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!  

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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 

• Treat the disease! Ie. infections, dermatoses 

• We talk about this here on previous podcasts: 

• Vulvar itching

• Benign vulvar dermatoses

• 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. 

Pediatric Vulvovaginitis

Infrequently in the general gynecologist’s office, you may be asked to evaluate a child for concern of vulvovaginitis. Today’s episode will review some common questions regarding approach in pediatric gynecology, and be specific to a pre-pubertal population.

Many times this is the first time that the young patient has seen a gynecologist! It’s going to be a scary and unfamiliar environment, as the only context for physicians for many children at this point are their pediatrician or family physician. You’ll likely have to lean in to the parent/close relative/guardian for history and more information regarding chronicity, anxieties, and specific complaints.

Common complaints can include:

• Itching or discharge.

• Pain or irritation.

• Issues with going to the bathroom (ie. some children may have issues of leaking urine, seemingly losing the developmental milestone of urinary continence).

The approach in pediatrics is somewhat different:

• Getting the trust of the patient - this may be harder for us as Ob/Gyns, since we are not always used to dealing with a pediatric population.

  1. Stickers, coloring books, asking about school and friends etc.

• If they are old enough to speak for themselves, always ask them what’s going on!

• Then ask/tell them that you are going to talk to their parent/guardian who is with them that you’d like to ask them as well what is going on — this is respectful of the child and keeps them involved.

• For adolescent patients, usually have the parents/guardian step out of the room for some time for sensitive questions 

  1. Assess risk: safety at school, home, people they don’t get along with or who may be hurting them 

  2. Drug/alcohol/tobacco use - kids may feel guilty about using. Ask if friends/family use, then can broach the subject with them.

  3. Sexual activity (usually approached with “Do you have anyone at school that you might like? Have you held hands or kissed them?).

Specific questions related to the complaint:

• Assessment of vulvar hygiene

  1. Showering/bathing habits - bubble baths? What types of soaps? 

  2. Toileting - how do they wipe? Have them demonstrate 

  3. Choice of clothing/clothing due to hobbies/activities - leotards, tights, swimsuits, etc - how long are they wearing them during the day? What kind of underwear? What about pajamas? 

• The exam

  1. Most children will not have had a pelvic exam, and most (read: almost all) do not require a speculum exam!

  2. Check for abnormal breast development (ie. early breast development) in younger children.

  3. Check for abdominal masses.

  4. Pelvic exam:

     1. Child can be laid back on the table in frog leg position, can also have parent sitting on exam table and holding child on lap in this position.

     2. Careful external examination, also can spread labia from lower legs/bottom and look at urethra/hymenal ring.

        1. Look for skin changes on the labia - red? White? Thin? 

        2. Also, see if there is labial adhesions.

        3. Purulent discharge/other types of discharge can be seen on underwear as well 

     3. Q-tip test to evaluate for vaginal potency.

     4. Foreign objects that cannot be easily removed should not be done in the office with smaller children, may require vaginoscopy  

Now let’s review some differential diagnoses that may present in young children.

Infectious 

1. Candida 

   1. Possible to have yeast infection in children who have had recent antibiotic treatment or if they wear diapers.

   2. Usually uncommon in normal prepubertal girls, unlike in women.

   3. If mostly on the outside, or diaper dermatitis, can use topical antifungal agents like nystatin, clotrimazole, miconazole, etc.

2. Gardnerella - also possible, but it is not common. Treat like BV. 

3. STI - suspect if purulent discharge with evidence of sexual abuse on interview/exam

   1.  Evidence includes anal or genital tears, evidence of ejaculation.

   2. Laceration to lower half of the hymenal ring, usually 3-9 o’clock is consistent with penetrating injury.

   3. Suspicion of child abuse is something that requires mandatory reporting to authorities.

   4. Things to test for include gonorrhea, chlamydia, trichomonas.

   5. Genital warts: can be diagnosed clinically and usually with biopsy.

Noninfectious 

• Foreign body

  1. Can cause acute and chronic vulvovaginitis with purulent discharge, foul smell, and even bleeding.

  2. Most common things are toilet paper, small toys, etc → can usually be removed with warm vaginal lavage (ie. obtaining thin catheter and attach to 60cc syringe). Place the tip of catheter into the vaginal canal, and can lavage several times 

  3. Can treat introitus with small amount of Xylocaine jelly if needed for pain / local anesthetic.

  4. If large object or not easily removed, may need sedation/anesthesia for extraction.

  5. If there is suspicion for battery within the vagina, this is a reason for anesthesia, vaginoscopy for possible burns 

• Trauma 

  1. Vulvar trauma can cause significant bleeding - area is highly vascular 

  2. Interview is important - was there recent straddle injuring/skating injury?

     1. History should correlate with physical finding - otherwise suspect abuse.

  3. Straddle injury: injury usually anterior area of the vulva, including mons, clitoral hood, and anterior aspect of the labial 

     1. Should not have injury to the posterior fourchette and hymenal areas - this would suggest sexual abuse.

     2. Assess ability to urinate and presence of hematoma; if unable to urinate,, need to drain bladder, ice, and give pain medication if large hematoma.

        1. If not obstructive, can ice and give pain medication. Most hematomas will resolve spontaneously 

     3. Surgery is rarely needed and can result in introduction of skin → infection 

Skin issues 

• Lichen sclerosus 

  1. We talked about lichen sclerosus in postmenopausal women previously!

  2. It can cause itching, discomfort, even discharge.

  3. Usually appears white, thin skin (onion skin, cigarette-paper), and usually around the vulva and perianal regions.

     1. Can usually diagnose with visual inspection, and biopsy is rarely needed, though in adults you should biopsy (can be associated with malignancies in adulthood).

  4. Treatment: superpotent topical steroids → first start with more frequent treatment, then maintenance therapy.

• Labial adhesions

  1. Most frequently in infants and young children, peak incidence up to 3% in second year of life in girls.

  2. Usually due to inflammation + low estrogen.

  3. Can lead to discomfort and possible issues with urination, recurrent urinary tract infection.

  4. If asymptomatic, no treatment is necessary especially if it only involves a small portion of the labia.

  5. If symptomatic - initial treatment with topical estrogen/estradiol cream twice a day with fingertip or Q-tip, sometimes with a little pressure, but do not try to manually separate the adhesion as this can cause tearing/pain/bleeding.

     1. Usually can see a thin, translucent raphe in the middle (location of placing estrogen) 

     2. Another option is topical betamethasone as alternative or adjunctive topical treatment  

  6. Surgical separation - rarely indicated. Usually only for those with severe obstruction to urinary flow or who have urinary retention. 

• Vulvar ulcers 

  1. Can be non-sexually transmitted ulcers and can present with systemic symptoms like fatigue, malaise, fever, etc.

  2. Etiology may not always be determined, but viruses can sometimes cause them (ie. flu A, EBV, mycoplasma, CMV).

     1. Take a careful sexual history to rule out other STDs, HSV - but perform these tests as well just in case.

  3. Can also test with CBC and monospot test.

  4. If continues to be painful, unable to urinate, some girls may need to be admitted for pain control and foley placement.

  5. Other things to rule out: Behcet’s syndrome (if chronic ulcers), Crohn’s disease.

Nonvaginal issues 

• Urethral prolapse

  1. Distal end of the urethra can prolapse either partially or in a complete circumferential fashion (“donut-like”).

  2. Tissue can be friable and can become infected.

  3. Usually will have pain with urination, bleeding, etc. 

  4. May need to differentiate from other things like sarcoma botryoides or prolapsed ureterocele (may need a urologist!).

  5. If symptomatic, can be treated with topical estrogen 2x/day for two weeks, and then reassess.

• Pinworm 

  1. Can cause vulvar symptoms as well, like itching, but usually is perianal itching.

  2. Caused by the worm enterobiasis.

  3. Can be diagnosed with visual inspection or “paddle test” where there is a plastic paddle sometimes with adhesion pressed to perianal area → then place on glass slide to see worms.

  4. Treatment is with albendazole or mebendazole, and should think about treating the entire household.

  5. Wash all bedding and clothes!