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Vulvodynia and Vulvar Vestibulitis

Vulvodynia has a prevalence of  15 percent.¹  Vulvodynia is a syndrome of unexplained vulvar pain that is frequently accompanied by physical disabilities, limitation of daily activities (such as sitting and walking), sexual dysfunction and psychologic disability.² Originally suggested by McKay,⁴ the term "vulvodynia" has also been suggested by the International Society for the Study of Vulvar Disease Task Force to describe any vulvar pain vulvodynia, vulvar vestibulitis, vulvodinia, vestiblitis, vulvadinia, vulvadynia

 The incidence and prevalence of vulvodynia have not been well studied.¹ Age distribution for the condition may range from the 20s to the 60s, and it is limited almost exclusively to white women.² Obstetric and gynecologic history is usually unremarkable. Risk-taking sexual behavior is rare, and few patients have a history of sexually transmitted diseases.⁵ Vulvar pain usually has an acute onset, at times associated with episodes of vaginitis or certain therapeutic procedures of the vulva (cryotherapy or laser therapy). In most cases, vulvodynia becomes a chronic problem lasting months to years. Vulvar pain is frequently described as burning or stinging, or a 

Most patients consult several physicians before being diagnosed. Many are treated with multiple topical or systemic medications, with minimal relief. In some cases, inappropriate therapy may even make the symptoms worse.⁶ Since physical findings are few and cultures and biopsies are frequently negative, patients may be told that the problem is primarily psychologic, thus invalidating their pain and adding to

Diagnostic and Management Challenges

Subsets of Vulvodynia

Several subsets of vulvodynia have been identified.^4,8 Since vulvodynia is a multifactorial condition, certain subsets may also coexist with

Vulvar Vestibulitis Syndrome
Vulvar vestibulitis syndrome is also known as adenitis or focal vulvitis. It is characterized by entry dyspareunia, discomfort at the opening of the vagina, a positive swab test, tenderness localized within the vulvar vestibulum, and 

Chronic vestibulitis lasts for months to years, and patients may experience entry dyspareunia and pain when attempting to insert a tampon.^6,8 The etiology of vulvar vestibulitis syndrome is unknown. Some cases seem to be provoked by yeast vaginitis. Other suspected causes include recent use of chemical irritants, a history of destructive therapy such as carbon dioxide laser or cryotherapy, or allergic drug reactions.⁵ When surgical specimens were evaluated by polymerase chain reaction, human papillomavirus was present in many women with vulvar vestibulitis syndrome

Histologic examination of symptomatic vestibular tissue has confirmed the presence of mixed chronic inflammatory infiltrates in the superficial stroma, but inflammatory cells have not been found to 

Cyclic Vulvovaginitis
Cyclic vulvovaginitis is probably the most common cause of vulvodynia and is believed to be caused by a hypersensitivity reaction to Candida.^14,15 While vaginal smears and cultures are not consistently positive, microbiologic proof should be sought by obtaining candidal or fungal cultures during an asymptomatic phase. Pain is typically worse just before or during menstrual bleeding. It also may be exacerbated after intercourse, especially on the following day.^4,8 Findings on pelvic or colposcopic examination are usually normal. The diagnosis of cyclic vulvitis is made retrospectively based on

Dysesthetic Vulvodynia
Dysesthetic vulvodynia (essential vulvodynia) typically occurs in women who are peri- or postmenopausal.¹⁶ Pain that occurs in women with this subtype of vulvodynia is usually a diffuse, unremitting, burning pain that is not cyclic. Patients with dysesthetic vulvodynia have less dyspareunia or point tenderness than patients with vulvar vestibulitis syndrome.¹⁶ The physical examination shows no evidence of vestibulitis or cutaneous changes.⁶ Urethral or rectal discomfort is often associated with vulvar pain.⁵ The hyperesthesia is believed to result from altered cutaneous perception, either

Vulvar Dermatoses
Vulvar dermatoses may be manifested by itching and, in some cases, pain (Figures 3 through 5). Vulvar dermatoses include papulosquamous (thick and scaly) lesions. Erosions or ulcers may result from excessive scratching. If the patient has blisters or ulcers and denies scratching, the cause may be a vesiculobullous disease. Differential diagnoses of papulosquamous lesions and vesiculobullous lesions are included in Table 2.⁶ Neoplastic lesions

Papillomatosis
Vestibular papillomatosis is the term describing the presence of multiple small (1- to 3-mm) papillae over the entire inner labia (Figure 7). These papillae are probably congenital in origin and are a normal anatomic variant.¹⁹ A link with human papillomavirus has not been confirmed.^20,21 Patients with vulvar pain and papillomatosis should undergo a colposcopically directed biopsy to rule out pathology. The significance of papillomatosis

Evaluation

The evaluation of patients with vulvar vestibulitis or vulvodynia should include a thorough history, pelvic examination, fungal and bacterial cultures, and KOH microscopic examination. Biopsy of any suspicious areas should be performed using acetowhitening and/or colposcopy to rule out dermatoses

Treatment and Management of Vulvodynia and Vulvar Vestibulitis

Medical Therapy
Some treatments are specific to the subtype of vulvodynia that can be most closely associated with the patient. Vulvodynia is multifactorial in cause, and each subset probably has a different etiology. Cyclic vulvovaginitis is believed to be a reaction to yeast, which may be detected at times and not

Vulvar vestibulitis syndrome has been treated successfully in some cases with topical estrogen cream (about a pea-sized amount), applied two times a day for

Other treatments that have been helpful in patients with vulvodynia are a low-oxalate diet and, in some cases, the addition of oral calcium citrate (Citracal), two tablets (200 mg/950 mg each) orally three times a day to neutralize oxalates in the urine. One theory is that oxalate may irritate the vestibulum and may be a contributing cause to vulvodynia pain over a 

Therapy with potent topical corticosteroids should be limited to brief or short-term use. Long-term use may induce telangiectasias, skin friability, striae formation and easy bruising. Potent steroids can also cause periorificial dermatitis, a rebound inflammatory reaction with erythema and a burning sensation that occurs as the steroid is withdrawn. A cycle of vulvar dermatitis may become worse as the patient treats the erythema and discomfort with the same potent topical steroids that

Physical Therapy and Biofeedback

Since vaginal muscle spasm aggravates the pain and discomfort of vulvodynia, physical therapy using biofeedback and gynecologic instruments has been successful in many patients with vaginismus (spasm of the vaginal muscle) and

Surgical and Laser Therapy

Laser or surgical treatment should be reserved for use in cases in which all forms of medical treatment have failed. Many cases of vulvar vestibulitis that are refractive to medical therapy respond to vulvar vestibulectomy or treatment with excited dye laser. According to Marinoff and Turner,²⁶ surgery should be reserved for use in patients with pain of at least six months' duration, pain that partly or completely prevents sexual intercourse and patients

Flashlamp-excited dye laser therapy for the treatment of idiopathic vulvodynia has been used with some success and may reduce the need for 

Psychologic Considerations

Vulvodynia may cause drastic alterations in lifestyles. It may decrease the patient's ability to walk, exercise, sit for long periods or participate in sexual activities. All of these normal activities may exacerbate the vulvar pain.⁵ Many women with vulvodynia have been diagnosed with a psychologic problem because of the lack of physical findings.¹⁵ Patients may become anxious or angry as diagnosis is delayed after numerous physician visits and