Vaginal Diazepam Use With Urogenital Pain/Pelvic Floor Dysfunction

Serum Diazepam Levels and Efficacy Data

Donna J. Carrico, MS, WHNP; Kenneth M. Peters, MD

Disclosures

Urol Nurs. 2011;31(5):279-284. 

In This Article

Background of the Problem

PBS/IC is currently defined as urinary frequency, urgency, and pain in the absence of other pathological causes or infections (Hanno, Keay, Moldwin, & VanOphoven 2005). Recently, a large cohort study noted that over 70% of its patients with PBS/IC had pelvic floor hypertonus (Butrick, Sanford, Hou & Mahnken, 2009), a finding that has been previously supported in the literature (Peters, Carrico, Kalinowski, Ibrahim, & Diokno, 2007). Vestibulodynia (previously vulvar vestibulitis syndrome) has been reported in 11% of women with PBS/IC in surveyed populations (Gordon, Panahian-Jand, McComb, Melegari, & Sharp, 2003). Vulvodynia is reported as the fourth most common PBS/IC-associated symptom, affecting 25% to 85% of women with PBS/IC (Alagiri, Chottiner, Ratner, Slade, & Hanno 1997; Gardella et al., 2008). The literature reports that there are more than 2.4 million women with vulvodynia in the United States (Goetsch, 1991; Harlow & Stewart 2003; Reed, Crawford, Couper, Cave, & Haefner, 2004).

The term "vulvodynia" will be used in this article and will include vestibulodynia and all types of vulvodynia as defined by the International Society for the Study of Vulvovaginal Diseases (ISSVD) (Moyal-Barracco & Lynch, 2004). Vulvodynia is characterized by persistent generalized or localized vulvar pain of varying degrees often characterized as "burning," suggestive of a neuropathic pain response. There may be redness of the vulvar tissues, pain fiber proliferation, and hypertonicity of the levator muscles (Reed, 2006). The ISSVD defines vulvodynia as "vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder" (Moyal-Barracco & Lynch, 2004, p. 772). It is diagnosed by touching the area with a cotton swab and noting any pain (mild, moderate, severe, or score = 0 to 10 on a visual analog scale [VAS]). At this time, the standard clinical test for vulvodynia is the cotton swab (Q-Tip®) test with reported Kappa values of 0.66 to 0.68 for inter-rater agreement and from 0.49 to 0.54 for test-retest reliability in measuring vulvar pain ratings (Bergeron, Binik, Khalife, Pagidas, & Glazer, 2001; Gordon et al., 2003; Haefner et al., 2005; Pukall, Binik, Khalife, Amsel, & Abbott, 2002).

Glazer, Rodke, Swencionis, Hertz, and Young (1995) noted that changes in the vulvar, epithelium may cause contraction in the pelvic floor muscles and stimulate histamine release, chronic pain, and inflammation through stimulation of the autonomic nervous system. Pelvic floor dysfunction associated with vulvodynia was treated with physical therapy and biofeedback leading to improved pain, sexual function, and decreased pelvic floor instability. In addition, research has shown that women with vestibulodynia have significantly more hypertonicity of the pelvic floor in the superficial and deep muscle layers than women without vulvar pain syndromes (Reissing, Brown, Lord, Binik, & Khalife, 2005). Researchers at a National Institute of Health (NIH) meeting on vulvodynia recognized the possibility of a relationship between pelvic surgeries, the pelvic nerves, and pelvic floor dysfunction (Leppert & Turner, 2003), and have included these pain syndromes in the Multidisciplinary Approach to Pelvic Pain Research Network (MAPP) grant research currently underway.

In the authors' large clinical practice, women with PBS/IC often suffer from vulvodynia as well as pelvic floor hypertonicity. This is not surprising since innervation to the bladder from the sacral and pudendal nerves also innervates the clitoris, vulva, and perineum (Tank, 2005), with support provided by the levator muscles.

To assess symptom improvement, the global response assessment (GRA) is often used as a reporting tool in NIH and other clinical trials (Propert et al., 2006; Peters, Killinger, Ibrahim, & Villalba 2008). This 7-point scale ranges from "markedly worse" to "markedly better" (see Figure 2) and may be customized for specific symptoms. In these clinical trials, the GRA has been shown to demonstrate patient response to treatment and deemed useful in making clinical decisions related to treatment.

Figure 2.

Patient Report Form Vaginal Diazepam Documentation
Source: Used with permission from D.J. Carrico and K.M. Peters.

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