Varovanje zdravja žensk / Women's health Fizioterapija 2013, letnik 21, suppl 1 Terapija s transkutano električno živčno stimulacijo pri pacientki z izzvano vulvodinijo – poročilo o primeru Viš. pred. mag. Darija Šćepanović, viš. fiziot.¹, asist. Gabrijela Simetinger, dr. med., spec. gin. in porod., FECSM² ¹Ginekološka klinika, Univerzitetni klinični center Ljubljana, Slovenija; ²Splošna bolnišnica Novo mesto, Slovenija Korespondenca/Correspondence: Darija Šćepanović; e-pošta: darija.scepanovic@kclj.si Uvod: Vulvodinija je definirana kot neugodje, najpogosteje razloženo kot pekoča bolečina v predelu vulve, ki nastane v odsotnosti ustreznih vidnih sprememb ali specifičnih klinično spoznavnih nevroloških motenj (1). Vulvodinija se deli glede na anatomsko mesto bolečine in glede na to, ali je bolečina izzvana ali neizzvana. Etiologija vulvodinije je najpogosteje primarno razložena z biomedicinskimi dejavniki, spremembami v imunskem sistemu in iatrogenimi dejavniki. Tudi različni psihološki in spolni dejavniki lahko vplivajo na stanje ali ga celo izzovejo. Za obravnavo vulvodinije je želen timski pristop, ki vključuje ginekologa in strokovnjake s področij psihoseksualne medicine, fizioterapije in obravnave bolečine (1). Pri bolnicah z lokalno izzvano vulvodinijo, odporno na druge oblike zdravljenja pride v poštev vulvektomija. Namen poročila o primeru je prikazati primer pacientke z izzvano vulvodinijo, pri kateri je bila zaradi neodziva na zdravila indicirana vulvektomija. Da bi se temu izognili, smo se odločili poskusiti terapijo s transkutano električno živčno stimulacijo (TENS). Pacientka je pisno privolila v raziskavo. Prikaz primera: Petintridesetletna pacientka se je že pri 18 letih starosti zdravila zaradi depresije. Ob zamenjavi službe po drugem porodu so se ji pojavili napadi tesnobnosti, povišan krvni pritisk, tiščanje v prsih in alergija. Začela je terapijo z anksiolitikom in beta blokatorjem. Opravila je alergična testiranja, na katerih je bila dokazana alergija na nekatere snovi. Urološka anamneza je bila brez posebnosti. Pred enim letom je prišla na pregled zaradi srbečice na spolovilu. Pri ginekološkem pregledu so bile vidne petehije po perineju. Terapija z antimikotikom, kortikosteroidom in lokalnim anestetikom je bila neuspešna. Test z vatirano palčko je razkril občutljivost in bolečnost na vestibulumu. Histološka slika biopsije bolečega mesta je ustrezala blažjemu nespecifičnemu kroničnemu vnetju. Pacientki je bil prepovedan vaginalni spolni odnos. Oralni spolni odnos je bil dovoljen. Za oceno uspešnosti terapije s TENS-om sta bila pred zadnjo obravnavo in po njej uporabljena vizualna analogna lestvica in indeks spolne funkcije pri ženskah (2). Stimulacija z vaginalno sondo je bila aplicirana v dveh 15-minutnih intervalih (prvi interval: dolžina dražljaja 50 μs, frekvenca 10 Hz, drugi interval: dolžina dražljaja 100 μs, frekvenca 50 Hz), 20-krat, 2-krat na teden (3). Rezultati: Stopnja srbečice, merjena z vizualno analogno lestvico, je bila pred terapijo ocenjena z 10, po terapiji pa z 0. Srbečica je izginila že po prvih dveh terapijah. Pacientka je na indeksu spolne funkcije pred terapijo zbrala 32 točk, ob odpustu pa 91 točk (nad 26 točk ni spolne disfunkcije). Zaključek: TENS je enostavna, učinkovita in varna terapija za zdravljenje izzvane vulvodinije. Ključne besede: vulvodinija, izzvana, biomedicinski dejavniki, transkutana električna živčna stimulacija, timski pristop. Varovanje zdravja žensk / Women's health Fizioterapija 2013, letnik 21, suppl 1 Transcutaneous electrical nerve stimulation in a patient with provoked vulvodynia - a case report Background: Vulvodynia has been defined as vulvar discomfort, most often described as burning pain, occurring in the absence of relevant findings or a specific clinically identifiable neurologic disorder (1). Vulvodynia is classified according to the localisation of pain in the vulva, whether it is generalised or localised, and whether it arises on provocation of the area or occurs spontaneously. Most commonly it is primarily explained by bio-medical factors, changes in the immune system and iatrogenic factors. However, various psychological, sexual and context related factors have also been documented to contribute to or perhaps elicit the condition. To manage the various components, a team approach may be required, headed by a lead clinician and assisted by experts in psychosexual medicine, physiotherapy, and pain management teams (1). In patients with local provoked vulvodynia refractory to other treatments, surgical excision of the vestibule may be considered. The purpose of this case report is to present the patient whose provoked vulvodynia was refractory to other treatment modes and surgical excision of the vestibule was therefore considered. To avoid surgical treatment, transcutaneous electrical nerve stimulation (TENS) was tried out. The patient consented to participate in the study. Case description: A 35-year-old patient had been treated for depression since the age of 18. Since she changed her job after she had given birth to her second child, she started suffering from anxiety, hypertension, chest pressure and allergy. She was treated with anxiolitic and beta blocker. She took allergy tests, which confirmed allergy to a number of different allergens. Her urinary tract function was normal. A year ago she came for a check-up for genital itching. Gynaecological examination revealed petechiae on perineum. Treatment with antimycotic locally and orally, corticosteroid ointment and local anesthetic proved unsuccessful. Cotton swab testing of the vestibulum of the vagina revealed sensitivity and pain. Histological picture of biopsy from the painful area corresponded to changes associated with mild non-specific chronic inflammation. The patient was strongly encouraged to abstain from vaginal intercourse, while oral sex was allowed. Her clinical conditions were assessed by the Female Sexual Function Index questionnaire and the visual analogue scale symptoms assessment at baseline and immediately after completing the 20 treatment sessions on a twice per week basis (2). The stimulation was delivered through a commercially available vaginal probe. Protocol for TENS was 15 minutes of 10 Hz frequency and pulse duration of 50 μs followed by 15 minutes of 50 Hz frequency and pulse duration of 100 μs (3). Results: The baseline score of visual analogue scale was 10 and the post-treatment score was 0. The vaginal itching disappeared after only two consecutive treatment sessions with TENS within a period of one week. Female Sexual Function Index score improved from 32 to 91. Conclusions: TENS is a simple, effective and safe treatment for the management of provoked vulvodynia. Keywords: vulvodynia, provoked, bio-medical factors, transcutaneous electrical nerve stimulation, team approach. Literatura/References 1. Damsted Petersen C (2012). Sexual pain disorders. In: Porst et al. The ESSM Syllabus of sexual medicine. Amsterdam: Medix: 912–19. 2. Rosen R, Brown C, Heiman J et al (2000). The Female Sexual Function Index (FSFI): a multidimensional self- report instrument for the assessment of female sexual function. J Sex Marital Ther 26: 191–208. 3. Murina F, Bianco V, Radici G et al (2008). Transcutaneous electrical nerve stimulation to treat vestibulodynia: a randomised controlled trial. BJOG 115: 1165–70.