Vulvodynia

What is vulvodynia?

Vulvodynia is the word that describes pain and discomfort in the vulva. The vulva is a woman’s external genital area, or the area around the opening to the vagina.

Vulvodynia is an uncommon cause of pelvic pain encountered in clinical practice.

Vulvodynia probably is not a single clinical entity, but rather the conglomeration of a variety of disorders that can cause pain in this anatomical region. Included in these disorders are chronic infections of the female urogenital tract; chronic inflammation of the skin and mucosa of the vulva without demonstrable bacterial, viral, or fungal infection; and bladder abnormalities, including interstitial cystitis, pelvic floor muscle disorders, reflex sympathetic dystrophy, and psychogenic causes.

All these disorders have in common the ability to cause chronic, ill-defined pain of the vulva that is the hallmark of vulvodynia.

What are the symptoms of vulvodynia?

The pain associated with vulvodynia is usually described as a burning, stinging, itching, irritating or a raw feeling. Sexual intercourse, walking, sitting or exercising can make the pain worse.

Vulvodynia usually starts suddenly and may last for months to years. Although it isn’t life threatening, the pain may make you cut back on some of your normal activities. It can also make you upset or depressed. It might even cause problems in your relationship with your spouse or partner, because it can make sexual intercourse painful.

Physical examination of patients with acute vulvodynia is directed at identifying acute infections of the vulva, urinary tract, or both that may be readily treatable. Patients with acute infections, including yeast infections and sexually transmitted diseases, have a vulva that is irritated, inflamed, raw to the touch, and tender to palpation. For patients with chronic vulvodynia, the physical findings are often nonspecific, with the vulva mildly tender to palpation and an otherwise normal pelvic examination. Changes of the skin and mucous membranes of the vulva resulting from herpes infection, chronic itching, irritation, or douching also may be present. Lichenification from chronic scratching may be present. In a few patients with vulvodynia, spasm of the muscles of the pelvic floor may be shown on pelvic examination. Allodynia of the vulva and perineum may be present, especially if the patient has a history of trauma, such as surgery, radiation therapy, or straddle injuries. Vulvar malignancy always should be considered in any patient with vulvodynia 

Extravulvar pathological processes can manifest with the primary symptom of vulvodynia. One of the most common causes of vulvodynia of extravulvar origin is malignancy involving the pelvic contents other than the vulva. Tumor involving the lumbar plexus, cauda equina, or hypogastric plexus rarely can manifest as pain localized to the vulva and perineum. Postradiation neuropathy can occur after radiation therapy for the treatment of malignancy of the vulva and rectum and can mimic the pain of vulvodynia. Ilioinguinal or genitofemoral entrapment neuropathy also can manifest clinically as vulvodynia.

Causes & Risk Factors

How did I get vulvodynia?

The exact cause of vulvodynia isn’t known. Some factors may include:

  • Frequent yeast infections or sexually transmitted infections
  • Chemical irritation of the external genitals (from soaps, feminine hygiene products or detergents in clothing)
  • Rashes on the genital area
  • Previous laser treatments or surgery on the external genitals
  • Nerve irritation, injury or muscle spasms in the pelvic area
  • Diabetes
  • Precancerous or cancerous conditions on the cervix

Common Causes of Vulvodynia

  • • Infectious
    • Herpes simplex virus
    • Candidiasis
    • Dermatophytosis
    • Bacterial infections
    • Recurrent urinary tract infections
  • • Infestations
    • Scabies
    • Pediculosis pubis
    • Pediculosis corporis
  • • Hormonal
    • Menopausal vulvar mucosal changes
    • Amenorrhea associated with lactation
    • Oral contraceptives
  • • Irritant contact dermatitis
    • Tampons and pads
    • Incontinence pads and briefs
    • Menstrual blood
    • Lubricants
    • Condoms
    • Sex toys
    • Vaginal discharges
    • Urine and feces
    • Foreign bodies
  • • Allergic contact dermatitis
    • Latex
    • Spermicides
    • Fragrances
    • Essential oils
    • Preservatives
    • Corticosteroids
    • Topical anesthetics
    • Neomycin component of triple antibiotic ointment
    • Metal allergy to piercings
  • • Traumatic
    • Obstetrical injuries
    • Piercings
    • Genital cutting and mutilation
    • Sex toys
    • Loofahs
    • Grooming practices
    • Straddle injuries
    • Cold injury from ice packs
  • • Iatrogenic
    • Surgical trauma
    • Drug sensitivities
    • Radiation induced
    • Postsurgical neuroma
  • • Cancer
    • Extramammary Paget disease
    • Squamous cell carcinoma
    • Vulvar intraepithelial neoplasm
    • Syringomas
    • Other vulvar malignancies
  • • Neurological
    • Postherpetic neuralgia
    • Nerve entrapment and compression
    • Plexitis
    • Neuroma
  • • Inflammatory
    • Lichen planus
    • Lichen sclerosis
    • Psoriasis
    • Plasma cell vulvitis

The pain of vulvodynia is characterized by dull, stinging, aching, or burning pain of the vulva. The intensity of pain is mild to moderate and may worsen with bathing, urination, or sexual activity. The pain may be referred to the perineum, rectum, or inner thigh. Irritative urinary outflow symptoms and sexual dysfunction often coexist with the pain of vulvodynia, with vulvodynia being one of the leading causes of dyspareunia. All patients with chronic vulvodynia should be questioned regarding a history of sexual abuse, sexually transmitted diseases, and psychological abnormalities related to sexuality.

Diagnosis & Tests

How is vulvodynia diagnosed?

You may need to have a pelvic exam and tests to check for bacteria and yeast. If any test results don’t seem normal, your doctor may want you to have a colposcopy or a biopsy. Colposcopy is an exam of the genital area that uses a special magnifying glass. If you have a biopsy, your doctor first numbs your genital area with a painkiller, then takes a small piece of tissue to be looked at with a microscope.

Pelvic examination is the cornerstone of the diagnosis of patients with vulvodynia. Careful examination for infection, cutaneous or mucosal abnormalities, tenderness, muscle spasm, or tumor is crucial to avoid overlooking vulvar malignancy. Interactive pelvic examination with patient participation using a handheld mirror may help decrease patient anxiety. Systematic palpation of the entire anogenital region using a moistened cotton swab will allow the patient to not only identify painful areas but grade the intensity of pain using a verbal analogue scale. Differential nerve block using topical 4% lidocaine applied for 3 minutes before retesting may help identify centrally mediated pain ( Fig. 96.3 ). Vulvoscopy of the painful areas may help the clinician identify subtle mucosal changes. Vulvar algesiometry may also be useful in helping quantify the intensity of pain before and after treatment interventions. Ultrasound examination of the pelvis is indicated in all patients with vulvodynia. If any question of occult malignancy of the vulva or pelvic contents exists, magnetic resonance imaging (MRI) or computed tomography (CT) of the pelvis is mandatory to rule out malignancy or disease of the pelvic organs, such as endometriosis, which may be responsible for the pain symptoms. Urinalysis to rule out urinary tract infection also is indicated in all patients with vulvodynia. Culture for sexually transmitted diseases, including herpes, is indicated in the evaluation of all patients thought to have vulvodynia.

Electromyography helps distinguish entrapment neuropathy of the genitofemoral or ilioinguinal nerves from lumbar plexopathy or lumbar radiculopathy. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. MRI of the lumbar plexus is indicated if tumor or hematoma is suspected.

Differential Diagnosis

Extravulvar pathological findings, including reflex sympathetic dystrophy and lesions of the lumbar plexus, nerve roots, and spinal cord, can mimic the pain of vulvodynia and must be included in the differential diagnosis. As mentioned earlier, because of the disastrous results of missing a diagnosis of pelvic or vulvar malignancy when evaluating and treating patients thought to have vulvodynia, it is mandatory that malignancy be high on the list of differential diagnostic possibilities.

How is vulvodynia treated?

The treatment depends on the cause of your vulvodynia. Some types of vulvar pain get better with creams or pills made to treat yeast infections. Sometimes the pain goes away if you use creams that contain estrogen or cortisone, but cortisone cream isn’t good to use for long periods of time. Some antidepressant medicines can help nerve pain and irritation. Other treatments that may help include interferon injections, laser therapy or surgery.

A variety of treatments have been advocated in the treatment of vulvodynia with varying degrees of success. Initial treatment of the pain associated with vulvodynia should include implementation of the approaches listed below along with a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors. If an offending substance is thought to be responsible for the patient’s symptomatology, it should be immediately removed. If menstrual blood is thought to be the offending agent, a trial of menstrual cups and cloth menstrual pads should be considered. Local application of heat and cold with sitz baths may be beneficial. Excessive bathing and scrubbing of the vulva should be avoided. Patients should be instructed to use bland soaps without fragrance or antibacterial substances and to thoroughly rinse all soap from genital areas when bathing. Refrigerated petroleum jelly may provide symptomatic relief. An arbitrary treatment course of antibiotics, such as doxycycline 100 mg twice daily for 2 weeks, may be worth trying, even though urine cultures are negative. A course of treatment for vaginal yeast infection concurrently with the antibiotics also should be considered. A short course of topical steroids or steroid-sparing antiinflammatory drugs such as tacrolimus may be beneficial if there is a significant inflammatory component. Anecdotal reports of decreased pain after treatment with adjuvant analgesics such as a tricyclic antidepressant (e.g., nortriptyline 25 mg at bedtime and titrating upward as side effects allow) or gabapentin make these drugs a consideration for patients who continue to have pain in the absence of demonstrable treatable disease.

First-Line Treatment Options for Vulvodynia

(From Glazer HI, Ledger WJ. Clinical management of vulvodynia. Rev Gynaecol Pract. 2002;2:83–90.)

  • Cease use of potentially irritating perfumed soaps, lotions, sprays, or douches
  • After urination, rinse vulvar skin with distilled water
  • Rinse all underwear in a separate cycle with only water after laundering with detergent
  • Do not use fabric softener on underwear
  • Use only 100% cotton menstrual pads and tampons
  • Wear only 100% cotton underwear and stockings, not nylon pantyhose
  • Bathe in water with oatmeal, baking soda, Aveeno, or sitz baths with tea; no bubble baths; cold compresses
  • Lubricate with vitamin E oil or vegetable oil, Desitin, or A&D ointment

Specific Treatment Options for Vulvodynia

(From Groysman V. Vulvodynia: new concepts and review of the literature. Dermatol Clin. 2010;28:681–696.)

  • Treat abnormal visible conditions such as infections, dermatoses, and both malignant and premalignant conditions
  • Vulvar care measures; avoidance of irritants
  • Topical medications
    • Lidocaine 5% jelly at introitus at bedtime
    • Nitroglycerin
    • Amitriptyline 2%, baclofen 2% (± ketoprofen 2%)
    • Capsaicin
  • Oral medications
    • Antidepressant class
    • Tricyclic medications (≤150 mg/day)
    • Venlafaxine extended release (150 mg/day)
    • Duloxetine (60 mg twice daily)
    • Anticonvulsant class
    • Gabapentin (≤3600 mg/day)
    • Pregabalin (≤300 twice daily)
  • Injections
    • Triamcinolone 10 mg/mL, 0.2–0.4 mL into trigger point
    • Botulinum toxin A injections
    • Intralesional interferon-α (no longer used)
  • Pelvic floor physical therapy
  • Pelvic floor surface electromyography and biofeedback
  • Low-oxalate diet with calcium citrate supplementation (controversial)
  • Cognitive behavioral therapy, sexual counseling
  • Surgery (for vestibulodynia only), localized excision, vestibulectomy, or perineoplasty

For patients who do not respond to these treatment modalities, caudal epidural nerve blocks with a local anesthetic and steroid may be a reasonable next step. Psychological evaluation and interventions should take place concurrently with the previously mentioned treatment modalities, given the high incidence of coexistent psychological issues associated with all pelvic pain syndromes.

Muscle spasms in your pelvic area can also make vulvar pain worse. Physical therapy or biofeedback treatments (treatments that help you strengthen and relax your pelvic muscles) may help ease the spasms. If you decide to try one of these treatments, look for a therapist trained in women’s health. With practice, you can learn to relax your pelvic muscles with exercises you do at home.

What else can I do to help my symptoms?

Some of the following steps may help ease your symptoms. If they help, keep doing them. If they don’t help, stop and talk with your doctor about other possible treatments.

  • Try to avoid using soap in the genital area. Just wash with water. Don’t use creams, petroleum jelly, bubble baths, bath oils or feminine deodorant sprays.
  • Wash your genital area frequently with plain water to wash away any vaginal secretions that may cause irritation. Rinse with clear water from a squeeze bottle after urinating.
  • Wear only all-cotton underwear and loose clothing. Avoid wearing pantyhose or other close-fitting synthetic clothing.
  • Use only white, unbleached toilet tissue and 100% cotton unscented sanitary products (tampons and pads).
  • Report any increased discharge and irritation to your doctor so that yeast and bacterial infections can be treated right away.
  • Try to avoid using contraceptive devices and contraceptive creams that might irritate your genital area. Talk with your doctor about other methods of birth control.
  • Wash new underwear before wearing. Always rinse underwear thoroughly after washing to remove soap residue.
  • Don’t sit around in a wet swimsuit for a long period of time. Doing so can cause an excess of bacteria and yeast in the genital area.

Questions to Ask Your Doctor

  • What is the likely cause of my pain?
  • Do I need any tests?
  • What can I do to relieve my pain?
  • Will medicine or some other treatment help?
  • Is it safe for me to have sex? What if the pain starts to interfere with my relationship?

Complications

The major pitfalls in the care of a patient with vulvodynia are threefold: (1) the misdiagnosis of extravulvar pathological processes responsible for the patient’s pain, (2) the failure to identify vulvar or pelvic malignancy or both, and (3) the failure to address the psychological issues surrounding the patient’s pain.

Clinical Pearls

The clinician should be aware that the relationship of the genitalia to the female psyche presents some unique challenges when treating patients with vulvodynia. The behavioral and psychological issues must be addressed concurrently with the medical issues if treatment is to be successful. The possibility for vulvar or pelvic malignancy is ever present and should be carefully sought out in all patients with vulvodynia

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