II. Definitions
- Vulvodynia
- Vulvar Pain without obvious cause and present for at least 3 months
III. Epidemiology
- Most common cause of Dyspareunia in premenopausal women
- Prevalence: 12% (believed to be an under estimate)
IV. Pathophysiology
- Likely multiple causes that result in localized inflammation and secondary nerve fiber remodeling
V. Types
- Spectrum of Vulvodynia
- Generalized Vulvar Dysesthesia
- Localized Vulvar Dysesthesia
- Previously known as Vulvar Vestibulitis
- Timing
- Provoked Vulvodynia (triggered by touch)
- Unprovoked Vulvodynia (continuous Vulvodynia)
VI. Symptoms
- Chronic vulvar discomfort
- Vulva is stinging, irritated, burning, and raw
- Timing: Onset with provocation, lasting hours to days
- Provocative: Intercourse, tampon, sit, tight clothes
VII. Signs
- Dermatitis suggests alternative diagnosis
- Erythema may be only finding
- No visible dermatoses
- No identifiable neurologic disorder
- Cotton swab testing (pressure point testing)
- Touch moist cotton swab to vulva and vaginal wall
- Vulvar vestibule
- Posterior introitus
- Posterior hymen
- Indent mucosa 0.5 cm
- Pain on indentation (especially intense, highly localized pain) suggests Vulvodynia
- Touch moist cotton swab to vulva and vaginal wall
VIII. Diagnosis
- Vulvar Pain without obvious cause and present for at least 3 months
IX. Labs
- KOH and saline (wet prep)
- Vulvar biopsy (consider)
X. Differential Diagnosis
- See Dyspareunia
- Vaginismus (pelvic floor muscle spasm)
- Pruritus Vulvae (Chronic Vulvar Itching, no burning)
- Allergic Vulvitis (local Contact Dermatitis)
- Herpes Simplex Virus
- Candida Vulvovaginitis (chronic)
- Lichen scleroris
- Lichen Planus
- Vulvar atrophy
- Vestibular Papillomatosis
- Paget Disease
- Vulvar intraepthelial neoplasia
- Squamous Cell Carcinoma
- Local Skin Trauma or iatrogenic injury (e.g. Radiation Therapy, prior surgery)
-
Peripheral Neuropathy
- Pudendal Neuropathy
- Ilioinguinal Neuropathy
- Genitofemoral Neuropathy
XI. Associated Conditions
- Interstitial Cystitis
- Irritable Bowel Syndrome
- Fibromyalgia
- Chronic Pelvic Pain (including pelvic myofascial pain)
- Sexual Dysfunction
- Major Depression
- Anxiety Disorder
XII. Management: General
- Support group
- Physical therapy with pelvic floor biofeedback
- Cognitive behavior therapy
- Mindfulness-based stress reduction therapy
XIII. Management: Local therapies
- Eliminate potential irritants (Contact Dermatitis)
- Avoid harsh soaps (e.g. Irish Spring)
- Avoid products with perfumes or dyes
- Avoid use of fabric softeners
- Avoid nylon or synthetic underwear
- Wear only all-cotton underwear
- Ineffective therapies unless specific indications
- Topical Estradiol cream (Estrace Cream) 0.01% bid
- Effective in Menopause, Atrophic Vaginitis
- Low potency Topical Corticosteroid ointment
- Effective in Lichen Sclerosus
- Topical Estradiol cream (Estrace Cream) 0.01% bid
- Possible benefit
- Other measures studied
- Intralesional Interferon injection
XIV. Management: Systemic therapies
-
Amitriptyline (Elavil)
- Start at 10-20 mg PO hs
- Advance to 25 mg PO bid-tid
- Anticipate over 6 months therapy
- Desipramine (Norpramin)
- Venlafaxine (Effexor) or SSRI
- Gabapentin (Neurontin)
- Other measures with possible benefit
- Ineffective measures
XV. Management: Surgery
- Perineoplasty or Vestibulectomy
- Variable outcome: Symptoms may worsen after treatment
- Not recommended in most cases
- Reserved for severe, refractory cases
- Vulvodynia resolves spontaneously in many cases
- Yet surgery is permanent
-
CO2 Laser (listed for historical purpose)
- Not recommended for Vulvodynia due to poor outcomes
- Results in scarring and worsened symptoms
XVI. Course
- Vulvodynia resolves spontaneously in 50% of women
XVII. Resources
- National Vulvodynia Association
- http://www.nva.org
- Phone: 301-299-0775
- Vulvar Pain Foundation
XVIII. Reference
- Black (1995) OBGyn Dermatology, Mosby-Wolfe, London
- Apgar (1996) Am Fam Physician 53(4):1171-80 [PubMed]
- Barhan (1997) Postgrad Med 102(3):121-32 [PubMed]
- Metts (1999) Am Fam Physician 59(6):1547-56 [PubMed]
- Reed (2006) Am Fam Physician 73:1231-9 [PubMed]
- Ringel (2020) Am Fam Physician 102(9):550-7 [PubMed]
- Seehusen (2014) Am Fam Physician 90(7): 465-70 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Concepts | Disease or Syndrome (T047) |
SnomedCT | 33563008 |
English | Essential vulvodynia, Essential vulvodynia (disorder) |
Spanish | vulvodinia esencial (trastorno), vulvodinia esencial |
Ontology: Vulvodynia (C0406670)
Definition (MSH) | Complex pain syndrome with unknown etiology, characterized by constant or intermittent generalized vulva pain (Generalized vulvodynia) or localized burning sensations in the VESTIBULE area when pressure is applied (Vestibulodynia, or Vulvar Vestibulitis Syndrome). Typically, vulvar tissue with vulvodynia appears normal without infection or skin disease. Vulvodynia impacts negatively on a woman's quality of life as it interferes with sexual and daily activities. |
Concepts | Disease or Syndrome (T047) |
MSH | D056650 |
ICD9 | 625.7, 625.70 |
ICD10 | N94.819 , N94.81 |
SnomedCT | 238968009 |
English | Burning vulva, vulvodynia, vulvodynia (diagnosis), vulvar burning (symptom), vulvar burning, Vulvodynia, Vulvodynias, Vulvodynia NOS, Vulvodynia, unspecified, Vulvodynia [Disease/Finding], Burning (of);vulva, discomfort of vulva, burning vulva, vulva burning, vulvar discomfort, Vulvodynia (disorder), vulval discomfort |
Dutch | vulvodynie |
Czech | Vulvodynie, vulvodynie |
Japanese | ガイインブツウ, 外陰部痛 |
French | Vulvodynie |
German | Vulvodynie, Vulvodynia |
Italian | Vulvodinia |
Spanish | Vulvodinia, ardor en vulva, dolor urente en vulva, vulvodinia (trastorno), vulvodinia, quemazón vulvar |
Russian | ВЕСТИБУЛОДИНИЯ, VUL'VODINIIA, ГЕНЕРАЛИЗОВАННАЯ ВУЛЬВОДИНИЯ, VESTIBULODINIIA, GENERALIZOVANNAIA VUL'VODINIIA, ВУЛЬВОДИНИЯ |
Swedish | Vulvodyni |
Polish | Westibulodynia, Wulwodynia uogólniona, Wulwodynia |
Hungarian | Vulvodynia |
Norwegian | Essensiell vulvodyni, Vulvodyni |
Portuguese | Vulvodinia, Disestesia Vulvar |