//fpnotebook.com/
Vulvodynia
Aka: Vulvodynia, Vulvar Pain, Dysesthetic Vulvodynia, Essential Vulvodynia, Vulvar Dysesthesia
- See Also
- Vulvar Pruritus
- Vulvitis
- Vulvar Dermatitis
- Dyspareunia
- Definitions
- Vulvodynia
- Vulvar Pain without obvious cause and present for at least 3 months
- Epidemiology
- Most common cause of Dyspareunia in premenopausal women
- Prevalence: 12% (believed to be an under estimate)
- Pathophysiology
- Likely multiple causes that result in localized inflammation and secondary nerve fiber remodeling
- 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)
- 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
- 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
- Diagnosis
- Vulvar Pain without obvious cause and present for at least 3 months
- Labs
- KOH and saline (wet prep)
- Vulvar biopsy (consider)
- 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
- Associated Conditions
- Interstitial Cystitis
- Irritable Bowel Syndrome
- Fibromyalgia
- Chronic Pelvic Pain (including pelvic Myofascial Pain)
- Sexual Dysfunction
- Major Depression
- Anxiety Disorder
- Management: General
- Support group
- Physical therapy with pelvic floor biofeedback
- Cognitive behavior therapy
- Mindfulness-based stress reduction therapy
- 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
- Possible benefit
- Lidocaine gel or cream 2-5%
- Apply to introitus prior to bed or intercourse
- Not typically recommended as not found better than Placebo (may be trialed short-term)
- Cromolyn Cream 4% applied tid to introitus
- Requires compounding pharmacy preparation
- Other measures studied
- Intralesional Interferon injection
- 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
- Low-Oxalate Diet
- Oral Calcium Citrate (Citrucel)
- Ineffective measures
- Avoid longterm Analgesics and Narcotics
- 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
- Course
- Vulvodynia resolves spontaneously in 50% of women
- Resources
- National Vulvodynia Association
- http://www.nva.org
- Phone: 301-299-0775
- Vulvar Pain Foundation
- http://www.vulvarpainfoundation.org
- 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]