1. Bridget Keller, MD Stacey Seibel, PhD, LP
Vulvodynia
Bridget Keller, MD
Stacey Seibel, PhD, LP

2. Case Study
28 y.o. G1P1001 married female presents with chief complaint of dyspareunia and vulvar pain.
Pain is burning, raw and occurs with sexual intercourse, touch and tampon use.
Pain is localized to a specific area that she can show you.
She has seen at least 3 other physicians for this complaint with no relief. She is frustrated.
Evaluation?
Diagnosis?
Treatment options?

3. Objectives Discuss diagnosis and classification of vulvodynia
Review vulvar anatomy
Identify treatment strategies and discuss the importance of multidisciplinary treatment

4. Vulvodynia ISSVD Definition Diagnosis of exclusion
“Chronic vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable neurologic disorder”
Diagnosis of exclusion

5. Vulvodynia Prevalence Incidence
1 in 4 women affected at some point in life
3-7% reproductive aged women
Incidence
3.2%
All ethnicities
Highest incidence of symptom onset women age 18-25

6. ISSVD Classification
Vulvar pain due to a specific disorder (not vulvodynia)
Infection
Inflammatory
Lichen sclerosus, contact dermatitis
Neoplastic
Neurologic
Pudendal nerve entrapment, spinal nerve compression

7. ISSVD Classification Generalized Localized
Provoked (sexual, non sexual or both)
Unprovoked
Mixed
Localized
If confined to vestibule – “Provoked vestibulodynia”

8. ISSVD Classification
Vulvar pain related to a specific disorder is not considered vulvodynia
Infections
Inflammatory or dermatologic condition
Neoplasm
Neurologic disorder (nerve entrapment, spinal nerve compression)

9. Vestibulodynia: Overview
Chronic pain/discomfort around opening of vagina (e.g., the vestibule)
Often inflammation and irritation around the vestibule
Resultant pain with vaginal penetration (e.g., intercourse; tampon insertion)
Presenting Complaint: “Sex hurts”
Pain can also occur with wearing tight clothing, sitting, exercise, and pelvic exams

10. Pathophysiology Generalized vulvodynia – neuropathic pain syndrome
Co-morbid conditions
Interstitial cystitis
Fibromyalgia
IBS
Depression
Chronic fatigue syndrome

12. Vulvodynia Assessment
Clinical History
Risk factors
Co morbid conditions
Psychosocial issues
Physical Exam
Visual exam
Cotton swab test
Neurosensory exam
Pelvic floor exam

13. Vulvodynia Assessment

16. Vulvodynia Assessment
Clinical History
Risk factors
Co morbid conditions
Psychosocial issues
Physical Exam
Visual exam
Cotton swab test
Neurosensory exam
Pelvic floor exam

17. Vulvodynia: Treatment
Standard of care is a combination of medical, physical therapy and/or psychotherapy services
Individualized multidisciplinary care
The majority of women with vulvodynia can develop healthy, painless (and enjoyable) sexual relationships
Primarily treatable
Remission rates 17-25% in population based studies

18. Treatment: Medical Vulvar self care Topical medication Oral medication
Lidocaine, estrogen
Oral medication
TCA, Gabapentin
Injectable medication
Nerve blocks
Surgery
Vestibulectomy
Dietary modifications

19. Treatment: Medical Topical Medications/vestibulodynia
Zolnoun, et al 5% Lidocaine ointment to affected area at night. Soak cotton ball in 5% ointment and apply cotton ball directly to vestibule nightly for 3 months % improvement in ability to have intercourse at follow up.
2% Lidocaine jelly to affected area minutes prior to sexual activity and as needed up to 5 times daily
Reduces allodynia response on vulva

20. Treatment: Medical Oral medications/unprovoked generalized vulvodynia
Amitriptyline 10 mg q HS increase weekly up to 150 mg
Gabapentin 300 mg PO increase by 300 mg every 3 days to 3600 mg daily
Systematic Review states insufficient evidence to support use of antidepressant (JSexMed 2012;Sept 13)
Oral Despiramine and Topcial Lidocaine for provoked vestibulodynia: a RCT (Obstet Gynecol 2010; )
Oral despiramine and topical lidocaine as monotherapy or in combination failed to reduce pain more than placebo

21. Treatment: Medical Vestibulectomy For provoked vestibulodynia only
Superficial removal of affected area of vestibule with or without vaginal advancement
May be done in office under local anesthesia or in OR
Last resort treatment
Requires commitment to self care after surgery and physical therapy treatment after healing
Reported success rates 60-95%

22. Treatment: Medical
Vulvodynia Interventions – Systematic Review and Evidence Grading (Obstet Gynecol Surv May;66(5):
Insufficient evidence to support any non-surgical therapies for vestibulodynia
Single RPCT demonstrate lack of evidence for topical 5% xylocaine, oral desipramine, oral fluconazole, topical cromolyn, topical nifedipine, and botox injections.
Fair evidence of benefit of vestibulectomy
Placebo effect demonstrated
Insufficient direct evidence for efficacy of any intervention for generalized unprovoked vulvodynia

23. Non-Medical Impact of Vulvodynia
Adverse impact on perception of self as a woman
Sense of body betrayal
Feelings of inadequacy/abnormality
Disconnect from genitals due to representation of something negative /painful
Relationship discord
Other sexual health concerns in both partners (e.g., low sexual desire; erectile dysfunction)
Psychiatric impact (e.g., depression; hopelessness; anxiety)

24. Impacting Factors: Non-Medical
Self-protective response to physical pain
Body tenses up in anticipation of pain = pain
History of negative and/or unhealthy sexual experiences (e.g., trauma)
Psychiatric Co-morbidity (e.g., anxiety)
Sex as a linear concept (A = B = C)
Expectation that all intimacy will lead to sex
Muscle tension at “point of no return”
Unhealthy relationship dynamics
Can I trust he/she will respect boundaries?

25. Treatment: Physical Therapy
Goal: Relaxation of pelvic floor muscles with vaginal penetration through use of multiple modalities to restore sexual function
Vaginal dilators
A gradual approach to being able to receive penetration without pain
Anatomy and physiology education
Education in exercises for home
Biofeedback
Trigger point injections

26. Treatment: Psychotherapy Basics
Patient and partner education
Shifting intimacy dynamics
Breaking the association that all intimacy leads to expectation of intercourse
Expectation = muscle tension = pain
Even once physical components are treated, pain may remain present. Necessity of shifting intimacy dynamics.
Ban on intercourse until body is healed
Golden opportunity to bolster non-penetrative intimacy
Slowly pushing the limits of intimacy
Avoiding a 0 to 1000 approach (this does not work)
Allowing touch to be a positive experience again

27. Treatment: Psychotherapy Basics…
Often awkward, “clinical” and painless intercourse occurs prior to spontaneous, pleasurable and painless intercourse
Do not trust until experience absence of pain
Addressing impact to sense of self as a sexual being
Development of a healthy overall sexuality
Learning to cope with chronic pain
Impacts nearly every aspect of one’s life
Treating co-occurring psychiatric concerns (e.g., depression; anxiety)

28. Question:
28 y.o. G1P1001 with localized, burning vulvar pain that is worse with intercourse and tampon insertion. Her diagnosis is most likely
A. Generalized vulvodynia
B. Recurrent vulvar candidasis
C. Provoked Vestibulodynia
D. Pudendal nerve entrapment

29. Question:
28 y.o. G1P1001 with localized, burning vulvar pain. Exam reveals vestibular erythema and a positive cotton swab test. You prescribe
A. Topical 5% lidocaine
B. Pelvic Floor Physical Therapy
C. Sexual counseling
D. all of the above

30. Question:
Recommendations for the treatment of vulvodynia typically include which two (2) of the following:
A. Scheduling intercourse
B. Slowly increasing non-sexual intimacy
C. Increased sexual frequency as a means of de- sensitization
D. Initial ban on penetrative sex

31. Contact Information
Stacey Seibel, PhD, LP
Bridget Keller, MD

33. References
Vulvodynia: An Under-Recognized Pain Disorder Affecting 1 in 4 Women and Adolescent Girls. National Vulvodynia Association. Slides reproduced with permission.
Clin Anat Jan;26(1): Vulvar Pain: Anatomic and Recent Pathophysiologic Considerations.
J Sex Med Sep 13. A Systematic Review of the Utility of Antidepressant Pharmacotherapy in the Treatment of Vulvodynia Pain.
Obstet Gynecol Surv may;66(5): Vulvodynia Interventions – Systematic Review and Evidence Grading

34. References
Acta Obstet Gynecol Scand Nov;89(11): Surgical Treatment of Vulvar Vestibulitis: a Review.
Obstet Gynecol Sep;116(3): Oral Despiramine and Topical Lidocaine for vulvodynia: a Randomized Controlled Trial.
Br J Dermatol Jun;162(6): Guidelines for the Management of Vulvodynia.
Obstet Gynecol 2003;102: Zolnoun DA, Hartmann KE, Steege JF. Overnight 5% Lidocaine Treatment for Vulvar Vestibulitis
J Low Genit Tract Dis 2005;9(1): Haefner, HK, et al. The VulvoDynia Guideline.