Persistent Vulvar Pain
/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!
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
Treat the disease! Ie. infections, dermatoses
We talk about this here on previous podcasts:
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.