ACOG Guidelines on Vulvodynia

Vulvodynia is burning, stinging, irritation, or rawness in a normal-appearing vulva. It is not caused by a commonly identifiable infection, inflammation, neoplasia, or neurologic disorder. The American College of Obstetricians and Gynecologists (ACOG) published a committee opinion on this topic in the October 2006 issue of Obstetrics & Gynecology.

Vulvodynia is a diagnosis of exclusion and can be categorized as localized or general. It is unknown whether localized vulvodynia and generalized vulvodynia are different manifestations of the same condition. Early classification of the disease as localized or generalized aids in timely and appropriate treatment.

There are many possible causes of vulvodynia (e.g., embryologic abnormalities, increased urinary oxalate levels, genetic or immune factors, hormonal factors, inflammation, infection, neuropathic changes). A thorough history should be taken to determine duration of pain, treatment history, allergies, and sexual history.

To identify painful areas, a cotton swab test should be performed. When pain is present, the patient should be asked to categorize it as mild, moderate, or severe. The vagina should be examined, and tests (e.g., wet mount, vaginal pH, fungal culture, Gram stain) should be performed as indicated.

The patient should be advised to use gentle care with the vulva, including wearing 100 percent cotton underwear, avoiding vulvar irritants and douching, using mild soap when bathing, cleaning the vulva with only water, not using hair dryers on the vulvar area, patting the vulva dry after bathing, applying a preservative-free emollient (e.g., vegetable oil, petroleum jelly) topically, using 100 percent cotton menstrual pads, using lubrication during intercourse, applying cool packs to the vulvar area, and rinsing and patting the vulva dry after urination.

Topical medications can be applied before intercourse. These include estrogen cream and tricyclic antidepressants compounded to topical form. Topical steroids usually do not help; however, trigger-point injections of a combination of steroid and bupivacaine (Marcaine) sometimes help in localized vulvodynia. Oral tricyclic antidepressants and anticonvulsants also can be used for pain control. Patients of reproductive age should be advised to use ample contraception before an anti-depressant or anticonvulsant is prescribed. The patient may need to take these medications for up to three weeks before adequate pain control is achieved.

Physical therapy also may be helpful for patients with vulvodynia. Appropriate techniques include internal (i.e., vaginal and rectal) and external soft tissue mobilization and myofascial release; trigger-point pressure; visceral, urogenital, and joint manipulation; electrical stimulation; therapeutic exercises; active pelvic floor retraining; biofeedback; bladder and bowel retraining; instruction in dietary revisions; therapeutic ultrasonography; and home vaginal dilation. Patients who do not respond to treatment may benefit from vestibulectomy. Patients should be evaluated and treated for vaginismus before a vestibulectomy is performed.

Rapid resolution of vulvodynia, even with appropriate therapy, is unusual, and referral to a pain specialist may be helpful. Physicians should emphasize realistic expectations for pain resolution to their patients. Many patients may benefit from emotional and psychological support, sex therapy, and counseling.