Treatment in VVS and Vulvodynia

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TREATMENT

**medical and surgical methods are being used for treatment of VVS. However vaginal infection and inflammation, especially candidinal vaginitis must be treated before using these methods.

Medical and Conservative Treatment Options

  1. It is clearly known that agents such as acyclovir, alpha interferon which were used before do not have any effect.
  2. The most important one of the medical and conservative treatments is pelvic relaxation exercises and/or vaginal biofeedback applications. Patient must be taught how to relax her pelvis, hip and genital muscles. The first treatment option must always be pelvic floor relaxation. Unfortunately, the amount of gynecologist or physical therapist is very low who can apply this method which is very successful in treatment. Pain level reduces in most of the cases with these conservative methods, which we apply on our own patients.
  3. 3 agents that are used as systemic medical treatment agents are: Tricyclic antidepressants (5-25 mg/day amiltriptiline) SSRI (37.5 mg/day venflaxin) or anticonvulsants (300 mg/day gabapentine).However, this administration must be used in patients with vulvodini or neuropathic pain patients which occur without any induction. Their efficiency in VVS cases is debatable and the amount of placebo controlled studies is very low on this subject.
  4. Local anesthetic or epithelized pomade and/or ointment use is common in VVS cases. However, use of these agents is efficient in the beginning phases and they may be used as supportive treatment later on. Especially madecasole and bepantene cremes may reduce burn feeling before or after sexual intercourse.
  5. Two important medical treatment options are argued recently. First is topical crème application which involve capsaicin, a local anesthetic. While Steinberg et al. report that capsaicin treatment is very successful, Murina et al. report that pain levels are reduced during application but dyspareunia and vulvodynia relapses after the drug is quitted. Application of botulinum toxin (BT) is another medical treatment option. BT is actually most powerful toxin for humans. Very small doses of this toxin which is commonly used especially in plastic surgery and its certain molecular part is used on the patient. As a result, it paralyzes nervous transmission and muscle spasm. However, BT must be applied by experts who can detect muscle spasms during evaluation of pelvic floor muscle from the vagina. In case L. Ani muscle is totally spasmed, the area that will be applied BT gets very large and it is impossible to apply in this condition. It is totally impossible to use it on a wide area which is expensive already. Therefore, selection of proper patients is obligatory in order to avoid unnecessary cost and complications such as fecal incontinence which are actually rare!!
  6. Cognitive Behavioral Therapy is a treatment used in VVS treatment, commonly by psychiatrists. Although its success is low, it is efficient to an extent. However, it should be emphasized that because of the fact that VVS triggeres vaginismus and psychiatrists do not do pelvic examinations, they may evaluate avoiding reactions as vaginismus and treat VVS cases as vaginismus as I will also explain later. This condition causes unnecessary waste of time. Cognitive behavioural therapy really works in VVS but when the case is evaluated as vaginismus its benefits are very limited.

 

BASIC RULE: THE FIRST OPTION IN TREATMENT OF VVS IS ALWAYS CONSERVATIVE TREATMENT AND PELVIC FLOOR REHABILITATION!!

 

SURGICAL TREATMENT

First of all, let me emphasize a wrong done by us gynecologists. Vulvar Vestibulectomy is never a “back plastic” surgery. This operation is a surgery we commonly apply to women with tears due to childbirth. TeLinde’s surgical book is a gynecologic surgery book which we use for assistant education and which we follow during our expertise. In this book, it is referred as a perineoplasty modifiedfrom vestibulectomy or a back plastic surgery. Therefore, it is a common opinion in our country. Unfortunately, it should be told that a significant part of TeLinde is wrong about VVS.

 

As a result, vestibulectomy is the most efficient treatment option and it is very aggressive. Although it is considered to be easy for us who do cancer surgery, the problem is that vestibulectomy technique is changed in the last 6-7 years which is not inside the education of gynecology assistants and that it changed into the way inside Karram’s gynecologic surgery atlas. Therefore, the person who applies this method must be experienced. Patient’s pain persists and worse results may be acquired in surgeries that are not done properly. On the contrary, unnecessary surgeries especially back plastic surgery cases narrow the vaginal orifice and pain severity increases. Complication rates are %3-10 in various studies. Therefore, I defend pelvic rehabilitation at first.

The most efficient treatment method in VVS is surgical removal of vestibulum, vestibulectomy. The only prospective randomized study in the whole literature belongs to Bergeron et al. In this study, 78 women were randomized and 3 different treatment options; cognitive, electromyographic biofeedback, vestibulectomy were applied. Cases were evaluated after 4 weeks and 6 months, although a certain betterment was acquired in all of the groups, vestibulectomy showed reduction in dyspareunia in %70. New various studies (however they are not prospective randomized) show a success rate around %90.

Prof. Dr. Süleyman Engin Akhan


You can see an operation of vestibulectomy operated by me. I commonly show these pictures to my patients and tell how the surgery must be. What they want to know the most is how their vulva will look after the surgery. Let’s clearly explain this point, operation does not cause any cosmetic problems. However, I emphasize the importance of postoperative care. I will not tell this in detail but it is very detailed. There are things to do in the first 48 hurs after the surgery and rules that must be obeyed for the first week and two more weeks after and they must be told to patient. Although I have encountered a few complications in the first surgeries of mine, now my patients have a perfect sexual life and they are happy. Vestibulectomy is very efficient when done with proper technique on a proper patient. Still, unnecessary surgery must be avoided.

Literatür

1. Steinberg A.C., Oyama I.A., Rejba A.E. ve ark. Capsaicin for the treatment of vulvar vestibulitis. Am. J. Obstet. Gynecol. 2005; 192: 1549-1553.
2. Murina F., Radici G., Bianco V. Capsaicin and the treatment of vulvar vestibulitis syndrome: a valuable alternative? MedGenMed. 2004; 6: 48.
3. Jarvis S.K., Abbott J.A., Lenart M.B. Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated with spasm of the levator ani muscles. Aust. N. Z. J. Obstet. Gynaecol. 2004; 44: 46-50.
4. Bergeron S., Binik Y.M., Khalife S. A randomized comparison of group cognitive–behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain. 2001; 91: 297-306.
5.  Lavy Y., Lev-Sagie A., Hamani Y., Zacut D., Ben-Chetrit A. Modified vulvar vestibulectomy: simple and effective surgery for the treatment of vulvar vestibulitis. Eur. J. Obstet. Gynecol. Reprod. Biol. 2005; 120: 91-95.
6.  McGuire H., Hawton K. Interventions for vaginismus. Cochrane Database Syst. Rev. 2003; CD001760.