Evaluation and Management of Vulvar Pain
Begin evaluation by performing a focused physical examination looking specifically for porcelain-white plaques, fissures, ecchymosis, architectural changes (labial fusion, buried clitoris, introital narrowing), and erythema to distinguish between inflammatory dermatoses (particularly lichen sclerosus), infectious causes, and vulvodynia. 1, 2
Initial Clinical Assessment
Key Physical Examination Findings
Lichen sclerosus (most common in postmenopausal women): Look for porcelain-white plaques, fragile atrophic skin, characteristic fissures in a figure-eight pattern around vulva and anus (pathognomonic), ecchymosis, purpura, and architectural changes including labial fusion, buried clitoris, or introital narrowing 1
Vulvovaginal candidiasis: Examine for vulvovaginal erythema, white discharge, and measure vaginal pH (should be ≤4.5 if candidiasis) 2
Vulvodynia/dysesthetic vulvodynia: Burning pain without visible depigmentation or structural changes on examination 1
Diagnostic Testing
- Perform wet mount with 10% KOH to visualize yeasts or pseudohyphae if infectious etiology suspected 2
- Measure vaginal pH: normal is ≤4.5 (candidiasis), elevated >4.5 suggests bacterial vaginosis 2
- Biopsy is mandatory if diagnosis is uncertain, disease fails to respond to treatment, or there is suspicion of neoplastic change 1
Treatment Algorithm
For Lichen Sclerosus (Depigmented, Burning, Painful Areas)
Topical corticosteroids are first-line treatment for lichen sclerosus, which requires long-term monitoring due to risk of architectural changes and potential malignant transformation 1, 3
For Vulvovaginal Candidiasis
First-line: Fluconazole 150 mg oral single dose OR short-course topical azole therapy (1-3 days) with 80-90% cure rates 2
Topical options: Clotrimazole 1% cream 5g intravaginally for 7-14 days, miconazole 2% cream 5g intravaginally for 7 days, or terconazole 0.8% cream 5g intravaginally for 3 days 2
Pregnant women: Use only topical azoles for 7 days (oral agents contraindicated) 2
Recurrent candidiasis (≥4 episodes/year): Longer initial therapy followed by maintenance regimen for 6 months; evaluate for predisposing conditions (diabetes, immunosuppression, HIV, antibiotic use) 2
For Vulvodynia (Diagnosis of Exclusion)
When infectious and inflammatory causes are excluded, vulvodynia management includes:
- Vulvar care measures and self-management strategies 4, 5
- Tricyclic antidepressants for neuropathic pain component 4
- Physical therapy with biofeedback 4
- Calcium citrate supplementation 4
- Consider surgical intervention or laser therapy in refractory cases 4
Imaging Considerations
Physical examination is the foundation of evaluation; imaging is only indicated when physical examination is abnormal or specific pathology is suspected. 6
Transvaginal and transabdominal ultrasound with Doppler are the initial imaging modalities if pelvic mass or cyst is palpated 6
MRI pelvis is reserved for problem-solving when ultrasound is nondiagnostic, or when evaluating pelvic floor muscular hypertonicity in chronic pelvic pain syndromes 6
CT and plain radiography have no role in primary evaluation of vulvar pain 6
Critical Pitfalls to Avoid
Do not assume depigmentation is benign: Lichen sclerosus carries risk of malignant transformation and requires biopsy if diagnosis uncertain or treatment fails 1
Do not use oral fluconazole in children under 12 years due to limited safety data 3
Do not delay biopsy when architectural changes, non-healing lesions, or treatment failure occurs 1
Do not prescribe home-going opioids for routine postoperative vulvar surgery pain; multimodal opioid-sparing analgesia with scheduled NSAIDs and acetaminophen is sufficient 6