Committee Opinion ACOG Vulvodynia

ACOG
Committee on
Gynecologic Practice
Reaffirmed 2008
American Society
for Colposcopy and
Cervical Pathology
This document reflects emerging
clinical and scientific advances as
of the date issued and is subject
to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed.
The Committee and Society wish
to thank Hope K. Haefner, MD,
and Mark Spitzer, MD, for their
assistance in the development of
this document.
Copyright © October 2006
by the American College of
Obstetricians and Gynecologists.
All rights reserved. No part of this
publication may be reproduced,
stored in a retrieval system,
posted on the Internet, or transmitted, in any form or by any
means, electronic, mechanical,
photocopying, recording, or otherwise, without prior written permission from the publisher.
Requests for authorization to
make photocopies should be
directed to:
Copyright Clearance Center
222 Rosewood Drive
Danvers, MA 01923
(978) 750-8400
ISSN 1074-861X
The American College of
Obstetricians and Gynecologists
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920
Vulvodynia. ACOG Committee
Opinion No. 345. American College
of Obstetricians and Gynecologists.
Obstet Gynecol 2006;108:1049–52.
Committee
Opinion
Number 345, October 2006
Vulvodynia
ABSTRACT: Vulvodynia is a complex disorder that can be difficult to treat.
It is described by most patients as burning, stinging, irritation, or rawness.
Many treatment options have been used, including vulvar care measures,
medication, biofeedback training, physical therapy, dietary modifications,
sexual counseling, and surgery. A cotton swab test is used to distinguish generalized disease from localized disease. No one treatment is effective for all
patients. A number of measures can be taken to prevent irritation, and several medications can be used to treat the condition.
Vulvodynia is a complex disorder that can be difficult to treat. This
Committee Opinion provides an introduction to the diagnosis and treatment
of vulvodynia for the generalist obstetrician–gynecologist. It is adapted with
permission from the 2005 American Society for Colposcopy and Cervical
Pathology publication, “The Vulvodynia Guideline” (1).
Terminology and Classification
Many women experience vulvar pain and discomfort that affects the quality
of their lives. Vulvodynia is described by most patients as burning, stinging,
irritation, or rawness. It is a condition in which pain is present although the
vulva appears normal (other than erythema).
The most recent terminology and classification of vulvar pain by the
International Society for the Study of Vulvovaginal Disease defines vulvodynia as “vulvar discomfort, most often described as burning pain, occurring
in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder” (2). It is not caused by commonly identified infection (eg, candidiasis, human papillomavirus, herpes), inflammation (eg,
lichen planus, immunobullous disorder), neoplasia (eg, Paget’s disease,
squamous cell carcinoma), or a neurologic disorder (eg, herpes neuralgia,
spinal nerve compression). The classification of vulvodynia is based on the
site of the pain, whether it is generalized or localized, and whether it is provoked, unprovoked, or mixed. Although the term vulvar dysesthesia has been
used in the past, there is now consensus to use the term vulvodynia and subcategorize it as localized or generalized.
Several causes have been proposed for vulvodynia, including embryologic abnormalities, increased urinary oxalates, genetic or immune factors,
hormonal factors, inflammation, infection, and neuropathic changes. Most likely, there is not a single
cause.
Because the etiology of vulvodynia is unknown,
it is difficult to say whether localized vulvodynia
(previously referred to as vestibulitis) and generalized vulvodynia are different manifestations of the
same disease process. Distinguishing localized disease from generalized disease is fairly straightforward and is done with the cotton swab test as
described in the following section. Early classification to localized or generalized vulvodynia can facilitate more timely and appropriate treatment.
Diagnosis and Evaluation
Vulvodynia is a diagnosis of exclusion, a pain syndrome with no other identified cause. A thorough
history should identify the patient’s duration of pain,
previous treatments, allergies, medical and surgical
history, and sexual history.
Cotton swab testing (Fig. 1) is used to identify
areas of localized pain and to classify the areas
where there is mild, moderate, or severe pain. A diagram of pain locations may be helpful in assessing
the pain over time. The vagina should be examined,
and tests, including wet mount, vaginal pH, fungal
culture, and Gram stain, should be performed as
indicated. Fungal culture may identify resistant
strains, but sensitivity testing usually is not required.
Testing for human papillomavirus infection is
unnecessary.
Treatment
Most of the available evidence for treatment of vulvodynia is based on clinical experience, descriptive
studies, or reports of expert committees. There are
few randomized trials of vulvodynia treatments.
Outlined here are treatments used by clinicians with
an interest in vulvodynia. Multiple treatments have
been used (Fig. 2), including vulvar care measures;
topical, oral, and injectable medications; biofeedback
training; physical therapy; dietary modifications;
cognitive behavioral therapy; sexual counseling; and
surgery. Newer treatments being used include
acupuncture, hypnotherapy, nitroglycerin, and botulinum toxin.
Gentle care of the vulva is advised. The following vulvar care measures can minimize vulvar
irritation:
•
•
•
•
•
•
•
•
•
•
Figure 1. Cotton swab testing for vestibulodynia. The
vestibule is tested at the 2-, 4-, 6-, 8-, and 10-o’clock
positions. When pain is present, the patient is asked to
quantify it as mild, moderate, or severe. (Haefner HK.
Critique of new gynecologic surgical procedures: surgery for vulvar vestibulitis. Clin Obstet Gynecol 2000;
43:689–700.)
2
Wearing 100% cotton underwear (no underwear
at night)
Avoiding vulvar irritants (perfumes, dyes, shampoos, detergents) and douching
Using mild soaps for bathing, with none applied
to the vulva
Cleaning the vulva with water only
Avoiding the use of hair dryers on the vulvar
area
Patting the area dry after bathing, and applying
a preservative-free emollient (such as vegetable
oil or plain petrolatum) topically to hold moisture in the skin and improve the barrier function
Switching to 100% cotton menstrual pads (if
regular pads are irritating)
Using adequate lubrication for intercourse
Applying cool gel packs to the vulvar area
Rinsing and patting dry the vulva after urination
Different medications have been tried as treatments for vulvar pain. These include topical, oral,
and intralesional medications, as well as pudendal
nerve blocks. Many of these medications are known
to interact with other drugs, and many patients with
vulvodynia may be taking multiple medications.
Clinicians should check for any potential drug inter-
ACOG Committee Opinion No. 345
Physical examination
Cutaneous or mucosal surface disease present
Yes
No
Cotton swab test
Not tender, no area of vulva
touched described as area
of burning
Treat abnormal visible condition present (infections,
dermatoses, premalignant or malignant conditions)
Tender, or patient describes
area touched as area of
burning
Yeast culture
Alternative diagnosis (incorrect belief
that vulvodynia is
present)
Positive
Negative
Antifungal
therapy
Inadequate
relief
Adequate relief
Good relief
Treatment Options
1. Vulvar care measures
2. Topical medications
3. Oral medications
4. Injections
5. Biofeedback/physical therapy
6. Dietary modifications
7. Cognitive behavioral therapy
8. Sexual counseling
Inadequate relief
and pain localized
to vestibule
Inadequate relief and
pain generalized
No additional treatment;
stop treatment when indicated
Surgery
(Vestibulectomy)
High-dose and
multiple
medications for
neuropathic pain;
consider referral
to pain specialist;
consider
neuromodulation
Figure 2. Vulvodynia treatment algorithm. (Adapted from Haefner HK, Collins ME, Davis GD, Edwards L, Foster DC,
Hartmann EH, et al. The vulvodynia guideline. J Low Genit Tract Dis 2005;9:40–51.)
actions before prescribing a new medication. Before
prescribing a new course of therapy, clinicians may
stop use of all topical medication.
Commonly prescribed topical medications
include a variety of local anesthetics (which can be
applied immediately before intercourse or in extended use), estrogen cream, and tricyclic antidepressants compounded into topical form. Although
topical steroids generally do not help patients with
ACOG Committee Opinion No. 345
vulvodynia, trigger-point injections of a combination of steroid and bupivacaine have been successful
for some patients with localized vulvodynia (3).
Tricyclic antidepressants and anticonvulsants
can be used for vulvodynia pain control. When first
prescribing drugs, clinicians should avoid polypharmacy. One drug should be prescribed at a time.
Before prescribing antidepressants or anticonvulsants for a patient of reproductive age, the clinician
3
should emphasize the need for contraception.
Antidepressants have been found to have a 60%
response rate for various pain conditions; however,
no randomized, controlled studies have been published regarding the use of antidepressants for
vulvodynia. Both tricyclic antidepressants and anticonvulsants take time to achieve adequate pain control, which may take up to 3 weeks. Patients usually
develop tolerance to the side effects of these medications (particularly sedation, dry mouth, and dizziness).
Biofeedback and physical therapy also are used
in the treatment of both localized and generalized
vulvodynia (4). Physical therapy techniques include
internal (vaginal and rectal) and external soft tissue
mobilization and myofascial release; trigger-point
pressure; visceral, urogenital, and joint manipulation; electrical stimulation; therapeutic exercises;
active pelvic floor retraining; biofeedback; bladder
and bowel retraining; instruction in dietary revisions; therapeutic ultrasonography; and home vaginal dilation.
Vestibulectomy has been helpful for many
patients with localized pain that has not responded
to previous treatments (5). Patients should be evaluated for vaginismus and, if present, treated before a
vestibulectomy is performed. For generalized vulvar
burning unresponsive to previous behavioral and
medical treatments, referral to a pain specialist may
be helpful.
Conclusion
Vulvodynia is a complex disorder that frequently is
frustrating to both clinician and patient. It can be difficult to treat, and rapid resolution is unusual, even
with appropriate therapy. Decreases in pain may
take weeks to months and may not be complete. No
single treatment is successful in all women.
Expectations for improvement need to be realistically addressed with the patient. Emotional and psychologic support is important for many patients, and
sex therapy and counseling may be beneficial.
Resources
Haefner HK, Collins ME, Davis GD, Edwards L,
Foster DC, Hartman ED, et al. The vulvodynia guideline. J Low Genit Tract Dis 2005;9:40–51. Available at: http://www.jlgtd.com/pt/re/jlgtd/pdfhandler.
00128360-200501000-00009.pdf. Retrieved March
15, 2006.
National Vulvodynia Association
http://www.nva.org
PO Box 4491
Silver Spring, MD 20914-4491
301-299-0775
References
1. Haefner HK, Collins ME, Davis GD, Edwards L, Foster
DC, Hartmann EH, et al. The vulvodynia guideline. J Low
Genit Tract Dis 2005;9:40–51.
2. Moyal-Barracco M, Lynch PJ. 2003 ISSVD terminology
and classification of vulvodynia: a historical perspective.
J Reprod Med 2004;49:772–7.
3. Segal D, Tifheret H, Lazer S. Submucous infiltration of
betamethasone and lidocaine in the treatment of vulvar
vestibulitis. Eur J Obstet Gynecol Reprod Biol 2003;
107:105–6.
4. Bergeron S, Binik YM, Khalife S, Pagidas K, Glazer HI,
Meana M, et al. A randomized comparison of group cognitive-behavioral therapy, surface electromyographic
biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain 2001;
91:297–306.
5. Haefner HK. Critique of new gynecologic surgical procedures: surgery for vulvar vestibulitis. Clin Obstet Gynecol
2000;43:689–700.