Types of vulvodynia

From handout my vulvar specialist doctor gave me:

Generalized vulvodynia - also termed generalized vulvar dysesthesia and essential vulvodynia: a condition in patients who lack significant changes on physical examination but complain of constant burning sensation in the vulva. This is thought to be a NERVE DISORDER.

Vulvar vestibulitis - also termed localized vulvodynia and vestibulodynia: a chronic clinical syndrome characterized by: 1) severe pain on vestibular touch or attempted vaginal entry, 2) tenderness to pressure localized within the vulvar vestibule, and 3) physical findings confined to vestibular redness of various degrees. Another attribute: usually no pain unless touched. This is felt to be a problem of LOCALIZED SKIN INFLAMMATION

Women may have one or the other or have a MIX of generalized vulvodynia and vulvar vestibulitis.

Vulvodynia - a general term, defined as chronic vulvar discomfort, especially that characterized by the patient's complaint of burning, stinging, irritation, or rawness.

Vaginismus: tight and painful muscles in the pelvis around the vagina which make intercourse painful. They can feel like a "blockage" or "wall" inside. This tightness can result in a smaller vaginal opening and cause little splits in the skin there during intercourse. Muscles that spasm can also develop into a burning feeling.

Theories:

Dysthetic, generalized vestibulodynia is a problem of nerve cells. They transmit a message of PAIN when they should be indicating TOUCH. Vulvar nerve fibers that are usually silent may begin transmitting pain, either with touch or spontaneously. Central neurons in the spinal nerves also become more excitable. Such differences in function result in heightened sensitivity. The area that hurts is broad and non-focal. Examination does not note any unusual appearance of the vulvar area.

Application of topical lidocaine liquid does not result in reduction of the pain with touch, as would be the case with vestibulitis, which is a problem of inflammation of surface skin.

In some women it can seem the case that spasm in pelvic muscles can cause pain that seems like it is from the skin, not the muscles. This can be confusing, so a physical therapy examination can be important.

A therapy of calcium citrate supplements in conjunction with restriction of acid foods has had variable success in treating gneralized pain. The calcium therapy is not harmful. Extreme adherence to the low oxalate diet, however, can be problematic as regards to healthy nutrition.

Vulvar vestibulodynia is a problem of too many skin nerves in small zones. Use of topical lidocaine liquid for several minutes reverses the pain, so it is very superficial pain. Theories include increased local inflammation factors like histamines and substances, which keep the capillaries dilated and increase the nerve endings. Another theory is that estrogen receptors disappear, and this somehow signals the extra nerves to grow. Only in menopause is estrogen therapy really helpful, as younger women have estrogen, but the tissues cannot sense it.

Surgery has the best results for vulvar vestibuloydnia, and this has been shown in more than 20 reports.

Some success in treating vulvodynia comes from a group of medications that work on the nervous system. These medications act on nerves to influence their messages. A wide variety of antidepressants, anticonvulsants, and muscle relaxants can help. While these medications are categorized one way, there has been success using them for chronic pain conditions. Amitriptyline is an example, as it is a tricyclic antidepressant. In that family are nortriptyline (Pamelor) and desipramine (Norpramin). Another pair of medications is venlafaxine (Effexor) and duloxetine (Cymbalta). These medications are used for the pain. One final common medication is gabapentin (Neurontin) in the anticonvulsant family, and clonazepam (Klonopin) which is a muscle relaxant.

BTW My doctor also told me that 50 mg/day of amitriptyline would be the lower threshold dose for treating pain. (Although, of course, want to build up to that level, not start taking it immediately.)
900 mg/day of gabapentin would be the lower threshold dose for treating pain. (again, want to build up to this level.)

NOTE that Amitriptyline = Elavil.

ALSO: So I have a mix (both vestibulitis and generalized vulvodynia.) Does anyone have this and had a surgery that helped symptoms? Not sure if I should try the surgery.