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BASICS

  • Chronic vulvar pain ≥3 months, no visible findings or neurologic disease.
  • Provoked vulvodynia: sensation of blockage or too small vagina for penetration.
  • Unprovoked vulvodynia: constant burning or stinging unrelated to sexual activity.

EPIDEMIOLOGY

  • Occurs at any age; most diagnosed between 20 and 40 years.
  • Annual incidence: 1.8%; lifetime incidence ~15%.
  • Provoked vulvodynia most common sexual pain cause in women <30 years.
  • Latina women 80% more likely to present than White or Black women.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Multifactorial with unknown exact cause.
  • Neuropathic: increased neuronal proliferation and branching in vulvar biopsies.
  • Pelvic floor muscle hypertonicity and decreased relaxation.
  • Recurrent infections (candidiasis, others), immune-mediated inflammation.
  • Chemical or physical trauma.
  • Reduced estrogen receptor expression or altered estrogen levels.
  • CNS involvement similar to other chronic pain syndromes.
  • Trauma history: episiotomy, forceps delivery, abuse.

RISK FACTORS

  • Recurrent vulvovaginal infections.
  • Hormonal changes (perimenopause/menopause).
  • Pelvic floor dysfunction.
  • Interstitial cystitis/painful bladder syndrome.
  • Childhood physical or sexual abuse.
  • Depression, anxiety, other chronic pain disorders.

GENERAL PREVENTION

  • Wear cotton underwear during day, no underwear at night.
  • Avoid douching, perfumes, dyes, detergents.
  • Avoid abrasive activities, tight/synthetic clothing.
  • Avoid panty liners.
  • Clean vulva with water only, pat dry.
  • Avoid hair dryers on vulvar area.

COMMONLY ASSOCIATED CONDITIONS

  • Chronic pain syndromes.
  • Chronic cystitis.
  • Irritable bowel syndrome.
  • Anxiety, endometriosis, low back pain.

DIAGNOSIS

  • Clinical diagnosis; no definitive test.
  • Use pain scales like McGill Pain Questionnaire.
  • Rule out infections, dermatologic lesions.
  • History: sexual, social, pain history, bowel/bladder dysfunction, trauma, infections.
  • Physical exam: erythema especially at vestibule, pain on labial separation.
  • Vaginal exam: pain localized or generalized; evaluate for pelvic floor hypertonicity.

DIFFERENTIAL DIAGNOSIS

  • Infections: candidiasis, herpes, HPV, bacterial vaginosis, trichomoniasis, dermatophytes.
  • Inflammatory: lichen sclerosus, lichen planus.
  • Neoplasia: Paget disease, vulvar/vaginal intraepithelial neoplasia, squamous cell carcinoma.
  • Neurologic/muscular: herpes neuralgia, spinal nerve compression, vaginismus.

DIAGNOSTIC TESTS & INTERPRETATION

  • Tampon test reproduces pain in real-life settings.
  • Test for concurrent infections.
  • Biopsy of suspicious lesions.
  • Vaginal pH, wet mount, yeast culture to rule out vaginitis.
  • STI testing if risk factors present.
  • Advanced imaging only if symptoms dictate.

TREATMENT

General Measures

  • Multidisciplinary treatment (medical, psychotherapy, physical therapy) best outcomes.
  • Cognitive-behavioral therapy (CBT) superior to supportive therapy.
  • Avoid irritants, tight clothing; pelvic floor relaxation exercises.

Medications

Oral

  • Tricyclic antidepressants (e.g., amitriptyline, nortriptyline): start low dose, titrate up; side effects include fatigue, constipation.
  • Anticonvulsants (gabapentin, topiramate, lamotrigine) if others fail.
  • SSRIs/SNRIs occasionally used.

Topical

  • Lidocaine 5% ointment (provoked vestibulodynia): apply 15-20 mins before intercourse or overnight for weeks.
  • Cromolyn 4% cream (mast cell stabilizer).
  • Capsaicin 0.025% cream.
  • Topical amitriptyline + baclofen for vaginismus.
  • Topical corticosteroids/testosterone ineffective.
  • Botulinum toxin A injections may help.

ISSUES FOR REFERRAL

  • Multidisciplinary team: psychology, partner therapy, pain management.
  • Pelvic floor physical therapy.
  • Referral to vulvar specialists if refractory.

ADDITIONAL THERAPIES

  • CBT reduces vulvar discomfort by ~30%.
  • Biofeedback and pelvic floor therapy (12-16 weeks).
  • Vaginal dilators for vaginismus.

SURGERY

  • Vestibulectomy for localized/provoked vulvodynia refractory to conservative therapy.
  • Not recommended for generalized vulvodynia.
  • 60-80% success in selected patients.
  • Less success in vaginismus.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Acupuncture shows some benefit.

ONGOING CARE

  • Educate on chronic nature and symptom control.
  • Encourage home remedies: ice packs, sitz baths, olive oil, barrier creams.

PROGNOSIS

  • Traditionally chronic pain disorder; remission possible.
  • About 10% report remission regardless of treatment.

REFERENCES

  1. Sadownik LA. Etiology, diagnosis, and clinical management of vulvodynia. Int J Womens Health. 2014;6:437-449.
  2. Shah M, Ho...
  3. Boardman LA, Stockdale CK. Sexual pain. Clin Obstet Gynecol. 2009;52(4):682-690.
  4. Nunns D, Mandal D, Byrne M, et al; British Society for the Study of Vulval Disease Guideline Group. Guidelines for management of vulvodynia. Br J Dermatol. 2010;162(6):1180-1185.
  5. Stockdale CK, Lawson HW. 2013 Vulvodynia guideline update. J Low Genit Tract Dis. 2014;18(2):93-100.
  6. Stenson AL. Vulvodynia: diagnosis and management. Obstet Gynecol Clin North Am. 2017;44(3):493-508.
  7. De Andres J, Sanchis-Lopez N, Asensio-Samper JM, et al. Vulvodynia—an evidence-based literature review and proposed treatment algorithm. Pain Pract. 2016;16(2):204-236.

ICD10

  • N94.819 Vulvodynia, unspecified
  • N94.818 Other vulvodynia
  • N94.810 Vulvar vestibulitis

Clinical Pearls

  • Vulvodynia is a clinical diagnosis in any woman with chronic vulvar/introitus pain.
  • Improvement may take weeks to months and may not be complete.
  • No universal treatment; many improve over time with or without treatment.