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

Slide 26 (35:50) Vulvodynia – some tips

In summary, and some tips, I think it’s important to spend some time explaining to the patient a bit about chronic pain, talking about pain memory and amplification. I think treatments should be combined as much as possible. Patients do need encouragement, particularly with some of the drugs. Patients need time to think things through. They need to do their homework and I usually direct them to the VPS website and tell them to self-manage. This issue of self-management for chronic pain is incredibly important, really - we have to move away slightly from this medical model of prescription given to these patients. Individually, I think we have to look at our own skills when it comes to these patients, because vulval pain encompasses so many different facets, from chronic pain, sexual therapy, vulval examination to the whole host of different treatments, and I guess as doctors we have limited numbers of skills, limited numbers of things we can give patients - our toolkit, as it were. We might have to define in our own minds what we want to treat patients with before asking other health professionals to come in. A very clear example would be things like sexual therapy and physiotherapy – those are patients we generally refer on. Something not so clear might be the prescription of drugs for vulval pain. Many doctors are happy giving amitriptyline and nortriptyline, but they’re not happy about giving gabapentin or pregabalin. So it may be that these sorts of patients who are needing more advanced pain management strategies need to be referred onwards.

Slide 27 (37:53) Topics to be covered: Framework for care of women with vulvodynia

This leads on to a framework of care for women with vulvodynia. I usually divide these women up into ‘complicated’ and ‘uncomplicated’. An uncomplicated patient is one that responds quite well to basic treatment: when I say ‘basic treatment’, the psychoeducation, the nortriptyline drugs, acupuncture -  somebody who’s responding, managing well, has the information and is quite happy to be left on an open appointment. But sometimes individual patients will need more than that, and this is where I think a team can be very important.

Slide 28 (38:35) Management

If we look at a team, then we’re looking at perhaps a lead person, a lead clinician to take charge of the overall package of care for the patient, and that lead is going to be making the diagnosis, starting basic treatment, and then, importantly, referring patients out to physio, psychosexual therapy, even pain management clinics. So patients might have quite a number of hospital visits to make for their treatment, but as long as patients are signed up for that, I think it’s worth it. When patients aren’t really engaged in treatment, they’re not really wanting to come to the hospital for treatment, they’re halfheartedly taking their treatment, they’re not attending clinics, then I think you’ve got probably a patient that’s not going to respond well. Our other colleagues, for example, Pain Management, have access to a whole host of other things in their toolkit: nerve blocks, pain management courses, sometimes access to clinical psychologists that in our speciality we can find difficulty getting. It’s essentially a multidisciplinary team. I’m not arguing for more new clinics to be established, but it might be styles of working within a hospital.

Slide 29 (40:01) Topics to be covered: Vulval Pain Society

Just finally, a little bit about the Vulval Pain Society, which we set up in 1996 as an information and support network to women with vulval pain. Most of our work is focused on the website, and also workshops, which are carried out twice a year around the country. We get some very insightful comments made by women through the support groups to us, which I’d like to share with you.

Slide 30 (40:33) The doctor-patient relationship

This is my last slide: the doctor-patient relationship. I think as doctors there is a perception that women with vulvodynia can be difficult to deal with: they’re angry, they’re complicated, complex, and they take a lot of time. Well, that’s one point of view. However, if you look at it from the patient’s point of view, and this is feedback I’ve had from patients, patients say not infrequently that they’re not taken seriously, there’s never enough time to discuss their problems, they always see different doctors when they come to the clinic, there’s rarely a cause given or basic information, there’s no instruction on treatment, for example, tricyclics, there never seems to be a plan and there’s no access if there is a problem. An example of that would be a tricyclic given to a patient without instruction and the patient gets dryness, dizziness soon after taking the tablet and then has to stop because of symptoms. There’s no way into the system to see a doctor, and the patient’s left in limbo until the next appointment, which is in three months’ time. It’s quite interesting to get this patient perspective, and on the basis of this, what I try and do is, I myself see the patient the same time she comes; I’ve got a whole array of factsheets; for difficult patients I might make a double slot; I always send the patient a copy of the GP letter; at the top of the letter there is access to the clinic should there be a problem – it’s always better to know there’s a problem rather than see the patient three or six months later and the treatment’s not been tried.

So I hope this lecture has been of help. If you would like more information, then please contact me at the Vulval Pain Society. Thank you for listening.