Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Dysesthetic Vulvodynia
N94.819: Vulvodynia, unspecified
I. DEFINITION
Chronic mild-to-severe vulvar pain that is described as burning, stinging, irritating, and/or rawness that occurs alone or in conjunction with other vulvar pain syndromes or dermatoses and may occur with or without an identifiable provocation. The name is derived from the Greek word odynia (“pain”). The vulvar discomfort may involve the urethra, perianal area, and the thighs, as well as the generalized vulvar area. This condition accounts for 15% of gynecology visits and affects women of all ages. Current thinking is that vulvar pain is a symptom and not a diagnosis.
II. ETIOLOGY
A. May not be one single etiology, but rather a mixed etiology
B. Chronic infection could be the precipitating factor. Careful diagnosis of Candida is made by positive wet mount or fungal culture, whereby the vulva becomes permanently sensitized from infection.
C. Cutaneous perception or sensory nerve damage—neuropathic pain
1. The vulva is rich with nerve fibers that may be disrupted or altered by inflammation and cause a sustained prolonged firing along the nerve even after the initial causative agent is removed or treated (i.e., infection).
a. C fibers in the vestibule that are unmyelinated and are mecha- nosensitive and thermosensitive nociceptors. Inflammatory cytokines wrap around C fibers (nociceptors) and fire repeatedly.
b. The remainder of the vulva is rich with A delta fibers that are mechanosensitive and myelinated and sensitive to light touch and thermosensitive nociceptors plus C fibers. The A delta fibers are hypersensitive.
2. Sensitization occurs with chronic stimulation or irritation, resulting in allodynia (pain from a nonnoxious stimulus).
3. Pain or hypersensitivity in radiating areas, such as the thighs and perianal area, may be suggestive of pudendal neuralgia.
4. Hyperpathia: stimulus causes greater pain than would be expected
5. Central sensitization: related to lower parts of the brain and the cortex as well as centers of the spine. This sensitization is caused by a persistent signal to the nerve center that causes sensitization. Neurotransmitters activate these pain centers as well and are the same chemicals that are increased in stress and anxiety. Lower peripheral pain thresholds in other sites, such as the thumb and
shin, have been noted in women with vulvodynia and help to support this theory. Brain interpretation of pain results in motor and sensory abnormalities in the body located outside of the vulva. Lowered pain thresholds may precede genital pain (e.g., migraines).
6. Dysesthetic vulvodynia is associated with cutaneous pain perception unrelated to touch.
7. Neuroimmunologic mechanisms involved in the allodynia/ hyperpathia process in vulvodynia. These proposed mechanisms are under study.
D. Embryogenic correlation with interstitial cystitis: tissue from two anatomic sites that have a common embryonic origin, the urogenital sinus; because of this common origin, this may have a similar pathology response when provoked
E. Inflammatory dermatosis: related to prolonged topical steroid use, where temporary relief rebounded with more severe discomfort on dis- continuing the topical or associated with benzylkonium chloride in pads and tampons or meds such as benzocaine and lidocaine or lotrisone
F. Genetic relationship: check whether other female family members have had problems with tampon use or dyspareunia
G. Pelvic floor dysfunction: the muscles involved in the pelvic floor are both tight and weak; the increase in muscle tone decreases blood flow to the vulvar tissue, with decreases in nutrients and buildup of lactic acid, causing tightness and pain. The resting tone of the muscle is most associated with the pain and secondarily with the variability of the contractile signal.
III. HISTORY
A. What the patient may present with
1. High incidence of anxiety and emotional distress as a result of the vulvar pain
2. Pain experienced for years
3. Stable relationship status
4. Having been examined by several clinicians
5. History of one or more chronic pain conditions
a. Migraines
b. Fibromyalgia
c. Irritable bowel syndrome
d. Low back pain
e. Interstitial cystitis
f. Chronic fatigue syndrome
g. Other
B. Begin with a thorough history
1. Use open-ended questions about the pain and associated factors
a. Location and duration of pain
b. Any initiating factors
c. Medications used and their effects on the pain
d. Family history of similar pain
e. Use of soaps, detergents, feminine products
f. Contraceptive use
g. History of trauma—vulvar surgery, episiotomy
h. Discomfort with intercourse or pelvic exams
i. Impact on daily living
j. Any associated symptoms—urinary, bowel
k. Pain or discomfort for hours or days following a pelvic exam or intercourse
l. Constant or intermittent discomfort not related to touch or pressure
m. History of seeing many clinicians without successful therapy
IV. PHYSICAL EXAMINATION
A. As appropriate to the history
B. Pelvic exam
1. Inspect for erythema, erosions, ulcers, vesicles, whitened epithelium, any vulvar lesions, or alterations in the vulvar architecture
2. Cotton Q-tip test: light pressure, indent 5 mm to labia, urethra, hymenal remnants, and thighs, especially the posterior introitus and posterior hymenal remnants, and note areas of tenderness— Patients with vulvodynia will have more generalized pain, not necessarily made worse by touch or any pressure.
3. Signs and symptoms of infection/potassium hydroxide (KOH) for fungal infection
4. May be no objective findings or some mild erythema noted
5. Pelvic exam—note any associated pelvic pain and vaginal muscle tone
6. Check for vaginismus
7. Check for dermographia because antihistamine may be helpful if the test is positive
V. LABORATORY EXAMINATION
As indicated by history and physical examination
A. Bacterial cultures and wet mount (KOH, saline)
B. If wet mount is negative for Candida, do a fungal culture
C. Herpes simplex virus (HSV) culture if erosions, fissures, or vesicles are present
D. Vulvar biopsy if there is a suspicious vulvar lesion, ulcers, vesicles, papules
VI. DIFFERENTIAL DIAGNOSIS
A. Infection: Candida or other fungal, herpes or other viral, bacterial
B. Inflammatory dermatoses: contact dermatitis, immunobullous disorders, lichen planus, lichen sclerosus, erosive lichen planus
C. Neoplastic: squamous cell carcinoma, Paget’s disease, vulvar intraepithelial neoplasia (VIN) neoplasm
D. Neurologic: HSV neuralgia, spinal nerve compression, pudendal nerve compression
VII. TREATMENT
A. Chronic pain model emphasizing ameliorating pain rather than cure
B. Patient education: good vulvar care—avoid tight clothes, 100% cotton underwear, as well as tampons or pads. Use of hypoallergenic detergents and stress-reduction methods; avoid chemical irritants— soaps, feminine sprays
C. Multidisciplinary team approach; consider gynecologist, dermatologist, urologist, gastroenterologist, physical therapist, and pain specialist per individual situation and accompanying symptoms. Acupuncture may be helpful.
D. Establish a sound, communicative, and trusting relationship
E. Establish one clinician as coordinator for the multidiscipline team (nurse practitioner [NP] ideal)
F. Treat any identified infections first, vaginal atrophy, or HSV with appropriate medication, including topical estrogen if indicated
G. Begin with local topical anesthetics, such as lidocaine 5% ointment, applied to a cotton ball and placed at the vestibule overnight
H. Medications for neuropathic pain include:
1. Tricyclics: Initially, use amitriptyline or nortriptyline, with gradual dose increases to numb the nerves by decreasing the electrical signals. Improvement may be sporadic at first and takes weeks— allow 3 months of use initially. Educate patient about tricyclic side effects.
2. Neurontin (gabapentin) antiseizure medication that is used for neuropathic pain
3. Selective serotonin and norepinephrine reuptake inhibitors such as Cymbalta, Effexor
4. None of these medications are U.S. Food and Drug Administration (FDA) approved for use in neuropathic pain.
a. Refer to an appropriate clinician with experience with these drugs or
b. Work with an appropriate clinician in treating the patients
c. Doses and effectiveness will vary, as will adverse events
d. Closely monitor
5. Alpha interferon injections intralesionally to the vestibule in vestibulodynia only
I. Advise a low-oxalate diet with calcium citrate—eliminates irritants, so may be beneficial, but as yet no scientific data to support its effectiveness
J. Refer to physical therapy (PT) for biofeedback to train the muscles to relax and teach the patients some control of these muscles
1. Specific surface electromyography (sEMG) to identify pelvic floor muscle abnormality and treatment to those muscles (craniosacral, myofascial)
2. Trigger point muscle massage—work with a physical therapist or massage therapist trained in women’s health
3. Muscle-stabilizing program, based on each woman’s individual needs (6–8 months of PT)
K. Suggest acupuncture and/or hypnosis
L. Suggest personal counseling to decrease the woman’s personal distress related to vulvar pain when necessary
M. Suggest marital counseling and sexual counseling when appropriate for issues related to intimacy discomforts that may arise with vulvodynia. As a woman’s pain decreases, so may her sexual discomforts, distress, and anxiety because these are correlated.
VIII. COMPLICATIONS
A. Development of additional symptoms following institution of treatment
B. Side effects of any medications
C. Coexistence of life-threatening condition
IX. CONSULTATION/REFERRAL
A. Specialist in vulvodynia, dermatologist
B. Psychotherapy, marital, sexual counseling
C. PT, massage therapy, other complementary and alternative therapies
D. Nutritional therapy
E. Gastroenterologist
F. Pain specialist or pain clinic
G. If treating vulvar pain, consider taking a postgraduate course, and seek to further educate yourself about this complex condition.
X. FOLLOW-UP
A. Return for recheck after treatment is initiated
B. Team review as warranted by patient’s response to interventions
C. As indicated by therapy or for further diagnostic work and consultation
Websites: http://www.mayoclinic.com/health/vulvodynia/DS00159; www.nva
.org/whatIsVulvodynia.html