How I Practice Video Series
Jay R. Trabin, MD, FACOG

HIP: Vulvodynia from ACOG on Vimeo.

HIP: Vulvodynia from ACOG on Vimeo.

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When I speak with a patient who comes to me with vulvar pain, it can be very frustrating and very time consuming. It's important to address certain key critical issues at the very beginning of your conversation because if you don't, the patient may feel that it's all in her head. One of the most important things that you can do as a young physician in the very beginning is to reassure the patient that no it is not all in your head. In fact this is a real medical disorder. Many years ago, we used to think that perhaps it was a psychiatric illness because often times we could not see any visible lesions, and so it was difficult to diagnose. Then came the understanding that there are certain problems inherent in neurophysiology that produce chronic pain in the absence of physical findings. We reassure the patient that there are real entities including genetic predisposition, abnormalities in cellular metabolism, and other disorders that cause chronic pain. I like to explain to the patient that there are related disorders such as chronic reflex sympathetic dystrophy such as causalgia, such as irritable bowel syndrome, fibril myalgia, depression, and other disorders that we often see with vulvodynia. We like to explain to the patient that vulvodynia used to be called vestibulitis, vulvar vestibulitis. Now we not only call it vulvodynia, but divide it into categories such as diffuse, localized, such as provoked or unprovoked or spontaneous and this helps the patient to feel more comfortable knowing that there really is something wrong, rather than as may have been told to her by other well meaning physicians that "it's all in your head."

We also like to explain to the patient that: no, you're not alone. A lot of patients that come in with vulvar pain syndromes, which they often describe as sharp, stabbing, and knife-like, sometimes provoked by sexual intercourse, sometimes spontaneously making even difficult to wear tight clothing, many times they feel like they are some sort of freak because most people don't talk about this disorder. In fact, in many recent studies it was shown to be far more prevalent than we used to think. In certain recent studies for example, the lifelong prevalence of this disorder varies between 2 and as high as 25%. In specific populations basically between the ages of 20-45, it has an incidence rate of 2-4% and as high as 9%. We also explain that it is more common in Hispanics and we also explain that even though it seemed more commonly in middle age, it sometimes and not infrequently makes its way and initial occurrence in adolescence and can be seen in the 60 or 70 year old age bracket. It's important to reassure patient that you're not alone; there are many other patients that have this disorder.

The next question that we usually get from patients (they're starting to feel a bit more comfortable at this point) is: What is it that I have? What is vulvodynia? So the first thing we do at this point is that we explain to them that there are secondary causes of vulvar pain. These can include infections such as candida, herpes, or chronic allergy symptoms. These can include trauma, these can include neurogenic causes such as pudendal nerve entrapment, pudendal neuropathy and they can also include what we call dermatoses, such as lichen sclerosis or erosive lichen planus and other skin disorders. They can even be manifestations of a different organ system such as Crohn's disease which not infrequently causes vulvar pain. So once you have ruled out, and this is basically done through a very careful physical history, once you've ruled out the secondary forms of vulvar pain, then one explains to the patient (and I usually do this after the examination) our diagnosis that we're working with now is vulvodynia. At this point it's very useful to give the patient brochures and other references and online website support groups that may help to further empower her, knowing that it's not all in her head and no she's not alone, and she does have a medical disorder. That's usually my starting off point in the management of vulvodynia and that's the way I practice.


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