Transcript of VPS Podcast 6 - Vulval conditions and the new NHS: a presentation given by David Nunns

Pathways are very important. Every patient with a health problem should be on some sort of pathway. They’re very well established in cancer care. If you’ve got a suspected cancer, you’ve developed symptoms, you see your GP, you get a referral to the hospital, you get tests, you get a diagnosis, you get treatment, you get discharged, and you follow that pathway – it’s very well defined. Does that pathway exist for vulval conditions? The answer is that it’s very poorly developed in the UK, but this is perhaps what we would want to happen in the future. The blue arrow is a consultation, perhaps the onset of symptoms – soreness, burning, itching – a problem, and so the woman would go to see her GP as the first port of call. At that first visit, we’d want assessment, take a history, maybe a swab, certainly a close examination, maybe a diagnosis being made and then some form of treatment. It might be an emollient; it might be a Canesten pessary if it’s thrush; it might be a steroid ointment. Often a follow-up visit’s necessary, or if things don’t subside, then a return visit to see the GP. But after a period of time, if there’s repeated visits, that GP would refer on, thinking that this wasn’t straightforward. He or she would send that patient to the hospital – secondary level healthcare. So, that’s a referral. Now, usually that is going to be a specialist within Gynaecology or Dermatology, depending on the local services. Dermatology are skin specialists; gynaecologists are women’s health specialists. Gynaecologists are surgeons; dermatologists don’t usually do surgery on the vulva. I can tell you now that the gynaecologists have very little training (and dermatologists) in vulval problems – it’s a real fraction of their overall training. Your Obs & Gynae consultant, and I am one - basically the majority of the work is obstetrics, and there is gynaecology attached to it, of which vulval disease forms a very small part of the training. So new consultants don’t have a huge exposure to vulval problems. It’s the same for Dermatology: vulval dermatology forms a very small part. Anyway, you go to these clinics, but new consultants should know about all the basics I’ve talked about – history, assessment, examination. So you might be seen in this service here – history, examination, diagnosis, treatment, perhaps a follow-up visit. If things are fine, great – you might be returned to general practice. If things aren’t fine after a series of visits, then that’s their next level, this vulval service that I’ve talked about, this multidisciplinary team, and it’s at this service that you might then access the bigger team - the specialist physiotherapy for pelvic floor rehabilitation, sexual therapy for psychosexual problems – low libido, vaginismus, arousal disorders – we’re going to hear about all these problems later on today. Pain management I’ll come onto in a sec – CBT, cognitive-behavioural therapy, for the bigger picture. I’ve said to you before, I think often patients get stuck here in general practice, or they’ve dipped into the hospital and they’re back in general practice.

If you’re in this setup, you can’t stay here forever - these slots are usually quite precious, so it’s back to general practice for follow-up. It’s a pyramid structure, and at the bottom of the pyramid, very important, you’ve got self-management. You’re all self-managing because you’ve come to days like today, you’re reading, you’re looking on the internet, you’re watching the webinars, you’re listening to the podcasts, you’re joining support groups, you’re networking with other women with vulval pain and you’re actively self-managing, and that’s throughout the whole process, really – understanding your condition, becoming the expert patient, that’s absolutely crucial.

One more part to this slide that I’ve put together is GU Medicine clinics. I’m not sure if you’re aware of this service, but GU Medicine clinics offer an excellent service to women with vulval problems. I know we’ve got some GU Medicine people here – they might want to chip in at the end with questions. They offer a free - well, everything’s free - a confidential, anonymous service to patients, and women do dip into these clinics for flare-ups, for exclusion of thrush, for STI checkups and sometimes they just go because of problems at this level here. Every hospital has a service. There are more community services now, but they fall outside any referral pattern from GPs to hospital, hospital to vulval service. But they are integrated very much into vulval services in the UK.

Back to Toolkit of Skills – well, this may be pretty basic, but just to open up your minds to some other people that might be involved with your vulval problem, and this is quite honest, and again, we can have a discussion about this afterwards, but I think there is a role for pain management teams, specialist hospital or community-based teams. You get there via a GP referral. If a GP has seven minutes per patient, they generally have 20 - 30 minutes per patient for a new patient. Their role is advanced pain management: nerve blocks, spinals, epidurals, advanced pain-modifying drugs; they have a whole different toolkit of options they can offer to women with vulvodynia. However, many of these health professionals will not examine the vulva. They’re pain management consultants and nurses, they often have an anaesthetic background, so they probably won’t be looking at your vulva for them to check you out.