocks.

What’s in the pipeline?

Dr. Lonky: What therapies for vulvar pain are on the horizon?

Dr. Edwards: I believe that cognitive behavioral therapy, sex therapy, and couple counseling will play a larger role in the management of vulvar pain.

Dr. Gunter: Any therapy used in other pain conditions will probably eventually find its way to the management of vulvodynia.

Some investigators believe that Tarlov cysts play a role in vulvar pain and recommend that all women undergo sacral spine and nerve-root magnetic resonance imaging. The problem is that many asymptomatic women have Tarlov cysts, and the surgery to remove them is not at all risk-free. I strongly believe that more research is needed before we can suggest that Tarlov cysts be removed.

Dr. Haefner: Transcutaneous electrical stimulation and biofeedback have been used successfully in the treatment of vulvodynia.³¹ Some patients benefit from spinal cord stimulators, such as the sacral nerve stimulator, for pain control. Sacral nerve modulation (SNM) works primarily by modulation of the nerve signals to and from the pelvic floor muscles, bladder, and rectum. It applies low-amplitude electrical stimulation to the third sacral nerve via electrodes in a tined lead passing through the S3 foramen, which contains afferent sensory, efferent autonomic motor, and voluntary somatic nerves. Other studies have utilized a different spinal cord level. More studies are needed to demonstrate the full effect of SNM on vulvodynia.

A comprehensive review of the various treatments for vulvodynia can be found in the Journal of Lower Genital Tract Disease.²

Dr. Lonky: Thanks again for your expertise. We’ll focus on provoked vestibulodynia in the final installment of this series on vulvar pain, in the November 2011 issue of OBG Management.

Vulvar pain therapies mentioned in this discussion

Lifestyle changes Cotton and/or wicking underwear Avoidance of vulvar irritants, douches, soap Use of lubricants during intercourse
Physical therapy Internal (vaginal and rectal) and external soft-tissue mobilization and myofascial release Trigger-point pressure Visceral, urogenital, and joint manipulation Electrical stimulation Therapeutic exercises Active pelvic floor retraining Biofeedback Bladder and bowel retraining Therapeutic ultrasound
Topical agents Lidocaine 2% jelly Lidocaine 5% ointment Lidocaine/prilocaine Doxepin 5% cream Amitriptyline 2%/baclofen 2% Estrogen Petrolatum Gabapentin
Oral agents Tricyclic antidepressants Amitriptyline Nortriptyline Desipramine Other antidepressants Duloxetine Venlafaxine Anticonvulsants Gabapentin Pregabalin Topiramate
Other agents Capsaicin Botulinum toxin type A Corticosteroids Nerve block

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