Etiopathogenesis and treatment of localized provoked vulvodynia

Localized provoked vulvodynia (LPV), a subset of vulvodynia, is associated with pain induced by touch to the vulvar vestibular mucosa in the absence of any other recognizable disease. This results in severe dyspareunia. LPV mostly affects young fertile-aged women, with an incidence of 8-15%. LPV severely impairs a patient s quality of life, and can even result in infertility since women with the most serious symptoms have to abstain from sexual activity. Details of the etiopathogenesis of LPV have remained unknown. Studies on individual medical treatment options show that some patients, though not all, benefit from conservative management. Surgery has shown to be effective in refractory patients. The objective of this study was to investigate short-term and long-term results of surgical treatment and to compare the long-term well-being of LPV patients treated either conservatively or by surgery. The second aim was to characterize immune and neural details of the diseased vestibular mucosal tissue in order to explain the pain mechanism. The study material consisted of 97 patients with severe LPV who had been treated according to a multidisciplinary treatment algorithm at Helsinki University Hospital Vulva Clinic between 1995-2007. We analyzed short-term well-being and complications of surgery in the 70 surgically-treated patients, and long-term well-being in 57 surgically-treated and in 27 conservatively-treated patients. Dyspareunia was evaluated by the visual analogue scale (VAS) and vestibular tenderness by cotton swab testing. Sexual well-being and overall patient satisfaction were evaluated by validated instruments and face-to-face interviews. To investigate the etiopathogenesis of LPV, we analyzed the removed vestibular mucosal tissues of 27 surgically-treated patients by immunohistochemical methods. As comparison we had vestibular mucosal tissue specimens from 15 healthy controls. The multidisciplinary treatment algorithm, including guidance of a gentle vulvar care, physical therapy, sexual and psychological counseling, and neuromodulatory pharmacotherapy, turned out to be effective. Surgery by posterior vestibulectomy was shown to be a safe and effective treatment option in patients refractory to conservative treatment. Around 90% of the patients in both groups reported long-term satisfaction with the treatment outcomes. In the tissue analyses, we demonstrated vestibule-associated lymphoid tissue (VALT) in the vestibular mucosa and showed that VALT had become activated in LPV. This immune activation was further shown to be associated with neuroproliferation, which may explain the pain sensitization in LPV. In conclusion, our results suggest that immunoinflammatory pathways play an essential role in the pain pathogenesis of LPV. Algorithm based multidisciplinary treatment including selected conservative treatment modalities provides good long-term well-being in a number of patients. Surgery by posterior vestibulectomy is a safe and effective treatment option for refractory patients.