Persistent Vulvar Pain

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Reading: Committee Opinion No. 673 - Persistent Vulvar Pain 

What is persistent vulvar pain? 

    • Persistent vulvar pain is a complex disorder and often very frustrating to both the patient and the provider 

    • Because it is difficult to treat and even with appropriate treatment, pain may not resolve completely 

  • Terminology and Classification - from 2015 Consensus Terminology and Classification of Persistent Vulvar Pain 

    • From the International Society for Study of Vulvovaginal Disease: 

      • Can be caused by a specific disorder or it can be idiopathic 

      • Idiopathic vulvar pain = vulvodynia

    • Vulvar pain caused by specific disorder: 

      • Infectious (ie. recurrent candidiasis, herpes) 

      • Inflammatory (lichen sclerosus, lichen planus, etc.) 

      • Neoplastic (ie. Paget disease, SCC) 

      • Neurologic (postherpetic neuralgia, nerve compress or injury) 

      • Trauma

      • Iatrogenic (postoperative, chemotherapy, radiation) 

      • Hormonal deficiencies (ie. genitourinary syndrome of menopause, lactational amenorrhea) 

    • Vulvodynia = vulvar discomfort, most often reported as burning pain, which occurs in the absence of relevant visible findings or a specific, clinically identifiable neurological disorder for at least 3 months 

      • Descriptors 

        • Localized (ie. vestibulodynia, clitorodynia), general, or mixed (can be localized or generalized) 

        • Provoked (ie. insertional, contact), spontaneous, or mixed (provoked and spontaneous) 

        • Onset (primary or secondary) 

        • Temporal pattern (intermittent, persistent, constant, immediate, delay) 

How do we evaluate what the cause of vulvar pain is? 

  • Exclude other causes before assigning vulvodynia 

    • Vulvodynia = diagnosis of exclusion 

  • History

    • Do your normal OPQRS – how long has the patient been having pain? Where is it? 

    • Also obtain medical and surgical history

    • Sexual history - make sure to ask permission 

    • Allergies 

    • Previous treatment 

  • Physical exam 

    • Know your anatomy!  

UPTODATE

  • Cotton swab test

    • Using a cotton swab and moving across the labia → start on thighs → labia majora → interlabial sulci. Then test vestibule in the 2, 4, 6, 8, 10 o’clock position 

  • R/o infection  

    • Wet mount, vaginal pH, fungal culture, and gram stain 

  • Vulvoscopy - usually not needed 

  • If there is concern, you can also biopsy an area - can find dermatoses 

  • Musculoskeletal evaluation 

    • Palpation of the different muscles within the pelvis to see if there is referred pain

    • Palpation of the pubovaginalis portion of the levator ani, obturator internus, and urethrovaginal sphincter 

Treatment 

  • Unfortunately, the evidence for treating vulvodynia is based on clinical experience and observational studies - few randomized studies exist 

    • If there is obvious cutaneous or mucosal disease present 

    • If there is not, do the cotton swab test 

      • If no areas of tenderness then consider alternative diagnosis 

      • If there is tenderness or burning with cotton swab test, do a yeast culture 

        • Positive yeast culture: antifungal 

        • If negative, or if antifungal does not provide adequate relief, move to:

          • Vulvar care measures

            • Cotton underwear and no underwear at night 

            • Avoid vulvar irritants and douching 

            • Mild soaps for bathing, or anti-allergenic soaps, do not apply directly to vulva 

            • Apply preservative free emollient (ie. coconut oil) 

            • Switch to 100% cotton menstrual pads 

            • Use water based lube for intercourse 

            • Cool gel to vulvar area for relief 

          • Topical medications - ie. estrogen cream, tricyclic antidepressants can be compounded 

          • Oral medications - TCAs and anticonvulsants; use one drug at a time 

            • TCAs should be used for up to 3 weeks to assess adequate pain control 

          • Injections (ie. botox for trigger point injections, can also use steroids for trigger point injections ) 

          • Biofeedback/physical therapy - assess for pelvic floor dysfunction 

          • Dietary modification 

          • CBT 

          • Sexual counseling 

        • If still no adequate relief and localized pain → can consider surgery with vestibulectomy 

          • Should only be done if other treatments have failed 

          • Success rate is 60-90% compared to 40-80% for nonsurgical interventions 

        • If generalized pain - consider increasing the dose of medication, combining meds, etc.