1026
U N I T 1 1
Genitourinary and Reproductive Function
eczema or dermatitis and may produce few symptoms
other than pruritus, local discomfort, and exudation.
The lesion may become secondarily infected, causing
pain and discomfort. The malignant lesion gradually
spreads superficially or as a deep furrow involving all of
one labial side. Because there are many lymph channels
around the vulva, the cancer metastasizes freely to the
regional lymph nodes, including those of the inguinal
and femoral chains.
Early diagnosis is important in the treatment of vul-
var carcinoma. Because malignant lesions can vary in
appearance and commonly are mistaken for other con-
ditions, biopsy and treatment often are delayed. Any
vulvar lesion that is increasing in size or has an unusual
wartlike appearance should be biopsied. Treatment is
primarily wide surgical excision of the lesion for non-
invasive cancer and radical excision or vulvectomy with
node resection for invasive cancer.
Vulvodynia
Vulvodynia is a syndrome of unexplained vulvar pain,
previously referred to as
vulvar pain syndrome
or
burn-
ing vulva syndrome
.
12,13
The terminology and diag-
nostic criteria used for this chronic disorder remain in
flux, but the most recent classification system of the
International Society for the Study of Vulvovaginal
Disorders (ISSVD) defines it as a condition charac-
terized by a sensation of burning, stinging, irritation,
soreness or rawness in the absence of relevant visible
findings or a specific, clinically identifiable neurological
disorder.
12,14
Vulvodynia is further classified as localized
or generalized, and as to whether it is provoked, unpro-
voked, or of mixed origin.
Localized vulvodynia
or
vestibulodynia
, formerly
referred to as
vulvar vestibulitis syndrome
, is charac-
terized by pain at onset of intercourse, localized point
tenderness near the vaginal opening, and sensitivity to
tampon placement, tight-fitting pants, bicycling, or pro-
longed sitting. It is the leading cause of dyspareunia in
women younger than 50 years of age. The pain can be
primary (present from first contact) or secondary (devel-
oping after a period of comfortable sexual relations).
The etiology is unknown, but the problem may evolve
from chronic vulvar inflammation or trauma. Nerve
fibers that supply the vestibular epithelium may become
highly sensitized, causing neurons in the dorsal horn of
the spinal cord to respond abnormally, thus transform-
ing the sensation of touch in the vestibule into pain.
Generalized vulvodynia
, formerly called
vulvar dys-
esthesia
or
essential vulvodynia
, involves severe, con-
stant, widespread burning the vulvar area that interferes
with daily activities. No abnormalities are found on
examination, but there is diffuse and variable hypersen-
sitivity and altered sensation to light touch. The quality
of this unprovoked pain shares many of the features of
other neuropathic pain disorders, particularly complex
regional pain syndrome (see Chapter 35) or pudendal
neuralgia. Although the cause of the neuropathic pain is
unknown, it has been suggested that it may result from
myofascial restrictions affecting the sacral and pelvic
floor nerves.
12,13
There are many proposed triggers for vulvodynia,
including chronic recurrent vaginal infections; chemi-
cal irritation or drug effects, especially prolonged use of
topical steroid creams; the irritating effects of elevated
urinary levels of calcium oxalate; and immunoglobulin
A deficiency or other disorders of immune regulation.
Often it is multifactorial in origin.
Careful history taking and physical assessment
are essential for differential diagnosis and treatment.
Vulvodynia
is a diagnosis of exclusion after ruling
out infections, such as candidiasis and genital herpes;
inflammatory conditions, such as squamous cell hyper-
plasia and lichen sclerosus; vulvar cancer; or neurologic
disorders, such as herpes neuralgia or spinal nerve com-
pression, as causes for the pain.
Treatment of vulvodynia is aimed at symptom relief,
is frequently long term, and often needs to be managed
from a multidimensional, chronic pain perspective.
12,13
Local measures include avoidance of harsh soaps and
perfumed products, use of sitz baths, and application
of topical anesthetic agents (i.e., lidocaine gel). Because
dermatologic conditions such as atopic dermatitis and
candidiasis are responsible for many of the symptoms
of vulvodynia, some health care providers recommend
treatment with antihistamines and oral antifungal medi-
cations, as well as avoiding contact with potential irri-
tants.
14
Biofeedback and physical therapy may be used
to reverse the changes in pelvic floor musculature and
help women control the muscles, regaining strength and
improving relaxation.
14
Oral medications, including
tricyclic antidepressants and other antidepressants, are
often used to treat the neuropathic pain associated with
vulvodynia. Botulism toxin A injections block the cho-
linergic innervation of the target tissues and have been
shown to be effective in some women with vulvodynia.
14
Another treatment option for women with severe dis-
comfort is surgical excision of the vestibule. It is com-
monly the last option and should be reserved for women
with long-standing severe symptoms after all other man-
agement has yielded unsatisfactory results.
14
Disorders of the Vagina
The normal vaginal ecology depends on the delicate bal-
ance of hormones and bacterial flora. Normal estrogen
levels maintain a thick, protective squamous epithelium
that contains glycogen. Döderlein bacilli, part of the
normal vaginal flora, metabolize glycogen, and in the
process produce the lactic acid that normally maintains
the vaginal pH of 3.8 to 4.5.
15
Disruptions in these nor-
mal environmental conditions predispose to infection.
Vaginitis
Vaginitis represents an inflammation of the vagina that
is characterized by vaginal discharge and burning, itch-
ing, redness, and swelling of vaginal tissues.
15,16
Pain
often occurs with urination and sexual intercourse.
Vaginitis may be caused by chemical irritants, foreign
bodies, or infectious agents. The causes of vaginitis dif-
fer in various age groups. In premenarchal girls, most
vaginal infections have nonspecific causes, such as poor
