Vulvodynia and Concomitant Femoro-Acetabular Impingement: Long-Term Follow-Up After Hip Arthroscopy. Coady, D et al. J Lower Gen Tract Dis 2015;19).

Michelle Spicka, DPT

May 6^th, 2015

Pelvic Physical Therapy Distance Journal Club

Description: The researchers hypothesized that in patients with vulvodynia and femoro-acetabular impingement, vulvar pain may actually be generated by the effect of femoro-acetabular impingement on pelvic floor structures and treatment with arthroscopy may improve vulvodynia.

Vulvodynia affects 8-16% of women but effective treatment is often difficult due to inadequate understanding of the causes. 

Close relationships between intra-articular hip disorders, pelvic floor and chronic pain in the pelvis in proximity to the hip have recently been recognized.  Femoro-acetabular impingement can refer pain into the pelvic floor via the obturator internus and other shared muscles and connective tissues and leads to the development of nonoptimal movement patterns.

Methods: A case series of patients with vulvodynia and femoro-acetabular impingement underwent physical therapy and, if hip symptoms did not improve, arthroscopy.  Three to five years post op follow up was performed using chart review and a patient questionnaire. 

The case series started in 2008 when routine evaluation of all patients with chronic vulvar pain began to include assessment for hip disorders.  Assessment included: current or past hip discomfort, injuries or repetitive athletic activities, congenital hip disorders.  Exam findings considered suspect for hip disorders included positive FABER test (pain with flexion, abduction and ER) and OI tenderness on pelvic floor exam.

In September 2013, medical record review was performed for patients whom had an arthroscopy and vulvodynia.

Results: During a 26 month period from 2008-2013, 75 patients with vulvodynia were diagnosed with concomitant hip disorders by clinic and radiologic evaluation.  Three patients had OA and were excluded; the remaining 72 patients (aged 23-74) were diagnosed with femoro-acetabular impingement (with or without labrum tears) in addition to vulvodynia (in varying levels of disability and pain). 

The 72 patients underwent 3-6 months of PT, focusing specifically on the hip and pelvic floor.  The majority of the patients experienced satisfactory improvement after PT and did not require further intervention. 

Twenty-six vulvodynia patients underwent arthroscopy and femoro-acetabular impingement was confirmed in all cases. 

Six patients experienced sustained improvement in their vulvodynia and no longer required evaluation or treatment for vulvar pain.  All six patients were aged 22-29.

Twenty patients with femoro-acetabular impingement did not obtain lasting improvement in vulvodynia after arthroscopy, although 14 had previously reported several months of vulvar pain benefit.

Older mean age and longer preoperative duration of vulvar pain were associated with not obtaining lasting vulvodynia improvement after arthroscopy.  More than 50% who did not improve had vulvodynia for 5 years or longer.  Severe levels of vulvar pain were also associated with lack of improvement and none of the patients who were fully disabled by their vulvar pain obtained benefit. 

Discussion:

1)      Improved vulvodynia outcomes after arthroscopy for femoro-acetabular impingement in women younger than 30 years

2)      No lasting improvement occurred in older went, most of whom had severe vulvar pain of long duration.

a.       Temporary post op benefit may have been due to anesthesia, the effect of hip traction or placebo effects.

b.      Most patients with longstanding vulvodynia symptoms have developed centralized pain which is more challenging to treat.

3)      This study adds to the information base about possible causes of generalized unprovoked vulvodynia by relating femoro-acetabular impingement with pain sensations perceived in the vulva. 

4)      Biomechanical consequences of hip impingement may lead to pain in the vulva because of close anatomical relationship of hip muscles and the vulva’s main sensory innervations, the pudendal nerve.

5)      Chronic low level hip discomfort can contribute to postural and gait changes that affect the obturator internus, other hip rotators, deep and superficial pelvic floor muscles.  The resulting dysfunction may contribute to changes over time in the pelvic floor muscles along with possible compression of the pudendal nerve, contributing to the burning neuropathic pain patients with generalized unprovoked vulvodynia commonly describe. 

6)      All women with vulvodynia need to be routinely assessed for pelvic floor and hip disorders.

Study Limitations:

1)      Non-randomized observational research

2)      Homogenous population

3)      No control for concomitant therapies/treatments

Other Research:

1)      Prather H, et al. Musculoskeletal etiologies of pelvic pain. Obstet Gynecol Clin North Am. 2014sep;41(3):433-42.

2)      Tamaki T, et al. Hip dysfunction-related urinary incontinence: a prospective analysis of 189 female patients undergoing total hip arthroplasty.  Int J Urol. 2014 Jul;21(7):729-31.

3)      Kim SH, et al. Clinical effectiveness of the obturator externus muscle injection in chronic pelvic pain patients. Pain Pract. 2015 Jan;15(1):40-6.

4)      Shelkey J, et al. Case report: pelvic congestion syndrome as an unusual etiology for chronic hip pain in 2 active, middle-age women. Sports Health. 2014 Mar;6(2):145-8.

5)      Hammoud S, et al. The recognition and evaluation of patterns of compensatory injury in patients with mechanical hip pain. Sports Health. 2014 Mar;6(2):108-18.

6)      Bredella MA, et al. Pelvic morphology in ischiofemoral impingement. Skeletal Radiol. 2015 Feb; 44(2):249-53.

7)      Prather H, et al. Early intra-articular hip disease presenting with posterior pelvic and groin pain. PMR 2009; 1:809-15.