Persistent Vulvar Pain Flashcards
Cotton swab testing is used to identify the areas of pain (classifying each area of pain as mild, moderate, or severe) and to differentiate between generalized and localized pain.
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The vulva and vagina should be examined, and infection ruled out when indicated using tests, including wet mount, vaginal pH, fungal culture, and Gram stain, or other available point-of-care testing or polymerase chain reaction testing.
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Medications used to treat vulvar pain include topical, oral, and intralesional medicinal substances, as well as pudendal nerve blocks and botulinum toxin. Tricyclic antidepressants and anticonvulsants also can be used for vulvodynia pain control.
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An emerging treatment for vulvodynia is transcutaneous electrical nerve stimulation.
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Vulvodynia is defined as vulvar pain of at least 3 month’s duration without identifiable cause and with potential associated factors
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Tricyclic antidepressants and anticonvulsants also can be used for vulvodynia pain control. When first prescribing these medications, 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 should emphasize the need for contraception. Tricyclic antidepressants and anticonvulsants take up to 3 weeks to achieve adequate pain control. Patients usually develop tolerance to some of the adverse effects of these medications (particularly sedation, dry mouth, and dizziness).
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Amitriptyline often is used as a first-line agent beginning at an oral dose of 5–25 mg nightly and increased by 10–25 mg each week, generally not to exceed a total of 150 mg daily (4). If cessation is necessary, tricyclic antidepressants should not be stopped suddenly; weaning the patient by 10–25 mg every few days is indicated. Gabapentin, used to manage neuropathic pain disorders, is the most studied and used anticonvulsant for vulvodynia (4). Dosage can be increased over time from 300 mg total daily to a maximum dose of 3,600 mg daily (1,200 mg by mouth three times a day), and may need adjustment to avoid adverse effects. It is unusual, however, to experience adverse effects that lead to discontinuation. In elderly patients with vulvodynia, it may exacerbate gait and balance problems.
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