Vulvodynia is a complex disorder reported by up to 16% of women in the general population. While most patients describe it as burning, stinging, irritation, or rawness, it is underreported and underrecognized by providers. Vulvodynia is costly both economically and psychologically due to its negative impact on quality of life. Vulvodynia is a diagnosis of exclusion with unknown etiology and may involve multiple sources of pain in the same woman. Thus, there are no clinical or histopathologic criteria for the diagnosis other than consideration and careful evaluation to exclude other causes of pain. Successful therapy often requires a multidisciplinary approach with more than one therapeutic intervention to address the physical, psychological, psychosexual, and relationship components.
Introduction
The International Society for the Study of Vulvovaginal Disease (ISSVD) most recently defined vulvodynia as “vulvar pain occurring in the absence of an underlying recognizable disease.” . Vulvodynia is further classified based on the site of the pain, whether it is provoked, unprovoked, or mixed and subcategorized as generalized or localized.
Vulvodynia significantly impacts patients’ quality of life and can be the source of physical, psychosexual, and relationship distress for affected women. Similarly, clinicians experience frustration in diagnosing and treating vulvodynia in an efficient and effective manner.
The cost of vulvodynia management in the United States is estimated to be $31 to $72 billion per year . Unfortunately, there remains a relative paucity of research despite the impact on women and society.
Epidemiology
Among women living in the United States, the prevalence of vulvodynia has been estimated to range from 4% to 16% . A clinic-based prevalence study identified 15% (of 210 women) with localized vulvodynia . Half of the patients reported lifelong symptoms whereas a significant proportion of the remaining patients reported onset following childbirth . Subsequently, a population-based study found nearly 16% (of 4915 women) reported a 3-month history of vulvar pain . Localized vulvodynia was confirmed in 78% who presented for clinical exam . Symptoms were associated with younger age, earlier menarche, and pain with first tampon use . White and African American women had similar prevalences, whereas Hispanic women were 80% more likely than either white or African American women to experience vulvar pain .
While 60% of women reporting vulvar pain sought treatment (the majority by at least three providers), the diagnosis remained elusive . Similarly, a population-based study including >2200 women found that about half of women meeting vulvodynia criteria sought treatment for their symptoms and only 1.4% were diagnosed with vulvodynia . Because vulvodynia is a diagnosis of exclusion, findings from epidemiologic studies without clinical confirmation should be interpreted with caution.
Etiology
While many theories regarding associated factors and vulvodynia have been suggested, evidence for the underlying etiology remains elusive.
Embryology
Vulvodynia has been associated with other chronic pain conditions including painful bladder, irritable bowel syndrome, and fibromyalgia . Given the shared embryologic origin (urogenital sinus) for the lower genital tract, a unifying mechanism of pain development has been proposed.
Neuropathic pain
Perhaps the most compelling origin of vulvodynia is a neuropathic pain disorder. Neuropathic pain is defined by the International Association for the Study of Pain as a complex pain initiated by a primary lesion or dysfunction of the nervous system . The pain described by patients with vulvodynia is similar in nature to that described by patients with neuropathic pain such as postherpetic neuralgia and diabetic neuropathy. Patients most often describe a burning pain which can be constant, but may be exacerbated by certain triggers. Studies suggest both central and peripheral responses to neuro-modulating agents, further supporting this etiology. Additionally, patients with vulvodynia have an increase in number and caliber of nerves, specifically pain-sensing nociceptors, which may lend to increased sensitivity .
Infection
Potential infectious etiologies have been investigated . While Farage et al. reported that up to 80% of women with vulvodynia have a self-reported history of recurrent vulvovaginal candidiasis, Bornstein noted that treatment with fluconazole did not improve vulvar pain symptoms among 40 women with vulvodynia, several of whom had culture-proven vulvovaginal candidiasis . However, it is unclear whether symptoms were related to the topical therapies used for treatment or the candidal infection.
The human papillomavirus (HPV) was also implicated as a factor in the development of vulvodynia . However, subsequent studies have not demonstrated an association between HPV and vulvodynia . Thus, HPV noted among women with vulvodynia is likely a reflection of the general prevalence rather than a true association.
Inflammation
Based on the presence of vulvar erythema, older terminology referred to vestibulitis, “-itis” signifying inflammation. This was initially corroborated by tissue samples of patients with vestibulodynia who were noted to have an inflammatory infiltrate. However, subsequent studies noted the presence of an inflammatory infiltrate in asymptomatic controls . Thus, the presence of inflammation, either clinically or histologically, is not a diagnostic marker for vulvodynia.
Genetics
Genetic features may predispose women to the development of neuropathic pain. Specifically, allele 2 of interleukin 1 beta ( IL-1 beta ) receptor antagonist (an inflammatory mediator) may be associated with an exaggerated response to inflammation due to decreased ability to downregulate the inflammatory activity .
Hormonal influence
Based largely on anecdotal evidence, vulvodynia was noted to occur in women with possible alterations in hormonal milieu, specifically resulting from hormonal birth control. While several studies have demonstrated an association with combined hormonal contraception and the risk of developing vulvodynia, other studies have not .
Dietary influences
The association of dietary oxalates and vulvodynia was based on a single case report describing the complete relief of vulvodynia in a woman following a low-oxalate diet with calcium citrate supplementation . Two subsequent case-controlled studies found no difference in oxalate excretion nor an association with vulvodynia . Thus, dietary oxalate consumption is not currently recommended for the management of vulvodynia.
Anatomic
Pelvic floor dysfunction can be a predisposing or coexisting condition. While it remains unclear whether pelvic floor dysfunction is a result of chronic pain from vulvodynia or a precipitating factor, physical therapy and biofeedback can improve muscle tone and pain symptoms when present.
Psychosocial
Vulvodynia causes significant emotional and psychosocial distress in affected patients, and subsequently their families and their sexual partners. While it has been postulated that avoidance of intimacy may be due to an increased incidence of childhood physical or sexual abuse in women with vulvodynia, evidence remains contradictory . Furthermore, women with vulvodynia were noted to share similar psychological characteristics to controls and have comparable marital satisfaction . Regardless of which occurred first, pain or psychologic distress, targeted psychosocial therapy leads to improvement of pain for some patients .
Prognosis
A prospective study involving 239 women with provoked vestibulodynia noted significant improvement in pain ratings, sexual satisfaction, sexual function, and depressive symptoms (as assessed by Beck Depression Inventory) over 2 years, regardless of treatment modality . While the most common treatments were physical therapy, sex/psychotherapy, and medical treatment, 41% received no treatment. The only single treatment with superior outcome was surgery; however, this treatment improved only depressive symptoms and did not affect pain . Although this study is prognostically informational, it did not have the data to support the use of one treatment modality over another. Rather, this study supports the use of placebo-controlled trials to assess treatment outcomes beyond the apparent natural progression of provoked vestibulodynia.
Diagnosis
Women with vulvodynia present with varied complaints depending on the subtype of their disease. Most patients with vulvodynia complain of a burning or tearing pain which can be constant or intermittent, spontaneous (unprovoked) or provoked (i.e., with vaginal penetration during physical examination, sexual intercourse, or placement of a tampon.) Given that vulvodynia is a diagnosis of exclusion, careful history and physical examination to rule out other etiologies of pain is imperative.
Patient history
Patients presenting with vulvar pain should be queried regarding character and duration of symptoms; medical, psychosocial, and surgical history; sexual history; allergies; and previous treatments. One should specifically inquire about current products that patients are using (including both over-the-counter and prescribed topicals), as the vulvar skin is particularly sensitive to additives in commonly used hygiene products as well as to components of sanitary and laundry products.
A menstrual history clarifies whether pain is associated with menses and whether the patient is in a hypoestrogenic state such as menopause. Contraception methods should be assessed as barrier protection can cause contact irritation, while some hormonal methods can contribute to atrophy.
It should be noted whether the patient is sexually active, including number and gender of partners and whether lubricant, sex toys, or dilators are used. Risk of infection such as yeast should be assessed as symptoms can mimic those of vulvodynia.
Regarding medical and psychosocial history, diagnoses such as irritable bowel syndrome, painful bladder syndrome, and depression have been associated with vulvodynia . While history of physical or sexual abuse should be determined to assist with optimal patient management, childhood physical or sexual abuse should be queried as both have been found to be more prevalent in a population of women with vulvodynia .
Physical trauma or history of pelvic surgery (e.g., pelvic reconstruction, cystocele repair, rectocele repair, etc.) can contribute to the development of nerve injury and resultant pain. Thus, obstetric history including route of delivery, use of forceps/vacuum, birth weight, and resultant obstetrical trauma with mode of repair should be included.
Finally, it should be noted whether the patient has been examined for these symptoms in the past and the outcomes from treatments rendered.
Physical exam
The physical examination should include an abdominopelvic exam with specific attention paid to vulvar findings. The vulvar exam should begin with visualization of the entire vulva. This includes inspection from the mons anteriorly to the perianal skin posteriorly and into the intertriginous zones lateral to the labia majora. Careful examination helps to assess for change in color, erythema, edema, mass, or lesion. Shaving and waxing, as well as piercings, should be noted as they can predispose the patient to folliculitis and further exacerbate symptoms. The absence of a normal hair pattern and normal vulvar architecture may otherwise be suggestive of vulvar dermatoses.
Bilateral inguinal areas should be palpated to assess for lymphadenopathy. Further evaluation of the patient’s pain requires palpation of the vulva. At this point, the patient should demonstrate by pointing to where the pain is most severe. Offering a mirror with the back of the examining table elevated can assist the patient and practitioner in locating her pain. The examiner should then use the cotton swab to assess for areas of point tenderness which would determine whether the pain is generalized or localized, provoked or unprovoked. Asking the patient if she has pain before palpation with the cotton swab can further elucidate if the pain is spontaneous (unprovoked). A single-finger palpation of the perineal muscles should be undertaken to assess for evidence of vaginismus. A bimanual examination may be performed if there is concern based on history that the symptoms may be caused by pain in the upper genital tract. Finally, as vulvar pain can be referred pain from other parts of the body, such as the back or hips, a musculoskeletal evaluation may be indicated.
Further testing
Additional testing should be based on the patient’s history and clinical exam. We recommend a wet mount for microscopy, vaginal pH, and fungal culture. A biopsy is not necessary unless there is a focal lesion suspicious for neoplasia or there is concern for underlying pathology/dermatoses.
Treatment
Vulvodynia is often multifactorial in origin; thus, a multidisciplinary approach to treatment should be considered. The team of providers may involve sexual counselors, clinical psychologists, physical therapists, and pain specialists in addition to the primary treating provider. It is crucial to maintain communication among all involved treating providers to avoid duplication of therapy and optimize a cohesive treatment plan.
It is critical to have a good working relationship with the patient. Any treatment approach should begin with a discussion including an explanation of the diagnosis and realistic treatment goals. A general guiding principle is to begin with those treatment options with the fewest side effects or potential complications. The patient should be counseled that follow-up is needed to evaluate treatment responses and adjust the therapeutic plan as needed to maximize pain reduction.
The majority of therapeutic regimens for vulvodynia have been established based on expert opinion, clinical experience, and observational studies with no single best regimen identified. Few randomized controlled trials exist. Current modalities include vulvovaginal skin care guidelines; use of medical therapies including oral, topical, and injectable medications; biofeedback and physical therapy; psychosexual counseling; and surgical intervention, as well as complementary and alternative therapies. It is important to note that the majority of the research to date has focused on the treatment of vestibulodynia and less on the treatment of generalized vulvodynia. Additionally, modalities such as vestibulectomy do not apply to treatment of generalized vulvodynia.
Skin care guidelines
Products used on the vulva may incite contact irritation further contributing to vulvodynia. Thus, we recommend elimination of all potential irritants ( Table 1 ). Additional recommendations include cleansing the vulvar skin with warm water only and patting dry, use of white cotton underwear, and avoidance of tight-fitting clothing. The patient should be educated that lubrication is imperative for intercourse and encouraged to use plain unscented/unflavored silicone- or oil-based products that generally maintain their lubricating properties for longer than water-based products.
| Perfumed laundry detergents |
| Fabric softeners/dryer sheets |
| Perfumed body soaps |
| Feminine wipes |
| Douches |
| Pads and tampons with perfumes/avoid use of daily panty liner |
| Topical medications |
The patient’s household members and sexual partners should make similar changes regarding products in order to prevent cross contamination (from shared laundry) and continued irritation (from direct contact). A common barrier to implementing these changes is the patient report that they have “always used such methods and products” without prior difficulty. It is important to emphasize that product formulations as well as vulvar sensitivity can change over time. Thus, elimination of possible irritants is imperative for treating both localized and generalized vulvodynia.
Clinicians should also consider elimination of prescription products and starting anew as patients can develop sensitivities to these products or the base in which they are prepared.
Medical management
Topical
With all topical medications, it is helpful to use a mirror in the clinic setting and show the patient exactly how much and where to apply the medication to ensure they receive the desired effect and minimize local and systemic side effects. Some patients may develop worsening of discomfort with use of a topical medication, which may signify sensitivity to the medication and/or to the base in which it is prepared. As noted, ointments are better tolerated than creams due to additives, specifically drying agents, which tend to be present in cream preparations. If a patient develops sensitivity to multiple agents, evaluation may be warranted. Medication can then be compounded to avoid vehicles to which the patient is sensitive.
Lidocaine
The most commonly prescribed topical medication for the treatment of vestibulodynia is lidocaine (2–5%) in the form of a gel, cream, or ointment. It can be used as a palliative measure for sexual intercourse or it can be used to treat the skin. In the case of sexual intercourse, it should be applied 20–30 min prior to penetration or on an as-needed basis.
Following application of 5% lidocaine ointment nightly for a mean of 7 weeks, 57% (of 61 patients) with vestibulodynia reported a significant (>50%) decrease in dyspareunia and 40% more women were able to have intercourse .
By contrast, a randomized, double-blinded, placebo-controlled trial compared the use of oral desipramine and topical 5% lidocaine cream as both monotherapy and combination therapy. The aim was to target both peripheral and central neuronal pathways, which would also potentially elucidate the origin of the neuropathic component of this diagnosis. All arms of the study, including the double placebo arm, demonstrated a decrease in vulvar pain. There was no significant difference between pain reduction in patients treated with placebo versus topical lidocaine monotherapy (33% vs. 20%) . Yet another study compared the use of electromyographic biofeedback and topical lidocaine treatment over 4 months and found similar pain improvement in both groups .
The side effects of lidocaine include burning sensation at the site of application and toxicity which can be minimized by use of the smallest effective dose. Lidocaine 5% ointment (or 2% jelly) is most commonly prescribed for application 30 min before sexual activity . Topical use of benzocaine and diphenhydramine should be avoided due to potential sensitization and irritation.
Cromolyn
Despite a case series demonstrating benefit, a randomized double-blind placebo-controlled study found cromolyn 4% cream to be no more effective than placebo in symptom reduction in women considered to have a possible allergic etiology of vestibulodynia .
Capsaicin
Although observational studies demonstrated moderate improvement in dyspareunia in the majority of patients with vestibulodynia applying capsaicin >four times daily, treatment is often discontinued due to intolerance/discomfort with local application. This is not surprising given that capsaicin is the spicy element in hot chili peppers. Moreover, almost all patients who completed treatment required use of topical lidocaine or narcotic pain medication prior to the application of capsaicin and therefore it is unclear how much of the desired effect is attributed to capsaicin use .
Nifedipine
While application of topical nifedipine has been shown to be successful in treating chronic anal fissure, a double-blind placebo-controlled trial demonstrated no difference in improvement in pain in women with vestibulodynia between the treatment and placebo groups (mean pain intensity improved in all arms of the study) .
Nitroglycerin
Similar to nifedipine, nitroglycerine has demonstrated benefit for treating chronic anal fissure. A small prospective cohort study found 91% (of 34 women) with vulvodynia with introital dyspareunia noted improvement in overall pain following topical application of 0.2% nitroglycerine cream . However, side effects including headaches, lightheadedness, dizziness, or fainting limit its use in clinical practice.
Diazepam
Due to its use in treatment of muscle spasm, observational studies primarily from the urology literature have evaluated the effect of vaginal diazepam on pain associated with pelvic floor dysfunction/hypertonicity . While observational findings have suggested some improvement in a subgroup of women with vulvodynia, serum levels are similar to levels with systemic use, which raises concern for development of tolerance and substance dependence .
Gabapentin
Based on success following oral gabapentin for neuropathic pain conditions and limited clinical observation with its use for vulvodynia (generalized and localized), the efficacy and tolerability of topical gabapentin were retrospectively evaluated. Twenty-eight (of 35 women with vulvodynia) demonstrated at least 50% improvement in pain scores. Furthermore, topical application was well tolerated .
Amitriptyline/baclofen
Combined amitriptyline 2%, baclofen 2% cream was evaluated in a retrospective review of 38 women with vestibulodynia refractory to other medical treatment. Of this cohort, 71% identified a response of at least 30%, while 53% reported >60% improvement in dyspareunia . Subsequently, the application of topical 2% amitriptyline twice daily was evaluated as a monotherapy in a prospective cohort of women with vestibulodynia over 3 months . Fifty-six percent (of 150 patients) reported improvement, 10% of whom reported complete resolution of pain and pain-free intercourse .
Estrogen
While an association between the use of combined hormonal contraceptives and vulvodynia remains controversial, a recent retrospective review of 50 premenopausal women using combined hormonal contraceptives with secondary vestibulodynia reported improvement in posttreatment pain scores following discontinuation of their medication and local application of topical estradiol and testosterone twice daily for an average treatment duration of 20 weeks .
Fibroblast lysate
A recent crossover study evaluated the use of fibroblast lysate cream for treatment of vestibulodynia in 30 patients. There was a statistically significant (though clinically modest) decrease in erythema and dyspareunia with treatment over placebo .
Other topicals
Topical steroids, progesterone, and antifungals have not been shown to be effective in the treatment of vulvodynia.
Oral medications
Antidepressants
Antidepressant medications have been successfully used in the treatment of various chronic pain syndromes, not only for effects on depression which can accompany chronic pain, but also for effects on pain. Antidepressants have been shown to be effective in patients with and without depressive symptoms . Additionally, patients report improvement in symptoms with low numbers needed to be treated .
As noted previously, a double-blind, placebo-controlled, four-arm study using oral desipramine and topical 5% lidocaine cream as both monotherapy and combination therapy was conducted. All arms of the study, including the double-placebo arm, demonstrated a decrease in vulvar pain. There was no significant difference between pain reduction in patients treated with placebo versus oral desipramine (33% vs. 24%) . A cohort study noted at least 50% improvement among 87% participants following combined tricyclic antidepressant (TCA) combined with counseling and support for vulvodynia of which 47% of 32 patients reported complete relief . However, the proportion of improvement attributed to the TCA is unclear given the use of combined therapy. Subsequently, in a prospective cohort evaluating the TCA effectiveness, 59% (of 83 women) using a TCA for vulvodynia improved by >50% in contrast to 38% (of 79 women) not using a TCA .
While antidepressant medications have not been directly compared, TCAs are the most studied and appear to be more effective than other classes. In reports of previously failed therapy with selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs), TCAs were found to be successful in reducing vulvar pain . There is evidence for the use of SNRIs in neuropathic pain, although this has not been studied in vulvodynia . SSRIs are generally less effective than TCAs for pain, but the side-effect profile of SSRIs are generally better than the notorious anticholinergic side effects of TCAs. It is recommended that low doses be used initially and titrated based on patient tolerance and response.
Common anticholinergic side effects with TCA use are dry mouth, blurred vision, constipation, drowsiness, and increased appetite. Many women will experience a modest weight gain with TCAs. Most side effects are short term and resolve once the patient is stabilized on therapy. It has also been reported that some antidepressants, typically the SSRIs and SNRIs, can have negative effects on sexual function . This is not typically noted with the TCAs. Although this has not been well described in the vulvodynia literature, it warrants mention given that patients with vulvodynia are often struggling with poor sexual function and comorbid psychosexual conditions. Thus, disclosure is important and titrating adequate doses for pain control can be limited by patient tolerance of side effects.
Antiepileptics
In patients who cannot tolerate adequate doses of TCAs or report inadequate relief of vulvodynia, anticonvulsant medications are often considered. Antiepileptics are Food and Drug Administration (FDA) approved for treating other forms of neuropathic pain. Gabapentin has been the utilized and most studied anticonvulsant for all types of vulvodynia . Other anticonvulsants useful for vulvodynia treatment in cohort studies include pregabalin, lamotrigine, and carbamazepine .
Similar to studies of other therapies for vulvodynia, randomized trials or comparative studies are not available. The side effects of gabapentin are similar to those noted with antidepressants (e.g., mild cognitive impairment, weight gain, and increased appetite), but are thought to be less severe. Generally, improvement in vulvodynia pain was noted following the use of topical and oral gabapentin as well as oral lamotrigine in observational studies . However, whether the improvement in pain occurred because of therapy or represented a regression to the mean was questioned. No randomized trials studying the effectiveness of gabapentin against placebo have been performed.
When prescribing antidepressant or anticonvulsant medications, it is important to attempt use for several weeks (e.g., 4–8 weeks) before determining the full effect. When discontinuing after stable use, it is important to taper the dose, as abrupt discontinuation can have significant effects similar to alcohol or benzodiazepine withdrawal including insomnia, restlessness, agitation, anxiety, and confusion.
Injections
Corticosteroid
Thought to be due to anti-inflammatory effects, submucosal injection of corticosteroid has been reportedly successful at improving vulvar pain associated with vestibulodynia .
Botulinum toxin A
Suggested following successful use in other pain syndromes, botulinum toxin may have a specific pain-modulating effect in addition to its paralytic effects . While several small, open-label studies have shown improvement in symptoms with botulinum toxin at doses of 20–100 units, the only randomized, double-blinded, placebo-controlled trial demonstrated no improvement with 20 units over placebo in 64 women with vulvodynia .
Other injections
A recent placebo-controlled study was undertaken to evaluate enoxaparin based on the increased presence of heparanase in the vestibule of women with vestibulodynia. While modest, 15 of 20 enoxaparin-treated women reported >20% reduction in pain compared to five of 18 women in the placebo group .
Vestibulectomy
Surgical intervention is not generally considered first-line therapy due to the desire to pursue less invasive options. Thus, patients proceeding with surgical therapy have often failed a number of other medical therapies or interventions. Vestibulectomy is reserved for patients with vestibulodynia and not those with generalized unprovoked vulvodynia. A critical review of the literature to date suggests that vestibulectomy is successful in 60–90% of cases, whereas other nonsurgical therapies are 40–80% effective. However, there is no consensus or standardized definition for evaluation of outcomes between studies . While there are no studies comparing surgical management with placebo, some approaches appear to be more successful than others. Vestibuloplasty, where the vestibule is simply incised and re-approximated, has been noted to be ineffective. Furthermore, there may be subsets of patients more likely to experience a benefit from vestibulectomy. Indications, risks, benefits, as well as the specific procedures utilized are described in the chapter on surgery of the vulva.
Laser
Few studies have been performed evaluating the utility of laser therapy in the treatment of vulvodynia. A retrospective study noted less pain with sexual intercourse among 24 of 37 women treated with pulsed laser therapy for vestibulodynia . However, 35% of the patients in the study went on to have vestibulectomy for the control of symptoms .
Biofeedback therapy and physical therapy
Due to the significant component of pelvic floor hypertonicity associated with vulvodynia, more often vestibulodynia, women should be assessed for pelvic floor dysfunction. Biofeedback and physical therapy are essential in treating both localized and generalized pain accompanied by myofascial-related dysfunction as reviewed in the chapter on physical therapy.
Psychotherapy
Vulvodynia, like other chronic pain syndromes, has a significant emotional impact on the patient. Thus, a comprehensive treatment approach is imperative as sexual pain, no matter the cause, involves physical, psychological, and relationship components and benefits from sexual counseling and emotional support. Patients need assurance that referral for emotional therapy does not imply that the clinician has concluded the pain is not real. Rather, dialogue regarding a comprehensive treatment approach including counseling and psychological support can help allay fears that the patient may already have about their pain being psychological. Evaluation and management is covered in the section on psychosexual aspects of vulvar disease.
Alternative medicine strategies
Hypnotherapy
Limited findings for hypnotherapy noted a significant decrease in pain associated with gynecologic examination and intercourse, as well as increased sexual satisfaction in nine patients .
Acupuncture
Similarly, the use of acupuncture for vestibulodynia described a significant increase in positive quality-of-life measures and a significant decrease in negative quality-of-life measures .
The success for both hypnotherapy and acupuncture remains unclear given the lack of available evidence to date.
Treatment summary
Available data evaluating medical therapy for the treatment of vulvodynia suggest improvement with most proposed therapies. In the few placebo-controlled trials available, there are similar responses to both the treatment and placebo groups. Surgical therapy remains the most effective form of treatment for vestibulodynia, but has not been compared to placebo. Because less invasive options are typically beneficial, surgery is not generally used for initial treatment. An individualized, multidisciplinary approach should be considered to optimally address each underlying pain factor.
Summary
In summary, vulvodynia is a pain disorder that affects up to one in six women in the United States. The physical, psychosocial, and financial distress caused by chronic vulvar pain related to the diagnosis is significant for patients and their families. Diagnosis and treatment remains a frustrating endeavor for women’s health providers due to the lack of understanding regarding the etiology and optimal treatment. It is unclear whether there is a significant difference between generalized unprovoked vulvodynia and vestibulodynia; however, most research has been done specifically pertaining to the latter. Proposed therapeutic measures are abundant; however, there is minimal evidence to suggest improvement in symptoms over placebo.
The rapid resolution of vulvar pain is unusual, even with appropriate therapy. Thus, expectations for improvement should be addressed with the patient. Despite many published studies on the treatment of vulvodynia, management needs to be individualized. Future research should aim at identifying the underlying etiologies and pathogenesis as well as identifying the optimal multimodal approach to improve outcomes in women with this complex symptom constellation.
