Vulvodynia: Diagnosis and
or vulvar pain syndrome is a multifactoral clinical syndrome
of vulvar pain, sexual dysfunction, and psychological distress.
Recognizing the four specific subtypes of vulvodynia is important
in the management approach. The most common four subtypes
are vulvar vestibulitis syndrome, cyclic vulvovaginitis, dysesthetic
vulvodynia, and vulvar dermatoses. Simple clinical guidelines
can be developed to improve the evaluation and treatment of
these often long-suffering patients.
is different from itching or vulvar pruritus. Vulvodynia actually
precludes itching because the burning and pain cause an intolerance
to scratching. Over the years, the terminology used to describe
vulvodynia has varied. The term vulvodynia has now been recommended
by the International Society for the Study of Vulvar Disease
(ISSVD) to describe any vulvar pain, regardless of etiology.
pain usually has an acute onset. The onset can be associated
with vaginitis (yeast, bacterial), changes in sexual activity
(new sexual partner), or medical procedures on the vulva (cryotherapy,
laser). In most cases, the vulvar pain then becomes a chronic
problem varying in length from months to years. The intensity
of the pain can vary from mild to disabling. It can be burning,
stinging, irritating or raw. Most women with vulvodynia have
been to many physicians either with inaccurate diagnoses or
unsatisfactory treatment. Many women have been left feeling
especially frustrated and at times mistreated because they
have been told that their problem is purely psychological
and there is nothing physically wrong with them. Because of
the dramatic impact on their lives these women continue to
seek help, and can become increasingly fearful and anxious
about cancer or sexually transmitted diseases.
incidence of vulvodynia is not known but it is clearly more
common than is generally thought. In a general gynecological
practice the prevalence can be as high as 15% when actively
looked for.1 Characteristics of the
patients with vulvodynia are nonspecific. The age distribution
ranges from mid-20s to late 60s. Their Ob/Gyn history is unremarkable.
They generally do not have other chronic health problems,
and rarely have a history of sexually transmitted diseases.
Sexual promiscuity is generally not a factor in these cases.
Often, women with vulvodynia do report depression, but it
is just as easily a result of the condition as it is a cause.
pain reported can be in the general vulvar area, but is typically
located in the vulvar vestibulum. The vestibule comprises
the area between the labia minora and the hymenal ring, anteriorly
from the frenulum of the clitoris, and posteriorly from the
fourchette to the vaginal introitus. The urethra, Skenes glands,
Bartholins glands and the minor vestibular glands are all
located in the vulvar vestibule.
minimal findings are detected on the physical examination
and most of the time there are not physical findings at all.
The cotton tip applicator is used to determine the location
of the pain. Touching the vestibulum lightly with a moist
cotton-tipped swab reveals a sharp pain most often in the
posterior vestibule, anterior vestibule or both. Occasionally
red spots of inflammation can be detected at 5 oclock and
7 oclock or in a U-shaped area at the posterior fourchette.
Classification of Vulvodynia
dermatoses can often cause both itching or pain and can be
acute or chronic. Dermatoses are also dissimilar to other
causes of vulvodynia because there can be physical signs of
erythema, erosion or blisters. A partial list of vulvar dermatoses
includes psoriasis, seborrheic dermatitis, tinea cruris, contact
dermatitis, lichen simplex chronicus, lichen planus, lichen
sclerosus, pemphigus, and erythema multiforme. Many dermatoses
can be difficult to diagnose and may require a biopsy for
a definitive diagnosis.
vulvovaginitis (CVV) is probably the most common cause of
vulvodynia. The pain is typically cyclic and specifically
worse during the luteal phase of the cycle. Symptoms are characteristically
aggravated by vaginal sexual activity with the pain being
usually worse the next day.2,3 CVV is
thought to be caused by a hypersensitivity reaction to Candida
antigen. If Candida cannot be detected during the symptomatic
phase by culture, due to the bodys immune response, then culture
specimens during an asymptomatic phase.
treatments include antimycotics for temporary relief, but
symptoms recur soon after the treatment. Boric acid suppositories
twice daily for 4 weeks and then once per day for 5 days during
the menses only, for 4 more months is generally more successful
for chronic yeast vaginitis than conventional antifungal agents.
Boric acid suppositories were effective in curing 98% of the
patients who had previously failed to respond to the most
commonly used antifungal agents.4 However,
many women do not tolerate the boric acid that leaks out of
the vagina and further irritates the tissue. Lanolin or vitamin
E oil or petroleum jelly or some other ointment (calendula)
can be used to coat the vulvar tissue at the posterior fourchette
where the irritation would be greatest. Other alternative
treatments include local treatments such as lactobacillus
suppositories, tea tree suppositories, garlic suppositories,
herbal combination suppositories or douches (berberis hydrastis,
usnea); systemic immune support (A, C, E, Zn, Glycyrrhiza
glabra, Allium sativum, Hydrastis canadensis). Swabbing the
vagina with genitian violet has been a longstanding specific
treatment for candida, as has iodine douching (one part iodine
in 100 parts water, twice daily for 14 days). Reinoculation
from the anus requires attention to hygiene and possibly an
approach that also addresses the gastrointestinal tract. Dietary
considerations include a diet low in simple carbohydrates
and refined foods, low in alcohol, and low in fats.
Vulvar Vestibulitis Syndrome
vestibulitis syndrome (VVS) is characterized by dyspareunia,
severe point tenderness on touch (positive cotton swab test),
and erythema. The etiology of VVS is unknown. Some cases are
aggravated by yeast vaginitis. Other suspected causes include
chemical sensitivities, other irritants, a history of laser
or cryotherapy, and allergic drug reactions. Some studies
have suggested that VVS may be associated with human papillomavirus
of VVS is difficult and can require great patience and persistence
on the part of both patient and practitioner. Conventional
treatment is often fraught with overtreatment using antimicrobials
and destructive or ablative therapies for suspected HPV. Conventional
treatment can escalate to include interferon injections and
vestibulectomy for severe incapacitating cases. The most promising
alternative treatment that I have experienced in my practice
is the use of calcium citrate. In patients whose urine shows
evidence of excess oxalate, epithelial reactions similar to
those found in vulvodynia are observed. Women have periodic
hyperoxaluria and pH elevations related to the symptoms of
vulvar pain. 1000mg of calcium citrate daily, in divided doses,
is given to modify the oxalate crystalluria. A low oxalate
diet is an additional cornerstone to managing these cases.7
addition, I can cite cases in my private practice where an
eclectic treatment plan of a topical ointment (vitamin A,
tincture of thuja and lomatium isolate), oral beta carotene
(75,000IU to 150,000/day), eliminating food intolerances,
and a constitutional homeopathic remedy, have yielded anywhere
from 50% improvement to 100% improvement. Unfortunately, I
can also cite cases where there was only minimal improvement.
I have heard anecdotal reports using elaborate chemical desensitizing
methods and dramatic improvements, but I have not personally
investigated these cases. Psychological intervention must
always be considered for assistance in dealing with the illness,
and perhaps therapeutic intervention can then allow the immune
system to adequately address the chronic syndrome.
subtype of vulvodynia is more common among older women who
are either perimenopausal or postmenopausal. Patients have
constant noncyclic vulvar or perineal discomfort. These women
have less dyspareunia and less point tenderness than the women
with VVS. No significant changes are observed on the physical
examination except diffuse hyperaesthesia which occurs on
a wider area compared to VVS. Sharp pain can also be elicited
with light touch. The hyperaesthesia is thought to be a result
of an altered sense of cutaneous perception. A neurological
basis is probably the explanation for the nonspecific burning.
The sensation mimics the neuralgia associated with herpes.
Urethral or rectal discomfort is often associated with their
medicine often prescribes tricyclic antidepressants8
for dysesthetic vulvodynia. Side effects are a common problem
with tricyclics, and occur in up to half of the patients.
Theoretical nutritional and botanical alternatives for dysesthetic
vulvodynia include Folic acid, B12, Piper methysticum (kava-kava),
Ginkgo biloba, Hypericum perforatum (St. Johns Wort).
Physical Therapy for Vulvar Pain
use of physical therapy to relieve vulvar pain should not
be overlooked. Spasm of the inner thigh muscles or hip muscles
can be a result of guarding against the pain of weight resting
directly on vulvar skin while sitting. There are specific
devices for removing pressure from the vulvar area when sitting.
Manual therapy techniques can also be used to relieve pain
by releasing severe muscle spasms. Trigger points in the pelvic
floor muscles from fibromyalgia can refer pain to the vulvar
skin and the vagina. Trigger point therapy and pelvic floor
muscle strengthening and relaxation can also relieve pelvic
floor muscle spasms.
pain syndromes provoke psychological as well as physical distress.
Sexual relationships become seriously strained in women with
vulvodynia. Women tend to feel defective, less womanly, less
sexually attractive ashamed and embarrassed. Dealing with
spouses and partners who are having difficulty coping is an
additional stress. Anxiety and depression set in with unsatisfactory
visits to their health care practitioners and unsatisfactory
results. Hopelessness can become the greater illness but practitioners
should be cautioned against being overly optimistic in encouraging
them to try another promising treatment. If it fails, it further
escalates the hopelessness.
of the specific subsets of vulvodynia is extremely important
in improving the diagnosis and treatment of this complex multifactoral
syndrome. Simple guidelines and recommendations augment the
evaluation and management.9
Rule out underlying problems
not overlook cervix
Use a multidisciplinary approach
diagnosis of vulvar dermatoses
diagnosis of vulvar erosions
Provide empathy and support
the patient in their understanding of the problem
the patient to cope with the problem
them that symptoms fluctuate
Best questions to be asked
there any days without burning?
the pain related to menses?
is the pain associated with vaginal penetration?
Set simple goals
bad days, more good days
better takes some time
them to stick with the treatment
MF. Vulvar vestibulitis: Prevalence and historic features
in a general gynecologic practice population. Am J Obstet
Gynecol 1991; 164:1609-16.
2. McKay M. Vulvodynia:
a multifactorial clinical problem. Arch Dermatol 1989; 125.
3. McKay M.
Subsets of vulvodynia. J Reprod Med 1988; 33:695-8.
R, Congema E, Nguyen H. Antifungal Agents vs. Boric Acid
for Treating Chronic Mycotic Vulvovaginitis J Reprod Med 199;36:593-597.
5. Turner MLC, Marinoff
SC. Association of human papillomavirus with vulvodynia
and the vulvar vestibulitis syndrome. J Reprod Med 1988; 33:533-7.
Umpierre SA, Kaufman RH, Adam E, Woods KV, Adler-Storz K.
Human papillomavirus DNA in tissue biopsy specimens of vulvar
vestibulitis patients treated with interferon. Obstet Gynecol
C, Melmed M, Heitler S. Calcium Citrate for Vulvar Vestibulitis.
J Reprod Med 1991; 36:879-882.
McKay M. Dysesthetic (essential) vulvodynia. Treatment
with amitriptyline. J Reprod Med 1993; 38:9-13.
Paavonen J. Diagnosis and Treatment of Vulvodynia. Ann
Med 27:175-181, 1995. Resources The Vulvar Pain Foundation,
P.O. Drawer 177, Graham, North Carolina 27253; 910-226-0704.