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Treatment
Options for Persistent Vulvar Pain
The American College of Obstetricians
and Gynecologists (ACOG) and the American Society for
Colposcopy and Cervical Pathology offer recommendations and
conclusions for the diagnosis and treatment of persistent
vulvar pain though an updated committee opinion drafted by
the ACOG Committee on Gynecologic Practice. Recommendations
and conclusions include:
• Vulvar pain can be caused by a
specific disorder or it can be idiopathic. Idiopathic vulvar
pain is classified as vulvodynia.
• The classification of vulvodynia is
based on the site of the pain; whether it is generalized,
localized, or mixed; whether it is provoked, spontaneous, or
mixed; whether the onset is primary or secondary; and the
temporal pattern (whether the pain is intermittent,
persistent, constant, immediate, or delayed).
• A thorough history should identify
the patient’s duration of pain, medical and surgical
history, sexual history, allergies, and previous treatments.
• 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.
• 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.
• A musculoskeletal evaluation would
help rule out musculoskeletal factors associated with
vulvodynia, such as pelvic muscle overactivity and
myofascial or other biomechanical disorders.
• 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.
• Choosing the proper vehicle for
topical medications is important because creams contain more
preservatives and stabilizers than ointments and often
produce burning on application, whereas ointments are
usually better tolerated.
• Women with vulvodynia should be
assessed for pelvic floor dysfunction.
• An emerging treatment for vulvodynia
is transcutaneous electrical nerve stimulation.
• When other nonsurgical management
options have been tried and failed, and the pain is
localized to the vestibule, vestibulectomy may be an
effective treatment.
• Although optimal treatment remains
unclear, consider an individualized, multidisciplinary
approach to address all physical and emotional aspects
possibly attributable to vulvodynia.
• It is important to begin any
treatment approach with a detailed discussion, including an
explanation of the diagnosis and determination of realistic
treatment goals.
Citation: American College of
Obstetricians and Gynecologists. Persistent vulvar pain.
Committee Opinion No. 673. Obstet Gynecol. 2016;128:e78–84.
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