AUTONOMIC TESTING FOR SMALL FIBER NEUROPATHY IN VULVODYNIA PATIENTS DENA HARRIS MD, DEBORAH COADY MD, JESSICA ROBINSON-PAPP MD SOHO OBGYN, NEW YORK UNIIVERSITY LANGONE MEDICAL CENTER, AND MOUNT SINAI MEDICAL CENTER, NEW YORK, NEW YORK ABSTRACT METHODS Objective: The purpose of the study is to determine if generalized vulvodynia patients have small fiber neuropathy on autonomic testing. Autonomic testing evaluates small fiber function on the rationale that if autonomic nerves are abnormal then pain fibers probably are too. Methods: 17 patients with longstanding generalized unprovoked vulvodynia underwent autonomic testing for small fiber neuropathies. Autonomic reflex screens were done: 1. Quantitative Sudomotor Axon Reflex Test (QSART) measuring the total sweat volume; 2. Continuous monitoring of heart rate and blood pressure response during Valsalva Maneuver (VM); 3. Tilt table testing to monitor heart rate and blood pressure for evidence of orthostatic intolerance; 4. Blood pressure and heart rate response to deep breathing (HRDB) during standardized paced deep breathing. Demographics, co-morbidities, length of illness, and medication usage were compared with respect to testing results. Results: Ten out of 17 patients had results consistent with small fiber neuropathy. The average age of the patients tested was 44 years, with a range of 24 to 65 years. The average ages and ranges did not differ between those with abnormal and normal tests. The average length of illness with abnormal testing was 9 years versus 5 years in patients with normal testing. At the time of testing 50% of the patients with both normal and abnormal results were on pain medications. Co-morbidities more likely to be associated with abnormal testing results were Crohn’s disease, gluten sensitivity, connective tissue disorders, chronic tinnitus, and RSD of limb. Conclusions: Evidence points to the possibility that some chronic vulvar pain is due to small fiber neuropathy. With autonomic testing we have documented features of small fiber neuropathy in a significant proportion of patients with chronic generalized vulvar pain. Patients with a longer duration of illness were more likely to have abnormal testing. This diagnosis will help with appropriate medical management 17 patients with longstanding generalized unprovoked vulvodynia underwent autonomic testing for small fiber neuropathy Autonomic testing evaluates small fiber function on the rationale that if autonomic nerves are abnormal then pain fibers probably are too Autonomic reflex screens were done: 1.Quantitatve Sudomotor Axon Reflex Test (QSART) measuring the total sweat volume 2. Continuous monitoring of heart rate and blood pressure response during Valsalva Maneuver (VM) 3. Blood pressure and heart rate response to deep breathing (HRDB) during standardized paced deep breathing 4. Tilt table testing to monitor heart rate and blood pressure for evidence of orthostatic intolerance OBSERVATION The quality of pain that many vulvodynia patients describe is a burning pain with allodynia, similar to what most patients with neuropathic pain describe HYPOTHESIS A subset of generalized unprovoked vulvodynia patients have small fiber neuropathies which can be documented with autonomic testing BACKGROUND The autonomic nervous system’s contribution to the function of women’s external genitalia has not yet been well characterized Erectile problem are well known and studied in men The neurologic basis for vaginal lubrication may be similar to sweating, which is small fiber mediated Demographics, co-morbidities, length of illness, and medication usage were compared with respect to testing results RESULTS Ten out of 17 patients (59%) had results consistent with small fiber neuropathy Age range: 24-65 years Average age at time of testing – 44 years Positive test results – average age 43 (range 24-60) Negative test results – average age 47 (range 2465 ) Length of illness: 1-31 years Normal testing - average of 5 years (range 1 year to 13) Abnormal testing - average of 9 years (range 5 years to 31 Medical conditions more likely to test positive for small fiber neuropathy than overall group: Connective Tissue Dysfunction: 3 - 100% tested positive Gluten sensitivity: 2 - 100% positive Crohn’s disease: 1 - 100% positive Tinnitus: 1 - 100% positive RSD in limb: 1 - 100% positive IBS-Constipation: 4 - 75% positive Lumbar spine disorders: 6 – 67% positive Hip dysfunction: 14 – 63% positive Coccydynia: 8 - 60% tested positive Medication usage: (duloxetine, milnacipran, pregabalin, amitriptyline, hydroxyzine, tylenol with codeine, tapentadol, quetiapine, escitalopram) Normal and abnormal testing ~ 50% of each group used medication Subgroups less likely to test positive for small fiber neuropathy: Vestibulodynia: 14 – 58% positive Depression: 9: - 56% positive Rectocele: 2 - 50% positive Eating disorder: 3 - 33% positive Lichen sclerosis: 3 - 33% positive OBJECTIVES To determine if generalized vulvodynia patients have small fiber neuropathy on autonomic testing Small Fiber Neuropathy - disorder of the peripheral nerves that affects small somatic fibers, autonomic fibers, or both - results in sensory changes and/or autonomic dysfunction Symptoms and Signs: - pain, burning, numbness - autonomic dysfunction (lack of sweating) in the hands and feet - strength not affected - normal tendon reflexes - normal nerve conduction studies The Pudendal Nerve: - the main sensory nerve of the vulva - a peripheral somatic nerve - carries motor fibers which are large fibers - carries sensory fibers, large and small, depending on the sensory modality - typically neuropathy occurs distally because it is an axonal "dying back" phenomenon - the vulva is distal since it is where the pudendal nerve fibers terminate RESEARCH POSTER PRESENTATION DESIGN © 2011 www.PosterPresentation s.com CONCLUSIONS - Some chronic vulvar pain is due to small fiber neuropathy - Autonomic testing documents features of small fiber neuropathy in a significant proportion of patients with chronic generalized vulvar pain - Patients with a longer duration of illness are more likely to have abnormal testing - This diagnosis will help with appropriate medical management REFERENCES 1. Jinny Tavee MD and Lan Zhou MD PhD: Small fiber neuropathy:A burning problem, Cleveland clinic Journal of Medicine 2009; 76 (5 297-305; doi:10.3949.76 a08070 2. Steven D Arbogast, DO; Chief Editor: Nicholas Lorenzo, MD: Autonomic Neuropathy: Treatment and Management, Medscape Reference 2009 3. Low, PA Composite quantification autonomic scoring scale for laboratory of generalized autonomic failure. Mayo Clin Proc. 1993; 68(8):748-752 CONTACT drharris@sohoobgyn.com