Brief Discussion

"What are you eating under there?"
               "Under where?"
           - 1st grade potty humor


The under wear question is huge with the vulvodynia/vestibulitis/urethritis population.  Everyone has an opinion, and, as usual, the answer is a very individual choice.

We were all told by our mothers (well, maybe just me) that white cotton, loose fitting, full coverage underwear is the best for our "girl parts."  Granny underwear.  And all of us, as soon as we had any choice in the matter, began exercising our individuality in panties.  Victoria Secret is a modern girl's best friend.  But wait - there is deep, good truth in the advice given to us about white cotton. 

Dyes can be very irritating to the external genitalia.  Unnatural fibres, and some natural ones (silk and wool) can irritate skin and mucous membranes.  Cotton seems to really be the best option for most people.  Even the cotton panel - the underwear industry's feeble attempt to combine beauty with health - doesn't quite cut it, unless the whole garment is made from some breathable cloth.  I have talked  to a few (OK, one) people (person?) that feels most comfortable with spandex - I do not suffer from any of these conditions, and spandex underwear will absolutely irritate the tissues around my vagina.  It is a very individual choice, but cotton really is best for MOST people.

What about style?  The industry has truly changed over the years, bikini briefs, french cut, thong (oh - I will get back to these), classic "granny,"  I'm sure they have a real name - but I've never met anyone that calls it any different.  My new favorite is the boy-cut.  These have the comfort of a brief, but without the elastic at the legs.  Tight fitting elastic around the legs can disrupt blood, nerve and lymph supply to the region - not enough to cause permanent damage, but if the area is already sensitive and irritated, there is no point in pushing it.

It is much easier these days to find pretty, sexy underwear with less irritating qualities.  The severity of your symptoms may dictate your choices from day to day, so if symptoms fluctuate, or if you are not that severe, you may have more options.  Lacy pretty fabrics are still OK, as long as they are breathable fabrics, and are combined with a white cotton panel.  Look for styles that are not binding around the legs, and if you are prone to bladder pain, look for styles with the waist cut either below, or well above the bladder.

Now it is time for me to get on my soap box and rant about thong underwear.  This style was virtually unheard of until the late '80's, except with male strippers.  When they first hit the scene, it was an instant "no panty line" success.  Everyone I knew that tried them hated it, but wore them anyway, because fashion is such a callous dictator.  Remember, this was the era of spandex leggings, wide belts and BIG hair.  Today they are so common that many of my patients and younger relatives can't even imagine wearing anything different.  Convincing people to give up thong underwear often feels like a culture war (I'm showing my age - it may even be a generation gap).  But, it is a HEALTH issue.  

Our rectum and vagina are seperate openings for very good reasons.  The bacteria that lives in our large bowell is essential for breaking down waste at the end of digestion.  There are also yeast in the bowell, and they live in a delicate balance with the bacterias.  None of these things belong in the vagina.  The vagina is a particularly friendly environment for yeast to grow and flourish.  Anyone that suffers chronic vulvar pain knows how bad yeast infections can be, how they can make things worse, or even be the precipitating factor in a flare.  Thong underwear can create a miniature superhighway for migrating yeast.  Direct route from the rectum to the vagina.  Not a good thing, and completely avoidable.

Remember, you always have choices, and the more educated you are about potential consequences, the better your choices can be.  If you are getting ready for prom or some other special occasion, and want to wear a super tight, sexy skirt, or some flowing clingy material - by all means, where the thong.  Be sensible, wear it for the evening, and go back to cotton whities for a few days after.

Share your stories (and opinions).

V is for Victory!

Vulvodynia, Vulvar Vestibulitis, Vulvar Dysesthesia, Vaginitis, Vaginismus, Vestibulodynia. It reads like a list of alien invaders, and for women afflicted with these conditions, it feels like it. These are words that show up as a diagnosis or diagnostic criteria with nearly 15% of all gynecological visits in the US today. That’s a lot of women, and this number doesn’t reflect the number of women that are mis-diagnosed or undiagnosed.

Let’s break down the laborious terminology here.

· Vulva- (or vulvo-): is a root word that means “external female genitalia,” which includes the inner and outer labia (lips) the clitoris, vaginal and urethral opening, and that little fold of skin-like connective tissue around the opening (the vestibule).

· Vestibul- : see above

· -dynia: pain (vuvlodynia – pain in vulva; vestibulodynia – pain in vestibule)

· -itis; inflammation – typically characterized by: redness; pain (often burning); maybe swelling; and tenderness to touch

· -mus: tightness or spasm

· Dysesthesia – (dys- impaired function; -esthesia: sensation) in this context, the sensory input from the vaginal area to the brain does not match the stimulus. Typically in painful conditions it means the nerve endings are hypersensitive, light touch should not cause searing pain, but for those with dysesthesia, it does.

Basically what we have here is a collection of symptoms that often serve as a diagnosis when no one can figure out WHY the symptoms have appeared. There are a lot of theories as to why this happens to so many women (some studies show as many as 50% of women will have these symptoms in their life-time), and there is constantly new research getting us closer and closer to the cause.

Here are some of the things we know (or suspect) that may predispose a women to having these problems:

· Genetics – a grant has recently been awarded to allow researchers to explore a link with certain genes that may cause an increase in the proliferation of nerve cells and irritant cells in the vulvar area, and genes that effect protein synthesis in these areas.

· Mast cell proliferation – these are the irritant cells mentioned above. Everybody has them, they are largely responsible for that histamine response you get from allergies, but for some reason they seem to be overly abundant in certain areas in certain people. They have proven that there is a hyperactive mast cell response in the bladder lining of interstitial cystitis (IC) sufferers.

· Chronic yeast infections – the constant irritation can cause the nerves to become hyper-sensitive, causing pain and irritation, even after the yeast is long gone. And please remember that thong underwear can carry yeast and other bacteria from anus to vagina very easily.

· Lichen planus, HPV, various bacterial and viral conditions.

· Contact dermatitis – This happens when a product irritates the area, and the nerves remain sensitized even after the irritant is gone. Soaps, perfumes, toilet paper, dyes in clothing can all be irritating. Here’s the kicker: many of the products we use to relieve vaginal itching or burning are hugely implicated in contact dermatitis. Anti-yeast creams are the biggest culprits, and so are anti-itch creams. Even prescription ones are considered to be causative factors. The safest way to handle a yeast infection is to get it cultured before taking ANYTHING, use the most appropriate treatment as recommended – but only once! If you are very sure it is yeast, and you use an over the counter medication, if it doesn’t work be sure your doctor knows what you tried, and the experts recommend that you not use a prescription cream if the over the counter doesn’t work, you are better off to use an oral medication.

· Pelvic Floor Dysfunction – O.K.; if you read this blog even occasionally, you knew I was getting to this. Pressure on the nerves from tight muscles can irritate the already hypersensitive nerves. Trigger points within the muscles can set up pain patterns that mimic vulvodynia pain when the muscle is stretched or tightened. Guarding (tightening up the muscle in anticipation of pain) can lead to vaginismus.

So what do you do? FIRST – go to a doctor! The most important thing is to rule out conditions that can be treated medically. If all the cultures come back negative, it is time to start working on the symptoms.

As a physical therapist, I help you try to eliminate pain. We use biofeedback and visualization techniques to teach you to relax that pelvic floor, and take the pressure off the nerves. We work manually (internally and externally) to eliminate trigger points and to improve the muscular balance around the pelvis. We use electrical modalities including therapeutic ultrasound, and electrical stimulation to help relieve pain. We educate you about avoiding irritants (diet, chemical, mechanical). Once the pain level is controlled, we teach you how to stay pain free, or manage flares as they arise.

A side note on my own personal treatment philosophy: The most effective way to deal with pelvic floor muscle tightness is to work internally on trigger points and muscle spasms. Many of my vulvar pain patients cannot handle vaginal work, and are so uncomfortable with rectal palpation that the costs out-weigh the benefits. With these women, I use as many indirect techniques as possible until we have achieved a comfort level with internal work. With manual therapy, you may experience some extra soreness the next day – but several days (or even two) of agony is too much, and not (in my mind) effective. It is imperative that you talk with your physical therapist during your treatment, don’t undergo weeks of “torture” because you think it might help. If you don’t tell your PT how painful it is, she will assume everything is just dandy. Chances are if she is aware of the problems you are having, she will be able to modify the treatments.

All of this is in cooperation with your medical team. There are medical interventions to help relax the muscles and control the nerve pain, and depending on the acuity of your condition, sometimes the medical interventions are what make it possible for me to do my job.