Chronic Urogenital Pain

Vulvodynia – Bladder Pain Syndrome/Interstitial Cystitis

Historical Background to the Study of Vulvodynia

From ancient Egyptian papayri, to the 1st century writings of Soranus of Ephesus, antiquity provides very early accounts of female dyspareunia akin to modern day vulvodynia (McElhiney et al., 2005). In more recent times, the medical literature of the 18th and 19th century again documents the existence of chronic vulvar pain, which was reported to cause great discomfort and distress in some female gynaecology patients. In 1874, T. Gilliard Thomas in his book A Practical Treatise on the Diseases of Women describes hyperesthesia of the vulva with patients experiencing “excessive hypersensibility of the nerves supplying the mucous membrane of some portion of the vulva” (Thomas, 1874, p. 115).

In 1889, Skene in his Treatise on the Diseases of Women, described a condition of chronic pain characterised by pain on touch and examination of the vulva (Skene, 1889) and in 1928, Kelly, in his book Gynaecology, reported the occurrence of tender areas close to the hymenal ring sufficient to cause a patient to cry out aloud (Kelly, 1928).
In 1976, Weisfogel, speaking at a congress of the International Society for the Study of Vulvovaginal Diseases (ISSVD), introduced a disorder, primarily affecting young women, who complained of a problem described as “the burning vulva.” Physical examination and laboratory testing showed no evident pathology. Weisfogel described the condition as one in which “I see nothing. I hear nothing. I smell nothing. I feel nothing” (Moyal-Barracco & Lynch, 2003). The ISSVD meeting discussed the problem of the “burning vulva syndrome” as the symptoms were reported to be resistant to a wide range of medications (Young et al., 1984). The same year, Pelisse and Hewitt, provided a review of 30 women with hypersensitivity of the vulva (Pelisse & Hewitt, 1976). In 1978, Tovell and Young suggested that the terms “vulvodynia” or “pudendagra” might best describe the localized sensation of burning reported by women (Tovell & Young, 1978). At the same time, Dodson and Friedrich described a form of vulvovaginal pain and dyspareunia, and named it “psychosomatic vulvovaginitis” (Dodson & Friedrich, 1978). In 1982, a task force was established to survey ISSVD membership views concerning the burning vulvar syndrome (Young et al., 1984). Two-thirds of the respondents put forward a range of ideas regarding etiology, suggesting psychogenic, neurogenic, infectious and dermatological causes of the disorder. At the 1983 congress, the ISSVD task force proposed the term vulvodynia, to describe this idiopathic form of vulvar discomfort, most often characterised by patient’s complaints of burning. The same year, Woodruff and Parmley gave account of 15 patients with infection of the minor vestibular glands causing pain (Woodruff & Parmley, 1983) and in 1986, Peckham and others, reported on 67 women with a condition they called “focal vulvitis” (Peckham et al., 1986). In general, vulvodynia and the burning vulva syndrome were seen as symptomatic of an “end-stage” condition that was recalcitrant to most treatments and psychogenic factors were thought to be strongly implicated but not well defined (Young et al., 1984).
In 1987, Friedrich, on the basis of his study of 86 patients, offered the first classification describing the condition of “vulvar vestibulitis syndrome” (Friedrich, 1987). The classification suggested by Friedrich was the first to systematize the diagnosis of vulvar pain, providing the basis for further discussion and future comparative studies. Friedrich’s criteria were widely accepted and still continue to be used for diagnostic and research purposes (Payne et al., 2007). According to his classification, the syndrome was characterised by three key diagnostic features:

  • pain on penetration (entry dyspareunia),
  • introital tenderness, and
  • mild to moderate introital erythema.

Patients suffering symptoms would commonly describe their discomfort as a sensation of burning, rawness, and discomfort. These symptoms would occur in the absence of any visible clinical or neurological findings. The term vulvar vestibulitis syndrome was not only widely accepted but was often used synonymously with vulvodynia.
By 1988, several subtypes of vulvodynia were proposed (McKay, 1988) and were well summarized in a review of then current concepts in vulvodynia (Masheb et al., 2000). The first subtype was vulvar dermatoses (lichen sclerosus, lichen planus, chronic dermatitis, and eczema); the second subtype was cyclic candidiasis/vulvitis, often associated with recurrent candida infections; the third subtype was vulvar papiliomatosis, confirmed by the presence of small papillae found around the vulvar vestibule and possibly associated with human papillomavirus (HPV); the fourth subtype was essential vulvodynia, a form of dysesthesia arising from nerve irritation similar to postherpatic neuralgia; and the fifth subtype was vulvar vestibulitis syndrome (VVS), characterised by hypersensitivity in the vulvar vestibule, but occurring in the absence of physical findings, with the exception of varying degrees of erythema. Later classifications separated chronic vulvar pain into two categories, a category listing vulvar pain due to identifiable medical causes and a category listing types of vulvodynia occurring in the absence of any know medical causes.
In 1991 the ISSVD made further changes and replaced the term “burning vulva syndrome” with “vulvodynia”. Recognizing the existence of various subsets of chronic vulvar pain, some too difficult to classify, the ISSVD added two additional terms, essential vulvodynia and idiopathic vulvodynia to describe patients who showed no significant changes on physical examination and for patients reporting a dull continuous pain, originating from areas deeper than the vestibule but with no medical diagnosis (McKay et al., 1991). Discussions on terminology and classification continued through the 1990’s until the 2003 classification system was established. In 2003, at the 17th Congress of the ISSVD, the membership of the society voted to accept a reversion to the term vulvodynia, and in 2004, the current terminology and classification of vulvodynia was published (Moyal-Barracco & Lynch, 2004).