Bridget Keller, MD
Stacey Seibel, PhD, LP
 28 y.o. G1P1001 married female presents with chief
complaint of dyspareunia and vulvar pain.
 Pain is burning, raw and occurs with sexual intercourse,
touch and tampon use.
 Pain is localized to a specific area that she can show you.
 She has seen at least 3 other physicians for this
complaint with no relief. She is frustrated.
 Evaluation?
 Diagnosis?
 Treatment options?
 Discuss diagnosis and classification of vulvodynia
 Review vulvar anatomy
 Identify treatment strategies and discuss the
importance of multidisciplinary treatment
 ISSVD Definition
 “Chronic vulvar discomfort, most often described as
burning pain, occurring in the absence of relevant
visible findings or a specific, clinically identifiable
neurologic disorder”
 Diagnosis of exclusion
 Prevalence
 Incidence
 1 in 4 women
 3.2%
affected at some
point in life
 3-7% reproductive
aged women
 All ethnicities
 Highest incidence
of symptom onset
women age 18-25
 Vulvar pain due to a specific disorder (not vulvodynia)
 Infection
 Inflammatory
 Lichen sclerosus, contact dermatitis
 Neoplastic
 Neurologic
 Pudendal nerve entrapment, spinal nerve compression
 Generalized
 Provoked (sexual, non sexual or both)
 Unprovoked
 Mixed
 Localized
 Provoked (sexual, non sexual or both)
 If confined to vestibule – “Provoked vestibulodynia”
 Unprovoked
 Mixed
 Vulvar pain related to a specific disorder is not
considered vulvodynia
 Infections
 Inflammatory or dermatologic condition
 Neoplasm
 Neurologic disorder (nerve entrapment, spinal nerve
compression)
 Chronic pain/discomfort around opening of vagina
(e.g., the vestibule)
 Often inflammation and irritation around the vestibule
 Resultant pain with vaginal penetration (e.g.,
intercourse; tampon insertion)
 Presenting Complaint: “Sex hurts”
 Pain can also occur with wearing tight clothing, sitting,
exercise, and pelvic exams
 Generalized vulvodynia – neuropathic pain
syndrome
 Co-morbid conditions
 Interstitial cystitis
 Fibromyalgia
 IBS
 Depression
 Chronic fatigue syndrome
 Clinical History
 Risk factors
 Co morbid conditions
 Psychosocial issues
 Physical Exam
 Visual exam
 Cotton swab test
 Neurosensory exam
 Pelvic floor exam
 Clinical History
 Risk factors
 Co morbid conditions
 Psychosocial issues
 Physical Exam
 Visual exam
 Cotton swab test
 Neurosensory exam
 Pelvic floor exam
 Standard of care is a combination of medical, physical
therapy and/or psychotherapy services
 Individualized multidisciplinary care
 The majority of women with vulvodynia can develop
healthy, painless (and enjoyable) sexual relationships
 Primarily treatable
 Remission rates 17-25% in population based studies
 Vulvar self care
 Topical medication
 Lidocaine, estrogen
 Oral medication
 TCA, Gabapentin
 Injectable medication
 Nerve blocks
 Surgery
 Vestibulectomy
 Dietary modifications
 Topical Medications/vestibulodynia
 Zolnoun, et al 5% Lidocaine ointment to affected area at
night. Soak cotton ball in 5% ointment and apply cotton
ball directly to vestibule nightly for 3 months. 36-76%
improvement in ability to have intercourse at follow up.
 2% Lidocaine jelly to affected area 15-20 minutes prior to
sexual activity and as needed up to 5 times daily
 Reduces allodynia response on vulva
 Oral medications/unprovoked generalized vulvodynia
 Amitriptyline 10 mg q HS increase weekly up to 150 mg
 Gabapentin 300 mg PO increase by 300 mg every 3 days
to 3600 mg daily
 Systematic Review states insufficient evidence to
support use of antidepressant (JSexMed 2012;Sept 13)
 Oral Despiramine and Topcial Lidocaine for provoked
vestibulodynia: a RCT (Obstet Gynecol 2010;116-58493)
 Oral despiramine and topical lidocaine as monotherapy
or in combination failed to reduce pain more than
placebo
 Vestibulectomy
 For provoked vestibulodynia only
 Superficial removal of affected area of vestibule with or




without vaginal advancement
May be done in office under local anesthesia or in OR
Last resort treatment
Requires commitment to self care after surgery and
physical therapy treatment after healing
Reported success rates 60-95%
 Vulvodynia Interventions – Systematic Review and
Evidence Grading (Obstet Gynecol Surv. 2011
May;66(5):299-315
 Insufficient evidence to support any non-surgical




therapies for vestibulodynia
Single RPCT demonstrate lack of evidence for topical 5%
xylocaine, oral desipramine, oral fluconazole, topical
cromolyn, topical nifedipine, and botox injections.
Fair evidence of benefit of vestibulectomy
Placebo effect demonstrated
Insufficient direct evidence for efficacy of any
intervention for generalized unprovoked vulvodynia
 Adverse impact on perception of self as a woman
 Sense of body betrayal
 Feelings of inadequacy/abnormality
 Disconnect from genitals due to representation of
something negative /painful
 Relationship discord
 Other sexual health concerns in both partners (e.g.,
low sexual desire; erectile dysfunction)
 Psychiatric impact (e.g., depression; hopelessness;
anxiety)
 Self-protective response to physical pain
 Body tenses up in anticipation of pain = pain
 History of negative and/or unhealthy sexual
experiences (e.g., trauma)
 Psychiatric Co-morbidity (e.g., anxiety)
 Sex as a linear concept (A = B = C)
 Expectation that all intimacy will lead to sex
 Muscle tension at “point of no return”
 Unhealthy relationship dynamics
 Can I trust he/she will respect boundaries?
 Goal: Relaxation of pelvic floor muscles with vaginal
penetration through use of multiple modalities to
restore sexual function
 Vaginal dilators
 A gradual approach to being able to receive penetration
without pain
 Anatomy and physiology education
 Education in exercises for home
 Biofeedback
 Trigger point injections
 Patient and partner education
 Shifting intimacy dynamics
 Breaking the association that all intimacy leads to expectation of
intercourse
 Expectation = muscle tension = pain
 Even once physical components are treated, pain may remain
present. Necessity of shifting intimacy dynamics.
 Ban on intercourse until body is healed
 Golden opportunity to bolster non-penetrative intimacy
 Slowly pushing the limits of intimacy
 Avoiding a 0 to 1000 approach (this does not work)
 Allowing touch to be a positive experience again
 Often awkward, “clinical” and painless intercourse occurs
prior to spontaneous, pleasurable and painless intercourse
 Do not trust until experience absence of pain
 Addressing impact to sense of self as a sexual being
 Development of a healthy overall sexuality
 Learning to cope with chronic pain
 Impacts nearly every aspect of one’s life
 Treating co-occurring psychiatric concerns (e.g.,
depression; anxiety)
 28 y.o. G1P1001 with localized, burning vulvar pain that
is worse with intercourse and tampon insertion. Her
diagnosis is most likely
 A. Generalized vulvodynia
 B. Recurrent vulvar candidasis
 C. Provoked Vestibulodynia
 D. Pudendal nerve entrapment
 28 y.o. G1P1001 with localized, burning vulvar pain.
Exam reveals vestibular erythema and a positive cotton
swab test. You prescribe
 A. Topical 5% lidocaine
 B. Pelvic Floor Physical Therapy
 C. Sexual counseling
 D. all of the above
 Recommendations for the treatment of vulvodynia
typically include which two (2) of the following:
 A. Scheduling intercourse
 B. Slowly increasing non-sexual intimacy
 C. Increased sexual frequency as a means of de-
sensitization
 D. Initial ban on penetrative sex
Stacey Seibel, PhD, LP
Stacey.Seibel@ParkNicollet.com
Bridget Keller, MD
Bridget.Keller@ParkNicollet.com
 Vulvodynia: An Under-Recognized Pain Disorder Affecting
1 in 4 Women and Adolescent Girls. National Vulvodynia
Association. Slides reproduced with permission.
 Clin Anat. 2013 Jan;26(1):130-3. Vulvar Pain: Anatomic and
Recent Pathophysiologic Considerations.
 J Sex Med. 2012 Sep 13. A Systematic Review of the Utility
of Antidepressant Pharmacotherapy in the Treatment of
Vulvodynia Pain.
 Obstet Gynecol Surv. 2011 may;66(5):299-315. Vulvodynia
Interventions – Systematic Review and Evidence Grading
 Acta Obstet Gynecol Scand. 2010 Nov;89(11):1385-95.




Surgical Treatment of Vulvar Vestibulitis: a Review.
Obstet Gynecol. 2010 Sep;116(3):583-93. Oral Despiramine
and Topical Lidocaine for vulvodynia: a Randomized
Controlled Trial.
Br J Dermatol. 2010 Jun;162(6):1180-5. Guidelines for the
Management of Vulvodynia.
Obstet Gynecol 2003;102:84-7. Zolnoun DA, Hartmann KE,
Steege JF. Overnight 5% Lidocaine Treatment for Vulvar
Vestibulitis
J Low Genit Tract Dis 2005;9(1):40-51. Haefner, HK, et al.
The VulvoDynia Guideline.