When evaluating women with pelvic pain, consider the vestibule, says an urologist and sexual medicine specialist who says clinicians should stop ignoring this underappreciated component of the female anatomy. The study is presented at the Sexual Medicine Society of North America (SMSNA) Fall 2017 Scientific Meeting.
According to Rachel Rubin, an urologist, many women diagnosed with interstitial cystitis/bladder pain syndrome (IC/BPS) actually have provoked vestibulodynia disorder (PVD), which is not a bladder disorder and which needs different treatment. "Women with interstitial cystitis/bladder pain syndrome may have underlying PVD as the pathophysiology and not intrinsic bladder pathology. Treatment of PVD, in turn, may improve bladder symptoms."
There is wide clinical overlap between PVD and IC/BPS, as both conditions may include dyspareunia, chronic pelvic pain, and lower urinary tract symptoms. Patients with PVD are diagnosed by having confirmed vestibular pain and positive cotton swab (Q-tip) testing. IC/BPS, in contrast, is a diagnosis of exclusion, and tests that confirm PVD are frequently not performed on patients with bladder complaints, Dr Rubin said.
In a study she reported here, based on a series of 75 women diagnosed with PVD, 49 achieved at least 40% improvement in pain after appropriate treatment; 33% of this subset had been previously diagnosed with IC/BPS and had not improved with treatment. Treatment of PVD resulted in improvements in bladder symptoms previously attributed to IC/BPS, Dr Rubin noted.
The PVD could result from hormonal changes, inflammation, neurological factors, and hypertonic pelvic floor muscles. Deficiency in testosterone is especially common, mostly in younger women receiving oral contraceptives and in menopausal women. Pelvic muscle health is also a big factor. When pelvic floor muscles are tight and overactive, pain can be referred to the vestibule, and this can mimic bladder pain symptoms.
For their PVD diagnosis, 50% were considered to have hormonally mediated PVD treatable by cessation of hormonal contraceptives (if currently using) and topical estradiol/testosterone creams. Other PVD pathophysiologies included neuro-proliferative PVD (63%), which is treated with vulvar vestibulectomy, and pelvic floor hypertonicity (44%), treated in part with physical therapy.
Lidocaine, botulinum toxin into the pelvic floor muscles, nerve blocks, capsaicin, and pain desensitization were other treatments these women received. Among the 49 patients with more than 40% improvement in pain after treatment for PVD, 88% reported their symptoms improved by at least 60%.
Think Beyond the Bladder
Irwin Goldstein from San Diego Sexual Medicine, agreed that problems with the vestibule largely go unrecognized and that clinicians should look beyond the bladder. "I think a lot of people who are thoughtful, who don't have a bias toward the need to see this [IC/BPS] as a bladder disorder, will see that it's not a bladder disorder. It's actually outside the bladder”
The key here is not to put the patient in a box, to not [believe you have to] get bladder distention, or intravesical infiltration. Among other things, get a vulvoscopy, where you can examine the anatomy of the patient under magnification.