Dyspareunia – Vulvodynia
Vulvar Vestibulitis Syndrome
A patient’s letter…
A patient entered in my office in the medical faculty 2 years ago and said “professor, I do not want to tell my problem anymore. I went to so many doctors and told too many times I cannot stand anymore”. She passed a paper written in handwriting. It was the history of her disease and actually a typical dyspareunia/VVS history.However, patient’s writing and facial expression was very important for showing how her life became a hell due to this disease. I want to share this letter and I took her consent. A truth never changes for doctors. You can read the diseases but you can only treat the patient by understanding patient’s feelings, life and what she had been through and by combining it to your knowledge (Original letter is still in my possession and this text includes the sentences of the letter).
“My disease began 4 years ago when I returned. I sat down on my wet bathing suit without changing it properly. Burning in my vagina and difficulty in urination began as symptoms of my disease. I went to many urologist and gynecologists. Each time, I was treated with intense antibiotics. Sistoscopy was applied at the end. I was told that I had 2 plaques in bladder. TUR was applied to my bladder. However, there were no improvements. This condition broke m nervous system down. Frequent bleedings begin. My doctor said that my uterus had thickenings (as a result of my biopsy). In the year 2005, Prof. Dr. … operated me (had my uterus and ovaries removed). Same problem persists, burning and pain reflects to my anus. No one explains to me my disease. There are no doctors that I didn’t consult. In some period, my vaginal discharge sample was examined. I was told that it was candida fungus. A series of treatment were applied. The result is the same. I have trouble in having intercourse with my husband. I want to live without the fear of having burn and pain obsession when I wake up.
Actually, patient is explaining her problem perfectly. Life of these patients turns into a hell due to VVS and “living without the obsession of pain and burn feeling” becomes very much important. You will ready much information and symptom below, but I admit that no book knowledge can tell this disease to you just as these sentences. Believe me the sentences above are more real, basic and primary than the text below.
What is Dyspareunia?
Dyspareunia is defined as “repetitive and constant genital pain during sexual intercourse” by American Psychiatrists Association in DSM-IV. Although the term “dyspareunia” was first defined by Robert Barnes in 1874 as “painful sexual intercourse”, articles in the literature belong to the last 20 years.
We gynecologists consider painful sexual intercourse as a symptom of upper genital system infection or endometriosis. Although, what really means from “pain disorder” that occur during sexual intercourse is being a “psychosocial pathology with organic origins” but not resulting from gynecological problems told above.
Dyspareunia is a very common problem. The difference between reported articles derives from the use of different intervals when questioning dyspareunia. In a study conducted by Laumann and Rosen in USA which questions the complaint of dyspareunia, it has been reported that %14.4 of the cases expressed they had pain during sexual intercourse. Dunn et al. published a research in 1998 in England telling that %18 of women expressed that they had dyspareunia at that time while %45 told that they had pain during intercourse at least once in their lifetime. In a study we conducted in Gynecology and Obtetric department of Istanbul University Medical Faculty, we found out that prevalence of dyspareunia was %3 in women of reproductive age between the ages 18 and 46 who had regular menstruation bleedings while in postmenopausal period including sexually active women between the ages 41 and 70 we found this rate to be %17.
Vulvodynia and Vulvar Vestibulitis Syndrome
Vulvar vestibulitis syndrome is a special clinical case that is not clearly known by gynecologists which should be emphasized when dyspareunia is discussed.
Before reading the text below, you should understand where vulva and vulvar vestibulum is, which area of female genital organs they do represent. Vulva defines the hymen, labium major and minor which form the external genital organ of women and its surrounding tissue while vestibulum is used for expressing an embryologic urethra-like tissue in the same area 1-2 cm inside the hymen. This graphic below is taken from a study conducted by Pukall and Binik in 2002 (Pain (96)2002; 163-175)
Actually, there is confusion in the naming of recently. You can find the term vulvodynia from the books and websites. When VVS is searched, it is commonly confused for the definition of vulvodynia. Vulvodynia is a general definition and it is used for defining the discomfort that occurs in the vulva. Localization of pain is difficult. The graphic below wil help for understanding the subject.
VVs is known for almost a hundred years and it is the cause of pain during sexual intercourse in premenopausal period. Although it has been suggested that it cannot be found in postmenopausal women, today it is known that it may be seen in women in menopause (less common than in reproductive age).
VVS is a special subtype of severe dyspareunia. It is found in %50 of all dyspareunia cases. Its incidence is believed to be %12 in the whole population. It was defined by Thomas 100 years ago as hyperesthesia of vulva then found its place in the classic book of Skene later on with similar definitions. In the same year, it had been defined as the clinical case in which sensitive spots are detected in the orifice of the vagina by Kelogg and it had been showed as one of the causes of dyspareunia.
However, Frieerich was the first to desctibe basic diagnostic criteria in the year 1987 and ISSVD (International Society for the Study of Vulvar Disease) accepted this case a syndrome with 3 basic diagnostic criteria:
1. Severe pain during cohabiting or in case of vestibular contact
2. Sensitivity in vulvar vestibule that appears with pressure
3. Physical examination findings limited to vulvar erythema in various severities.
** In order to make a diagnosis, the case must not involve acute inflammatory conditions that show up in the last 6 months and must not involve symptoms related to surgery operated in the last 6 months.
In order to define sensitive spots, Freiderich suggested use of cotton swab test. In this test, cotton swab is touched on the vestibulum in the directions of 3-5-7-9 o’clock. However, we touch on the 6 o’clock in our practice. After this induction, visual analogue scale is used and the pain is recorded in numbers and the average of these numbers is calculated. This is called “vestibular score”. Gynecologist must check for vaginal spasms after each touch. Vaginal spasm is occurrence of involuntary contractions that make the examination difficult in whole pelvic floor muscles. It is noticeable that diagnostic criteria are very subjective. Especially the question how much force will be applied on the cotton swab is still debatable. Therefore, experience is very important during the examination.
Why does it occur??
The physiopathology of VVS has been researched for a long time. In women who are diagnosed with VVS, mast cells are increased in the vulva and vestibulum, these cells increase secretion of neuronal growth factor and an increase occurs in nervous terminals right here. In other words, an excessive sensitivity occurs in vulva, “allodynia”.
Allodynia is the conidition in which an impulse triggers the pain which would not normally do so. Patients become excessively sensitive to excitations. Therefore, simple physiologic events which would not trigger the pain in us trigger it in some of our patients. Pain causes contractions in the pelvic floor. As a result of these contractions severe pain occurs in the beginning especially in the period penis enters the vagina. After a while, this muscle pain spreads to whole pelvic floor and it occurs when patient sits, wears a tight pant etc. and a condition develops in which woman’s life quality is lowered. In longer periods, pain may become chronic; however this chronic period may not develop in every patient and factors that play a role in the development of chronic vulvar pain are not known.
You can see the pathophysiology I have formed and published in various book chapters below. I tried to show how vaginismus is included in this pathophysiology and how these two trigger each other in the graphic to the right.
1. Reissing E.D., Binik Y.M., Khalife S. Vaginal spasm, pain, and behavior: an empirical investigation of the diagnosis of vaginismus. Arch. Sex. Behav. 2004; 33: 5-17.
2. Binik Y.M., Reissing E., Pukall C. The female sexual pain disorders: genital pain or sexual dysfunction? Arch. Sex. Behav. 2002; 31: 425-429.
3. Bergeron S., Binik Y.M., Khalife S., Pagidas K. Vulvar vestibulitis syndrome: a critical review. Clin. J. Pain. 1997; 13: 27-42.
35. Laumann E.O., Paik A., Rosen R.C. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999; 281: 537-544.
4. Dunn K.M, Croft P.R., Hackett G.I. Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey. J. Epidemiol. Community Health. 1999 ; 53: 144-148.
5. Danielsson I., Sjoberg I., Stenlund H., Wikman M. Prevalence and incidence of prolonged and severe dyspareunia in women: results from a population study. Scand. J. Public Health. 2003;31: 113-118.
6. Süleyman Engin Akhan. Kadında cinsel ağrı bozuklukları ve vaginismus. Röprodüktif Tıp ve Psikiatri Sempozyumu, 16-17 Aralık 2005 İstanbul. Özet Kitabı, sayfa: 30-32.
7. Reissing E.D., Binik Y.M., Khalife S. ve ark. Vaginal spasm, pain, and behavior: an empirical investigation of the diagnosis of vaginismus.
Arch. Sex. Behav. 2004; 33: 5-17.
8. Gottschalk A., Smith D.S. New concepts in acute pain therapy: preemptive analgesia. Am. Fam. Physician. 2001; 63: 1979-1984.
9. Butrick C.W. Chronic pelvic pain: how many surgeries are enough? Clin. Obstet. Gynecol. 2007; 50: 412-424.
10. Mense S. Nociception from skeletal muscle in relation to clinical muscle pain. Pain. 199; 54: 241-289.
11. Bornstein J., Zarfati D., Goldshmid N. ve ark. Vestibulodynia–a subset of vulvar vestibulitis or a novel syndrome? Am. J. Obstet. Gynecol. 1997; 177: 1439-1443.
12. Graziottin A. Sexual pain disorders in adolescent. In: Genazzani A.R., Schenker J., Artini P.G., Simoncini T. Human Reproduction. Rome, CIC Edizioni Internazionali. 2005; 434-449.
13. Reissing E.D., Brown C., Lord M.J. ve ark. Pelvic floor muscle functioning in women with vulvar vestibulitis syndrome. J. Psychosom. Obstet. Gynaecol. 2005; 26: 107-113.