Abstract ID: A14
Abstract Title: Vulvovestibulitis Treatment with Local Anesthetic Nerve Blockade
Poster Type: Either
ABSTRACT BODY
Introduction. Vulvar Vestibulitis (VV) is a painful disorder of the vulva . In general gynecologic practice the prevalence of this condition may be as high as 15% . The characteristic pain of VV is generally long-standing, not subject to spontaneous remission and the signs and symptoms are typified by a) severe pain with normal pressure stimulus b) vestibular burning, stinging raw sensation c) inability to have intercourse due to pain. An exam most often reveals erythema and allodynia with gentle touch with a cotton swab in the region of the vulvar vestibule.
Patients have been treated with multiple medications with mixed results. Increasing doses of medications for neuropathic pain such as tricyclic antidepressants or anticonvulsants have also been used. As a last resort, surgical excision of the vulvar vestibule has been utilized, with a success rate of less than 50%. A neural-multi-level treatment approach is proposed to allow for elevation of the threshold for firing in the periphery without resorting to the more invasive and often destructive techniques such as surgical excision, that could lead to scarring and further sensitize the nerve endings .This approach to the treatment of pain arising from excessive nerve ending sensitivity is to interrupt the pain signals from the periphery with repeated injections of local anesthetics, thus altering central (spinal cord and brain stem) facilitation.
Methodology: The protocol includes: First level is to treat the local skin areas of vestibular tenderness including subcutaneous nerves of the vestibule utilizing 25-gauge spinal needle and local a dilute anesthetic infiltration. Second level is to treat the peripheral nerves innervating the area of primary involvement such as the superficial and deep perineal branches of the pudendal. Third level is to treat the spinal ganglion that reflects the area of primary involvement. In our cases of vulvar involvement the spinal ganglion of S3-S4 will be targeted with a caudal block.
Results. To date we have evidence in four women in an ongoing pilot trial that this triple level paradigm has had favorable impact on the pain threshold as measured with the vulvalgesiometer, spontaneous pain, dysparuenia, and suffering experienced by these patients. Daily pain assessments with visual analog scale , Beck’s depression inventory, behavioral and attitudinal scale, and sexual dysfunction questionnaire, as well as physical therapy evaluation of the pelvic floor muscles, will be presented. In addition to these four pilot patients, data will be collected on new patients currently enrolled in the study.
Discussion. This multiple level therapeutic approach is demonstrating encouraging results and is both logical and neurologically based, by specifically targeting the three initial areas involved in early development of this debilitating disease complex. As noted, the results to date are encouraging. Further time and careful analysis will determine if this therapy is successful in the treatment of vulvar vestibulitis syndrome.
ATTACHED FILES
Reg Anesth Pain Med 2004; 29(2):A14