Alessandra Graziottin - Vulvar Pain: From Childhood to Old Age
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- 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 ), 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 .
- 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
- Time is the leading differentiating criteria: vulvar pain is defined as chronic when it persists more than 36 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. ).
- 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 (Haanp et al. ).
- 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. ). It is:
- Not finalized , i.e ., non-resolving.
- Persistent , chronic.
- Of variable intensity.
- Highly sensible to stressors , physical and emotional. They can upregulate the central inflammatory process with further worsening of the vulvar pain perception.
- Treatment of neuropathic vulvar pain / vulvodynia and its subtypes is therefore oriented at modulating the CNS components of vulvar pain , while keeping attention to persistent vulvar trigger of pain, when present:
- Relaxation of the tightened , hyperactive pelvic floor , either primarily or in response to the persisting pain, is a critical part of an effective treatment.
- Avoidance of penetrative vaginal intercourse is essential , to avoid further microtraumas of the vulnerable introital mucosa, until vulvar pain is adequately addressed.
- Antalgic peripheral treatment with temporary, periodic block of the Walter ganglion can be reserved to cases resisting to the standard treatment.
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