Vulvodynia

1. See Also
   1. Vulvar Pruritus
   2. Vulvitis
   3. Vulvar Dermatitis
   4. Dyspareunia
2. Definition: Vulvodynia
   1. Chronic vulvar discomfort
      1. Vulva is stinging, burning, and raw
   2. No visible dermatoses
   3. Erythema may be only finding
3. Types (may fall along spectrum of Vulvodynia)
   1. Generalized Vulvar Dysesthesia
   2. Localized Vulvar Dysesthesia
      1. Previously known as Vulvar Vestibulitis
4. Symptoms
   1. Characteristics
      1. Burning, irritating, or sharp pain
   2. Timing: Onset with provocation, lasting hours to days
   3. Provocative: Intercourse, tampon, sit, tight clothes
5. Signs
   1. Dermatitis suggests alternative diagnosis
   2. Cotton swab testing
      1. Touch cotton swab to vulva and vaginal wall
         1. Posterior introitus
         2. Posterior hymen
      2. Indent mucosa 0.5 cm
      3. Pain on indentation suggests Vulvodynia
6. Labs
   1. KOH and saline (wet prep)
7. Differential Diagnosis
   1. See Dyspareunia
   2. Vaginismus (pelvic floor muscle spasm)
   3. Pruritus Vulvae (Chronic Vulvar Itching, no burning)
   4. Allergic Vulvitis (local Contact Dermatitis)
   5. Candida Vulvovaginitis (chronic)
   6. Lichen scleroris
   7. Lichen Planus
   8. Vulvar atrophy
   9. Vestibular Papillomatosis
8. Management: General
   1. Support group
   2. Physical therapy with pelvic floor biofeedback
   3. Cognitive behavior therapy
9. Management: Local therapies
   1. Eliminate potential irritants (Contact Dermatitis)
      1. Avoid harsh soaps (e.g. Irish Spring)
      2. Avoid products with perfumes or dyes
      3. Avoid use of fabric softeners
      4. Avoid nylon or synthetic underwear
         1. Wear only all-cotton underwear
   2. Ineffective therapies unless specific indications
      1. Topical Estradiol cream (Estrace Cream) 0.01% bid
         1. Effective in Menopause, Atrophic Vaginitis
      2. Low potency Topical Corticosteroid ointment
         1. Effective in Lichen Sclerosus
   3. Possible benefit
      1. Lidocaine gel or cream 5%
         1. Apply to introitus prior to bed or intercourse
      2. Cromolyn Cream 4% applied tid to introitus
         1. Requires compounding pharmacy preparation
   4. Other measures studied
      1. Intralesional interferon injection
10. Management: Systemic therapies
    1. Amitriptyline (Elavil)
       1. Start at 10-20 mg PO hs
       2. Advance to 25 mg PO bid-tid
       3. Anticipate over 6 months therapy
    2. Desipramine (Norpramin)
    3. Venlafaxine (Effexor) or SSRI
    4. Gabapentin (Neurontin)
    5. Other measures with possible benefit
       1. Low-Oxalate Diet
       2. Oral Calcium Citrate (Citrucel)
    6. Ineffective measures
       1. Avoid longterm Analgesics and Narcotics
11. Management: Surgery
    1. Perineoplasty
       1. Variable outcome: Symptoms may worsen after treatment
       2. Not recommended in most cases
          1. Reserved for severe, refractory cases
          2. Vulvodynia resolves spontaneously in many cases
             1. Yet surgery is permanent
    2. CO2 Laser (listed for historical purpose)
       1. Not recommended for Vulvodynia due to poor outcomes
       2. Results in scarring and worsened symptoms
12. Course
    1. Vulvodynia resolves spontaneously in 50% of women
13. Resources
    1. National Vulvodynia Association
       1. http://www.nva.org
       2. Phone: 301-299-0775
    2. Vulvar Pain Foundation
       1. http://www.vulvarpainfoundation.org
14. Reference
    1. Black (1995) OBGyn Dermatology, Mosby-Wolfe, London
    2. Apgar (1996) Am Fam Physician 53(4):1171-80
    3. Barhan (1997) Postgrad Med 102(3):121-32
    4. Metts (1999) Am Fam Physician 59(6):1547-56
    5. Reed (2006) Am Fam Physician 73:1231-9