From the Guidelines
Vulvodynia and vestibulodynia should be investigated and treated with a multimodal approach, prioritizing conservative measures and topical treatments, with a focus on improving quality of life and reducing morbidity and mortality. Vulvodynia and vestibulodynia are chronic pain conditions affecting the vulvar region in women, with vulvodynia referring to pain in the entire vulvar area and vestibulodynia specifically affecting the vestibule (entrance to the vagina) 1. Investigation begins with a thorough medical history and physical examination to rule out other conditions like infections, dermatological disorders, or neurological issues.
Key Considerations
- Treatment typically follows a multimodal approach, starting with conservative measures such as avoiding irritants, wearing cotton underwear, and using lubricants during intercourse 1.
- Topical treatments include lidocaine 2-5% ointment applied 15-30 minutes before intercourse or regularly for pain relief 1.
- Oral medications that may help include tricyclic antidepressants (amitriptyline starting at 10mg nightly, gradually increasing to 25-75mg), anticonvulsants (gabapentin 300mg daily, increasing to 300mg three times daily), or SNRIs (duloxetine 30-60mg daily) 1.
- Physical therapy focusing on pelvic floor exercises and biofeedback is often beneficial, typically requiring 8-12 weekly sessions 1.
- For vestibulodynia specifically, vestibulectomy surgery may be considered in refractory cases, though it should be reserved for patients who haven't responded to other treatments 1.
- Psychological support through cognitive behavioral therapy helps address the emotional impact of chronic pain 1.
Treatment Approach
The treatment approach should be tailored to each patient's specific symptoms and needs, taking into account the potential causes of vulvodynia and vestibulodynia, including nerve sensitization, pelvic floor dysfunction, hormonal influences, and psychological factors 1.
Imaging and Further Evaluation
Imaging may be indicated in the context of an abnormal physical exam, with ultrasound being the initial modality of choice, and MRI may be appropriate for further characterization in select cases 1.
Patient Education and Support
Patient education and support are crucial in managing vulvodynia and vestibulodynia, with a focus on improving quality of life and reducing morbidity and mortality 1.
From the Research
Definition and Prevalence of Vulvodynia and Vestibulodynia
- Vulvodynia is a common, recurrent, vulvar pain condition that affects approximately 8% to 12% of women during their lifetimes 2.
- Vulvar vestibulodynia (VVD) is the most common form of vulvodynia, characterized by pain with touch at the vulvar vestibule and resulting entryway dyspareunia 2.
- Provoked vestibulodynia is a subtype of chronic vulvar pain, characterized by acute recurrent pain located at the entry of the vagina in response to pressure application or attempted vaginal penetration 3.
Investigation of Vulvodynia and Vestibulodynia
- A comprehensive assessment is needed to understand the pain experience of women presenting with vulvodynia, including medical history, physical examination, and psychological evaluation 4.
- Proper vulvar hygiene is recommended as part of the assessment and treatment process 2.
Treatment Options for Vulvodynia and Vestibulodynia
- Non-pharmacological interventions, including psychological therapy and pelvic floor physical therapy, are recommended as first-line treatments for vulvodynia 5, 4.
- Multimodal physical therapy has been shown to be effective in reducing pain intensity during intercourse and improving sexual function and sexual distress in women with provoked vestibulodynia 3.
- Vestibulectomy (surgery) may be recommended for women with provoked vestibulodynia who have not responded to other treatments, with success rates of 60% to 90% 2, 4.
- Pharmacological treatments, such as oral tricyclic antidepressants, gabapentin, and topical lidocaine, may be used, but their efficacy and safety need to be further studied 5, 6, 4.
- Alternative therapies, such as physiotherapy, psychotherapy, and cognitive behavioral therapy, may also be considered as part of a multidisciplinary treatment approach 6, 4.