In a patient recently treated for a urinary tract infection who now has localized provoked vestibular pain without vulvar lesions, what is the appropriate first‑line therapy?

Vestibulodynia Following UTI Treatment: First-Line Therapy

For a patient with localized provoked vestibular pain without vulvar lesions following UTI treatment, topical lidocaine (Option A) is the appropriate first-line therapy, as it provides immediate symptomatic relief for this neuropathic pain condition while other interventions are considered.

Understanding Vestibulodynia

Provoked vestibulodynia (PVD) is characterized by vulvar pain localized to the vestibule, provoked by touch and sexual activity, occurring in the absence of a clear identifiable cause 1. This condition represents a chronic pain syndrome characterized by sensitization of peripheral and central nociceptive pathways, with pain arising due to dysfunctional neuronal activity 1, 2.

The clinical presentation in this case—localized provoked pain at the vestibule without vulvar lesions—is classic for vestibulodynia 1, 2.

First-Line Management Approach

Topical Lidocaine (Option A)

Topical lidocaine 5% ointment should be tried first for vestibulodynia-related dysaesthesia 3. This neuropathic pain will not respond to topical corticosteroids, so treatment must be aimed at eradication of neuronal sensitization 3.

• Lidocaine provides immediate symptomatic relief and can be used as needed before activities that provoke pain 3
• It addresses the neuropathic component of the pain directly 3
• This approach has minimal systemic side effects and can be initiated immediately 3

Tricyclic Antidepressants (Option B)

If topical lidocaine is unresponsive, progression to amitriptyline is recommended 3. Low-dose amitriptyline (up to 75 mg daily) has demonstrated a 60% positive response rate in Candida-negative vestibulodynia patients 4.

• TCAs should be considered second-line therapy after topical lidocaine trial 3
• Treatment duration of 8 weeks is reasonable to assess response 4
• This addresses central pain sensitization mechanisms 1, 2

Fluconazole (Option C)

Fluconazole is NOT appropriate for this presentation because:

• The patient has no vulvar lesions, making vulvovaginal candidiasis (VVC) unlikely 3
• VVC diagnosis requires signs and symptoms of vaginitis with demonstration of yeasts or pseudohyphae on wet preparation, or positive culture 3
• Identifying Candida in the absence of symptoms should not lead to treatment 3
• While there is an association between Candida infection and vestibulodynia development 5, 4, treating with antifungals is only appropriate when positive Candida cultures are documented 4

Clinical Algorithm

1. Initial assessment: Confirm localized provoked vestibular pain without visible lesions (vestibulodynia diagnosis) 1, 2

2. First-line: Topical lidocaine 5% ointment as needed for symptomatic relief 3

3. If inadequate response after 2-4 weeks: Consider low-dose amitriptyline (starting 10-25 mg at bedtime, titrating up to 75 mg daily as tolerated) 3, 4

4. Consider Candida testing: If there is history of recurrent yeast infections or positive culture, long-term antifungal therapy may be beneficial (71% cure rate when Candida-positive) 4

Important Caveats

• Do not confuse with UTI: This is a distinct neuropathic pain condition, not a persistent infection requiring antibiotics 1, 2
• Avoid unnecessary antifungals: Without evidence of candidiasis (no lesions, no discharge, no positive culture), fluconazole is inappropriate and may delay proper treatment 3
• Early intervention is key: PVD is highly treatable, especially with early intervention, and most women can expect significant improvement with fairly simple interventions 1
• Multidisciplinary consideration: If symptoms persist despite initial management, referral to specialized vulvar medicine services or pelvic floor physical therapy may be beneficial 1, 6

The answer is A: Topical lidocaine as first-line therapy, with progression to TCAs if unresponsive.