| VULVODYNIA - 1) imidazoles 2) amitriptyline 3) calcium citrate, low oxalate diet 4) The Vulvar Pain Foundation 5) isoprenosine 6) doxepin 7) biofeedback 8) SSRIs 9) capsaicin 10) Aquanil HC 11) CAM 12) zonolon 13) dibucaine I have been caring for a 40 year old woman with dysplastic nevi for the past 6 or 7 years - one year ago she developed vulvar inflammation which has clinically cleared but has left her with vulvodynia which is severe enough to completely disrupt her life She has been seen by some of the best gynecologists in New York and they really have little to offer - she and I would be very happy to receive some clinical suggestions. She has been treated with Zovirax orally and topically, steroids topically, zinc oxide paste, silvadene,local anaesthetics, and topical antibacterials. A friend recently told here to use Crisco which helps a bit but the problem persists. What are the therapeutic pearls which I have not yet learned? Irwin Freedberg It is possible that the original inflammation was due to yeast, and that now she has the chronic low grade yeast described by Marilyn Mackay (?sp) which causes mild tender erythema of the vault. She treats with long term, months, of p.o. azoles. If she needs a lubricant the word in the community is Astroglide. Diane Thaler - The literature on vulvodynia is confusing, the nomenclature is ambiguous and the data is often sparse. One framework in which to approach vulvodynia is to try to differentiate it into vulvar vestibulitis, essential vulvodynia and cyclic vulvovaginitis. Topical treatment, though we all use it as first-line therapy, often is not sufficient in controlling the symptoms of any of these subtypes. Essential vulvodynia often responds to tricyclic anti-depressants such as amitriptyline. If you choose to use a tricyclic anti-depressant, to aid in compliance you might consider emphasizing its effect in altering the sensation of pain rather than its effect on depression. Concurrent emotional and psychological support can be invaluable. The use of oral calcium citrate along with a low oxalate diet is controversial but may help some women; the "natural" and nutritional approach is certainly attractive to many people. Even if these dietary measures are not helpful, they probably will not hurt your patient and may indeed assist in buying some time for other modalities to be efficacious. If finances permit, you might also consider referral to one of the nationally known vulvar specialists outside of NYC, as patients with vulvodynia are often desperate. A support group can be beneficial. While I have limited experience with "The Vulvar Pain Foundation", one patient of mine was grateful that I alerted her to them, as she no longer feels so isolated and embarrassed. The Vulvar Pain Foundation also publishes a newsletter. The address that I have is: The Vulvar Pain Foundation Post Office Drawer 177 Graham, NC 27253 Telephone, Tuesdays and Thursdays (910) 226-0704; Fax (910) 226-8518 Good luck with your patient-vulvodynia is a complex disorder that is frequently frustrating to both practitioner and patient. Some recent references: Dysesthetic ("Essential") Vulvodynia Treatment with Amitriptyline. McKay M. Jour Reprod Medicine 1993;38:9-13. Vulvar Pain Syndrome: A review. CME Review Article. Baggish MS, Miklos JR. Obstet and Gyn Survey 1995;50:618-27. Diagnosis and Treatment of Vulvodynia. Paavonen J. Annals of Medicine 1995;27:175-81. Stephen L. Comite MD - Here's one to try: Petersen CS and Weismann K, Isoprenosine improves symptoms in young females with chronic vulvodynia, Acta Dermatovenereologica, 1996:76(5) 404. Ten patients with chronic vulvodynia were treated with 1g po TID for 12 weeks. 4 of 10 became asymptomatic, 2 showed marked reduction of symptoms, no effect on the other 4. No adverse reactions were seen. Haines Ely - Amitriptyline or doxepin are the most helpful in my experience. I start with 25mg 2 to 3 hours before bedtime and then increase by 25mg increments at 1 to 2 week intervals as tolerated. The entire dose is given in the evening. Most women (and men with penile and scrotal pain) who will respond, do so at about 75mg per day. 60% of patients get enough relief to make life tolerable and about 40% will clear completely. Gae Rodke MD, a gynecologist in New York is doing some excellent work on biofeedback to allow pelvic floor relaxation. She is the best person in NYC for vulvodynia, I think. Her address is 146 Central park West, Suite 1G; tele # 496-9891. Peter Lynch - What does pelvic floor relaxation have to do with vulvodynia for goodness sake! Does this mean that women who do Kegel exercises (which I find suspect as well) will be at greater risk for vulvodynia? May we try oropharnx relaxation for glossodynia, or, do as Freud did and offer surgeries on the nose, removing bone and cartilage, as it is the organ most resembling the genitals, at least the male's? Diane Thaler - Re: the several posts questioning the rationale for the use of tricyclics and biofeedback for vulvodynia. First, definition and diagnosis. Before using the term vulvodynia it is, of course, necessary to rule out any recognizable (clinical or histological) disease such as LP, LS, candidiasis etc. Assumming that has been done, you are left with what (given today's level of knowledge, at least) is an idiopathic process. This idiopathic vulvar pain is then divided into two groups: those with visible (often punctate)vestibular redness (vestibulitis) and those with no visible change (essential vulvodynia). Second, is the process inflammatory? Biopsies from either vestibulitis (with redness) and from vulvodynia (without redness) reveal a few inflammatory cells (lymphocytes and plasma cells). However Moyal-Barracco et al note that redness of the type seen in vestibulitis occurs with equal frequency in a control population and Nylander Lundquist et al found about the same number of inflammatory cells in vulvar biopsies from control women. (I do not believe that either of these studies are as yet in press.) This suggests to me that inflammation is not a critical part of the condition. In any event, anti-inflammatory therapy does not work. Third, as is true with most idiopathic processes, treatment plans are arrived at empirically. Taking a leaf from the treatment of other chronic pain syndromes, tricyclics were tried. They worked. Published and presented reports indicate about a 60% response rate. It is interesting to speculate on why they might work. Since effectiveness, if it is to occur at all, begins more quickly, and at lower doses, than are required for the treatment of depression, the effect is probably via a different mechanism. That is, there may be a biochemical effect on neuropeptides that has nothing whatsoever to do with "psychologic" considerations. Fourth, tricyclics (and biofeedback) seem to me to represent a far safer approach to the treatment of pain than the laser and surgical options that are favored by many gynecologists. I have no problem with the use of other "reversible" medical forms of therapy but none of these has the established track record of tricyclics. Retin A and Zostrix, for instance have been tried and have failed to help. Fifth, I use tricyclics for men with penile and scrotal pain (as indicated earlier) as well as for lip, tongue, facial and scalp pain. They are equally (that is about 60%) effective in these conditions as well. Peter Lynch - Agreed that tricyclics work for certain pain. I agree with the distaste for the gyn approach. What about the pelvic floor relaxation, though. Or is the biofeedback working some other way. Another interesting idea in terms of pain is the SSRIs increasing ones pain threshold-maybe these could be given along with/without the tricyclics. And seriously, I have never seen a patient of Elavil informed of its obesity side effect. Diane Thaler - SSRIs don't work for pain in post-herpetic neuralgia (according to Dr. Peter Watson of Toronto, a world authority on that subject.) Elavil is thought to work (when it works) by increasing the tone in the adrenergic descending spinothalamic tracts which INHIBIT ascending pain impulses, preventing permanent (or long-lasting) modification of pain perception at the level of the CNS. This is why I give Elavil on Day One to people with zoster - to prevent post-herpetic neuralgia. A little Elavil early on saves a lot of trouble later. By analogy with PHN, I would choose Elavil over SSRI for vulvodynia - and I would administer it early rather than saving it for a last resort when all else has failed. Having said all of that, I have had better CLINICAL results in burning mouth and burning vagina with SSRIs than with Elavil, perhaps because what I'm treating in these cases is not a chronic pain syndrome per se, but a manifestation of depression. I've now moved on from SSRIs to the RIMA class of MAOIs - notably Manerix - because of a better side effect profile and almost complete absence of effect on sexual function. Kevin C. Smith MD FRCPC The sexual dysfunction with SSRIs may be overcome with amantadine, in some reports. Also, there is an OTC antihistamine which also works, but I have blanked out on which one. Wellbutrin also is a good one for people experiencing this problem on Prozac and Zoloft. Diane Thaler. - Periactin is probably the antihistamine you were trying to think of - has been reported to counter SSRI-associated sexual dysfunction. KC Smith MD FRCPC - How much will That cost? I can't even imagine the costs for this type of therapy near Park Avenue! Robert I. Rudolph, M.D., FACP - In reply to Dr. Rudolph regarding the cost of biofeedback (for vulvodynia) in NYC, I'm sorry, I don't know. Gae Rodke and her co worker presented their work as part of a study and I don't know if the study is ongoing or not. Peter Lynch - Two additional references on Vulvodynia Fitzpatricks's Journal of Clincial Dermatology Sept?Oct 1995 vol3 #5 pp9-12 Articles by Caroline S. Koblenzer, MD andLibby Edwards, MD Same Journal Jan/Feb 1994 pp37-38 Author Elaine T. Kaye, MD Bill Liss I might consider MRI of lower spine to r/o metastatic OR occult melanocytic disease or other disease, such as, degenerative osteoarthritis of spine with neural compression. Then, I would consider capsaicin, diluted in vehicle of your choice, with gradual increase in strength titrated to efficacy (as long as mucous membrane isn't involved). Patrick Carrington, M.D. - I have long considered that some cases of vulvodynia...and related pain syndromes at the same segments...might be related to occult entrapment syndromes similar to meralgia paresthetica. I was abit hesitant to suggest same in a public forum, but since Dr. Carrington brings up the subject, I think such an etiology merits some consideration. I might think of the situation in the same way as meralgia paresthetica, or even notalgia paresthetica. I am not sure how to prove it. I have been working with a very creative physiatrist in designing some tests to prove or disprove my theory. Certainly, Elavil is a very good agent in neuropathies of various types...I agree with Peter Lynch, and I use a similar approach. At the risk of being pilloried, would any of you wonder if standard chiropractic manipulations of the lumbar and sacral segments be of any value? Is accupunture to be considered? Elliot Puritz - Is the vulvodynia chronic or intermittant. If you do try Elavil, please warn the patient about weight gain. It brings to mind a survey done several years ago. When women were asked would they rather have a happy marriage or lose 10 pounds, they chose the weight loss. This might apply. I assume that vestibul"itis" implies histological/clinical inflammation. Clinically I understand the diagnosis is based on minute erythematous dots in the vestibule, associated with pain with Qtip pressure. For the life of me I can't understand why this "itis", as opposed to other inflammatory dermatoses, is treated with tricyclics and surgical excision. Where is the Plaquenil, the Dapsone, the ASA, the Doxycyline, and yes, the Accutane (as it is "glandular"). Dr. Fishers column in Cutis this month is about the perplexing problem of men who can't tolerate their pants. Elavil was not listed as therapies attempted, nor was surgical excision of their thighs. Diane Thaler - For topical Rx: 1. Topical doxepin is absorbed too much and ends up being sedating. It also occasionally behaves as a severe irritant. 2.. For local Rx of vulvar and perianal dermatoses I like Aquanil HC - lathered gently with a cotton ball or bare hand, then wiped off with a soft tissue. Not rinsing it leaves a thin soothing layer of it on raw tender skin. For daily cleansing plain Aquanil is great - less irritating than water when tested on diaper dermatitis. Gene Sienkiewicz, M. D. Gene, when I give acne patients samples of Aquanil, Cetaphil, SFC, and CAM lotion to try (along with Retin A), they always chose CAM. Have you tried the other soapless soaps? (CAM is made by Herald) Diane Thaler - Irwin, you might consider a consultation with a neurologist for a TCA, sometimes used in a variety of chronic pain syndromes. Jay Barnett Have you tried Zonolon cream? I recently had a similar patient who was helped tremendously by this. Jeff Marmelzat, M.D. I know it is not a cure for her problem, but perhaps Nupercainal ointment might afford her some relief. It is a vaseline base and delivers 1% dibucaine, an amide type anesthetic like lidocaine. She can buy it without a prescription next to the Anusol and Preparation H type stuff. E. Zabawski, DO, RPh I had a patient with intractable vulvdynia respond to capsacian cream. It might be worth a try, however, you would first warn her of the initial burning sensation accompanying the substance P depletion. Nortryptiline might also be worth trying. Rhett Drugge - | |
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