Vulvodynia

Question 1

Types

Answer 1

• Localised provoked vestibulodynia (LPV):
• Hypersensitivity to pain at vulval vestibule
• Generalised and spontaneous: Pain or burning occurring constantly or spontaneously, and may affect the whole vulva
• Mixed

Question 2

History for LPV

Answer 2

o Dyspareunia most common presentation
o Pain provoked by sexual intercourse, tampon use or tight clothing
o Pain or burning continues after intercourse
- This symptom may precede penetration pain
o May cause vulval dysuria
o Clarify primary or secondary
- Primary: Intercourse and tampons have always been painful
- Secondary: Previously had pain-free intercourse
* Need to exclude pain-sensitising genital condition
o Symptoms are not intermittent

Question 3

Examination

Answer 3

o Normal external genital appearance
o May have mild redness near introitus
o Cotton-tip test – light palpation of vulva produces tenderness
o Tenderness of pelvic floor muscles and spasm may occur internal examination

Question 4

Investigations

Answer 4

o HVS MCS
o Endocervical swab for chlamydia/gonorrhoea PCR
o Viral swab for HSV if skin splitting present

Question 5

Management

Answer 5

• Education
  o Explain chronic pain theory: Complex interplay psychological, phyisical. Triggers may illicit a learned “pain sensation” due to previous experiences. Hypersensitivity develops from changes to inhibitory mechanism of pain modulation.
  o Give written information
  o Explain generally good prognosis, with majority of women experiencing significant improvement over months
  o Treatment requires patient engagement and patience
• Refer to women’s physiotherapist for downtraining/desensitisation exercises
• Consider referral to psychologist with interest in sexual health
• 2% lignocaine gel 2-3/daily to introitus may be helpful
• 2% Endep cream to vulva (make at compounding pharmacist) – less drowsiness
• Pain modulators
  o Low dose TCA ie amitriptyline (Endep)
  o Alternative or addition is pregabalin (Lyrica)
  o Commence low dose and increase slowly
• Consider referral to pain specialist if no improvement