Saturday, July 12, 2014

Sex and chronic illness series: vaginal pain

Vulvodynia is vulvar pain in the absence of an identifiable cause.  It can causing burning, stinging or sharp pain in the vulva, labia and entrance to the vagina.  The pain may be intermittent or constant.  It may affect the entire area or only specific regions.  For many people with this condition, vaginal penetration is extremely painful.  Any activity which places pressure on the area can be painful, including sitting.  A common subset of vulvodynia is vulvar vestibulitis.  Vulvar vestibulitis is found in approximately 10-15% of women who receive regular gynecological care. 

Over the years, yeast infections, HPV infection, herpes infection, lichen planus, Paget disease, spinal nerve dysfunction and other conditions have been investigated as possible causes of vulvodynia.  Pelvic floor dysfunction can be a cause in some women.  Women with a chronic pain disorder, like interstitial cystitis or fibromyalgia, are about three times more likely to have vulvodynia.  When they have more than one disorder, their risk increases over five fold.  However, 73% of vulvodynia patients do not have another known chronic pain disorder. 
This condition is diagnosed based on the clinical presentation and lack of another medical cause for such symptoms.  Touching the affected areas with a Q-tip elicits a pain response.  Application of a vinegar solution and then viewing under a blue light shows affected areas, which turn white.
Mast cells have been heavily implicated in sexual pain disorders, including interstitial cystitis, provoked vestibulodynia and endometriosis.  Allergic reactions or mast cell degranulation may cause vulvodynia, as women with this disorder often have high numbers of degranulated mast cells in the biopsied tissue.  It is thought that the mast cell action stimulates C-fiber pain receptors, which are sensitized by an overabundance of histamine.  Mast cells also release neurotrophins that activate the nerve endings of pain fibers, causing proliferation and growth toward the nerve endings in the inflamed mucosa.  Increased amounts of TNF-a, a factor released by mast cells, is often found in biopsied tissue. The link between mast cells and vulvodynia is further supported by the fact that women who frequently have hives are more likely to develop vulvodynia.
Vulvodynia patients have lower levels of interleukin-1 receptor antagonist.  This means that they are less able to stop inflammation caused by interleukin-1B. 
People who suffer from vulvodynia should wear cotton underwear and avoid body washes and scented products if possible.  When washing, the area should be washed with cool water only.  Oxalate-rich diets have been found to irritate vulvodynia but not to cause it. 

There are several medication options for treating vulvodynia.  Hormone creams, including testosterone and estrogen, are sometimes helpful.  Tricyclic antidepressants like nortriptyline or amitriptyline can suppress the neurologic pain.  Lidocaine cream can be helpful.  Creams containing cromolyn sodium, a mast cell stabilizer, are also effective.
Physical therapy and biofeedback often provide significant improvement.  In this technique, sensors are applied to various pelvic areas to determine muscle tension.  Patients are then taught how to relax these muscles.  Regular Kegel exercises and relaxation techniques are helpful.  Development of strong ore muscles can take some of the strain off the pelvic floor and result in less regional pain.
For women who experience pain with penetration, dilation can be helpful.  In this technique, small rods of increasing size are inserted into the vagina and keep in place for 10-15 minutes at a time.  This trains the muscles and nerve endings to react appropriately to the pressure of penetration.  Lubrication must be used every time penetration occurs, with the exception of tampon insertion.  Vaginal lubricants should be water-based and sugar-free. 
Anesthetics and steroids are sometimes injected directly into the area to suppress the pain response.  This is reserved for cases of severe pain.  As a last resort, a vestibulectomy can be performed in which the affected tissue is removed.  Reports on success from this procedure vary from 60-93%, with the vast majority of them citing at least 80% effectiveness.
About 116 million people in the US live with chronic pain.  Women living with chronic pain are at increased risk for sexual pain disorders.
References:
Barbara D. Reed, MD, MSPH, Siobán D. Harlow, PhD, Ananda Sen, PhD, Rayna M. Edwards, MPH, Di Chen, MPHc, and Hope K. Haefner, MD. Relationship Between Vulvodynia and Chronic Comorbid Pain Conditions. Obstet Gynecol. Jul 2012; 120(1): 145–151.

Graziottin A. Mast cells and their role in sexual pain disorders in: Goldstein A. Pukall C. Goldstein I. (Eds), Female Sexual Pain Disorders: Evaluation and Management, Blackwell Publishing 2009, p. 176-179.
Bernard L. Harlow, Ph.D., Wei He, MS, and Ruby Nguyen, Ph.D.  Allergic Reactions and Risk of Vulvodynia.  Ann Epidemiol. Nov 2009; 19(11): 771–777.

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