Vulvodynia - Treatment and Disease Management

Treatment and Disease Management

There is no uniform treatment approach for vulvodynia or vulvar vestibulitis. Women have shown improved symptoms from a variety of treatments. Some find 100% relief from particular treatments, while others may experience only temporary or partial relief. Responses to the various and many treatments being tried are highly variable, with many patients often trying several treatments over the course of their diagnosis depending upon their levels of relief, the preferred method(s) of their doctor(s), and the affordability of these treatments; many treatments are still experimental and often not covered by health insurance — or the particular doctor using them does not take insurance. Treatments include:

1. Over the Counter Care: Wearing cotton underwear (no synthetics); avoidance of vulvar irritants (douching, shampoos, perfumes, laundry detergents); gently wash the vaginal area and labia with cool water only – using a washcloth is most effective – but do not use soap; cotton menstrual pads; rinsing and patting dry the vulva after urination; using a pad when sitting to alleviate pressure.
2. Lubrication: (for intercourse or used daily to minimize irritation) If you have problems with yeast, or are worried you will, avoid lubricants with glycerine in them, which acts like a sugar and will only add to your problems. Neem oil is a good topical treatment for irritation that is also anti-fungal so very safe if you are prone to yeast, and water-based lubricant are often suggested by doctors. Vitamin E and olive oil can also create bacterial growth so avoid using them topically.
3. Diet: Following a low-oxalate diet may help those whose urine oxalate levels are high and may be causing or exacerbating irritation. The level of oxalates can be tested by taking a 24-hour urine sample. Those following a low-oxalate diet often take a calcium citrate supplement. There is no evidence that this diet helps sufferers with normal oxalate levels in their urine.
4. Alternatives to Penetration: Sufferers are often encouraged to explore sexual activity besides penetrative intercourse, which is often a major source of pain. Patients may seek the assistance of a sex therapist to learn specific techniques and ways to maintain a positive image of sexual intimacy and one's body.
5. Education and accurate information about Vestibulodynia: Gynaecologist-led educational seminars delivered in a group format have a significant positive impact on psychological symptoms and sexual functioning in women who suffer from Provoked (caused by a stimulus such as touch or sexual activity) Vestibulodynia.
6. Medications: Patients have found variable success using topical creams and gels including estrogen and/or testosterone, often specially made through a compounding pharmacy; oral medicines including testosterone, antidepressants also used for pain disorders (e.g., nortriptyline, amitriptyline), and anti-anxiety drugs; and injectable medications including anesthetics, estrogens, tricyclic antidepressants compounded into a topical form or systemic, local steroids.
7. Biofeedback, Physical Therapy and Relaxation: Biofeedback, often done by physical therapists, involves inserting a vaginal sensor to get a sense of the strength of the muscles and help a patient get greater control of her muscles to feel the difference between contraction and relaxation. Sessions are linked with at-home recommendations including often Kegel exercises (e.g., hold for 9 seconds, relax for 30 for 10–15 sets) and relaxation (breathing deep into the gut). Other physical therapy involves direct manipulation of the muscles; the therapist may go inside the vagina and physically press on and stretch the muscles. (One may practice stretching along with Kegel's at home using a dilation kit or series of different size dildos. This is a common treatment for those suffering primarily from vaginismus, but may also help individuals with vaginismus that results from and worsens preexisting pain.) Other therapists encourage strengthening one's core muscles, believing that the pelvic region overcompensates for the work the core muscles should be doing, causing strain and pain.
8. Injection: This may be performed under CT, flurosocopy/C-arm or ultrasound guidance where the pudendal nerve is identified in its canal (where it is commonly compressed). Usually cortisone and local anaesthetic is injected and in rare cases, the nerve may be destroyed (ablated), if the pain is severe and unrelenting. In the latter instance, the trade off is permanent vulval numbness.
9. Surgery: Vestibulectomy. During a vestibulectomy, the innervated fibers are excised. A vaginal extension may be performed, in which vaginal tissue is pulled forward and sewn in place of the removed skin. The success rate of a vestibulectomy varies from a low of 60% to as high as 93%. There are over 20 studies citing a success rate greater than 80%.