Vulvovaginal Disease Update 2014: Must-read Nuggets

PHRC PTs with Drs. Badger and Venkatesan

PHRC PTs with Drs. Badger and Venkatesan

Last month three of our PTs, Allison, Malinda, and Stacey attended the Vulvovaginal Disease Update 2014. Vulvar dermatoses affects millions in the United States often greatly interfering with a woman’s quality of life. And as pelvic floor PTs, it’s certainly an issue that can overlap with the musculoskeletal impairments that we treat. Therefore, this annual conference, which is hosted by the North American chapter of the International Society for the Study of Vulvovaginal Disease, is one we tune in to.

Below are some must-read nuggets from the PHRC delegation in attendance:

“Vagisil makes you Ill” and other Lessons in Vulvar Skin Irritants

Stacey listened to Dr Aruna Venkatesan, MD, who spoke on chronic vulvar itching.

Dr. Venkatesan pointed out that when there is any kind of skin irritation involving the vulvar tissue it can be due to urine, fecal matter, menstrual blood, or washing too much. In addition, an allergy can cause irritation.

One of the irritants that she pointed to was the common “feminine hygiene” product Vagisil. In fact, “Vagisil makes you ill” is a common refrain among physicians who treat vulvar dermatoses. Dr. Venkatesan explained that although in the beginning of use the product can help anesthetize the tissue, in the long run it can cause irritation.

Also interesting was the fact that “Baby Wipes,” another commonly used hygiene product can cause skin irritation. Many who suffer with urine or fecal incontinence use Baby Wipes. The major irritant in Baby Wipes is methychloroisothiazolinone. (For more info on this topic, check out this article.)

Other irritants she listed include “carbonmate,” which is a substance that can leach out of the elastic band in underwear when bleached, fragrances found in soaps, detergents, or feminine hygiene products or spermicides.

Vulvodynia: Causes, Diagnoses, and Therapies

Allison heard Drs. Catherine Leclair, MD and Hope Haefner, MD speak about vulvodynia.

One important takeaway from the lectures was that providers are finding that symptoms of vulvodynia come from both the brain and the periphery (the area where the pain is present).

For her part, Dr. Haefner discussed research that showed that those with vulvodynia tended to be more sensitive all over their bodies compared to control subjects.

In addition, Dr. Haefner stressed that vulvodynia is a complex diagnosis and that recognition of multiple factors is important to appropriate patient evaluation and management.

For her part, Dr. Leclair spoke at length on therapies used to treat vulvodynia.

She began with vulvar care measures. For one thing, she said that cotton underwear is recommended and that no underwear should be worn at night. In addition, vulvar irritants and douching should be avoided, she said, adding that the patient should use mild soaps for bathing and not apply soaps to the vulva. Also, if menstrual pads are irritating, 100% cotton pads may be helpful.

Plus, adequate lubrication for intercourse is a must. Lubricants she recommended include:  olive oil, Replens, Astroglide, KY Liquid, Probe, Pjur Women, Slippery Stuff, uncooked egg whites, vegetable oil, Vitamin E oil, Surgilube, Sylk (Kiwi fruit vine), Moist Again Natural Feeling, and Lubrin, Femigel Natural, a product from tea trees.

Treatments she discussed include topicals, such as lidocaine and topical amitriptyline, medications, such as tricyclic antidepressants, like amitriptyline (Elavil®) and nortriptyline (Pamelor®); other antidepressants, such as Cymbalta, and anticonvulsants, such as Gabapentin (Neurontin®).

One thing she emphasized is that physicians should encourage patients to get to the goal dosage of these medications as there is research to back up their effectiveness in treating this patient population.

In addition, she recommended pelvic floor PT when there is a musculoskeletal component to the patient’s symptoms. Lastly, she spoke of the success of trigger point steroid and bupivacaine injections for some patients with localized vulvodynia.

Facts about Lichen Sclerosus, Lichen Plantus

Malinda heard Dr. Joanna Badger, MD, speak on lichen sclerosus and Dr. Aruna Venkatesan, MD, speak about lichen planus.

Lichen Sclerosus

One important takeway from the lichen sclerosus discussion was the importance of screening for the condition. Lichen sclerosus is a chronic, destructive, inflammatory skin condition with a preference for the skin of the genitalia. However, it does not affect the mucosal layers so it does not spread to the vaginal canal.

Clinical features of the condition include a hyperpigmentation of the skin with raised white patches appearing, tissue that may appear like wrinkled paper, and a red or purple discoloration of the skin. In addition, there is a chance of a reabsorption of the labia minora into the labia majora and a fusing of the clitoral hood. Symptoms can also appear on other parts of the body, such as the back, shoulders, neck and abdomen.

Although the cause of the condition is unknown, the hypothesis is that it is an autoimmune disease. The largest group affected are postmenopausal women. Common symptoms include itching, burning, and pain with sex. Dr. Badger stressed that with lichen sclerosus scratching can make symptoms worse.

Frustratingly, the condition is often misdiagnosed as being vaginal atrophy. Although the condition is not curable it is treatable with topical steroids. However, any anatomical changes that occur are not reversible.

Dr. Badger cautions that although some patients and physicians are hesitant about steroids, “lichen sclerosus can be potentially more harmful to the skin than topical steroids.”

For her part, Dr. Venkatesan spoke about lichen planus.

Lichen planus is an inflammatory skin condition, characterized by an itchy, non-infectious rash of small, many sided flat-topped pink or purple lesions that can affect the vulva and vagina (unlike lichen sclerosus, lichen planus can affect mucous membranes). Other parts of the body may also be affected, including the mouth, nails, scalp, arms and legs.

The cause of the condition is unknown. However, it can be triggered by taking certain medications, including thiazide diuretics, antimalarials and phenothiazines (a group of tranquilizing drugs with antipsychotic actions). Like lichen sclerosus, some specialists believe it is autoimmune in nature. A higher-than-normal percentage of people with hepatitis C and other liver diseases have lichen planus.

Like lichen sclerosus, lichen planus is most often controlled with topical steroids. Lichen planus symptoms on the skin can take up to two years to go away. However, once gone they hardly ever return. Oral lichen planus can take much longer to go away.

If you have any questions about any of the topics discussed in this post, please don’t hesitate to leave them in the comment section!

All our best,

Stacey, Allison and Malinda

 


8 thoughts on “Vulvovaginal Disease Update 2014: Must-read Nuggets

  1. Thanks so much for all your help.I would like to ask if there is a water repellent recommended for going in a pool.I have CRPS from tarlov cysts that presents more like pudendal neuralgia and I am trying to “water walk” but I feel it may be causing more burning.I had used a thin layer of sensitive petroleum ointment but I am wondering if there is something better?I appreciate your time to comment!

    • Dear Nancy,

      If Vaseline has not worked for you, I would try Aquaphor as some of our patients have had luck with it.

      Best,
      Liz

  2. I have chronic burning for 2 years… Saw numerous doctors and still no diagnostic .. Don’t hurt… Only burn… Could you please recommend doctors nearest to Lake Charles, Louisiana. Thank you

    • Hi Mona,

      Unfortunatley we do not have a referral for a therapist in Lake Charles, but we can refer you to a therapist in Lafayette. Her information is below.

      Jacqueline Bravo, PT
      Lafayette, LA
      (337) 406-0712
      Bravo Therapy Services

      Best,

      Rachel

  3. Have recently had 3 different occurrences of genital lesions. Not herpatic lesions current doctors continue to treat me with topical steroids but have no idea the cause. Any suggestions? Condition is very painful I do have sjogrens and take plaquenil

  4. I am 64 and have not been sexually active since 42 years old. In 1992, I experienced RSD as a result of severing the nerve to my right index finger. I believe I still suffer the effects throughout my entire body when pain becomes present.

    If I have surgery, it seems to take me longer to heal. If I have a tooth pulled it hurts so much. I over-stressed both my wrists and had tendonitis with such pain, my wrists felt they were on fire. I was given cortisone shots in each wrist, a 2nd one in the right one a month later. I had many other incidences where pain was amplified more than what it should have been for the condition.

    I tell I doctors I have RSD and it seems to go over their head. They don’t even put it in my medical record. When I experience pain, and I mean severe pain, I am unable to cope, yet I am left to bear it. Thank God, two times with intense pain, I was hospitalized for 5 days and was given morphine for the first 3 days and the 2nd time went to the E.R. and was given morphine also.

    Several years ago I was diagnosed with vaginal dystrophy and told to use Clobetosol for the r)est of my life. I suffer with ripped tissue, terrible pain when urinating (I am incontinent also and leaking urine leaves me constantly hurting). The inside of my vagina often bleeds and I look now and then to see a sac or polyp. I always itch and want to rip my private area off my body.

    A few months ago, I got a skin condition that jumped from my hand to my hands to all different parts of my body. I was unable to sleep because it felt like I had bugs harboring on my vulva and vaginal wall (I have no uterus). I keep myself quite clean because of the incontinence, but because the itching was driving me toward psychosis, I looked down there and saw a heavy white covering all over my private area. Only a month earlier, I went to my primary doctor and the Nurse Practitioner checked to see if I had a infection. I did not. I wonder if I had the white then, but the N.P. said nothing to me. Now I’ve been diagnosed with lichen sclerosis. The inside and outside of my private area is a mess. If the pain scale is 1-10, mine is a 16. I cry often. I’m told to use the Clobetosol every day for two weeks, taper down and eventually apply it on Wed/Sunday …. forever.

    I take a cloth and clean off the thick, white, curd-like substance because the sensation is again like a nest of spiders moving around on my labia mons. That crazy itching does ease, but the pain intensifies and it feels like raw meat inside and out.

    I still wonder if I am properly diagnosed with the correct lichen disease, if it makes a difference. I read on this page the vaginal wall is not affected with lichen sclerosis. Mine is affected and that is where the most pain exists for me.

    I think I have both lichen sclerosus and lichen planus [arms, neck area, very heavily, legs, hands, feet, face and even into my hairline.] It’s months before any dermatologist in this area are available. I saw one woman dermatologist who made the diagnosis and she was an ice woman and didn’t even give me a “johnny” to put on. I’ll not ever see her again.

    Now…I feel silly asking but is there a chance I might have multiple sclerosis whereas my immune system is always being compromised? I asked the N.P. to do a complete blood work up and to take scrapings, but she said I all ready had my quarterly blood work done and all was fine. She felt the scraping wasn’t necessary.

    I live an hour north of Boston and wonder if there is anyone you can recommend who would acknowledge the RSD and the exceptional pain I experience.

    Also, what is your judgement on acupuncture?

    • Author Stephanie Prendergast says:

      “The proper way to diagnose lichen sclerosis is with a biopsy and then it is confirmed or ruled out by a pathology lab. It is possible that you have pelvic floor problems and lichen sclerosis, which could explain the skin issue but also the vaginal pain. We have an office in Lexington, I suggest that you make an appointment with one of our therapists and they can help you form an effective treatment of providers who understand your problem.”

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