Pocket ObGyn – Vestibulodynia
See Abbreviations
Definitions, Epidemiology, and Etiology (J Reprod Med 2004:49:772)
- Sev, localized pain of the vulva provoked by focal touch or pres, lasting >3 mo & not explained by another
- 11–16% prevalence
- Unk Current hypothesis: Insult to mucous membrane of the vulvar vestibule ® chronic inflammation ® central nervous system sensitization ® allodynia. Risks include vulvovaginal candidiasis, OCP use, presence of IC.
Clinical Manifestations
- Cardinal sign: Sev pain upon vaginal penetration, touch or focal vulvar pres for 3–6 mo w/o relevant visible findings or clinically characterized neurologic d/o. Most common site of provoked pain ® post
- Provoked by coitus, vulvar contact w/ tampon, speculum, tight clothing, washing, or wiping vestibule; sitting, biking, or horseback
Physical Exam and Diagnostic Workup
- Pelvic exam: Gross inspection, mapping by palpation w/ cotton tipped applicator to localize pain, single digit exam, speculum exam; tenderness in vulvar vestibule w/ or w/o areas of erythema; no pathognomonic features, no bx
- A clinical dx of exclusion w/ history & physical exam
- Labs: Vaginal pH & microscopy, yeast culture
- R/o other causes: Infectious, inflamm, neoplastic, neurologic, musculoskeletal, psychosexual; depression, domestic abuse or relationship discord; DDx include fungal vulvitis, lichen planus, lichen sclerosus, lichen simplex chronicus, atopic or contact dermatitis, vulvar intraepithelial neoplasia
Subsequent Workup
- Treat vulvar dermatosis w/ steroids, if no improv in sx ® poss Serial yeast cx if culture negative yet pt experiences recurrent vulvovaginal pruitus or burning.
Treatment and Medications
- Extensive pt education (www.nva.org) & vulvar care (unscented products, 5–10 min sitz baths)
- 1st-line therapy: Pelvic floor muscle rehabilitation w/ either topical gabapentin 6% or topical 5% lidocaine gel; 5 mL of topical lidocaine to the vestibule 20–30 min prior to vaginal intercourse
- Tricyclic antidepressants w/ nortriptyline or desipramine gradual max daily dose of
100–150 mg PO; alternative regimen w/ gabapentin (64% showed ¯ 80% of sx)
(J Reprod Med 2007;52(2):103)
- Botulinum toxin type A injections
- Surgical intervention as a last rx (~30–50%: Improv) Woodruff’s original perineoplasty, post, modified, or simplified vestibulectomy &