Microsoft word - endebrock-november 2008.doc

Submission template for Capstone Project Case Report TITLE OF CASE Vulvodynia: Real pain, real psychological effects. AUTHORS OF CASE Please indicate corresponding author by * Kristy Endebrock SUMMARY Up to 150 words summarising the case presentation and outcome L.M. is a 26-year-old G0P0 Caucasian female, who presented to the office complaining of dyspareunia. She stated the pain was worse with penile insertion and lasted throughout sexual intercourse. Vulvar pain continued one day following sexual intercourse and she reported associated pain with urination one day following sexual intercourse. She denied any pain with menstruation. On physical examination, no vulvar lesions or vaginal discharge were noted. She was then diagnosed as having vulvar vestibulitis with possible interstitial cystitis. Estrace and EMLA cream were initiated. During her follow-up visit, a PST was performed and found to be negative. Her symptoms continued to persist, so estrace and EMLA cream were discontinued and vulvar injections were initiated. The patient noted relief for several months; however, at her last office visit, she reported no relief of her symptoms. Therefore, she was referred to the Vulvodynia Vestibulitis Clinic at the University of Michigan. Her appointment at U of M was on 10/15/08, and she was to schedule an OB/GYN office visit following her appointment. BACKGROUND Why you think this case is important/why you decided to write it up Vulvodynia is a commonly misdiagnosed condition. Patients are often repeatedly treated for vaginal infections in hopes of reducing any inflammation causing pain. On the other hand, some practitioners, who do not understand this condition, have dismissed their patient’s pain.1 This case demonstrates the importance of diagnosing and treating women who suffer from vulvodynia. If their pain is not managed, many women experience depression and sexual avoidance. Therefore, practitioners need to understand and recognize the presentation of this condition in order to provide the proper care these women need. CASE PRESENTATION Presenting features, medical/social/family history *Patient presented to the office on 11/12/07* L.M. is a 26 y/o G0P0 Caucasian female with a c/o dyspareunia. Pain associated with penile insertion and throughout sexual intercourse. Pain continues one day following sexual intercourse. Dysuria for one day following sexual intercourse. Last pap smear = September 2006; normal. Maternal grandmother = breast cancer in her forties Maternal aunt = breast cancer in her forties Recently married and works as a sales representative. Deals with stress and heavy lifting at work. Smokes approximately 2 cigarettes per month since 2002. Consumes approximately 10 beers per month since 2002. GU: Dysuria for one day following sexual intercourse. Vitals: Ht = 64’ Wt = 120lbs BP = 110/72 Gen: Well groomed and appears to be in good health. GI: Abdomen soft, non-tender. NBSx4. No guarding. INVESTIGATIONS If relevant Vaginal Culture: Overall negative test, patient tolerated well DIFFERENTIAL DIAGNOSIS If relevant Vulvar vestibulitis with possible interstitial cystitis. TREATMENT If relevant 11/12/07: EMLA cream applied at least one hour prior to sexual activity Injection of 1% lidocaine with epinephrine and 0.3mL kenalog to focused areas of Vestibular gland injections with 6mL 1:10 solution of 40mL kenalog and 0.25% Vestibular gland injections with 7cc 1:10 solution of 40mL kenalog and 0.25% Vestibular gland injections with 4cc 40mL kenalog and 0.25% marcaine Pateint follow-up to kenalog treatment; no relief Patient referred to Vulvodynia Vestibulitis Clinic at U of M OUTCOME AND FOLLOW-UP Vestibular gland injections were no longer successfully managing vulvar pain. Therefore, she was referred to the Vulvodynia Vestibulitis Clinic at U of M with an appointment on 10/15/08. DISCUSSION including very brief review of similar published cases (how many similar cases have been published?) 1. What is the pathophysiology of vulvodynia? 2. How is vulvodynia diagnosed? 3. What is the management of vulvodynia? 4. What is the prevalence of vulvodynia, and how many similar cases have occurred? 1. The International Society for the Study of Vulvar Disease (ISSVD) has characterized vulvodynia as burning, stinging, irritation, or rawness in the vulvar region. 7 Vulvodynia is a chronic condition lasting at least three to six months in duration and causes physical, sexual, and psychological distresses. 9 Although research is ongoing, little is known about the causes of vulvodynia.1,7-9,11 Current theory is that affected women are more likely to have altered contractile characteristics of the pelvic floor musculature.9 Therefore, pelvic floor muscle rehabilitation with biofeedback has been designed to improve muscle function and reduce vulvar pain. Several studies have proposed another possible etiology of vulvodynia. These studies identified minor immunologic changes in women with vulvodynia, such as altered levels of interleukin-1 and tumor necrosis factor in vestibular tissue. These changes could result in a decreased ability to down-regulate the inflammatory response. This may in turn be associated with neuropathic changes.9 More recently, vulvar biopsy specimens have shown increased neuronal proliferation and branching in the vulvar tissue of women with vulvodynia compared with tissue of asymptomatic women.9 Vulvodynia has also been attributed to changes in estrogen concentration and increased urinary oxalates.11 One study suggests estrogen affects sensory discrimination and pain sensitivity at multiple sites within the central and peripheral nervous systems.11 However, dietary oxalate consumption and oral contraceptive use have been refuted as causes of vulvodynia.5,6 2. Vulvodynia is a diagnosis of exclusion. It is important to get a thorough patient history in order to rule out any underlying cause of vulvar pain, such as vaginal infection, inflammation, neoplasm, or neurological disorder. If a patient complains of vaginal secretions or if they are noted on physical examination, cultures should be ordered to rule out an active infection. Occasionally, the patient may not be aware that the tenderness is originating from the introitus and may describe the pain as deeper into the vagina. Confirmation of the pain during physical examination will clarify this issue.9 Physical examination is very important in the diagnostic process. In patients with vulvodynia, the vulva may be erythematus. Erythema is most commonly visualized at the five and seven o’clock positions or on a horseshoe-shaped area of the lower vestibulum.8 If a rash, altered skin, or altered mucosa are present, it is inconsistent with vulvodynia and warrants further investigation and possible biopsy.3,9 A second test used on physical examination is the Q-tip test. In this test, a cotton swab is used to gently indent the skin on several locations around the labia, introitus, and hymenal remnants.9 This pressure will elicit pain in almost all patients with vulvodynia, especially in the area of the posterior introitus and hymenal remnants.8,9,11 3. A variety of treatment options are available for women who have vulvodynia. However, it is important to realize that successful therapy often requires trial and error because individual response varies greatly between medications. The general approach to these patients is to determine and eliminate any triggering factors and maintain good vulvar hygiene.12 Pelvic floor muscle rehabilitation has been found to be beneficial in patients with evidence of pelvic floor muscle hypertonicity. It is thought to decrease introital tenderness and enable women to engage in sexual intercourse with less discomfort.7-9,12 When beginning pharmacologic therapy, a TCA is typically the first agent used. Depending on the provider and the severity of the patient’s pain, a topical anesthetic may also be prescribed. If treatment with TCAs is found to be unsuccessful, management with medications that decrease neuronal hypersensitivity is the next treatment option. Examples include Norpramin, Neurontin, Paxil, and Effexor. 7-9,12 Local nerve blocks may be used if symptoms continue to persist despite oral and topical medications. An observational study of 22 women evaluated the effectiveness of methylprednisolone acetate and lidocaine cloridrate solution injected into the vestibule. Results showed seven women had complete remission of their symptoms, eight women stated they were markedly improved, while seven had no improvement in their pain over nine months.12 Lastly, it is very important to recognize that if a patient remains unresponsive to medical treatment, they should be referred to a specialist who can better help manage their symptoms. 4. Many articles have been published educating practitioners on diagnosing and managing vulvodynia patients. However, there is limited literature available regarding similar case reports. Likewise, conflicting data exists in the determination of the prevalence of vulvodynia. An article published by Dr. Metts in 1999 determined the prevalence of vulvodynia to be as high as fifteen percent. This article also found the mean age distribution to be between the second and sixth decade of life and almost exclusively in white females.8 In a more recent article published by Dr. Reed in 2006, three studies were analyzed. Each study systematically addressed the prevalence of vulvar pain in various clinical settings and determined the prevalence to be much greater than was previously estimated. One of the three studies found 15 percent of the patients in a successful gynecologist’s office have vulvodynia. The second study found 1.7 percent of the women, who answered their internet survey, complained of vulvar pain. Lastly, the third study found 8.6 percent, in a population-based study of symptomatic women in the Boston area, to have vulvodynia. When completed, the analysis of these studies extrapolated the prevalence of vulvodynia to occur in more than 2.4 million women in the United States and approximately 15 affected women in a family practice of 2,000 patients.9 A third article that was published in 2004 found the prevalence of chronic vulvar pain or burning to be unknown. It also estimated a lifetime cumulative incidence of chronic vulvar pain to be approximately 16 percent, estimating that 14 million women in the United States could experience vulvodynia in their lifetime.7 As previously stated, most articles were published to educate practitioners on how to provide care for vulvodynia patients. Many articles touched on the prevalence of vulvodynia, however each had conflicting results. It is important to recognize that more research is needed in order to fully understand the etiology and prevalence of vulvodynia. In regards to the patient presented in the case study, it appears as though diagnosis and management was sufficient. It was important to exclude interstitial cystitis as a possible cause of her pain because these patients have a high risk of acquiring vulvodynia.4 However, from research found on the management of vulvodynia patients, a TCA should have been used first line. If the TCA was found to be ineffective, another oral medication used to decrease neuronal hypersensitivity could have been initiated. Likewise, if this patient still experienced no relieve from her symptoms, the injections given were an appropriate next step in her management. It was also important that as her symptoms continued to persist despite medical management, she was referred to the Vulvodynia Vestibulitis Clinic at U of M for further care. LEARNING POINTS/TAKE HOME MESSAGES 3 to 5 bullet points Vulvodynia is a very painful condition that also causes depression and sexual avoidance. It is important to not only treat these patients symptomatically, but to also provide emotional and psychological support. There are many support groups available for these women: National Vulvodynia Association ( Vulvar Pain Foundation ( Vulvodynia is a diagnosis of exclusion. Therefore, it is important to exclude infectious, inflammatory, neoplastic, and neurologic disorders as a cause of vulvar pain. Response to medication is highly variable; successful therapy often requires trial and error. Thus, it is important to realize there are a variety of treatment options available for vulvodynia, including vulvar hygiene, topical anesthetics, TCAs, and many other pharmacological agents. Vulvodynia can be a frustrating condition for both the patient and the practitioner. It is important to realize that if multiple treatment options fail, there are vulvodynia clinics available for patient referral. 1. Bachmann, Gloria, Janice McElhiney, Shillena Peters, and Raymond Rosen. "Vulvodynia: Real condition, real pain." Sexuality, Reproduction and Menopause 4 (2006): 71-73. 2. Boardman, Lori. "Topical Therapy for Vulvodynia." National Vulvodynia Association 11 3. Bowen, A. R., A. Vester, L. Marsden, S. R. Florell, H. Sharp, and P. Summers. "The Role of Vulvar Skin Biopsy in the Evaluation of Chronic Vulvar Pain." American Journal of Obstetrics and Gynecology (2008). 4. Gardella, Barbara, Daniele Porru, Francesca Ferdeghini, Eva Gabellotti, Rossella Nappi, Bruno Rovereto, and Arsenio Spinillo. "Insight into Urogynecologic Features of Women with Interstitial Cystitis/Painful Bladder Syndrome." European Association of Urology 54 (2008): 1145-153. 5. Harlow, B. L., A. F. Vitonis, and E. G. Stewart. "Influence of Oral Contraceptive Use on the Risk of Adult-onset Vulvodynia." Journal of Reproductive Medicine 53 (2008): 102-10. 6. Harlow, B. L., H. A. Abenhaim, A. F. Vitonis, and L. Harnack. "Influence of Dietary Oxalates on the Risk of Adult-onset Vulvodynia." Journal of Reproductive Medicine 53 (2008): 171-78. 7. Lotery, Helen, Neil McClure, and Rudolph Galask. "Vulvodynia." The Lancet 363 8. Metts, Julius. “Vulvodynia and Vulvar Vestibulitis: Challenges in Diagnosis and Management.” American Family Physician (1999). 9. Reed, Barbara. “Vulvodynia: Diagnosis and Management.” American Family Physician 10. Stewart, Elizabeth, and Robert Barbieri. "Clinical Manifestations and diagnosis of vestibulodynia." 31 May 2008. Up To Date. 30 Oct. 2008. 11. Stewart, Elizabeth, and Robert Barbieri. "Clinical Manifestations and diagnosis of vulvodynia." 31 May 2008. Up To Date. 21 Oct. 2008. 12. Stewart, Elizabeth, and Robert Barbieri. "Treatment of Vulvar Pain." 31 May 2008. Up Date: November 5, 2008 PLEASE SAVE YOUR TEMPLATE WITH THE FOLLOWING FORMAT: Author’s last name and date of submission, eg, Smith_June_2008.doc


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