Vulvodynia

Aka: Vulvodynia, Vulvar Pain, Dysesthetic Vulvodynia, Essential Vulvodynia, Vulvar Dysesthesia

1. See Also
   1. Vulvar Pruritus
   2. Vulvitis
   3. Vulvar Dermatitis
   4. Dyspareunia
2. Definitions
   1. Vulvodynia
      1. Chronic vulvar discomfort
         1. Vulva is stinging, burning, and raw
      2. No visible dermatoses
      3. No identifiable neurologic disorder
      4. Erythema may be only finding
3. Types
   1. Spectrum of Vulvodynia
      1. Generalized Vulvar Dysesthesia
      2. Localized Vulvar Dysesthesia
         1. Previously known as Vulvar Vestibulitis
   2. Timing
      1. Provoked Vulvodynia (triggered by touch)
      2. Unprovoked Vulvodynia (continuous Vulvodynia)
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 (other than erythema) suggests alternative diagnosis
   2. Cotton swab testing
      1. Touch moist cotton swab to vulva and vaginal wall
         1. Posterior introitus
         2. Posterior hymen
      2. Indent mucosa 0.5 cm
      3. Pain on indentation (especially intense, highly localized pain) suggests Vulvodynia
6. Labs
   1. KOH and saline (wet prep)
   2. Vulvar biopsy (consider)
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. Associated Conditions
   1. Major Depression
   2. Anxiety Disorder
9. Management: General
   1. Support group
   2. Physical therapy with pelvic floor biofeedback
   3. Cognitive behavior therapy
10. 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 2-5%
          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
11. 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
12. 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
13. Course
    1. Vulvodynia resolves spontaneously in 50% of women
14. Resources
    1. National Vulvodynia Association
       1. http://www.nva.org
       2. Phone: 301-299-0775
    2. Vulvar Pain Foundation
       1. http://www.vulvarpainfoundation.org
15. Reference
    1. Black (1995) OBGyn Dermatology, Mosby-Wolfe, London
    2. Apgar (1996) Am Fam Physician 53(4):1171-80 [PubMed]
    3. Barhan (1997) Postgrad Med 102(3):121-32 [PubMed]
    4. Metts (1999) Am Fam Physician 59(6):1547-56 [PubMed]
    5. Reed (2006) Am Fam Physician 73:1231-9 [PubMed]
    6. Seehusen (2014) Am Fam Physician 90(7): 465-70 [PubMed]