1. VULVODYNIA Clinical Aspects and Research Initiative
Gloria A. Bachmann, M.D.
Nidhi Gupta, M.D.
Women’s Health Institute
UMDNJ-Robert Wood Johnson Medical School

2. Defining Vulvodynia
The International Society for Study of Vulvovaginal Diseases (ISSVD) defines vulvodynia as ‘chronic vulvar discomfort, characterized by the woman’s complaint of burning, stinging, irritation or rawness’

3. Types of Vulvar Pain PAIN from an IDENTIFIABLE ETIOLOGY VULVODYNIA
Vulvar Vestibulitis Subtype (provoked)
Dysesthetic Vulvodynia Subtype (unprovoked)
1. Pain from an identifiable etiology such as herpes simplex, cyclic candidial vulvovaginitis, lichen planus, etc.
2. Unprovoked generalized vulvar dysesthesia (also called dysesthetic vulvodynia* or
essential vulvodynia), unknown etiology
3. Provoked localized dysesthesia (also called vulvar vestibulitis or vestibulodynia)

4. Pain from an Identifiable Etiology
Infections such as chronic vulvovaginitis caused by Candida or other pathogens
Dermatoses and Dermatitis that involve the vulva such as Lichen Sclerosus, Lichen Planus, irritants and allergic dermatitis
Vaginismus
*Vulvodynia is used as an umbrella term and should not be used for pain from an identifiable etiology.
Vulvodynia needs to be differentiated from:
Recurrent yeast infection or recurrent BV or streptococcus infection
Atrophy not responding to estrogen
Culture negative UTI “urethral syndrome”
Dermatosis not responding to ultra potent steroids

5. Vulvodynia: Vulvar Vestibulitis Subtype
Friedrich’s criteria diagnostic:
1. Severe pain on vestibular touch or attempted vaginal entry.
2. Tenderness to pressure localized within the vulvar vestibule
3. Physical findings confined to vestibular erythema of various degrees
Pain is provoked and localized
Commonly seen in women aged 50 years or less
Friedrich’s criteria include:
Severe pain on vestibular touch or attempted vaginal entry.
2. Tenderness to pressure localized within the vulvar vestibule
3. Physical findings confined to vestibular erythema of various degrees

6. Vulvodynia: Dysesthetic Vulvodynia Subtype
Pain is constant and may be felt beyond the confines of vulvar vestibule
Usually pain is unprovoked
Diagnosed mainly in women who are peri- or postmenopausal
In Dysesthetic Vulvodynia, point tenderness and dyspareunia are less than in vulvar vestibulitis.
The vulvar tissue may look normal.
Dysesthesia could be hyperesthesia or alloynia.
Hyperesthesia – pain perceived is out of proportion to touch.
Allodynia – the sensation perceived is different than that applied.
These two types of pain vulvar vestibulitis and dysesthetic vulvodynia are collectively called as vulvodynia

7. Vulvodynia: Prevalence Statistics
Harvard-based study (n=16,000) estimates a 16% life time prevalence*
UMDNJ-based study estimates:
21% prevalence of chronic gynecologic pain
13.5% prevalence of vulvodynia-type pain
* Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Women's Assoc 2003;58:82-88
The literature estimates prevalence anywhere from 2-20% of U.S. women. A variety of studies exist, most of which are small-scale and based out of case reports or selected OB/GYN practices. For this reason, it is thought that previous estimates were on the lower side. Recent work at Harvard University supports this thought.
Preliminary studies from a large scale (n=16,000) Harvard-based, NIH-sponsored epidemiologic study of women in the Boston area aged years indicate a lifetime 16% prevalence of chronic vulvar burning, knife-like pain or pain on vulvar contact for 3 months or longer(1)
Unpublished results of a UMDNJ-based, NIH-sponsored survey study of women patients at a University-based medical group indicate a 21% (n=378) lifetime prevalence of chronic gynecologic pain and a 13.5% (n=242) prevalence of vulvodynia-like symptoms.
(1)Harlow BL,Stewart EG.A population-based assessment of chronic unexplained vulvar pain:have we underestimated the prevalence of vulvodynia?J Am Med Women's Assoc 2003;58:82-88

8. Vulvodynia: Demographics
Older data suggest the highest prevalence in white women
Accounts for 10 million doctor visits/year
Upwards of 14 million women are affected in their lifetime
Recent data suggest Hispanic women 80% more likely to have vulvar pain than other racial groups
Vulvodynia can affect women of all ages and ethnicities.
Vulvodynia accounts for 10 million doctor visits/year.
Upwards of 14 million women are affected in their lifetime.
40% of women with vulvodynia choose not to seek treatment (2).
Of those seeking treatment, 60% see three or more clinicians (2).
Of women seeking treatment, the majority of clinicians do not provide a diagnosis to the woman (1).

9. Etiology: Vulvar Vestibulitis Subtype
Prior vulvovaginal Candidiasis
Hypersensitivity to chemicals
Human Papilloma virus infection
High levels of urinary oxalates
Neurological dysfunction
Potential initiating events include chronic infection(s), surgery, or childbirth.
Increased prevalence of chronic sub clinical Candida infections have been reported
Vulvar Vestibulitis may originate from a myriad of inflammatory insults on the female genital tract.

10. Candida Etiology: Vulvar Vestibulitis Subtype
In 1989 Ashman and Ott proposed cross reaction between Candida albicans antigens and self-antigen in vulvovaginal tissue
Affected tissue has locally elevated concentrations of inflammatory cells and pro-inflammatory cytokines
These suggest a hyper-immune response, possibly from persistent antigen from the Candida

11. Proposed Etiologies: Vulvar Vestibulitis Subtype
Calcium oxalate crystals in urine may act as irritant to the vulva
Reduced estrogen receptor expression causing alteration in vulvar sensation*
CNS etiology, similar to other regional pain syndromes
* Eva LJ, MacLean AB, Reid WMN, et al. Estrogen Receptor Expression in Vulvar Vestibulitis Syndrome. Am J Obstet Gynecol 2003;189:1-4.
(2) Eva LJ, MacLean AB, Reid WMN, et al. Estrogen Receptor Expression in Vulvar Vestibulitis Syndrome. Am J Obstet Gynecol 2003;189:1-4.

12. Proposed Inflammatory Etiology: Vulvar Vestibulitis Subtype
An inflammatory event releases cytokines that sensitize nociceptors in the nerve fibers of the vulva*
Increased intraepithelial nerve endings in vestibulitis patients have been reported. Prolonged neuronal firing sensitizes neurons in dorsal horn of spinal cord, with subsequent abnormal interpretation as pain from touch**
* Westrom LV, Willen R. Vestibular Nerve Fiber Proliferation in Vulvar Vestibulitis Syndrome. Obstet Gynecol ;91:
** Bohm-Starke N, Hilliges M, Falconer C, et al. Increased Epithelial Innervation in Women with Vulvar Vestibulitis Syndrome. Gynecol Obstet Invest. 1998;46:
Prolonged neuronal firing sensitizes neurons in the dorsal horn of the spinal cord, causing them to abnormally interpret the sensation of touch in the vestibule as pain (3)
(3) Westrom LV, Willen R. Vestibular Nerve Fibre Proliferation in Vulvar Vestibulitis Syndrome. Obstet Gynecol ;91:
(4) Bohm-Starke N, Hilliges M, Falconer C, et al. Increased Epithelial Innervation in Women with Vulvar Vestibulitis Syndrome. Gynecol Obstet Invest. 1998;46:

13. Etiology: Dysesthetic Vulvodynia Subtype
Etiology not definitively known
Childhood trauma and OCP’s possible contributors
Sympathetic pain loops caused by repeated irritation/trauma leads to continuous vulvar symptoms*
* Davis GD, Hutchison CV. Clinical Management of Vulvodynia. Clinical Obstetrics and Gynecology. June 1999; 42(2):pp
Vulvar dysesthesia may be attributable to early childhood trauma and some to vaginal trauma in the later reproductive years.Major depressive disorder and oral contraceptive use may be independent risk factors.
(5) Davis GD, Hutchison CV. Clinical Management of Vulvodynia. Clinical Obstetrics and Gynecology. June 1999; 42(2):pp

14. Vulvodynia: Assessment of the Patient
OB/GYN history
Detailed pelvic exam to exclude pathology
Vaginal culture (in selected cases)
Pap smear
OB/GYN history should involve questions directed to vulvodynia and dyspareunia.
Vaginal cultures should be done for Candida, Chlamydia, Gonorrhea, Herpes, Gardenerella, Trichomonas.

15. Vulvodynia: Assessment of the Patient
Vaginal pH
Urinanalysis for oxalate content (select cases)
Biopsy of abnormal vulvar areas
Psychosocial assessment

16. Vulvodynia: Assessment of Pain Intensity
Clinician Assessment:
Q–tip test
Vulvalagesiometer- A device developed at McGill University for nominal scale vulvar pain measurement*
Vulvar Algesiometer- Developed by Curnow to quantify pain by nominal scale**
* Pukall CF, Payne KA, Binik YM, Khalife S. Pain measurement in vulvodynia. Journal of Sex and Marital Therapy. 29 Suppl 1:111-20,2003.
** Curnow JS, Barron I, Morrison G., et al. Vulval algesiometer. Med Biol Eng Comput 1996;34:266-9.
Q-tip test:The vestibule should be evaluated carefully with the Q-tip test after separating the labia minora.The vestibule should be palpated with a cotton tipped applicator around the face of the vestibular clock.
Vulvalgesiometer: Developed by Caroline Pukall and colleagues at McGill University for reliable pain ratings. This helps in the diagnosis, classification and understanding of vulvar pain conditions.
Vulvar Algesiometer: contains a hand held probe that includes a metal thrust probe in a plastic casing sleeve. This algesiometer measures vestibular tenderness for each area of the vestibule and the total for that visit is recorded on a vulvar map. The readings on the algesiometer will be compared before and after treatment.
(6) Pukall CF, Payne KA, Binik YM, Khalife S. Pain measurement in vulvodynia. Journal of Sex and Marital Therapy. 29 Suppl 1:111-20,2003.
(7) Curnow JS, Barron I, Morrison G., et al. Vulval algesiometer. Med Biol Eng Comput 1996;34:266-9.

17. Vulvodynia: Assessment of Pain Intensity
Patient Assessment:
McGill-Melzack Pain Questionnaire- 78 pain words grouped in 20 subclasses of 3-5 descriptive words*
Subclasses are grouped in four sections, sensory, affective, evaluative and miscellaneous.
Provides information on timeline, location and a quantitative measure of clinical pain.
(8) Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975;1: * Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975;1:

18. Vulvodynia: Differential Diagnosis
Exclude other pain causes:
Vaginitis, Candida, urethritis, interstitial cystitis, Herpes, Bartholin adenitis
Vulvar Dermatoses and Dermatitis such as eczema
Vaginismus, entry and deep dyspareunia
Atrophic Vulvo-Vaginitis
For entry dyspareunia, it is important to rule out vaginitis, especially candida, eczema, atrophy, urethritis, interstitial cystitis, herpes, cracked skin, bartholin adenitis and psychosexual problems.
For deep dyspareunia, consider endometritis, pelvic adhesions, adnexal pathology, retroverted uterus, pelvic inflammatory disease and pelvic congestion.

19. Vulvodynia: Diagnosis
“Diagnosis made after thorough evaluation fails to identify pain etiology”
After a thorough evaluation fails to identify or account for the patient’s pain, the condition is labeled as ‘Vulvodynia’

20. Vulvodynia: Management
Vulvar Vestibulitis Subtype:
Non-Pharmacologic
Pharmacologic
Surgical
Dysesthetic Vulvodynia Subtype:
Non-Pharmacologic- Not recommended
Surgical- Not recommended

21. NonPharmacologic Management: Vulvar Vestibulitis Subtype
Patient education and counseling
Physical therapy and biofeedback
Life-style modification
Application of ice and local anesthetics to the vulvar region as needed
Support and Reassurance:Validate the patients symptoms and reassure that vulvodynia is not a sexually transmitted disease or a malignant condition
Patient education and counseling:It is important to provide the patient information brochures on vulvodynia and encourage them to join the National Vulvodynia Association ( which can provide them with education and support.
Life style modification:
Elimination of irritants
Healthy vulvar hygiene
Diet changes( i.e. low oxalate diet)
Alternative therapy such as Acupuncture, Aromatherapy, Healing touch, Homeopathy, Hypnosis, Yoga have been tried; however the efficacy of these methods has not been proven.

22. NonPharmacologic Management: Vulvar Vestibulitis Subtype
Low Oxalate Diet
Oxalate is a metabolic breakdown product from certain food types
Oxalates excreted in urine as crystals
Vulvar surface contact with oxalate crystals causes irritation and burning
Low oxalate diet (with calcium citrate supplementation) may be beneficial
Foods low in oxalate :Foods of animal origin, Rice,Spaghetti, White bread,Butter, Vegetable oil, Aspartame(1 Tsp.), Lemon/Lime juice, Sweet ‘N Low(1 Tsp), Sugar,Eggs, Seafood, Apple Juice,Milk-Skim and low-fat,Wine(red and rose), Water, Avocado, Cauliflower,Cabbage, Mushroom, Onion, Banana, Cherries, Mango, Peaches,Plums.
Foods High in Oxalate:Beans,Eggplant, Green peppers,Sweet potatoes, Potato chips,Russet potato, Blackberries,Blueberries,Lemon ,Lime peel,Oranges,Tea,Juices containing berries,Raspberries, Strawberries,Tangerines,Fruitcake, Peanuts, Peanut butter,Chocolate, Cocoa powder,Gelatin, Vegetable/tomato soup

23. NonPharmacologic Management: Vulvar Vestibulitis Subtype
Calcium Citrate and the Low Oxalate Diet
Degradation of vulvar collagen and hyaluronic acid also increase oxalate pool
Calcium citrate inhibits hyaluronidase and the release of oxalates and acts as a free radical scavenger *
1200 mg of calcium citrate daily
aids in further reducing urinary oxalate levels **
(9) Lewin LM, Nevo Z, Gabsu Z, Nebel L.Hyalouronidase release from guinea pig spermatozoa as affected by reproductive tract secretions and metabolic inhibitors. Arch Androl 1978;1(2)
(10)Solomons CC,Melmed MH,Heittler SM.Calcium citrate for vulvar vestibulitis:a case report.J Reprod Med.1991;36: * Lewin LM, Nevo Z, Gabsu Z, Nebel L.Hyalouronidase release from guinea pig spermatozoa as affected by reproductive tract secretions and metabolic inhibitors. Arch Androl 1978;1(2)
* * Solomons CC,Melmed MH,Heittler SM.Calcium citrate for vulvar vestibulitis:a case report.J Reprod Med.1991;36:

24. Biofeedback: Vulvar Vestibulitis Subtype
Surface electromyographic biofeedback data suggest persistent vulvar injury leads to chronic reflex pain, resulting in increased muscle tension*
Pelvic floor muscle instability may be present
If pelvic floor abnormalities present, physical therapy often beneficial
* Glazer H, Ledger WJ. Clinical Management of Vulvodynia. Rev Gynecol Pract ;2:83-90.
Biofeedback studies have found chronic tension and spasticity in these patients.
(11) Glazer H, Ledger WJ. Clinical Management of Vulvodynia. Rev Gynecol Pract ;2:83-90.

25. Physical Therapy: Vulvar Vestibulitis Subtype
Physical therapy reduces muscle tension and spasm, decreasing pain levels by 40-60% *
Physical therapist can retrain dysfunctional pelvic floor muscles
* Hartmann EH, Nelson C. The Perceived Effectiveness of Physical Therapy Treatment on Women Complaining of Vulvar Pain and Diagnosed With Either Vulvar Vestibulitis Syndrome or Dysesthetic Vulvodynia. Journal of the Section on Women’s Health. 2001;25:13-18.
(12) Hartmann EH, Nelson C. The Perceived Effectiveness of Physical Therapy Treatment on Women Complaining of Vulvar Pain and Diagnosed With Either Vulvar Vestibulitis Syndrome or Dysesthetic Vulvodynia. Journal of the Section on Women’s Health. 2001;25:13-18.

26. Physical Therapy: Vulvar Vestibulitis Subtype
Physical therapy components:
Pelvic floor exercise
Myofascial release
Trigger point pressure
Massage
Resource: The American Physical Therapy Association ( APTA) or (

27. Medical Management: Vulvar Vestibulitis Subtype
Topical estrogens:
Improve epithelial maturation
Inhibit production of inflammatory mediators (cytokines and interleukin-1)
Lower pain threshold*
*Cutolo M,Sulli A,Seriolo B,et al.Estrogens,the immune response and autoimmunity.Clin Exp Rheumatol.1995;13:
The use of medication to manage vulvodynia does not work for every woman; response varies greatly from patient to patient and may be due to differences in the cause of vulvar pain.
(13) Cutolo M,Sulli A,Seriolo B,et al.Estrogens,the immune response and autoimmunity.Clin Exp Rheumatol.1995;13:

28. Medical Management: Vulvar Vestibulitis Subtype
Topical estrogen creams useful for women with thin vaginal epithelium and/or lose of vulvar adipose tissue
Can be used with other pharmacologic agents

29. Medical Management: Vulvar Vestibulitis Subtype
Tricyclic antidepressants (Amitriptyline-10mg hs: dose up to 150mg daily)
Fluconazole
Gabapentin (anticonvulsant), Venlafaxine-efficacy not proven
Selective serotonin receptor inhibitors (SSRIs)-efficacy not proven
Tricyclic antidepressants are commonly used to treat this condition. They are given in doses of 10 mg at bedtime increased to 150 mg or a dose that controls symptoms.Inform patients of the side effects (dry mouth, sedation,constipation, urinary retention).
Gabapentin, SSRIs and Venlafaxine are used, but efficacy is not proven.

30. Medical Management: Vulvar Vestibulitis Subtype
Corticosteroids: (topical and injections)
Topical anesthetics (nitroglycerin & lidocaine)
Alpha Interferon injections
Capsaicin cream (immune response modifier)
Corticosteroids have been used with no convincing results
Topical nitroglycerin cream may provide temporary, safe and effective relief from pain (14).
Topical lidocaine has shown promising results in some women, as it helps to break the nociceptor input to the CNS (15).
Capsaicin cream, an immune response modifier imiquimod, is being tried, but efficacy data do not exist (16).
(14)Walsh KE,Berman JR,Berman LA,Vierregger K.Safety and efficacy of topical nitroglycerine for treatment of vulvar pain in women with vulvodynia:a pilot study.J Gend Specif Med 2002;5:21-27
(15)New concepts in vulvodynia,Edwards,Libby MD,Am J Obstet Gynecol,Volume 189(3)Supplement,September 2003,ppS24-S30
(16) Zolnoun DA,Hartmann KE,Steege JF.Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis.Obstet Gynecol 2003;102:84-87

31. Surgical Management: Vulvar Vestibulitis Subtype
Excision of affected vulvar area to remove neural hyperplasia
Surgery reserved for non- responders to conservative treatments
Data suggest a success rate varying from %
Long term data lacking
Surgical procedures include focal excision, vestibuloplasty, vestibulectomy and perineoplasty.
Vestibulectomy excises the vestibule with vaginal advancement. The excision includes a U shaped area of the vestibule from 5 mm lateral to the urethra to the posterior fourchette. The hymenal ring is included. The margins of the vestibule are reapproximated to the vaginal wall.
Perineoplasty excises the vestibule from below and lateral to the urethral meatus, extending along the perineum to half the distance between the posterior fourchette and the anal canal. The vaginal mucosa is undermined 1-2 cm, advanced and sutured to the skin.

32. Surgical Procedures: Vulvar Vestibulitis Subtype
Types: focal excision, vestibuloplasty, vestibulectomy and perineoplasty
Vestibulectomy excises a U shaped area of the vestibule from 5mm lateral to the urethra and the posterior fourchette
Perineoplasty excises the vestibule from below and lateral the urethral meatus to the anal canal with the vaginal mucosa undermined 1-2cm.
Surgical procedures include focal excision, vestibuloplasty, vestibulectomy and perineoplasty.
Vestibulectomy excises the vestibule with vaginal advancement. The excision includes a U shaped area of the vestibule from 5 mm lateral to the urethra to the posterior fourchette. The hymenal ring is included. The margins of the vestibule are reapproximated to the vaginal wall.
Perineoplasty excises the vestibule from below and lateral to the urethral meatus, extending along the perineum to half the distance between the posterior fourchette and the anal canal. The vaginal mucosa is undermined 1-2 cm, advanced and sutured to the skin.

33. Pharmacologic Management: Dysesthetic Vulvodynia Subtype
Amitriptyline: first line therapy
Other tricyclic antidepressants- desipramine and imipramine-may be effective *
Selective serotonin reuptake inhibitors efficacy not proven
* McKay M. Dysesthetic Vulvodynia: treatmnet with amitryptyline. J Reprod Med 1993 ; 38:9-13
(17) McKay M. Dysesthetic Vulvodynia: treatment with amitryptyline. J Reprod Med 1993 ; 38:9-13