and Filippo Murina2
(1)
Center of Gynecology and Medical Sexology, San Raffaele Resnati Hospital, Milan, Italy
(2)
Lower Genital Tract Disease Unit V. Buzzi Hospital, University of Milan, Milan, Italy
Vulvar pain is a very common problem that affects women of all age groups. Too often, women endure pain and sexual dysfunction for years without an adequate definitive diagnosis. They are desperate for help, looking for every type of medical and alternative treatment and regularly self-treat, wasting a lot of money a year in disappointing/frustrating consultations, anti-yeast creams, and other over-the-counter treatments.
The incidence of vulvar pain has increased over the past three decades. The reason is twofold: on one hand, there is certainly greater awareness about vulvar pain, which is increasingly reported to healthcare providers (HCPs), and on the other hand, there is a real increase of etiologic factors (please see the Chaps. 3 and 6).
Among the most frequent, physicians should consider the Candida vaginitis epidemic, secondary to the antibiotic abuse and to the increase in dismetabolic diseases, diabetes first. Diabetes can triple Candida vaginitis and other infections, such as recurrent cystitis from the uropathogenic Escherichia coli (UPEC), so frequently comorbid with provoked vestibulodynia, up to 60 % in the Salonia et al. series (2013).
Nevertheless, vulvar pain is not a recent diagnosis.
As early as 1874, T. Galliard Thomas wrote: “This disorder, although fortunately not very frequent, is by no means very rare” (Thomas 1874). He went on to express “surprise” that it had not been “more generally and fully described.” Despite the focus Thomas directed to the issue, vulvar pain did not get much attention until the twenty-first century, when a number of studies began to gauge its prevalence. With the foundation of the International Society for the Study of Vulvovaginal Disease in the 1970s, interest and research in vulvar pain and other vulvar conditions increased.
The prevalence of isolated pain syndromes causing vulvar pain is difficult to estimate because of the private nature of this symptom, the lack of widespread knowledge among healthcare providers about vulvar pain disorders, and the belief, by some women, that vulvar or sexual pain of some extent is normal.
2.1 Dyspareunia: A Red Alert to Vestibular Pain
Coital pain at the entrance of the vagina (“introital dyspareunia”) has been relatively more investigated in comparison to vulvar pain. It can be considered the sexual correlate of vestibular pain. Its prevalence can therefore indirectly suggest the likely prevalence of vestibular pain, at least to some extent.
Latthe et al. (2006) identified 54 studies that specifically assessed dyspareunia. The reported prevalence rates of dyspareunia ranged widely, from 1 % in Sweden to 46 % in one US study. By restricting the review to the 18 well-designed studies with representative samples, prevalence rates ranged from 8 to 22 % (Latthe et al. 2006).
In the Study on Women’s Health Across the Nation (SWAN) (Avis et al. 2005), 17 % percent of premenopausal women complain of constant or occasional coital pain, compared with 24 % of postmenopausal women.
In the classic epidemiological study of Laumann et al. (1999) in the USA, carried out among women aged 18–55, 21 % report dyspareunia. In an older cohort of sexually active women, aged 57–85, dyspareunia was reported in 10.5 % (Laumann et al. 2008).
A European survey, carried out on 2467 women aged 18–70 in UK, France, Germany, and Italy, through validated questionnaires, found that the prevalence of dyspareunia was 14 % (Graziottin 2007).
Overall the most frequent prevalence figures range between 10 and 20 %.
2.2 Vulvar Pain in the Lifespan
2.2.1 Vulvar Pain in Childhood
Different etiologies may contribute to vulvar pain in prepubertal girls (please see the Chap. 4).
Traumatic unintentional accidental lesions of the vulva in childhood usually cause acute, intense, excruciating vulvar pain, given the extremely rich innervation of the area.
Pediatric genital injuries represented 0.6 % of all pediatric injuries. The mean age at injury was 7.1 years old and was distributed 56.6 % girls and 43.4 % boys. A total of 43.3 % had lacerations and 42.2 % had contusions/abrasions. The majority of injuries occurred at home (65.9 %), and the majority of patients (94.7 %) were treated and released from the hospital. The most common consumer products associated with pediatric genital trauma were bicycles (14.7 % of all pediatric genital injuries), bathtubs (5.8 %), daywear (5.6 %), monkey bars (5.4 %), and toilets (4.0 %) (Casey et al. 2013).
Traumatic intentional vulvar lesions
Sexual abuse. Every year, about 4–16 % of children are physically abused, and one in ten is neglected or psychologically abused. During childhood, between 5 and 10 % of girls and up to 5 % of boys are exposed to penetrative sexual abuse, causing severe genital (and vulvar!) pain. Up to three times this number are exposed to any type of sexual abuse. However, official rates for substantiated child maltreatment indicate less than a tenth of this burden (Gilbert et al. 2009; Bailhache et al. 2013).
Female genital mutilation/cutting (FGM/C) is defined by the World Health Organization (WHO) as “all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons” (WHO 2008) (please see the Chap. 5 ). Worldwide, an estimated 125–140 million girls and women live with FGM/C. The long-term gynecologic and obstetric outcomes of FGM/C include significantly increased risks of urinary tract infections (unadjusted RR = 3.01), bacterial vaginosis (adjusted OR (AOR) = 1.68), dyspareunia (RR = 1.53), prolonged labor (AOR = 1.49), caesarean section (AOR = 1.60), and difficult delivery (AOR = 1.88). Unfortunately vulvar pain is not mentioned in spite of the fact that the violent cutting trauma on the vulvar tissue causes excruciating acute pain and potential long-lasting consequences.
Lichen sclerosus (LS), the most relevant vulvar dermatosis, is an inflammatory dermatologic condition of autoimmune etiology, usually affecting the anogenital area in both sexes. Less than 10 % occurrence is reported elsewhere on the skin (Murphy 2010).
LS has been reported in all age groups and both sexes. Most often it occurs in postmenopausal females, but:
Approximately 7–15 % of all cases are found in prepubertal females, with a prevalence that has been reported to be 1 in 900–1100 (Lagerstedt et al. 2013).
A study on 44 Finnish girls diagnosed under the age of 19 with LS found a mean age of onset of symptoms of 7 years, and 86 % were prepubertal at the time of presentation (Lagerstedt et al. 2013).
Recurrence rates of prepubertal LS after medical therapy have been reported to range from 44 to 82 % (Smith and Fischer 2009; Focseneanu et al. 2013).
Key Point
LS should be considered as a chronic autoimmune condition with intermittent symptoms (vulvar itching and pain first). Symptoms may recur in the lifespan even after appropriate treatment.
2.2.2 Vulvar Pain in Adolescents and Young Women
Prevalence studies focusing on adolescents under 20 years of age have not yet been carried out. Available studies include larger age cohorts, usually from 18 to 40 years of age. Reported prevalence varies across studies.
A self-administered questionnaires from 5440 women in Boston Metropolitan area (BMA) and 13,681 in Minneapolis/Saint Paul Metropolitan area (MSP), 18–40 years of age, described their history of vulvar burning or pain on contact that persisted >3 months and that limited/prevented intercourse (Harlow et al. 2014). The study indicates that by age of 40 years, 7–8 % in BMA and MSP reported vulvar pain consistent with vulvodynia. Women of Hispanic origin compared to whites were 1.4 times more likely to develop vulvar pain symptoms (95 % confidence interval, 1.1–1.8). Many women in MSP (48 %) and BMA (30 %) never sought treatment, and >50 % who sought care with known healthcare access received no diagnosis (Harlow et al. 2014)!
The diagnostic neglect is even more likely in adolescents who have less access to medical facilities, less probability of being listened to with a caring diagnostic attention, less assertiveness toward healthcare providers (HCPs). Access to healthcare does not increase the likelihood of seeking (and finding!) care for chronic vulvar pain.
In a study on 1795 women participating in the Woman to Woman Health Study, a multiethnic population-based study, women who screened positive for depression had a 53 % higher prevalence of having vulvodynia (PR = 1.53; 95 % CI: 1.12, 2.10) compared with women who screened negative for depression. Women who screened positive for post-traumatic stress disorder (PTSD) had more than a twofold increase in the prevalence of having vulvodynia (PR = 2.37; 95 % CI: 1.07, 5.25) compared with women who screened negative for PTSD (Iglesias-Rios et al. 2015).
The increased prevalence of vulvodynia among those screening positive for depression or PTSD suggests that these disorders may contribute to the likelihood of reporting vulvodynia. Alternatively, vulvodynia, depression, and PTSD may have a common pathophysiologic and risk profile (Iglesias-Rios et al. 2015). The most pertinent hypothesis is that neuroinflammation associated with chronic vulvar pain and vulvodynia contributes to depression. Prospective studies are needed to improve our understanding of the temporal relation between mental health conditions and vulvar pain.
2.2.3 Vulvar Pain After Childbirth
The prevalence of vulvar pain and sexual dysfunction is high after childbirth and in the postpartum and puerperium periods, and data indicate that up to 86 % of women report one or more vulvar complain soon after delivery (Leeman and Rogers 2012) (please see the Chap. 7).
Dyspareunia and vaginal dryness frequently occur after childbirth and may independently contribute to a reduction in sexual drive, because of the negative feedback from the genitals.
The reported prevalence rates of perineal pain at 12–24 months postpartum range from 5 to 33 % (Williams et al. 2007).
In a prospective cohort study of 484 women, vaginal dryness, vaginal tightness, vaginal looseness, bleeding or irritation after sex, and loss of sexual desire were all reported as having significantly increased from 38 % before delivery to 64 % at 3 months postpartum. Within 6 months from delivery, 89 % of participants had resumed sexual activity. While significant improvements were noted in all of these parameters, they had not returned to predelivery levels (Barrett et al. 2000).
Postpartum genital and pelvic pain has also been shown to persist for longer than a year, particularly for women with a history of no genital chronic pain before childbirth (Paterson et al. 2009).
A recent Australian prospective study on 1507 nulliparous women indicates that prevalence of dyspareunia at 3, 6, 13, and 18 month is of 44, 45, 28, and 23 % respectively (McDonald et al. 2015). Lack of professional recognition and treatment of postpartum dyspareunia, and associated vestibular and/or vulvar pain, persists all over the world.
2.2.4 Vulvar Pain After Menopause
During menopause, women experience many physical changes caused by a decrease in estrogen and other hormones and the effects of aging.
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