Evaluating Vulvodynia – Making the Diagnosis and Key Management Points

CLINICAL ACTIONS:

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)
  • trauma
  • hormonal deficiency
  • 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

Classification

Multisocietal Definition Consensus (ISSVD, ISSWSH, and IPPS)

• Location
  • Localized (e.g. vestibulodynia)
  • Generalized (involves whole vulva)
  • Mixed (a combination of both)
• Provocation
  • Provoked (discomfort provoked by physical contact, sexual or nonsexual)
  • Spontaneous (can occur without any provoking physical contact)
  • Mixed (a combination of both)
• Onset
  • Primary (occurs with first provoking physical contact)
  • Secondary (did not occur with the first provoking physical contact)
• Temporal Pattern
  • 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

SYNOPSIS:

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.

KEY POINTS:

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 to 25 mg po nightly and increased by 10 to 25 mg weekly (maximum 150 mg daily) | If plan to stop tricyclics: Wean off (do not stop suddenly) by reducing dose 10 to 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)
• Transcutaneous electrical nerve stimulation (TENS)
• Pudendal nerve block, botulinum toxin injections
• If the vestibulodynia is primary and other treatments have failed, further neurologic workup and surgical approaches may be required

LEARN MORE – PRIMARY SOURCES:

ACOG ASCCP Committee Opinion 673: Persistent Vulvar Pain

2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia

Descriptors of Vulvodynia: A Multisocietal Definition Consensus (International Society for the Study of Vulvovaginal Disease, the International Society for the Study of Women Sexual Health, and the International Pelvic Pain Society)

New topical treatment of vulvodynia based on the pathogenetic role of cross talk between nociceptors, immunocompetent cells, and epithelial cells

Recent advances in understanding provoked vestibulodynia

Localized provoked vestibulodynia (vulvodynia): assessment and management

Nature Reviews Disease Primers: Vulvodynia