Etiology, diagnosis, and clinical management of vulvodynia

Figures & data

Table 1 Goals for assessment and initial management of vulvodynia

Focus of encounter	Visit 1	Visit 2	Visit 3
Clinical history: in-depth pain history	×
Examination to exclude other causes	×
Patient education: diagnosis	×
Recommend: skin care, symptom control	×
Follow-up discussion: review pain diary		×
In-depth sexual history		×
Patient education: psychosexual “fall out”		×
Counseling: sexual		×
Repeat examination: assess pelvic floor			×
Teach pelvic floor exercises			×
Individualize treatment recommendations			×

Table 2 Pain history

P	Precipitates	What caused the pain?
P	Provokes	What provokes the pain?
P	Palliates	What palliates the pain?
Q	Quality	What is the quality of the pain?
R	Radiation	Does the pain radiate? Where?
S	Severity	What is the severity? What activities are limited due to pain? (daily, sexual)
T	Temporal	How has the pain changed over time? Have there been any pain-free intervals of time?
T	Treatment tried	What treatments have been tried to date? Patient compliance?

Table 3 Causes of vulvovaginal symptoms and dyspareunia

Etiology	Examples
Infectious	Vulvitis: herpes, tinea, candidiasis Vaginitis: candidiasis, trichomoniasis, atrophic Cervicitis: chlamydia, gonorrhea Pelvic inflammatory disease Acute cystitis
Inflammatory	Vulvar dermatitis: irritant, contact Vulvar dermatoses: lichen sclerosus, psoriasis Vulvovaginitis: atrophic, endometriosis, Adenomyosis, interstitial cystitis, inflammatory bowel disease
Traumatic	Vulvar fissures
Anatomical	Imperforate hymenal ring, vaginal septum
Functional	Inhibited sexual arousal
Musculoskeletal	Vaginismus, osteoarthritic hips

Table 4 Systematic approach to examining the vulva

	Steps	Questions
S	Skin	Is the skin normal? (texture, color)
A	Anatomy	Is the anatomy/architecture of the vulva normal?
I	Inflammation	Is there any inflammation? (margins, color, degree)
L	Lesions	Are there any lesions? Use dermatological terms to describe

Figure 1 Biopsychosocial framework for treating women with vulvodynia.

Abbreviations: PF, pelvic floor; prn, as needed.

Table 5 Examples of medical therapies applied to vulvodynia

Medication applied to	PVD	GVD
Betamethasone/lidocaine injections	×
Botulinum toxin injections	×	×
Interferon injections	×
Oral calcium citrate	×
Oral TCA antidepressants (amitriptyline, desipramine)	×	×
Oral SSRI antidepressants (duloxetine)		×
Oral antifungals (fluconazole, ketoconazole)	×
Oral anticonvulsants (gabapentin, pregabalin)	×	×
Topical 5% lidocaine	×	×
Topical capsaicin	×
Topical cromolyn	×
Topical gabapentin	×	×
Topical montelukast	×
Topical nifedipine	×
Topical nitroglycerin	×

Abbreviations: PVD, provoked vestibulodynia; GVD, generalized vulvodynia.