23 The term vulvodynia was introduced for the first time in 1983 by the International Society for the Study of Vulvovaginal Disease. It was then subjected to discussion and reassessment, which led to a more precise definition, agreed in 2003. It was then defined as ‘vulval pain in the absence of relevant, visible physical findings, or a specific clinically identifiable neurological disorder’. This definition clearly introduces the concept that vulval pain due to specific diseases (such as herpes, or lichen sclerosus) must not be defined using the term vulvodynia. This term identifies a neuropathic pain, due to a dysfunction in peripheral and central nervous system pain processing. In this sense, vulvodynia is a type of allodynia, a term used to describe pain caused by a stimulus that in normal conditions does not provoke pain. Vulvodynia is not a symptom but a chronic pain syndrome where pain becomes a true disease. In view of this, a review of the classification was agreed in 2015 (see Box 23.1). This now relates to ‘persistent vulval pain’ including such pain caused by a specific disorder. It also lists common comorbidities seen in these women. Two specific subsets of vulvodynia, based on clinical features, have emerged (Figure 23.1). There are patients who describe constant generalized pain and those who have more localized pain that is provoked by touch or pressure. This latter group was described previously as having ‘vestibulitis’. The 2003 classification suggested that the suffix ‐itis should no longer be used as this implies that inflammation is the main pathogenic element in this type of vulval pain. The term vestibulodynia is now used for this localized pain at the vestibule. There may be some overlap with spontaneous and provoked types occurring in the same patient. Figure 23.1 Subsets of vulvodynia. Vulvodynia has been estimated to affect up to 16% of women at some time. It can occur in all age groups and ethnicities. Localized provoked pain tends to occur in younger women and is most common in the 20–40 year age group. The pathogenesis of vulvodynia is complex and multifactorial. Initially, inflammation was considered a significant factor in the onset and exacerbation of disease and a lot of attention was given to it. With the identification of neuropathic processes, the role of inflammation has been disproved, underlining the ISSVD recommendation to abandon the term ‘vestibulitis’. Over the years several other factors were postulated such as infection (HPV, Candida, HSV), oxalate secretion in urine, modification of the microbial ecosystem of the vulva, altered sensory perception, peripheral neuropathy, an abnormality in the muscular tone of the pelvic floor, iatrogenic, hormonal and psychological factors. None of these is believed to be a significant aetiological factor. It is now considered that the pathogenesis is that of neuropathic pain, which may be triggered or modified by psychological situations (sorrow, neglect, anxiety) or pathological states such as recurrent infections, increased muscular tone, perineal trauma. There is an increased frequency of other conditions with similar pain pathology – for example, fibromyalgia, irritable bladder, irritable bowel syndrome, migraine, facial pain and chronic fatigue syndrome. Sexual and psychological effects are common in these patients. They can develop severe problems with relationships because of their disease and it can be questioned that vulvodynia may be the ‘lesser evil’ that protects them from deeper psychological distresses. There is a higher incidence of anxiety in these patients but this is thought to be secondary to the chronic symptoms.
Vulvodynia
Definition
Epidemiology
Pathophysiology
Psychological Aspects of Vulvodynia
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