Transcript of VPS Podcast 5 - Vulvodynia: a podcast lecture by David Nunns

Slide 16 (16:31) Assessment of women with vulvodynia

I think it’s very important to take a proper pain history from patients because what we really want to do is develop a profile of this individual’s level of pain, and its impact on function. The site of the pain is important. To me, patients who’ve got one-sided vulval pain may have a problem with a low coccyx or a low back problem to account for their pain, for example. Patients who have radiation of the pain from their vulva down their thigh even into the leg and up into the back, that may indicate not so much vulvodynia, but a referred pain typical for a low back problem. What are the aggravating and relieving factors? Well, an example would be pudendal neuralgia, which is a nerve entrapment syndrome where the pudendal nerve is squeezed in its sheath in the pudendal canal when the patient sits. The classical history of the patients with pudendal neuralgia complain of is pain on sitting, but relieved by standing and lying flat, and they also experience the feeling of a lump or a pressure inside the vagina. I think this is important because these patients may need to be seen for a discussion, for example, with a pain management team about a pudendal block, which is one of many treatments that those patients can receive.

Also, the severity of the pain, I think, is very important. This can be just a very subjective assessment of pain, using a simple ‘How bad is your pain?’ question to the patient or it can be objective, using a pain scale and there are a number of questionnaires patients can fill in for this. But this is important, because a patient whose pain may be very minimal may be unaccepting of drugs such as the tricyclics or gabapentin because of their potentially sedative effects, whereas a patient whose pain is very maximal, 8 or 9 out of 10 on a pain scale, would be very keen to take some of these drugs, despite the side effects. So it’s important to gauge the severity of pain to decide on which treatment options the patient wishes to pursue.

I also ask about sexual pain - very important, particularly with patients with provoked pain, because sometimes it becomes the elephant in the room: when the patient is complaining of pain and painful sex, it’s the sexual pain that becomes the most important problem if the patient’s directly asked.

Back problems, coccyx injuries – again, very important because some patients with vulval pain have referred pain to the vulva from back problems or coccygeal injuiries.

Slide 17 (19:44) Topics to be covered: Management of women with vulvodynia

If we look at management of women with vulvodynia, then we have some evidence produced guidelines on the management of vulvodynia, from the British Society for the Study of Vulval Disease. Their website is www.bssvd.org, and this website has the guidelines available online. This organisation draws in a number of specialities, from gynaecology, dermatology and GU medicine, and they produce these guidelines to look at all the available high-quality evidence relating to the management of vulvodynia. I’m briefly going to touch on some of those points in the next few slides.

Slide 18 (20:37) Management of women with vulvodynia: Psychoeducation

When it comes to management, I’ve divided the categories into medical treatments, sexual therapy, physical treatments and holistic. Medical treatments - we’re referring to treatments that are generally available from doctors: drugs on prescription, for example, injections or surgery. Sexual therapy would be delivered by, perhaps, a psychosexual therapist. Physical treatments - now this is mainly going to focus on desensitising the vulval area, and this would generally be given by a physiotherapist. And then, the holistic treatments - this could be anything from exercise, breathing exercises, relaxation, meditation, yoga etc – anything that suits the patient, but it’s just really an acknowledgement that those are for her to look into. Perhaps the most important initial part of managing vulvodynia is this issue of psychoeducation: explaining to the patient what the condition is.

Slide 19 (21:46) Psychoeducation!

Psychoeducation is crucially important. Usually the patients, when they’ve had vulval pain for an average of one to two years, get stuck in a void of not only symptoms but an inadequate treatment plan, an absent diagnosis. In that void they can fill their minds with all sorts of worries about fertility, spreading to other parts of the body, cancer etc. So, generally when we give vulvodynia diagnosis, we explain what the condition is, give them reassurance on all the different issues, such as fertility, infection passing on to partners, and that.

But I don’t think that’s enough: I think there needs to be a discussion with the patient about chronic pain and setting this ground is very important, I think, because it will give the foundation for the patient to then try some of the treatment strategies that will on the face of it not be very attractive, i.e. the antidepressant drugs.

I tend to talk about, with chronic pain, this issue of function within the nerve endings - the nociceptors in the skin, this issue of allodynia, the reprogramming of nerve endings from a touch pressure to a pain sensation; how this passes up through the spinal cord into the pain centre of the brain and returns down to the vulva, where the pain is felt - and to stress the importance of what is essentially the chronic pain process, the chronic pain cycle that inherently involves the pain centre in the brain. I would perhaps draw as an analogy those patients with phantom limb pain to illustrate this. Diabetics who have amputations because of leg ulcers still feel pain in the amputation, and this is because over a period of time, usually more than six months, sometimes three months, a chronic pain process has developed which involves the brain, and therefore it is not just the vulva, it’s the brain as well.

I cover two things: amplification and memory of pain. Amplification of pain is essentially this issue of allodynia, of touch of the vulva leading to an exaggerated sense of pain because of the nerve endings malfunctioning. The strategies we need to help reduce pain involve reducing this level of amplification, reducing the level of touch sensitivity in the vulva, and there are a number of ways we can do that: an example would be drugs. The other issue I talk about is memory of pain. No doubt a lot of patients have chronic background pain with acute flareups, and it’s these acute flareups that patients find incredibly distressing. So, what we try and teach patients is to try and focus on triggers, triggers that will cause a memory of pain to show itself: what are those triggers, how can the patient deal with them? The most obvious thing is sex to cause a trigger of pain. But it’s just acknowledging that ampllfication and memory are important characteristics of chronic pain and those are going to be the strategies to deal with it: reduce amplification and to identify triggers in pain.

Slide 20 (25:50) Education is crucial!

I think education is crucial. This is a paper carried out in Canada, where patients with provoked vestibulodynia underwent educational led seminars – group therapy, essentially – run by gynaecologists, and there was basic information on vulval anatomy, physiology, pain management, skin care and sexual function, i.e. psychoeducation. This paper shows a sustained benefit to the patients when these seminars were carried out.