Introduction
Vulvar pain is not normally considered to be in the scope of practice of neurologists, but it should be. The pelvis, vulva, and vagina have a rich innervation with many nerves, somatic and autonomic, converging on the spinal cord and integrating with the rest of the pain system. Basic training gives neurologists an understanding of these neural systems and their function, which is important in understanding how to diagnose and treat chronic pain. In addition, neurologists are trained to conduct a relevant history and neurological examination and to perform tests to answer two questions: where is the lesion and what is the lesion? Neurologists also determine whether the pain is nociceptive or neuropathic, and what treatments are necessary. What some neurologists may lack, however, is the interest or ability to treat pain in a multidisciplinary manner.
The Wasser Pain Management Centre (WPMC) was formed in 1999. It offers a multidisciplinary, multi-professional, and multimodal approach to pain problems with staff members in neurology, nursing, dentistry, anesthesiology, gynecology, psychiatry, sex therapy, behavioral therapy, addiction medicine, and contacts in physical therapy, urology, acupuncture, urogynecology, dermatology, and yoga. Six intertwining “programs of care” have been established: complex pharmacotherapy (e.g., antidepressants, antiepileptics, opioids, anti-inflammatories, cannabinoids); pain, addiction, and chemical dependency; pelvic and genital pain; neuropathic pain; headache and facial pain; and arthritis and soft-tissue pain.
Patients referred to the WPMC fill out a detailed questionnaire including, if appropriate, a pelvic pain questionnaire. Based on the letter of referral and previous documents, the individual is triaged to see the most appropriate practitioner who does a detailed consultation and examination. Other team members may also see the patient if appropriate. Accurate diagnosis is emphasized, and multiple diagnoses may be offered. Further investigations may be ordered and then treatment plans are devised.
The female pelvic pain team can include the neurologist, gynecologist, nurse, physical therapist, anesthesiologist, and sex therapist. Evaluation includes general and neurological examination, abdominal, back and pelvic exam, vulvar examination including the cotton-swab test, and pin-prick evaluation. A drug and alcohol history is also taken.
Because of the emphasis of all aspects of chronic pain at the WPMC, the patients seen may be different, or at least evaluated differently, than in gynecology-based clinics. Examples illustrating the range of patients presenting at the WPMC include:
(1) A 55-year-old woman was referred for chronic migraine and only during the course of the evaluation did she describe a 25-year history of dyspareunia, specifically, superficial pain upon penetration.
(2) A 34-year old woman developed urgency, frequency, and dysuria. Urine cultures were negative. Investigations showed typical changes compatible with interstitial cystitis (IC). Three months later, she developed vulvar pain at rest and with intercourse. She was started on 75 mg of pregabalin twice a day, and increased to 150 mg twice a day. Her urinary symptoms improved as did her vulvar pain and dyspareunia.
(3) A 43-year old woman was referred with total body pain. Her vulva showed multiple cotton swab sensitivity areas, pin-prick hyperalgesia, and an exquisitely sensitive clitoris. The vulvar pain in this case was overshadowed by the widespread muscle pain to the point that she did not complain of it initially.
(4) A 45-year old woman complained of abdominal pain that started after a total abdominal hysterectomy for fibroids. Initially, the pain was restricted to the transverse lower abdominal scar on the right; over time, the pain spread down to the vulva on the right side and up to the right subcostal margin. After numerous tests, no explanation was found for this neuropathic pain other than the possible spreading effect of central sensitization from a lower abdominal segmental nerve injury. In this case, the vulvar pain was part of a larger neuropathic pain abnormality.
In addition, women presenting with provoked vestibulodynia (PVD) and/or generalized vulvodynia (GVD) and vulvar pain as part of a major genital or pelvic pain syndrome are common.
Many of our patients do not fit into the strict classification of vulvar pain offered by the International Society for the Study of Vulvovaginal Disease (ISSVD) [1]. There can be many sacral nerve functions affected and a variety of pain syndromes involved, in addition to overlap among syndromes. Therefore, treatment of vulvar pain depends on the clinical context. As such, we have developed a classification of vulvar pain based on patients presenting to the center (Table 26.1).
An Approach to Vulvar Pain Management
Our approach incorporates some broad principles of pain management. These principles are as applicable to the vulva as they are to other kinds of chronic pain syndromes. We refer to them as the five pillars of pain management (Table 26.2) [2].
Applying the Five Pillars to Vulvar Pain
Pillar One: Conduct a Risk Assessment
As a first step in treating anyone with pain or any other condition, the treating practitioner should establish treatment goals with the patient. In doing so, a risk assessment is needed: What are the risks of treating versus not treating the patient? At the WPMC, we treat vulvar pain patients using the universal precautions approach to pain management [3] within a multidisciplinary framework. We inquire about a history of alcohol and drug abuse in the patient and family, a history of smoking or gambling addiction, a history of sexual abuse and dysfunction, prior pain and other therapies, other pain issues, anxiety and depression, and any legal and litigation issues. Between 6% and 15% of the population have an addiction [4, 5]. The more “red flags” an individual has, the more risky and difficult the treatment.
Table 26.1 Vulvar pain classification.
| I Vulvodynia |
| a. vulvar vestibulitis or vestibulodynia (provoked) |
| b. dysesthetic vulvodynia (unprovoked) |
| c. mixed provoked and unprovoked vulvodynia |
| II Vulvar pain associated with other genital syndromes |
| a. clitoral pain |
| b. urethral pain and interstitial cystitis |
| c. anal pain |
| III Vulvar pain associated with comorbidities |
| a. fibromyalgia |
| b. temporomandibular syndrome |
| c. migraine |
| d. irritable bowel syndrome |
| e. pain and dependency issues |
| IV Vulvar pain as part of a larger neuropathic pain syndrome |
| a. peripheral such as painful diabetic neuropathy (such as painful diabetic neuropathy) |
| b. central such as multiple sclerosis (such as multiple sclerosis) |
| c. part of a lumbosacral radiculopathy |
| V Vulvar pain stemming from a pelvic region neuropathic pain injury |
| VI Vulvar pain as part of pudendal neuralgia or pudendal nerve entrapment (see Chapter 17) |
| VII Vulvar pain as part of a pelvic pain condition |
| a. endometriosis |
| b. pelvic congestion syndrome |
| c. fibroids |
| d. adenomyosis |
| VII Vulvar pain as part of another entity |
| a. yeast |
| b. lichen sclerosus |
Based on this assessment, patients are divided into three groups:
Group I, low risk: little evidence to suggest addiction or psychiatric problems;
Group II, moderate risk: no active addiction but the presence of psychiatric problems; and
Group III, high risk: serious active addiction and psychiatric issues.
Table 26.2 The five pillars of pain management.
| Pillar One |
| Risk assessment. What is the risk of treating the individual, risk to the patient, and risk to the practitioner? We apply the principles of universal precautions (Gourlay et al., 2005). |
| Pillar Two |
| Identify the underlying disease and treating it. This assumes that there are specific diseases causing pain and that there are specific treatments for those conditions and that treating the underlying condition will help the pain. |
| Pillar Three |
| Determine whether the pain is neuropathic or nociceptive (or both) and go down the evidence-based path of treatment for neuropathic and nociceptive pain. This applies more to pharmacotherapy than to nonpharmacological therapies. |
| Pillar Four |
| Treat psychosocial and comorbid conditions such as anxiety, mood and depression, addiction, sexual dysfunction, and sleep. |
| Pillar Five |
