Vu l v o d y n i a

Mitul Shah, MD, Susan Hoffstetter, PhD, WHNP-BC*

KEYWORDS
 Vulvodynia  Vulvar pain  Vaginismus

KEY POINTS
 Vulvodynia is a chronic pain disorder.
 Cause is considered to be multifactorial.
 Evaluation and diagnosis is key to appropriate management.
 Therapies include self-management and nonpharmacologic, pharmacologic, and surgical
treatment.
 Emotional and psychological support is invaluable.
 Vaginismus occurs commonly with vulvodynia.

DIAGNOSIS
Introduction
Vulvodynia has been described since the 1880s as an “excessive sensibility of the
nerves supplying the mucous membranes of the vulva”1 or “supersensitivities of the
vulva.”2 It was described as “burning vulvar syndrome” by the International Society
for the Study of Vulvovaginal Disease (ISSVD) in 1975. A variety of terms have been
used to label vulvar pain, including essential vulvodynia, dysesthetic vulvodynia, vulvar
vestibulitis syndrome, vulvar dysesthesia, provoked vulvar dysesthesias, or sponta-
neous vulvar dysesthesia. In 2003, the ISSVD settled on the current classification of
generalized or localized, and then each type subdivided into provoked, unprovoked,
or mixed.3

Definition
Chronic vulvar pain lasting 3 months or longer is termed vulvodynia. The ISSVD defines
vulvodynia as chronic vulvar discomfort or pain, characterized by burning, stinging,
irritation, or rawness of the female genitalia in which there is no infection, skin disease,
or neoplasia of the vulva or vagina, or specific clinically identifiable neurologic disorder
as the cause of these symptoms.4

The authors have nothing to disclose.

Department of Obstetrics Gynecology & Women’s Health, Saint Louis University School of
Medicine, 6420 Clayton Road, St Louis, MO 63117, USA
* Corresponding author.
E-mail address: [email protected]

Obstet Gynecol Clin N Am 41 (2014) 453–464

http://dx.doi.org/10.1016/j.ogc.2014.05.005 obgyn.theclinics.com
0889-8545/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
454 Shah & Hoffstetter

The classification of vulvodynia is based on the site of the pain, whether it is local-
ized or generalized, and whether the pain is provoked, unprovoked, or mixed.5 Pro-
voked refers to any touch or stimulation that elicits pain, sexual or nonsexual.
Unprovoked refers to pain that occurs in the absence of touch or stimulation, and
mixed refers to pain that varies with or without touch or stimulation. Localized and
generalized vulvodynia can be provoked, unprovoked, or mixed.
Localized vulvodynia or vestibulodynia is pain that is caused by touching a localized
area of the vulva, commonly occurring in the region of the vestibular glands. It can also
occur at the clitoris, clitorodynia or on one side of the vulva, hemivulvodynia. The pain
has been described as a feeling of burning, stinging, tearing, throbbing, razor blades,
or cut glass. Women with localized vulvodynia have dyspareunia or avoid sex,
because of the pain at the introitus. The pain can last for hours to days after sexual
touch, intercourse, or attempts at intercourse. Inserting or wearing tampons can be
painful. Women may not be able to engage in routine exercise or activities, such as
riding a bicycle or wearing tight clothing or jeans. Patients can be pain-free if the pain-
ful areas are not touched. Localized vulvodynia is further subdivided into primary,
vestibular pain during the first attempt at vaginal penetration versus secondary, and
vestibular pain after a period of normal function. A recent study showed that primary
and secondary vulvodynia had different histologic features, indicating they may be
different entities.6
Generalized vulvodynia is pain and burning on or around the vulva, including the
mons pubis, labia majora, labia minora, vestibule, and perineum. Women with gener-
alized vulvodynia describe burning, stinging, rawness, and aching in the vulva. The
pain may be constant or intermittent. It may range from mild discomfort to severe
pain that can prevent daily activities. Symptoms may be diffuse or in different areas
at different times. Some days the pain may be less than others, but the area hurts
most of the time, even when nothing is touching it. Sitting may be uncomfortable.
Some women report increased vaginal discharge with the pain. Urination may
contribute to the pain and burning. Sexual touch or intercourse is occasionally
possible for some women.

Symptoms and Prevalence

Vulvodynia affects women of all age groups, from adolescence through menopause.7
Common vulvar symptoms reported include burning, stinging, rawness, itching, ach-
ing, soreness, or throbbing of the vulvar tissues. Pain may be constant, intermittent,
localized, or diffuse. Symptoms may occur during intercourse and exercise, or even
while sitting or resting. A study by Sadownik8 found that women presented with symp-
toms including dyspareunia (71%), history of recurrent yeast infection (64%), vulvar
burning (57%), vulvar itching (46%), and problems with sexual response (33%).9
Repeated urogenital infections, such as bacterial vaginosis, candidiasis, condyloma,
trichomoniasis, and urinary tract infections, have been shown to be a risk factor for
the development of vulvodynia. Multiple infections compound the risk of vulvodynia,
with an odds ratio greater than 8 for 3 or more infections reported in the 12 months
before the onset of vulvodynia.10
Vulvodynia causes significant physical and psychological distress and affects qual-
ity of life. Vulvodynia is diagnosed through exclusion. The prevalence of vulvodynia is
approximately 8.3% to 16.0% of women in the United States.9,11 A National Institutes
of Health study estimates that 13 million women may experience symptoms at some
point in their lifetime12 and that 6% of women have symptoms before the age of
25 years.7 These prevalence rates are believed to be greatly underreported because
of the absence of visible abnormalities of the vulva.
 Vulvodynia 455

Etiology
The cause of vulvodynia is unknown. Theories suggest a multifactorial origin, including
embryonic derivation,12,13 chronic inflammation,14 genetic immune factors,15,16 nerve
pathways,17–20 abnormal response to environmental factors (eg, infection, irritants,
trauma), hormonal changes,21 human papilloma virus, and oxalates.22,23 The patho-
physiology suggests that vulvodynia is a chronic disorder of the nerves that supply
the vulva. The painful tissue has been shown to have nerve fiber proliferation or neural
hyperplasia.17–19 Chronic inflammation, such as is caused by contact irritants, recur-
rent vulvovaginal infections, hormonal changes, and chronic skin conditions, acts as a
trigger. Normal sensations are perceived as abnormal, which results in heightened
sensitivity.

Comorbidities with Psychological Diagnosis and Chronic Pain Conditions

A relationship has been shown between comorbid pain conditions. In a study by Reed
and colleagues,24 approximately 1940 women were screened for interstitial cystitis, ir-
ritable bowel syndrome, fibromyalgia, and vulvodynia. Prevalence ranged from 7.5%
to 11.8%. However, 27% screened positive for multiple conditions. The presence of
vulvodynia was significantly associated with other pain syndromes (P<.001), with an
odds ratio of 2.3 to 3.3. Other associated conditions include recurrent yeast infections
and chronic fatigue syndrome.25,26
The chronic nature of vulvodynia can negatively affect a woman’s self-image and
lead to psychological disorders, such as depression and anxiety. Vulvodynia is not
considered a psychopathological condition.7,27 However, in a study by Tribo and col-
leagues,28 more than 50% of women report depression and/or anxiety as a presenting
symptom. Further studies have shown that the odds of having vulvodynia are 4 times
more likely in women with antecedent mood or anxiety disorders.29 Vulvodynia has
also been associated with new or recurrent mood and anxiety disorders, with an
odds ratio of 1.7.29
Women presenting with vulvodynia may also experience significant sexual, psycho-
logical, and relationship problems. Many may benefit from psychological support, sex
therapy, and/or counseling. The cycle of pain caused by vulvodynia may ultimately
lead to avoidance of all sexual activities; fear of pain and anticipation of pain during
sexual intercourse may lead to partial avoidance of sexual intimacy and activity,
sexual arousal disorder, loss of libido, problems with orgasm/anorgasmic disorders,
phobic avoidance of sexual activities, and subsequent relationship difficulties.

Evaluation and Physical Examination

Evaluation of the patient with vulvodynia should include a comprehensive medical
history, noting any association of life changes, stressors, new medical conditions,
childbirth and lactation, menopausal status, surgeries, and previous failed therapies
with the onset of symptoms or symptom flares. Identification of possible contact irri-
tants through patient recall includes all products that come in contact with the vulvar
skin. This identification is critical to optimize the condition of the vulvar tissues.
Common irritants include scented detergents, soaps, and over-the-counter feminine
hygiene products.
The vulva should be inspected for any abnormalities, including dermatoses and pre-
malignant or malignant conditions. If any abnormal or suspicious conditions are iden-
tified, a biopsy or vulvar colposcopy is indicated and appropriate referral or treatment
performed. In the absence of abnormal dermatologic findings other than erythema, a
vulvar colposcopy has limited value.30
456 Shah & Hoffstetter

Cotton swab testing should be used to identify painful areas on the vulva or areas
that are symptomatic (Fig. 1). The cotton swap should be touched lightly in a consis-
tent pattern starting with the outer thighs, mons, labia majora, inner labia folds, labia
minora, posterior fourchette, and vestibule, and in the region of the periurethral and
Bartholin glands. For the vestibule, left and right sides should be examined separately
rather than trying to spread the labia and examine both sides at once. Patients should
be instructed to either classify areas as painless, or having mild, moderate, or severe
pain, or apply a number value based on a Likert 10-point pain scale (ranging from 0 5
none to 10 5 most severe level of pain). Localized vulvodynia can be diagnosed if the
patient experiences discrete areas of pain, and generalized vulvodynia can be diag-
nosed if the patient experiences pain in a broad area. If no pain, tenderness, or burning
is elicited with cotton swab testing, vulvodynia would not be considered in the differ-
ential diagnosis.5
Vaginal examination should be performed, including a wet mount analysis and yeast
culture. Infectious or inflammatory diseases should be ruled out, such as candidiasis,
recurrent vaginitis, herpes simplex virus, and a desquamative inflammatory vaginitis.
Normal findings such as atrophy should be considered in lactating or perimenopausal
to postmenopausal populations. A speculum examination is not always required,
because a cotton swab inserted vaginally is adequate to collect a specimen for wet
mount analysis. A yeast culture is the gold standard for identifying yeast and offers
species identification with drug sensitivities to guide treatment.31 The yeast culture
can be obtained from areas on the labia and vestibule, and from the vaginal canal.
Any abnormal conditions identified should be treated.
Vaginismus, or involuntary spasm of the pelvic floor muscles, is a common finding
with vulvodynia. Evaluation and management are necessary to improve patient out-
comes.32 To test for vaginismus, pressure with a gloved finger should be applied to
the levator ani and obturator internus muscles. If pressure elicits tenderness or pain,
and/or muscles are in a state of contracture, vaginismus can be diagnosed.

Fig. 1. Cotton swab testing. Check clockwise: 1–2, inner thigh; 3–5, labia majora; 6–8, inter-
labial sulcus; 9, clitoris and hood; 10, perineum; 11, vestibule.
 Vulvodynia 457

TREATMENT
Management Goals
Vulvodynia is a chronic pain condition that presents management challenges for clini-
cians and patients. Symptom resolution is not often a realistic outcome. The primary
goals of treatment are symptom reduction, improvement in quality of life and sexual
function, and return to activities of daily living. Patient understanding and acceptance
of treatment goals is critical. Treatments can be slow and frustrating because just as
there is no single cause for vulvodynia, there is no single treatment that is effective for
symptom relief for all women.
In 2006, the American College of Obstetricians and Gynecologists published
Committee Opinion #345 on vulvodynia, which stated a few important points for prac-
titioners to remember when treating patients with vulvodynia:
Most available evidence for the treatment of vulvodynia is based on clinical experi-
ence, descriptive studies, or reports of expert committees.
Few randomized controlled trials have been conducted of vulvodynia treatments.
Vulvodynia is a complex disorder that is difficult to treat, and rapid resolution is
unusual, even with proper treatment.
A decrease in pain may take weeks to months and may not be complete.
No single treatment is successful in all women.33
Initial treatment steps must include self-management strategies to maximize tissue
quality and eliminate possible contributing factors for vulvar pain. The addition of phar-
macologic agents, as tolerated in increasing dosages and combinations, is needed to
maximize the response. Nonpharmacologic approaches are equally important to offer
holistic care to these women.

Self-Management Strategies
Education regarding the implementation of strict vulvar care/hygiene is essential to
eliminate the possibility of contact irritants as a cause or trigger for vulvar symptoms.
Adherence to vulvar hygiene has been shown to be an effective initial strategy to
reduce vulvar complaints of burning, itching, pain, and dyspareunia.34 Dyes, per-
fumes, or enzymes in any product that come in contact with the vulvar tissues should
be considered a source of irritation, including laundry detergents, fabric softeners,
body soaps, feminine hygiene products, noncotton underwear, and over-the-
counter vaginal products.33
To reduce symptoms, bathing the vulva in a mild baking soda solution can be
soothing; this is a simple treatment that patients can use to attenuate their symp-
toms that does not require the use of medications. Lukewarm water is recommen-
ded, because hot water can exacerbate vulvar symptoms. Caution should be
exercised if using the bathtub for the sitz bath, because residue from cleaning prod-
ucts can serve as a contact irritant. Ice packs applied to the vulva for 2 to 3 minutes
at a time can offer relief without harm.5 To improve the quality of the vulvar skin,
vegetable oil or olive oil serves as an emollient. These substances can be used liber-
ally and often for comfort and to reduce symptoms. A&D ointment and zinc oxide
serve to form a barrier to protect the skin and can be applied twice a day as
necessary.

Pharmacologic Strategies
In selecting a vehicle for delivery of topical medications, ointments provide a better
mode of delivery, minimizing the risk of causing a flare of symptoms. Creams contain
 458
Shah & Hoffstetter
Table 1
Pharmacologic agents for vulvodynia

Name Dose Side Effects Comments

Topical Lidocaine 5% ointment Apply as needed in small amount Erythema Temporary relief before coitus;
medications Systemic absorption possible with short-term use only
frequent or excessive use
Doxepin 5% cream in Apply to skin once daily, with
water-soluble base gradual increase, not to exceed
4 times daily
Gabapentin 2%–6% in
water-soluble base
Amitriptyline 2% with Apply 1–3 times daily Irritation, erythema, rash Topical formulation has fewer side
baclofen 2% in effects than systemic
water-soluble base
Oral neuropathic pain modulators
Antidepressants Amitriptyline 10 mg nightly & increase by 10 mg Drowsiness, dizziness dry mouth, Have patients avoid more than
q3–4 wk constipation, weight gain, one drink of alcohol each day
Maximum dose 150 mg qd urinary retention, tachycardia, Advise contraception
blurred vision, confusion Consider lower doses in elderly
(over age 65) patients
Desipramine Same dosing as amitriptyline Drowsiness, dizziness, blurred
vision, dry mouth, constipation,
tachycardia, urinary retention,
diaphoresis, weakness,
nervousness, rash seizures,
tinnitus, anxiety, confusion
Duloxetine Start with 30 mg qd bid No data to support its use
Venlafaxine Start with 37.5 mg Headache, nausea, somnolence, Few data to support use
Maximum 150 mg qd weight loss, anorexia,
constipation, anxiety, vision
changes, diarrhea, dizziness, dry
mouth, insomnia, weakness,
sweating, hypertension
 Anticonvulsants Gabapentin Start with 100–300 mg at nightly & Dizziness, somnolence, ataxia,
advance as tolerated in divided fatigue, nystagmus, tremor,
dose bid to tid diplopia, rhinitis, blurred vision,
Common doses range from nausea, vomiting, nervousness,
300–1800 mg dysarthria, weight gain
Maximum dose, 3600 mg
Maximum dose, 1200 mg in a
single dose
Pregabalin Start with 50–75 mg Common Dizziness, peripheral edema, Faster onset; however, may be less
doses range from 75–150 mg weight gain, somnolence tolerated than gabapentin
Maximum dose, 600 mg bid
Other agents Topiramate Use only after previously Dose-related Few data to support use
mentioned therapies Fatigue, paresthesia, tremor, Interferes with hormonal
unsuccessful asthenia, confusion, dizziness, contraception
Start at 25 mg qd bid diplopia, difficult
Maximum dose, 200 mg bid concentration, memory
problems, nervousness
Lamotrigine Use after previously mentioned One clinical trial to support its use
therapies unsuccessful Interferes with hormonal
contraception
Hydroxyzine 25 mg to reduce pruritus
Cetirizine 10 mg to reduce pruritus

Vulvodynia
459
460 Shah & Hoffstetter

more preservatives and stabilizers, which can act as contact irritants and cause
burning on application.5
Topical Medications
Local anesthetics, such as lidocaine ointment, can provide temporary relief from the
pain to enable intercourse, if applied topically to the vulva a few minutes before
coitus. In 2003, Zolnoun and colleagues35 advised overnight use of topical lidocaine
to allow for healing, and reported that women experienced a significant decrease in
pain with sexual activity. Benzocaine is not advised because it can produce contact
irritation and may cause a flare-up of symptoms.36 The use of topical antidepres-
sants, such as doxepin 5% cream, gabapentin 2% to 6%, or amitriptyline 2% mixed
with baclofen 2% in a water-washable base can be applied by fingertip to the
affected areas.36
Pain Medications
Narcotic pain medications should be used with caution in patients with vulvodynia.
Tramadol and hydrocodone/acetaminophen combinations have been used in the
short term for vulvodynia flares.
Pain Modulators
The use of neuropathic pain modulators, including tricyclic antidepressants such as
amitriptyline or desipramine can help decrease neuropathic chronic pain through a
central action altering the transmission of pain impulses to the brain through the dorsal
horn.37 In a small National Institute of Child Health and Human Development–funded
study, amitriptyline with or without topical triamcinolone was no more effective than
self-management approaches in managing vulvar pain.38 A randomized controlled trial
showed that oral desipramine and topical lidocaine, alone or in combination, were not
superior to placebo.39 Other antidepressants, such as duloxetine and venlafaxine,
have also been used, but few data support their use. A randomized controlled trial
is currently evaluating the use of gabapentin, a drug that helps control epileptic sei-
zures, for women with provoked vestibulodynia.40
The newest anticonvulsant used for chronic pain is pregabalin. A small retrospective
chart review showed improvement in symptoms (Aranda J, Edwards L, unpublished
data, 2007). A small open-label trial with lamotrigine has shown a decrease in pain
at 8 weeks.41 Topiramate has also been used, but few supportive data are available.
Hydroxyzine and cetirizine have been used to reduce pruritis. For some women, com-
binations of neuropathic pain medications (eg, amitriptyline, gabapentin, and prega-
balin) can also be used, because they have different mechanisms of action.
Neuropathic pain medications should not be stopped suddenly; dosages should be
weaned before discontinuation (Table 1).
Nonpharmacologic Strategies
Nonpharmacologic strategies can be used as an adjunct to any of the therapies
mentioned earlier. Psychological treatment can provide techniques for relaxation or
coping with pain or an opportunity to explore other conditions that may relate to the
pain.5 Couples therapy and sexual therapy are additional options that may benefit
both the patient and partner. A randomized, controlled trial found that women who
had cognitive behavioral therapy reported a 30% decrease in vulvar pain that occurs
with intercourse.42
Limited research has been performed on hypnotherapy for vulvodynia.43 A case
report showed resolution of localized vulvodynia after 12 psychotherapy sessions, 8
 Vulvodynia 461

of which included hypnosis. Some small pilot studies have shown that acupuncture
treatment for localized vulvodynia was well tolerated, and that quality-of-life measure-
ments were higher after completing treatment and at 3-month follow-up.44–46
An association between oxalates and vulvar pain has been theorized. High levels
of oxalate in the urine can be reduced with diet and calcium citrate, although little
evidence exists to support the use or effectiveness of this treatment for vulvar
pain.23

Surgery
Surgical excision of the vulvar vestibule (ie, vestibulectomy) for women with localized
vulvodynia is an option chosen cautiously after failure of other attempted therapies.
Success rates vary from 60% to 85% at short-term follow-up.47–49 The area of exci-
sion is outlined in Fig. 2. Neuropathic pain medications are usually continued postop-
eratively to maximize quality of life and promote return of sexual functioning.36

Vaginismus
Vaginismus may develop subsequent to any chronic pelvic pain condition and is com-
mon with vulvodynia. Assessment for and treatment of this condition is critical,
because it may be the cause of continued pain and/or sexual dysfunction after suc-
cessful treatment of vulvodynia.

Nonpharmacologic Strategies
Nonpharmacologic treatment for vaginismus includes physical therapy with pelvic
floor exercises and biofeedback. Patient control of specific body responses enables
relaxation of pelvic muscles, resulting in subsequent pain reduction. The authors’ clin-
ical experience has found increased success, with lower cotton swab pain scores at
initiation of physical therapy. Physical therapists must be specifically trained in pelvic
floor and biofeedback for optimum results. Success rates of 60% to 80% have been
reported with pelvic floor–trained physical therapists.50
Vaginal dilators can be helpful to overcome tension in the pelvic floor muscles and
are available in varying sizes. Patient’s can use the dilator before attempting inter-
course to accommodate penetration when symptoms allow a return to sexual activity.
Hypnosis43 has been used with some limited success.

Fig. 2. Surgical excision of the vulvar vestibule, vestibulectomy.

462 Shah & Hoffstetter

Pharmacologic Strategies
Pharmacologic treatments include vaginal valium inserted at bedtime and topical
baclofen. Research studies are ongoing with Botox injections.51,52

SUMMARY AND DISCUSSION

Vulvodynia causes significant physical and psychological distress and impacts quality
of life in women and their families. Patients with vulvodynia often seek care from many
providers, attempting to find resolution of their symptoms. A prospective study of 300
patients showed that 60% of women consulted 3 or more physicians in seeking a
diagnosis, and 40% remained undiagnosed.8 Spontaneous remission has occurred
in some women, but most have had multiple attempts with medical management
without 100% resolution of symptoms. Referral to vaginal and vulvar disease clinics
should be encouraged to optimize management strategies and maximize quality of
life for these patients and their partners. Concurrent emotional and psychological sup-
port can be invaluable.

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