Treatment Options for Vulvodynia
Vulvodynia treatment should follow a stepwise approach beginning with conservative measures and progressing to more invasive options only when necessary, with pelvic floor physical therapy, psychological interventions, and topical treatments forming the cornerstone of first-line management. 1, 2
First-Line Treatments
Topical Treatments
- Lubricants and vaginal moisturizers: Apply 3-5 times per week to the vagina, vaginal opening, and external vulvar folds 1
- Topical lidocaine: Apply before sexual activity or at bedtime for persistent pain 1
- Overnight 5% lidocaine ointment has shown effectiveness in randomized controlled trials 3
- Topical anesthetics: Can be used for introital pain and dyspareunia 1
Physical Therapy Interventions
- Pelvic floor physical therapy: Addresses pelvic floor dysfunction, which is common in vulvodynia 1, 2
- Includes manual therapy techniques, stretching, and relaxation exercises
- Particularly beneficial for patients with pain or other pelvic floor issues 1
- Vaginal dilators: Beneficial for vaginismus, vaginal stenosis, and pain with examinations/sexual activity 1
- Most effective when started early in treatment 1
- Pelvic floor exercises (Kegels): Help decrease anxiety, discomfort, and lower urinary tract symptoms 1
Psychological Interventions
- Cognitive behavioral therapy (CBT): Effective for improving sexual functioning 1, 2
- Psychosexual counseling: Important for addressing the psychological impact of chronic pain on sexual function 1
- Mindfulness and relaxation techniques: Yoga and meditation may help alleviate associated symptoms 1
Second-Line Treatments
Pharmacological Options
- Oral medications:
Topical Prescription Medications
- Vaginal DHEA (dehydroepiandrosterone/prasterone): For women with vaginal dryness or pain, especially those on aromatase inhibitors 1
- Low-dose vaginal estrogen: For those with symptoms of vaginal/vulvar atrophy not responding to conservative measures 1
- Requires thorough risk/benefit discussion for women with hormone-positive breast cancer 1
- Ospemifene: For postmenopausal women without breast cancer experiencing dyspareunia or vaginal atrophy 1
Third-Line Treatments
Interventional Approaches
- Botulinum toxin injections: Consider for persistent pain not responding to other treatments 2, 3
- Interferon injections: May be considered as a second-line option 2
- Capsaicin: Potential second-line treatment that requires further research 2
Surgical Options
- Vestibulectomy: Recommended for provoked vestibulodynia that doesn't respond to conservative treatment 2
- Strong evidence supports this approach for specific cases 2
Multimodal Approach
For complex or refractory cases, combining treatments is often most effective:
- Physical therapy + psychological interventions + appropriate medications 2, 3
- Referral to specialists (urologist, urogynecologist, colorectal surgeon) for associated conditions like urinary/fecal incontinence 1
Special Considerations
- Menopausal symptoms: May require specific management if contributing to vulvodynia 1
- Cancer survivors: May need tailored approaches, especially those on endocrine therapy 1
- Lichen sclerosus: If present, requires specific treatment with ultrapotent topical corticosteroids 1
Common Pitfalls to Avoid
- Misdiagnosis: Vulvodynia is often misdiagnosed as vaginitis or other conditions 3
- Inadequate treatment duration: Most treatments require consistent use over time before benefits appear
- Ignoring psychological impact: The condition significantly affects quality of life and sexual functioning 1
- Focusing on only one treatment modality: Most patients benefit from a combination of approaches 2
- Failure to address comorbid conditions: Associated pelvic floor dysfunction, anxiety, or depression should be treated concurrently
By following this systematic approach to vulvodynia treatment, most women can experience substantial improvement in symptoms and quality of life.