Obstetrics and Gynecology

Vulvovaginal Disorders: Vulvodynia

Generalized Vulvodynia, Localized Vulvodynia, Vulvar Vestibulitis, Vestibulodynia

1. What every clinician should know

Vulvodynia is defined as chronic (three or more months) vulvar discomfort, mostly commonly burning, occurring in the absence of relevant visible findings (e.g., infection, inflammation) or a specific, clinically identifiable neurologic disorder. Patients tend to fall into two groups based on location of pain, although overlap is possible. Generalized vulvodynia refers to involvement of the entire vulva by persistent, chronic burning, stinging, and rawness. Localized vulvodynia specifies involvement of a portion of the vulva, such as the vestibule (also referred to as vestibulitis or vestibulodynia) or clitoris. In both instances, pain may be provoked (e.g., intercourse), spontaneous or mixed.

Population-based evidence indicates that approximately 16% of American women report histories of chronic vulvar burning or pain on contact. Proposed precipitating factors include a history of recurrent vaginal infections (most commonly yeast and bacterial vaginosis), the use of oral contraceptives (particularly early use), and a history of destructive therapies (e.g., use of trichloroacetic acid). There is some evidence of a genetic susceptibility for women with specific genetic variants. However, a multifactorial process appears to be involved in the development of vulvodynia. Commonly associated conditions include interstitial cystitis and irritable bowel syndrome, both of which may reflect aberrant neuronal interactions.

2. Diagnosis and differential diagnosis

History

Vulvodynia is a diagnosis of exclusion and the pain should be characterized using a targeted pain questionnaire. The provider should establish both the duration and nature (generalized versus localized, unprovoked or provoked, spontaneous or not) of the patient's discomfort. During the exam, other causes of vulvar discomfort (e.g., ulcerations, lesions) are noted and biopsied, cultured or both as indicated. A vaginal exam should be done to exclude other common causes of vulvovaginal discomfort (e.g., candidiasis, bacterial vaginosis).

Physical exam

Once cutaneous and mucosal disease has been ruled out in patients presenting with three or more months of vulvar discomfort, the cotton swab test should be done. Using a moistened swab, the vulva is tested starting at the thighs and moving medially to the vestibule (area just outside the hymen). The vestibule is systematically palpated at 2, 4, 6, 8 and 10 o'clock using light pressure. The patient is asked to rate the pain on a scale of 0-10 (0= no pain and 10=sharp stabbing pain). If pain is confirmed, a vaginal fungal culture is obtained to rule out a yeast infection, most notably an atypical Candida species. A negative fungal culture in combination with the patient's history and positive findings on the cotton swab test confirm the diagnosis of vulvodynia.

Differential diagnosis

As noted above, biopsy, culture or both should be used to rule out other causes of vulvar burning or irritation, including atypical candidaisis, bacterial vaginosis, trichomoniasis, herpes simplex, lichenification disorders (lichen sclerosus, lichen planus).

3. Management

Multiple treatments are often used with no clear evidence of superiority. Randomized trials are rare. While expectant management is reasonable, patients often present for evaluation following months to years of discomfort at which point expectant management is no longer indicated. Medical and surgical management options include:

Topical therapy

Lidocaine ointment: most commonly prescribed. Retrospective evidence showed that six to eight weeks of nightly 5% topical lidocaine application resulted in significant improvements in ability to have intercourse among a cohort of women with vestibulitis. In a recent RCT of topical lidocaine and oral desipramine, as monotherapy or in combination, revealed that pain reduction in treatment arms was no different than that in placebo arm. The authors caution that this lack of effect may have been secondary to placebo-related and placebo-independent effects.

Capsaicin cream significantly decreases pain and increases ability to have intercourse following 12 weeks of daily therapy using 0.025% capsaicin cream. In a retrospective cohort of women with provoked and spontaneous vulvodynia, 80% reported at least 50% improvement in pain and, among those with dyspareunia, 85% either reinstituted or increased frequency of intercourse following eight weeks of daily therapy using 2% to 6% gabapentin cream (requires compounding).

Injectable therapy

Limited data using varieties of combinations (e.g., trimacinolone acetonide 1% and bupivacaine) demonstrates some efficacy.

Oral therapy

Tricycle antidepressants are the most commonly used form of oral medication. Evidence of efficacy has been seen in retrospective studies, although in RCT noted above, use of desipramine with or without topical lidocaine showed no superiority to placebo. When using in older populations, starting at lower doses is recommended. Avoidance of use in patients with cardiac abnormalities or in those using MAOIs is recommended, and abrupt discontinuation of TCAs is not recommended.

Limited data from retrospective studies supports use of Gabapentin in patients with vulvar pain. As with TCAs, full pain response is not usually evident for three to four weeks.

Biofeedback/physical therapy

Vaginal surface electromyographic biofeedback, including internal and external soft tissue mobilization and myofascial release, trigger-point pressure application, electrical stimulation, and bladder/bowel training, has demonstrated success in pain reduction and return to intercourse. These techniques work best in highly motivated patients.

Surgery

Surgery is not indicated in women with generalized vulvodynia. For women with vestibulitis, vestibulectomy has been shown to result in high reported clinical cure rates (in excess of 80% in some trials, both controlled and uncontrolled). Success rates do, however, vary and are lower among women with primary vestibulitis and those with interstitial cystitis.

4. Complications

Chronic vulvar pain has the potential for negative impact on both women (e.g., depression) as well as their partners. Early counseling for women with sexual pain (including sex therapy, couples counseling and/or psychotherapy) may be helpful.

Complications as a result of therapy range of skin irritation/dermatitis with use of topical therapies to sedation, fatigue and anticholinergic side effects with the use of tricyclic antidepressants to blood loss, wound infection or separation, formation of granulation tissue or continued pain following vestibulectomy.

5. Prognosis and outcome

Even with appropriate therapy, rapid resolution of symptoms is uncommon. Realistic goals are critical, as the expected level of improvement in pain or sexual function may change with therapy and will vary from patient to patient.

6. What is the evidence for specific management and treatment recommendations?

Bachmann, GR. "Vulvodynia: a state-of-the-art consensus on definitions, diagnosis and management". J Repro Med. vol. 51. 2006. pp. 447-56.

(Good background on the field of vulvar pain.)

Bergeron, S. " A randomized comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis". Pain. vol. 91. 2001. pp. 297-306.

(One of the first RCTs in the field of vulvar pain, demonstrated surgery superior, although all treatments effective in reducing pain.)

Boardman, LA. "Topical gabapentin in the treatment of localized and generalized vulvodynia". Obstet Gynecol. vol. 112. 2008. pp. 579-85.

(Retrospective study of improvements in pain and sexual function among cohort of women with vulvodynia.)

Foster, DC. "Oral desimpramine and topical lidocaine for vulvodynia: a randomized controlled trial". Obstet Gynecol. vol. 116. 2010. pp. 583-93.

(Only randomized trial of topical and oral therapy for vulvodynia.)

Haefner, HK. "The vulvodynia guideline". J Low Genit Tract Dis. vol. 9. 2005. pp. 40-51.

(Good overview and algorithm for diagnosing chronic vulvar pain.)

Harlow, BL, Stewart, EG. "A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia?". J Am Med Womens Assoc. vol. 58. 2003. pp. 82-8.

(First population-based study to assess prevalence and epidemiology of vulvodynia.)

Masheb, RM. "On the reliability and validty of physician ratings for vulvodynia and the discriminant validity of its subtypes". Pain Med. vol. 5. 2004. pp. 349-58.

(Study assessing the role of vaginismus in the maintenance of vulvar pain.)

Reed, BD. "Treatment of vulvodynia with tricyclic antidepressants: efficacy and associated factors". J Low Genit Tract Dis. vol. 10. 2006. pp. 245-51.

(Large cohort of women treatment with TCAs, assessing outcomes and side effects.)

Zolnoun, DA. "Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis". Obstet Gynecol. vol. 102. 2003. pp. 84-7.

(One of first topical treatment trials to demonstrate a positive effect on pain and sexual function.)
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