Vulvar Pain: What’s Behind a Name

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 comprehensive term. Its main characteristics are described in Box 1.1.


Box 1.1. Vulvar Pain: Key Descriptors



Acute Vulvar Pain



  • Is referred to the vulvar organ, or part of it:



    • The vulvar vestibule (vestibular pain)


    • The clitoris (clitoral pain)


    • Localized vulvar pain in parts other than the vestibule or the clitoris (localized vulvar pain), i.e., affecting the left labia majora or right labia minora, or the Bartholin gland (Bartolinitis)


    • The entire vulva (vulvar pain)


  • Has a precise, objective etiology, easy to be visualized, described, and recorded


  • Acute tissue inflammation is the common denominator, resulting, among others, from:



    • A trauma:



      • Unintentional, such as blunt lesions during sport or accidental falls, cutting, and burning, among others


      • Intentional, including sexual abuse and female genital mutilations/modifications (FGM/M)


    • Infections, such as in Candida vulvitis, in herpes virus, and in pyogenic abscesses or parasitic infections


    • Acute nerve traumas, such as mechanical traumas


    • An iatrogenic damage:



      • Chemical, during topical treatment with immunomodulants, or chemotherapy


      • Physical, such as after laser therapy, diathermocoagulation, and radiotherapy


      • Surgical, during episiotomy/episiorrhaphy, vulvar surgery (excisional or not), and “cosmetic” vulvar interventions


    • A painful acute skin disease


  • It is a defensive, alerting response to an acute damage, unintentional or intentional, to the vulvar region and organ:



    • Nociceptive, i.e., a sign of an ongoing acute damage


    • A “friend signal,” in some ways, indicating the urgent need to withdraw from the cause of pain, understanding, and treating it


  • It can be continuous or remitting, constant, or have a circadian rhythm.


  • Acute vulvar nociceptive pain is usually worse at night.


  • Objective findings include:



    • Vulvar skin and mucosa turning red


    • Vulvar edema/swelling


    • Vulvar increase in temperature


    • Vulvar pain, spontaneous or provoked at gentle touching


    • Impaired functions, including sexual symptoms (Graziottin 2009), cosmetic functions, and impossibility to behaviors such as stay seated or wearing tight trousers


  • Response to treatment:



    • In acute vulvar pain, removal of the damaging agent and treatment of the lesions should resolve/restore normal vulvar cytoarchitecture and function, with or without scars.

Key Point

The acute inflammation underlying acute vulvar pain has three main characteristics. It is:





  • Resolving, i.e., finalized to restore the return to normality in terms of vulvar cytoarchitecture, anatomy, and function


  • Limited in time, usually within 3 months from the onset of traumatic agent


  • Limited in intensity, adequate and proportionate to cope with the ongoing tissue insult



Chronic Vulvar Pain



  • Time is the leading differentiating criteria: vulvar pain is defined as chronic when it persists more than 3–6 months, still maintaining most of the abovementioned characteristics.


  • Inflammation shifts progressively from physiologic to pathologic and tends to become “anarchic,” non-resolving, and of increasing and disproportionate severity (Graziottin et al. 2013, 2014, 2015; Graziottin and Gambini 2016).



Pathologic/Neuropathic Vulvar Pain



  • Pain progressively becomes a “disease per se”: symptoms of vulvar pain are included within the “dynia” group:



    • Vestibulodynia, when pain is referred to the vestibule


    • Clitorodynia, where pain is referred to the clitoris


    • Vulvodynia, where pain can be referred to part of it (localized vulvodynia) or to the entire organ (generalized vulvodynia)


  • The vulvar skin and mucosal damage are no more objectively identifiable:



    • Peripheral inflammatory signs gradually disappear.


    • Central involvement of the CNS (neuroinflammation) becomes prominent, the common denominator of all types of pain becoming neuropathic (Haanpää et al. 2011; Hampson et al. 2013; Regauer et al. 2015; Schaible 2015).


  • Vestibulodynia, clitoridynia , or vulvodynia can be spontaneous or provoked, with a remitting or persisting course.


  • Neuropathic vulvar pain usually disappears during night sleep.


  • Inflammation becomes pathologic and self–maintained by the upregulation of the immunitary system (with mast cells and microglia leading the pathophysiologic immunitary response) and the pain system (Graziottin et al. 2013, 2014, 2015; Graziottin and Gambini 2016). It is:

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Aug 25, 2017 | Posted by in GYNECOLOGY | Comments Off on Vulvar Pain: What’s Behind a Name

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