Histopathologic features of vulvar vestibulitis

Immunohistochemical staining with CD117 and PGP9.5 of excised vestibular tissue from patients with neuroproliferative vestibulodynia

BACKGROUND

Neuroproliferative vestibulodynia (NPV), a provoked genital pain characterized by severe allodynia and hyperalgesia, is confirmed in excised vestibular tissue by immunohistochemical staining (>8 CD117-positive immunostained cells/100× microscopic field) rather than by hematoxylin and eosin staining.

AIM

In this study we sought to assess immunostaining of tissue samples obtained during vestibulectomy surgery and to correlate results with patient outcomes.

METHODS

Patients (n = 65) meeting criteria for NPV who underwent vestibulectomy during the period from June 2019 through December 2022 formed the study cohort. We performed assessment of pathology of vestibular tissues by use of immunohistochemical staining, including quantitation of mast cells by CD117 (mast cell marker) and nerve fibers by protein gene product (PGP) 9.5 (neuronal marker). We analyzed 725 photomicrographs of immunostained tissue sections (100× and 200×) by manual counting and computer-assisted histometry and correlated these data to clinical assessments.

OUTCOMES

Outcomes included density of CD117 and PGP9.5 immunostaining in the 1:00-11:00 o'clock and 12:00 o'clock vestibular regions, and patient-reported outcomes assessing sexual function, pain, distress, and symptom improvement.

RESULTS

All 65 NPV patients (median age 26 years), 45 with lifelong and 20 with acquired NPV, had severe pain documented by PROs and vulvoscopy and had >8 CD117-immunopositive cells/100× microscopic field. Median cell count values were similar in the 1:00-11:00 o'clock and 12:00 vestibular regions (28.5 and 29.5/100× field, respectively). Likewise, the marker) and nerve fibers by protein gene product (PGP) 9.5 (neuronal marker). We analyzed 725 photomicrographs of immunostained tissue sections (100× and 200×) by manual counting and computer-assisted histometry and correlated these data to clinical assessments.

OUTCOMES

Outcomes included density of CD117 and PGP9.5 immunostaining in the 1:00-11:00 o'clock and 12:00 o'clock vestibular regions, and patient-reported outcomes assessing sexual function, pain, distress, and symptom improvement.

RESULTS

All 65 NPV patients (median age 26 years), 45 with lifelong and 20 with acquired NPV, had severe pain documented by PROs and vulvoscopy and had >8 CD117-immunopositive cells/100× microscopic field. Median cell count values were similar in the 1:00-11:00 o'clock and 12:00 vestibular regions (28.5 and 29.5/100× field, respectively). Likewise, the median area of CD117 immunostaining was similar in both regions (0.69% and 0.73%). The median area of PGP9.5 immunostaining was 0.47% and 0.31% in these same regions. Pain scores determined with cotton-tipped swab testing were nominally higher in lifelong vs acquired NPV patients, reaching statistical significance in the 1:00-11:00 o'clock region (P < .001). The median score for the McGill Pain Questionnaire affective subscale dimension was also significantly higher in lifelong vs acquired NPV patients (P = .011). No correlations were observed between hematoxylin and eosin results and density of mast cells or neuronal markers. Of note, 63% of the patient cohort reported having additional conditions associated with aberrant mast cell activity.

CLINICAL IMPLICATIONS

The pathology of NPV is primarily localized to the vestibular epithelial basement membrane and subepithelial stroma with no visible vulvoscopic findings, making clinical diagnosis challenging.

STRENGTHS AND LIMITATIONS

Strengths of this study include the large number of tissues examined with what is to our knowledge the first-ever assessment of the 12:00 vestibule. Major limitations are specimens from a single timepoint within the disease state and lack of control tissues.

CONCLUSIONS

Performing immunohistochemical staining of excised vestibular tissue with CD117 and PGP9.5 led to histometric confirmation of NPV, indications that NPV is a field disease involving all vestibular regions, validation for patients whose pain had been ignored and who had experienced negative psychosocial impact, and appreciation that such staining can advance knowledge.

Exploring Localized Provoked Vulvodynia: Insights from Animal Model Research

Provoked vulvodynia represents a challenging chronic pain condition, characterized by its multifactorial origins. The inherent complexities of human-based studies have necessitated the use of animal models to enrich our understanding of vulvodynia's pathophysiology. This review aims to provide an exhaustive examination of the various animal models employed in this research domain. A comprehensive search was conducted on PubMed, utilizing keywords such as "vulvodynia", "chronic vulvar pain", "vulvodynia induction", and "animal models of vulvodynia" to identify pertinent studies. The search yielded three primary animal models for vulvodynia: inflammation-induced, allergy-induced, and hormone-induced. Additionally, six agents capable of triggering the condition through diverse pathways were identified, including factors contributing to hyperinnervation, mast cell proliferation, involvement of other immune cells, inflammatory cytokines, and neurotransmitters. This review systematically outlines the various animal models developed to study the pathogenesis of provoked vulvodynia. Understanding these models is crucial for the exploration of preventative measures, the development of novel treatments, and the overall advancement of research within the field.

Inflammation, lipids, and pain in vulvar disease

Localized provoked vulvodynia (LPV) affects ∼14 million people in the US (9% of women), destroying lives and relationships. LPV is characterized by chronic pain (>3 months) upon touch to the vulvar vestibule, which surrounds the vaginal opening. Many patients go months or years without a diagnosis. Once diagnosed, the treatments available only manage the symptoms of disease and do not correct the underlying problem. We have focused on elucidating the underlying mechanisms of chronic vulvar pain to speed diagnosis and improve intervention and management. We determined the inflammatory response to microorganisms, even members of the resident microflora, sets off a chain of events that culminates in chronic pain. This agrees with findings from several other groups, which show inflammation is altered in the painful vestibule. The vestibule of patients is acutely sensitive to inflammatory stimuli to the point of being deleterious. Rather than protect against vaginal infection, it causes heightened inflammation that does not resolve, which coincides with alterations in lipid metabolism that favor production of proinflammatory lipids and not pro-resolving lipids. Lipid dysbiosis in turn triggers pain signaling through the transient receptor potential vanilloid subtype 4 receptor (TRPV4). Treatment with specialized pro-resolving mediators (SPMs) that foster resolution reduces inflammation in fibroblasts and mice and vulvar sensitivity in mice. SPMs, specifically maresin 1, act on more than one part of the vulvodynia mechanism by limiting inflammation and acutely inhibiting TRPV4 signaling. Therefore, SPMs or other agents that target inflammation and/or TRPV4 signaling could prove effective as new vulvodynia therapies.

Characterization of Early Inflammatory Events Leading to Provoked Vulvodynia Development in Rats

Background

Provoked vulvodynia (PV) is the main cause of vulvar pain and dyspareunia. The etiology of PV has not yet been elucidated. However, PV is associated with a history of recurrent inflammation, and its often accompanied by increases in the numbers of mast cells (MCs) and sensory hyperinnervation in the vulva. Therefore, this study aimed to examine the role of MCs and the early inflammatory events in the development of chronic vulvar pain in a rat model of PV.

Methods

Mechanical and thermal vulvar sensitivity was measured for 5 months following zymosan vulvar challenges. Vulvar changes in glutamate and nerve growth factor (NGF) were analyzed using ELISA. Immunofluorescence (IF) staining of the vulvar section after 20, 81, and 160 days of the zymosan challenge were performed to test MCs accumulation, hyperinnervation, and expression of pain channels (transient receptor potential vanilloid/ankyrin-1-TRPV1 & TRPA1) in vulvar neurons. Changes in the development of vulvar pain were evaluated following the administration of the MCs stabilizer ketotifen fumarate (KF) during zymosan vulvar challenges.

Results

Zymosan-challenged rats developed significant mechanical and thermal vulvar sensitivity that persisted for over 160 days after the zymosan challenge. During inflammation, increased local concentrations of NGF and glutamate and a robust increase in MCs degranulation were observed in zymosan-challenged rats. In addition, zymosan-challenged rats displayed sensory hyperinnervation and an increase in the expression of TRPV1 and TRPA1. Treatment with KF attenuated the upregulated level of NGF during inflammation, modulated the neuronal modifications, reduced MCs accumulation, and enhanced mechanical hypersensitivity after repeated inflammation challenges.

Conclusion

The present findings suggest that vulvar hypersensitivity is mediated by MCs accumulation, nerve growth, and neuromodulation of TRPV1 and TRPA1. Hence, KF treatment during the critical period of inflammation contributes to preventing chronic vulvar pain development.

The Tissue Renin-Angiotensin System and Its Role in the Pathogenesis of Major Human Diseases: Quo Vadis?

Evidence has arisen in recent years suggesting that a tissue renin-angiotensin system (tRAS) is involved in the progression of various human diseases. This system contains two regulatory pathways: a pathological pro-inflammatory pathway containing the Angiotensin Converting Enzyme (ACE)/Angiotensin II (AngII)/Angiotensin II receptor type 1 (AGTR1) axis and a protective anti-inflammatory pathway involving the Angiotensin II receptor type 2 (AGTR2)/ACE2/Ang1–7/MasReceptor axis. Numerous studies reported the positive effects of pathologic tRAS pathway inhibition and protective tRAS pathway stimulation on the treatment of cardiovascular, inflammatory, and autoimmune disease and the progression of neuropathic pain. Cell senescence and aging are known to be related to RAS pathways. Further, this system directly interacts with SARS-CoV 2 and seems to be an important target of interest in the COVID-19 pandemic. This review focuses on the involvement of tRAS in the progression of the mentioned diseases from an interdisciplinary clinical perspective and highlights therapeutic strategies that might be of major clinical importance in the future.

The Angiotensin II Type 2 Receptor, a Target for Protection and Regeneration of the Peripheral Nervous System?

Preclinical evidence, accumulated over the past decade, indicates that the angiotensin II type 2 receptor (AT2R) stimulation exerts significant neuroprotective effects in various animal models of neuronal injury, notably in the central nervous system. While the atypical G protein-coupled receptor superfamily nature of AT2R and its related signaling are still under investigation, pharmacological studies have shown that stimulation of AT2R leads to neuritogenesis in vitro and in vivo. In this review, we focus on the potential neuroprotective and neuroregenerative roles of AT2R specifically in the peripheral nervous system (PNS). The first section describes the evidence for AT2R expression in the PNS and highlights current controversies concerning the cellular distribution of the receptor. The second section focuses on AT2R signaling implicated in neuronal survival and in neurite outgrowth. The following sections review the relatively few preclinical studies highlighting the putative neuroprotective and neuroregenerative effects of AT2R stimulation in the context of peripheral neuropathy.

Dyspareunia is associated with chronic pain in premenopausal women with sickle cell disease

OBJECTIVES

Pain is common in women with sickle cell disease (SCD), but the prevalence of dyspareunia in this unique patient population is unknown. In this study, we sought to determine whether chronic pain is associated with an increased prevalence of dyspareunia in premenopausal women with SCD.

METHODS

A cross-sectional study of premenopausal women with SCD was systematically assessed for symptoms of dyspareunia and chronic pain using a standard questionnaire. These results were correlated with each subject's clinical pain phenotype determined by a review of the patient's electronic medical record.

RESULTS

Ninety-one premenopausal women with SCD were examined. Thirty-two percent of the women reported dyspareunia. Women with dyspareunia were more likely to have a history of chronic pain (90% versus 61%, p = .006), report more pain days per week (median (interquartile range): 6 (4-7) vs. 3 (0-7), p = .005)), and had a higher oral morphine equivalent dose (145 (45-226) mg vs. 60 (9-160) mg, p = .030). Using a multivariable classification tree analysis, number of days of pain experienced per week was an important predictor of dyspareunia (p = .001).

CONCLUSION

Dyspareunia is common in women with SCD, and more common in women with SCD and chronic pain. Providers should assess women with SCD for dyspareunia, especially those with a chronic pain syndrome.

Inflammatory Renin-Angiotensin System Disruption Attenuates Sensory Hyperinnervation and Mechanical Hypersensitivity in a Rat Model of Provoked Vestibulodynia

Vestibulodynia is characterized by perivaginal mechanical hypersensitivity, hyperinnervation, and abundant inflammatory cells expressing renin-angiotensin system proteins. We developed a tractable rat model of vestibulodynia to further assess the contributions of the renin-angiotensin system. Complete Freund's adjuvant injected into the posterior vestibule induced marked vestibular hypersensitivity throughout a 7-day test period. Numbers of axons immunoreactive for PGP9.5, calcitonin gene-related peptide, and GFRα2 were increased. Numbers of macrophages and T cells were also increased whereas B cells were not. Renin-angiotensin-associated proteins were abundant, with T cells as well as macrophages contributing to increased renin and angiotensinogen. Media conditioned with inflamed vestibular tissue promoted neurite sprouting by rat dorsal root ganglion neurons in vitro, and this was blocked by the angiotensin II receptor type 2 receptor antagonist PD123319 or by an angiotensin II function blocking antibody. Sensory axon sprouting induced by inflamed tissue was dependent on activity of angiotensin-converting enzyme or chymase, but not cathepsin G. Thus, vestibular Complete Freund's adjuvant injection substantially recapitulates changes seen in patients with provoked vestibulodynia, and shows that manipulation of the local inflammatory renin-angiotensin system may be a useful therapeutic strategy.

PERSPECTIVE

This study provides evidence that inflammation of the rat vestibule induces a phenotype recapitulating behavioral and cytological features of human vestibulodynia. The model confirms a crucial role of the local inflammatory renin-angiotensin system in hypersensitivity and hyperinnervation. Targeting this system holds promise for developing new nonopioid analgesic treatment strategies.

Anxiety Mediates the Relation Between Childhood Sexual Abuse and Genito-Pelvic Pain in Adolescent Girls

Previous research has demonstrated associations between child sexual abuse, anxiety, and genito-pelvic pain, but no study to date has examined whether sexual abuse may be associated with genito-pelvic pain through victims' elevated anxiety. The present study aimed to determine whether anxiety mediates the relationship between child sexual abuse and genito-pelvic pain. Using self-report questionnaires, data were gathered from 218 sexually active adolescent girls recruited from seven metropolitan high schools. As expected, results revealed a significant indirect effect of sexual abuse on the development of genito-pelvic pain through trait anxiety. This study thus suggests that anxiety may be one of the mechanisms by which child sexual abuse leads to an increased risk of developing genito-pelvic pain in this population.

A Local Inflammatory Renin-Angiotensin System Drives Sensory Axon Sprouting in Provoked Vestibulodynia

Vestibulodynia is a form of provoked vulvodynia characterized by profound tenderness, hyperinnervation, and frequently inflammation within well-defined areas of the human vestibule. Previous experiments in animal models show that inflammatory hypersensitivity and hyperinnervation occur in concert with establishment of a local renin-angiotensin system (RAS). Moreover, mechanical hypersensitivity and sensory axon sprouting are prevented by blocking effects of angiotensin II on angiotensin II receptor type 2 (AT2) receptors. This case-control study assessed whether a RAS contributes to hyperinnervation observed in human vestibulodynia. Vestibular biopsies from asymptomatic controls or patients' nontender areas showed moderate innervation and small numbers of inflammatory cells. In women with vestibulodynia, tender areas contained increased numbers of mechanoreceptive nociceptor axons, T-cells, macrophages, and B-cells, whereas mast cells were unchanged. RAS proteins were increased because of greater numbers of T cells and B cells expressing angiotensinogen, and increased renin-expressing T cells and macrophages. Chymase, which converts angiotensin I to angiotensin II, was present in constant numbers of mast cells. To determine if tender vestibular tissue generates angiotensin II that promotes axon sprouting, we conditioned culture medium with vestibular tissue. Rat sensory neurons cultured in control-conditioned medium showed normal axon outgrowth, whereas those in tender tissue-conditioned medium showed enhanced sprouting that was prevented by adding an AT2 antagonist or angiotensin II neutralizing antibody. Hypersensitivity in provoked vestibulodynia is therefore characterized by abnormal mechanonociceptor axon proliferation, which is attributable to inflammatory cell-derived angiotensin II (or a closely related peptide) acting on neuronal AT2 receptors. Accordingly, reducing inflammation or blocking AT2 represent rational strategies to mitigate this common pain syndrome.

PERSPECTIVE

This study provides evidence that local inflammation leads to angiotensin II formation, which acts on the AT2 to induce nociceptor axon sprouting in vulvodynia. Preventing inflammation and blocking AT2 therefore present potential pharmacological strategies for reducing vestibular pain.

Recent advances in understanding provoked vestibulodynia

Vulvodynia refers to pain in the vulva of at least 3 months’ duration in the absence of a recognized underlying cause. Provoked, localized vestibulodynia is the term used to describe superficial pain confined to the vulvar vestibule, provoked by touch. This review will focus on provoked vestibulodynia with regard to its suggested causative factors and will discuss the role of inflammation, vulvovaginal infections, mucosal nerve fiber proliferation, hormonal associations, central pain mechanisms, pelvic floor muscle dysfunction, and genetic factors.

Clinical observations, epidemiological studies, and data from basic research emphasize the heterogeneity of vulvar pain syndromes. There is a critical need to perform prospective, longitudinal studies that will allow better diagnostic criteria and subgrouping of patients that would lead to improvements in our understanding of provoked vestibulodynia and its treatment.

CD4-positive T-cell recruitment in primary-provoked localized vulvodynia: potential insights into disease triggers

OBJECTIVE

To better understand the potential disease triggers of neurogenic inflammation in provoked localized vulvodynia (PLV), our objective was to determine whether the types of infiltrating lymphocytes were different in vestibular biopsies from women with primary PLV, secondary PLV, and unaffected controls.

METHODS

Secondary retrospective analysis of archived vestibular biopsies from a series of adult premenopausal women with primary PLV (n = 10), secondary PLV (n = 10), and unaffected controls (n = 4) was performed. All study patients had severe entry dyspareunia for more than 1 year. Subjects were excluded if pregnant, or they had a known infection, or history of generalized vulvodynia. Biopsies were performed during the midfollicular phase. Lymphocyte subtypes were highlighted in histologic sections using antibodies against CD3, CD4, and CD8 and scored as the mean number of T-cell subtypes per high-power field. Flow cytometry was also used to test fresh biopsies from a de novo prospective series of primary PLV (n = 4) and unaffected controls (n = 2).

RESULTS

Unaffected control biopsies showed more CD8-positive than CD4-positive T cells, similar to previous reports of the gynecologic tract. In contrast, biopsies from women with primary PLV showed significantly more CD4-positive T cells than those from women with secondary PLV and unaffected controls (p = .003). This observation was further supported by flow cytometry.

CONCLUSIONS

CD4-positive T cells are more numerous in vestibular biopsies from premenopausal women with primary PLV. This may be important because subtypes of CD4-positive T cells are specifically recruited by infectious, allergic, or autoimmune triggers. Future studies distinguishing these subtypes may lead to new insights into this common disease.

Etiology, diagnosis, and clinical management of vulvodynia

Chronic vulvar pain or discomfort for which no obvious etiology can be found, ie, vulvodynia, can affect up to 16% of women. It may affect girls and women across all age groups and ethnicities. Vulvodynia is a significant burden to society, the health care system, the affected woman, and her intimate partner. The etiology is multifactorial and may involve local injury or inflammation, and peripheral and or central sensitization of the nervous system. An approach to the diagnosis and management of a woman presenting with chronic vulvar pain should address the biological, psychological, and social/interpersonal factors that contribute to her illness. The gynecologist has a key role in excluding other causes for vulvar pain, screening for psychosexual and pelvic floor dysfunction, and collaborating with other health care providers to manage a woman's pain. An important component of treatment is patient education regarding the pathogenesis of the pain and the negative impact of experiencing pain on a woman's overall quality of life. An individualized, holistic, and often multidisciplinary approach is needed to effectively manage the woman's pain and pain-related distress.

The recurrent pain and sexual sequelae of provoked vestibulodynia: a perpetuating cycle

INTRODUCTION

Optimal management of provoked vestibulodynia (PVD), thought to be the most common form of chronic dyspareunia, is unclear.

AIM

To integrate recent brain data on chronic pain circuitry with stress-induced neuroendocrine mechanisms in the skin and the stress burden (allostatic load) of women with PVD; to also clarify the typical chronicity and negative sexual sequelae associated with PVD; and then review modulation of pain circuitry by cognitive therapy and mindfulness practice and apply to PVD management. Methods.  Review of scientific publications in the areas of sexual medicine, pain, brain imaging, gynecology, stress response, mindfulness, and cognitive behavioral therapy (CBT).

MAIN OUTCOME MEASURES

(i) A model of PVD to reflect its etiology, typical chronicity, and the detrimental effects on sexual function; (ii) Interventions of sexual rehabilitation based on principles underlying changes associated with CBT and mindfulness practice.

RESULTS

A model emerges which reflects how stress-induced changes of pain amplification (central sensitization), characteristic of chronic pain conditions, may impair sexual response in addition to sexual dysfunction that arises from conscious pain avoidance and/or fear-related inattention to sexual cues. Stress from low self-acceptance may be a major component of the allostatic load present in women with PVD, only to be exacerbated by the sexual dysfunction precipitated by the pain of intercourse. Mindfulness-based CBT appears promising to target both the pain and sexual suffering from PVD.

CONCLUSION

New findings on brain activity associated with recurrent clinical pain, functional brain changes associated with CBT and mindfulness, plus new data on stress systems within the skin along with data on increased stress load in women with PVD, support the use of mindfulness-based CBT for the recurrent pain and sexual suffering from PVD.

Impact of educational seminars on women with provoked vestibulodynia

OBJECTIVE

Provoked vestibulodynia (PVD) is a common genital pain condition characterized by severe pain upon vaginal penetration. The treatment of women with PVD suggests variable efficacy across modalities. The emotional toll of PVD, because of the intimate and interpersonal nature of this sexually-provoked pain, and the relationship between PVD and anxiety, depression, and a host of subclinical emotional symptoms that may interfere with treatment, has been well documented. The role of the gynaecologist in identifying and managing these psychological symptoms has never been addressed. The goal of this study was to examine the efficacy of a brief, gynaecologist-led educational seminar on measures of psychological symptoms and sexual health.

METHODS

Twenty-nine women with PVD participated in three one-hour educational seminars led by a gynaecologist with expertise in the management of PVD. Participants completed questionnaires before, immediately after, and six months after the third session.

RESULTS

There were significant improvements in psychological symptoms of depression, anxiety, somatization, hostility, paranoid ideation, psychoticism, and the global severity index, both immediately post-seminar and at the six-month follow-up. Sexual arousal, orgasm, overall sexual function, and sexual distress also significantly improved in response to the seminars.

CONCLUSION

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 PVD.

Current perspectives in vulvodynia

Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Although its etiology is not well understood, it appears to be multifactorial. As such, treatment options are targeted to reduce singular symptoms in a piecemeal fashion. A number of randomized, controlled trials have been conducted and at least one paper on combination therapy has been published; however, further systematic research is needed in order to more fully inform clinical practice.

The role of vulvar skin biopsy in the evaluation of chronic vulvar pain

Sixty-one percent of refractory vulvodynia patients evaluated in a tertiary care vulvovaginal clinic had clinically relevant dermatoses based on dermatopathologist-analyzed vulvar biopsy including: lichen sclerosus, allergic/irritant dermatitis, lichen planus, and other inflammatory or neoplastic dermatoses. Given the frequency of dermatologic disease, vulvar biopsy and analysis by a dermatopathologist are recommended in patients with vulvodynia.

[Vulvar vestibulitis syndrome: a clinicopathological study of 14 cases]

BACKGROUND

Vulvar vestibulitis syndrome (VVS) is one of the most frequent causes of superficial dyspareunia in young women. VVS has a pronounced psychological impact. The results of pathological studies published thus far are controversial.

PATIENTS AND METHODS

Fourteen women with VVS were included in this study and underwent vestibular biopsy. Vulvar biopsies were taken from the orifice of Bartholin's gland. The biopsy samples were stained with a standard stain and PAS and 25 serial sections were prepared for each specimen.

RESULTS

The mean patient age was 26 years and VVS had been present for a mean 30 months. Extensive inflammation of mononuclear cells was observed in the vulvar chorionic epithelium. This inflammation was seen mainly around the minor vestibular glands. Mild exocytosis of lymphocytes was noted in the vestibular glands and ducts.

DISCUSSION

Most studies concerning this disease report chronic inflammation of the vulvar vestibular mucosa. This inflammation is seen mainly around the minor vestibular glands. We report the same pattern in our study. Moreover, we observed some exocytosis into the epithelium of minor vestibular glands and the excretory duct. This aspect has not been reported to date, further supporting the individual nature of this entity.

Vulvodynia: case report and review of literature

Vulvodynia is defined as chronic vulvar burning, stinging, rawness, soreness or pain in the absence of objective clinical or laboratory findings to explain these symptoms. Vulvodynia is a chronic pain syndrome affecting up to 18% of the female population and is generally regarded as an underdiagnosed difficult to treat gynecological disorder. An increasing number of patients present with symptoms of vulvar pain, soreness, burning or irritation, which becomes chronic. Vulvodynia is a term used to describe chronic burning and/or pain in the vulva without objective clinical or laboratory findings to explain these symptoms. We present a case of vulvodynia accompanying somatoform disorder and depression.

Vulvar vestibulitis syndrome

Vulvar vestibulitis syndrome (VVS) is one of the most common causes of genital pain and pain with sexual intercourse, affecting up to 15% of women. The syndrome is characterized by severe pain on vestibular touch or attempted vaginal entry, exquisite tenderness to palpation with a cotton swab, and often subtle physical findings confined to vestibular erythema. The etiology of VVS is unknown. However, it is probably best to consider VVS as a chronic local inflammatory condition with a wide variety of etiologic causes. The heterogeneity of potential etiologies for VVS results in the use of multiple treatment regimens in clinical practice. Scientifically rigorous studies are sorely needed to determine the best treatment approach.

Vulvodynia: a therapeutic challenge

Vulvodynia is a poorly understood, distressing and debilitating disorder. The management of this disorder remains insufficient and the lack of consistent terminology is confusing. The management of classic dysesthetic vulvodynia is fairly straightforward, using drugs effective against chronic neuropathic pain. However, vulvar vestibulitis syndrome remains a therapeutic challenge. A pragmatic approach is recommended for the management of patients with vulvar vestibulitis syndrome. In refractory cases, vestibulectomy has a high success rate, although the evidence is based mainly on small, descriptive studies. Comparative studies of conservative versus surgical management of vulvar vestibulitis syndrome are needed.

Psychological aspects of vulvar vestibulitis syndrome

This review is based on a MEDLINE/PSYCHINFO search for all papers on psychological aspects of vulvar vestibulitis syndrome (VVS) published 1995-2002. VVS is a condition in which painful patches appear on the vulva which make intercourse painful. Causation, natural history and prevalence of VVS are unknown. Attempts to identify psychological characteristics typical of women with VVS have not yielded consistent results with some studies suggesting high levels of psychopathology and others not. It is suggested that inconsistencies in findings reflect not only decisions by women about whether and how to access health care but also the health care system acting to actively filter those reaching specialist services and selecting those with particular psychological characteristics. There is no compelling evidence that VVS per se is associated with any particular psychological or behavioural characteristics other than the sort of difficulties in sexual functioning which might be expected with chronic vulval pain. However there is evidence for high levels of psychological distress in some samples of women with VVS being seen in secondary care.

Vulvodynie

Vulvodynia (vulvar dysesthesia) refers to vulvar pain (burning, irritation and rawness) of the external female genitalia for more than 3 months without other dermatological or gynecological causes. The term primary vulvodynia should be reserved for vulvar vestibulitis and essential (dysesthetic) vulvodynia. Vulvar vestibulitis is characterized by dyspareunia, allodynia and vulvar erythema. Most patients are Caucasian, premenopausal and sexually active. The prevalence is estimated as high as 15%. Damage to the sympathetic nerves with an increased pain sensitivity is the likely explanation for the burning sensation. Psychological impairment, which is common in many patients, rather seems to be the consequence of the chronic disease than a primary condition. Essential vulvodynia is characterized by vulvar burning, which is characteristically not limited to the vestibulum. The patients are generally older and dyspareunia is less severe. The prevalence of essential vulvodynia is 1-3%. Various interdisciplinary approaches to these two rather frequent genital diseases are discussed.

Women's Sexual Pain and Its Management

INTRODUCTION

Approximately 15% of women have chronic dyspareunia that is poorly understood, infrequently cured, often highly problematic, and distressing. Chronic dyspareunia is an urgent health issue.

AIM

To provide recommendations/guidelines concerning state-of-the-art knowledge for the assessment and management of women's sexual pain disorders.

METHODS

An international consultation, in collaboration with the major sexual medicine associations, assembled over 200 multidisciplinary experts from 60 countries into 17 committees. One six-member committee focused on women's sexual pain disorders, developing recommendations over a 2-year period.

MAIN OUTCOME MEASURE

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

There is increasing evidence for the role of neuropathic pain mechanisms in the pathophysiology of sexual pain disorders. Empirical literature has demonstrated the comorbid presence of clinical psychopathology. With regard to the pathophysiologic role of the pelvic floor and sexual pain disorders, studies reveal that (i) differentiation between vaginismus and dyspareunia using clinical tools is difficult; (ii) vaginal spasms have not been identified; (iii) physical therapists can differentiate vaginismic women from matched controls based on muscle tone/strength differences; (iv) the traditional treatment of vaginismus with vaginal "dilatation" plus psycho-education, desensitization, and so forth is not evidence-based; (v) pelvic floor muscle tone/strength measures for women suffering from vulvar vestibulitis syndrome are intermediate between those of women with vaginismus and no-pain controls; and (vi) the pelvic floor musculature is indirectly innervated by the limbic system and highly reactive to emotional stimuli and states. Pelvic floor therapies for dyspareunia may be effective.

CONCLUSION

Recommendations include (i) revising the definitions of vaginismus and dyspareunia; (ii) integration of treatment approaches; (iii) validation of nonspecific treatment effects; (iv) controlled studies to test interventions; and (v) sexuality education to help prevent sexual pain.

The Major Histopathologic Characteristics in the Vulvar Vestibulitis Syndrome

OBJECTIVE

In order to better understand the etiology of the vulvar vestibulitis syndrome, we examined the histopathologic parameters in vestibular mucosa, and compared the findings in specimens obtained from women with vulvar vestibulitis with those obtained from the control group.

STUDY DESIGN

Specimens of vestibulitis were obtained from 24 patients, undergoing circumferential vestibulectomy under general anesthesia due to the symptoms and signs consistent with vulvar vestibulitis. Control specimens were obtained from 16 women, without symptoms or signs of vulvar vestibulitis, undergoing reconstructive introital surgery due to roomy vagina, rectocele or painful episiotomy. All vestibular tissue specimens were examined for intensity of inflammation, extension of inflammatory cells into the epithelium, vascular proliferation, the presence of mast cells and proliferation of peripheral nerve bundles.

RESULTS

No significant difference was found regarding the degree of inflammation, the extension of inflammatory cells into the epithelium, the vascular proliferation and the presence of mast cells while comparing the study and the control groups. The only histopathologic feature, differentiating the patients with vulvar vestibulitis from the control group, was the proliferation of peripheral nerve bundles found in 19 out of 24 (79.1%) specimens expressing vestibulitis and in none of 16 control specimens (p < 0.0001).

CONCLUSION

Our results, therefore, support the existence of peripheral nerve hyperplasia in vestibular tissue obtained from patients with vulvar vestibulitis, and exclude the role of active inflammation or mast cells as probable etiologies for the vulvar vestibulitis syndrome.

Hyperinnervation and mast cell activation may be used as histopathologic diagnostic criteria for vulvar vestibulitis

OBJECTIVE

Vestibulitis is currently diagnosed based only on clinical criteria. To achieve histopathological diagnostic criteria, we carried out a computerized image analysis method.

METHODS

Vestibular tissues removed from 40 women with severe vestibulitis were immunostained for mast cell count and degranulation by C-kit and mast cell tryptase, respectively. Vestibular nerve cells total area was evaluated after S-100 stain. Controls were 7 women aged 18-48. The images were converted to a digital signal, and analyzed using Image Proplus V4 software.

RESULTS

We found a significant increase in inflammatory infiltrate, number of mast cells and degranulated mast cells in vestibulitis compared to normal controls. The inflammatory cells were localized around the superficial minor vestibular glands. The total nerve fiber area was ten times higher in vestibulitis patients than in controls. A significant positive correlation was found between the total nerve fiber area and the number of mast cells in the vestibulitis group of patients.

CONCLUSION

We documented two diagnostic histopathological criteria for vestibulitis: (1) the presence of eight or more mast cells per 10 x 10 microscopic field, and (2) the total calculated area of the nerve fibers is ten times higher than expected. These findings re-establish the inflammatory nature of the vestibulitis. It is speculated that the trigger for the local outburst of nerve fibers could be related to the activation of the mast cells by a topical agent.

Vulvodynia

CONTEXT

Vulvodynia is a term used to describe chronic burning and/or pain in the vulva without objective physical findings to explain the symptoms. The terminology and classification of vulvodynia continue to evolve, and much remains to be understood about the prevalence, pathogenesis, natural history, and management of this distressing condition.

STARTING POINT

James Aikens and colleagues showed that chronic vulval pain (vulvodynia or vulvar dysaesthesia) is associated with worse depressive symptoms (Am J Obstet Gynecol 2003; 189: 462-66). However, the increased scores for depression in this case-control study were attributed to sexual disinterest and experience of chronic pain rather than to features of depressive disorder. These results lend weight to the increasing need for better understanding of the pathogenesis of vulval pain and how to manage it appropriately. WHERE NEXT? The aetiology of vulvodynia and effectiveness of treatments need further study. Appraising the available literature, we have formulated a useful approach to patients with chronic vulval pain. There is a pressing need for further case-control studies of potential causes of vulvodynia and for randomised trials of interventions.

Sacral neuromodulation for chronic pain conditions

Some of the pelvic pain syndromes seem to have features of neurogenic inflammation and neuropathic pain in common. As opposed to being separate disease entities, they may represent a spectrum of clinical presentations of CRPS I of the pelvis. Sacral nerve root stimulation provides good symptomatic relief of pain and voiding dysfunction. The techniques of retrograde root stimulation may offer superior results with fewer complications and lead migrations when compared with other methods. Perhaps neuromodulation should be used earlier in the treatment paradigm for these disorders, before the potentially injurious procedures of hydrodistention, bladder installations, and cystectomies.

Vulvar vestibulitis severity—assessment by sensory and pain testing modalities

Vulvar vestibulitis syndrome (VVS) is a common cause of dyspareunia in pre-menopausal women. Previous quantitative sensory test (QST) studies have demonstrated reduced vestibular pain thresholds in these patients. Here we try to find whether QST findings correlate to disease severity. Thirty-five vestibulitis patients, 17 with moderate and 18 with severe disorder, were compared to 22 age matched control women. Tactile and pain thresholds for mechanical pressure and thermal pain were measured at the posterior fourcette. Magnitude estimation of supra-threshold painful stimuli were obtained for mechanical and thermal stimuli, the latter were of tonic and phasic types. Pain thresholds were lower and supra-threshold magnitude estimations were higher in VVS patients, in agreement with disease severity. Cut-off points were defined for results of each test, discriminating between moderate VVS, severe VVS and healthy controls, and allowing calculation of sensitivity and specificity of the various tests. Our findings show that the best discriminative test was mechanical pain threshold obtained by a simple custom made 'spring pressure device'. This test had the highest kappa value (0.82), predicting correctly 88% of all VVS cases and 100% of the severe VVS cases. Supra-threshold pain magnitude estimation for tonic heat stimulation also had a high kappa value (0.73) predicting correctly 82% overall with a 100% correct diagnosis of the control group. QST techniques, both threshold and supra-threshold measurements, seem to be capable of discriminating level of severity of this clinical pain syndrome.

New concepts in vulvodynia

Vulvodynia is chronic vulvar burning/pain without clear medical findings. The etiology of vulvodynia is unknown and health care professionals should thoroughly rule out specific, treatable causes or factors such as dermatoses or group B Streptococcus infections. Vulvodynia is divided into 2 classes: vulvar vestibulitis syndrome is vestibule-restricted burning/pain and is elicited by touch; dysesthetic vulvodynia is burning/pain not limited to the vestibule and may occur without touch/pressure. After diagnosis, critical factors in successful patient management include education and psychological support/counseling. Unfortunately, clinical trials on potential vulvodynia therapies have been few. Standard therapy includes treating neuropathic pain (eg, tricyclic medications, gabapentin) thought to play a role. Additional therapies may be considered: pelvic floor rehabilitation combined with surface electromyography, interferon alfa, estrogen creams, and surgery. Importantly, any therapy should be accompanied by patient education and psychological support. Because definitive data on effective therapies are lacking, further clinical investigations of treatment options are warranted.

Increased innervation of the vulval vestibule in patients with vulvodynia

BACKGROUND

Vulval vestibulitis is a condition characterized by the sudden onset of a painful burning sensation, hyperalgesia, mechanical allodynia, and occasionally pruritus, localized to the region of the vulval vestibulus. It is considered the commonest subset of vulvodynia. Pain precipitated in the absence of nociceptor stimuli might be triggered by previous peripheral nerve injury, or by the release of neuronal mediators, which set off inappropriate impulses in nonmyelinated pain fibres sensitizing the dorsal horn neurones. The pathophysiology of vulval vestibulitis is still unclear.

OBJECTIVES

The objective of this study was to evaluate the nerve fibre density and pattern, in specimens of vulval vestibulus, in normal subjects and in patients with vestibulitis, and provide objective diagnostic criteria for this condition. Methods Twelve patients with a history of the vestibulitis type of vulvodynia, and eight normal subjects underwent biopsy of the posterior wall of the vulval vestibule. Quantitative immunohistochemistry was performed, using antisera to the general neuronal marker protein gene product (PGP) 9.5, and to the neuropeptide calcitonin gene-related peptide (CGRP), on 15- microm sections.

RESULTS

There was a statistically significant increase of density and number of PGP 9.5 immunoreactive in the papillary dermis of patients with vulvodynia of the vestibulitis type, compared with those of controls. However, the distribution pattern of the innervation showed no significant change. There were no significant differences in CGRP staining between patients and controls.

CONCLUSIONS

It is concluded that the increase of PGP 9.5 immunoreactive nerve fibres, in patients with vulvodynia, may be either secondary to nerve sprouting, or may represent neural hyperplasia. Increased innervation may be applied as an objective diagnostic finding in vulval vestibulitis syndrome.

Interleukin-1beta gene polymorphism in women with vulvar vestibulitis syndrome

OBJECTIVE

The pathogenesis of vulvar vestibulitis syndrome remains unknown but may be related to a localized chronic inflammation. The relation between this syndrome and a polymorphism at position +3953 in the interleukin-1beta gene was examined. Allele 2 of this gene has been associated with increased pro-inflammatory immunity.

STUDY DESIGN

Buccal or vestibular swabs from 59 women with strictly defined vulvar vestibulitis and from 48 healthy women were tested by polymerase chain reaction for the presence of two alleles at the +3953 interleukin-1beta locus.

RESULTS

Allele 2 of the interleukin-1beta gene was identified in 27 (46%) women with vulvar vestibulitis as opposed to 12 (25%) control women (P=0.03). The interleukin-1beta 1,1 genotype was present in 36 (75%) controls as opposed to 32 (54%) vulvar vestibulitis syndrome patients (P=0.02). All subjects had been previously tested for induced interleukin-1beta production in response to bacterial lipopolysaccharide. In both patients and controls, possession of allele 2 was associated with a small but non-statistically significant increase in induced interleukin-1beta production.

CONCLUSION

Allele 2 in the interleukin-1beta gene is more common in women with vulvar vestibulitis syndrome than in other women. Susceptibility to vulvar vestibulitis syndrome might be influenced by carriage of this polymorphism.