Evaluating Vulvodynia – Making the Diagnosis and Key Management Points
Vulvar pain is a symptom and not a diagnosis. If symptoms persist for a minimum of three months and no other pathology can be identified, consider the diagnosis of vulvodynia.
Obtain a history and physical to determine other causes of vulvar pain such as:
infection (e.g., candidiasis)
musculoskeletal (pelvic muscle overactivity)
inflammation (e.g, lichen planus)
iatrogenic (radiation induced)
On physical examination, determine the location of the pain (see ACOG Committee Opinion in ‘Learn More – Primary Sources’ for illustrations on anatomy and how to perform the following test)
Using a Q-tip on the vestibule press on the vulva to determine which locations illicit a pain response
To determine a baseline place significant pressure on labia majora, interlabia sulci and labia minora
Touch, using the Q-tip, lateral and medial to Hart’s line
If sensitive to touch medial of Hart’s line a diagnosis of vestibulodynia can be established
NOTE: See ACOG Committee Opinion in ‘Learn More – Primary Sources’ for illustrations on anatomy and how to perform the following test
Multisocietal Definition Consensus (ISSVD, ISSWSH, and IPPS)
Localized (e.g. vestibulodynia)
Generalized (involves whole vulva)
Mixed (a combination of both)
Provoked (discomfort provoked by physical contact, sexual or nonsexual)
Spontaneous (can occur without any provoking physical contact)
Mixed (a combination of both)
Primary (occurs with first provoking physical contact)
Secondary (did not occur with the first provoking physical contact)
Persistent | At least 3 months, constant or intermittent
Constant | Symptoms always present
Intermittent | Symptoms not always present
Immediate | Occurs during the provoking physical contact
Delayed | Symptoms occur after the provoking physical event
Symptoms may include burning, stinging, itching, and may be constant or only upon contact (provoked). When the pain is primarily localized to the vestibule, the term vestibulodynia can be used. With respect to timing, pain can be persistent or cyclical. Most cases of vulvodynia can be treated hormonally or through pelvic floor physiotherapy. In the most extreme cases of vestibulodynia, rarely a vestibulectomy may be indicated.
Treatment of generalized vulvodynia or vestibulodynia may include the following
Review and discontinuation of products being used by patient (soaps, shampoo, pads)
If the pain is hormonally mediated, use of local topical hormonal creams (e.g., estrogen)
If pain is thought to be due to high pelvic tone, referral to a pelvic floor physical therapist may be appropriate
Consider pain medications such as tricyclics and Gabapentin: Start with lower dosage than typically used for depression or epilepsy
Amitriptyline (usually first-line): 5–25 mg po nightly and increased by 10–25 mg weekly (maximum 150 mg daily) | If plan to stop tricyclics: Wean off (do not stop suddenly) by reducing dose 10–25 mg every few days
Gabapentin: 300 mg total daily to a maximum 3,600 mg daily (1,200 mg by mouth three times a day) | Adjust dose based on adverse effects
Note: Above medications will need to be titrated, often over 3 to 4 weeks to arrive at optimal dose | Adverse effects include sedation, dry mouth, and dizziness (some patients will develop tolerance)
Additional Treatment Options
Use of topical medications such as lidocaine
For other topical medications, ointments are better tolerated than creams (creams contain more preservatives and stabilizers, which can cause burning)
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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