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Vulvodynia: A Common and Under-Recognized Pain Disorder in Women and Female Adolescents -- Integrating Current Knowledge into Clinical Practice
The muscle assessment begins with the examiner’s right index finger (bent approximately 30-60 degrees) palpating the patient’s right mid-pubic rami, which is the bony landmark for identifying the mid-segment (belly) of puborectalis muscle. After confirming the mid-position placement of the index finger, the examiner palpates the puborectalis muscle, which is immediately adjacent/behind the pubic rami. Then, the examiner rotates the index finger downwards (approximate length of 1-1.5 cm) parallel to the length of puborectalis, until the transition point/insertion to the superficial muscles (perineal muscle complex) is palpated. Using the left index finger, the examiner assesses the left puborectalis as described above and seen in this slide. The perineal muscle complex, which is immediately beneath the 6 o’clock mucosal position, is palpated last. These muscle sites are adjacent to the respective lower vestibular mucosal sites (5, 6, and 7). Women are asked to describe the pain character and rate the pain severity they experience (Zolnoun 2012).
Women with vulvodynia commonly report suffering from comorbid pain disorders, mood/sleep alteration and sexual impairment. It is vital to assess all of the factors that are contributing to a woman’s current pain state in order to delineate the most appropriate components of an individualized, multidisciplinary treatment regimen.
In a 2008 literature review, Desrochers critically examined studies on the psychosexual aspects of vulvodynia and concluded that, despite the presence of methodological limitations, some findings were consistently replicated. Overall, women with vulvodynia demonstrated impaired sexual functioning, including lower levels of sexual desire, arousal, and frequency of intercourse. Additionally, questionnaires revealed that anxiety, fear of pain, hypervigilence and depression were more prevalent among these women. Desrochers concluded that more rigorous studies are needed to establish whether psychosexual variables exacerbate and/or maintain vulvodynia.
A growing body of literature documents the association between vulvodynia and other chronic pain conditions. Warren (2008) proposed that vulvodynia may be a referred pain of interstitial cystitis in many cases. Several authors have proposed that both IC and vulvodynia are syndromes of the urogenital sinus-derived epithelium (McCormack 1990, Burrows 2008). Peters (2008) speculated that the conditions may be linked by common pelvic floor muscle dysfunction. Others have proposed that a common pathway may stimulate a single disease process (Kennedy 2007), or that in some women, IC and vulvodynia may be the same disease (Peters 2008).
Recently, researchers have explored the relationship between vulvodynia and orofacial pain, specifically temporomandibular disorders. Zolnoun (2008) speculated that a subset of vulvodynia patients may suffer from a widespread musculoskeletal pain disorder influenced more by genetic makeup and central nervous system dysfunction than by an inflammatory process in the vulva.
Kennedy (2007) proposed that: (i) IBS may predispose women to certain vulvar conditions (perhaps by the irritant nature of diarrhea, for example), (ii) treatment for vulvar conditions may lead to bowel symptoms, or (iii) both conditions may represent a “pelvic floor pain disorder.”
When studying the relationship between fibromyalgia and vulvodynia, Pukall (2005, 2006) proposed that the mechanisms involved in vulvodynia may be genital-specific in some women and possibly centrally mediated in others. Whether the generalized sensitivity or vulvar pain occurs first is unknown. For example, an untreated vulvar irritation could lead to central changes in sensory processing in genetically predisposed women, resulting in altered central pain processing and a widespread increase in sensitivity. On the other hand, women with vulvodynia may be more sensitive to pain in general and develop vulvar pain through a locally occurring event, such as a vulvar injury.