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. Vulvar Pain without obvious cause and present for at least 3 months
3. Epidemiology
   1. Most common cause of Dyspareunia in premenopausal women
   2. Lifetime Prevalence: 10-28%
4. Pathophysiology
   1. Likely multiple causes that result in localized inflammation and secondary nerve fiber remodeling
5. 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)
6. Symptoms
   1. Chronic vulvar discomfort
      1. Vulva is stinging, irritated, burning, tearing, aching, stabbing and raw
      2. Vulvar Pruritus suggests an alternative diagnosis (e.g. Vaginitis, Vulvar Dermatitis)
   2. Timing
      1. Onset with provocation, lasting hours to days
   3. Provocative
      1. Sexual Intercourse (Dyspareunia), tampon insertion, sitting, tight clothes
7. Signs
   1. Dermatitis suggests alternative diagnosis
      1. Erythema may be only finding
      2. No visible dermatoses
      3. No identifiable neurologic disorder
   2. Cotton swab testing (pressure point testing)
      1. Localized tenderness and erythema in region of hymen, especially posterior vestibule
      2. Reference locations of findings using a clock face (e.g. 12:00, 3:00, 6:00)
      3. Touch moist cotton swab to vulva and vaginal wall, with sequentially increased pressure
         1. Vulvar vestibule
         2. Posterior introitus
         3. Posterior hymen
      4. Indent mucosa 0.5 cm
      5. Pain on indentation (especially intense, highly localized pain) suggests Vulvodynia
8. Diagnosis
   1. Vulvar Pain without obvious cause and present for at least 3 months
9. Labs
   1. KOH and saline (wet prep)
   2. Consider cultures and PCR for infections
   3. Vulvar biopsy (consider for Lichen Sclerosus, Lichen Planus vs Contact Dermatitis)
10. 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. Herpes Simplex Virus
    6. Candida Vulvovaginitis (chronic)
    7. Lichen scleroris
    8. Lichen Planus
    9. Vulvar atrophy
    10. Vestibular Papillomatosis
    11. Paget Disease
    12. Vulvar intraepthelial neoplasia
    13. Squamous Cell Carcinoma
    14. Local Skin Trauma or iatrogenic injury (e.g. Radiation Therapy, prior surgery)
    15. Peripheral Neuropathy
        1. Pudendal Neuropathy
        2. Ilioinguinal Neuropathy
        3. Genitofemoral Neuropathy
11. Associated Conditions
    1. Interstitial Cystitis
    2. Irritable Bowel Syndrome
    3. Fibromyalgia
    4. Chronic Pelvic Pain (including pelvic Myofascial Pain)
    5. Sexual Dysfunction
    6. Major Depression
    7. Anxiety Disorder
    8. History of sexual abuse or physical abuse
12. Management: General
    1. Employ a multidisciplinary team approach
    2. Support group
    3. Physical therapy with pelvic floor biofeedback
    4. Cognitive behavior therapy
    5. Mindfulness-based stress reduction therapy
13. Management: Local therapies
    1. Eliminate potential irritants (Contact Dermatitis)
       1. Avoid harsh soaps (e.g. Irish Spring) and detergents
       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. Use cotton menstrual pads
    2. Ineffective therapies unless specific indications (e.g. Atrophic Vaginitis)
       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. Not typically recommended as not found better than Placebo (may be trialed short-term)
       2. Cromolyn Cream 4% applied tid to introitus
          1. Requires compounding pharmacy preparation
    4. Other measures studied
       1. Intralesional Interferon injection
       2. Compounded topical Gabapentin
       3. Compounded topical vaginal muscle relaxants
       4. Boutulinum Toxin A Pelvic Floor Injections
14. 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. Serotonin Norepinephrine Reuptake Inhibitors (e.g. Venlafaxine or Effexor)
    4. Selective Serotonin Reuptake Inhibitor
    5. Gabapentin (Neurontin)
    6. Other measures with possible benefit
       1. Low-Oxalate Diet
       2. Oral Calcium Citrate (Citrucel)
    7. Ineffective measures
       1. Avoid longterm Analgesics and Narcotics
15. Management: Surgery
    1. Perineoplasty or Vestibulectomy
       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
16. Course
    1. Vulvodynia resolves spontaneously in 50% of women
17. Resources
    1. National Vulvodynia Association
       1. http://www.nva.org
       2. Phone: 301-299-0775
    2. Vulvar Pain Foundation
       1. http://www.vulvarpainfoundation.org
18. 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. Ringel (2020) Am Fam Physician 102(9):550-7 [PubMed]
    7. Seehusen (2014) Am Fam Physician 90(7): 465-70 [PubMed]