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Vulvodynia: A Common and Under-Recognized Pain Disorder in Women and Female Adolescents -- Integrating Current Knowledge into Clinical Practice
After visible and/or neurologic causes of vulvar pain are identified and treated, one moves on to evaluate the patient for vulvodynia. Hyperalgesia and allodynia are present, with or without the presence of erythema. Although women with vulvodynia describe their pain in a variety of ways, e.g., stabbing, aching, raw, searing, sharp, throbbing, knife-like, etc., burning is most commonly reported. If the pain is localized to the vulvar vestibule and provoked, the diagnosis is likely to be Provoked Vestibulodynia (PVD). PVD is further categorized as primary or secondary. PVD is the most common subtype affecting 80 percent of women with chronic vulvar pain symptoms (Harlow 2003). If the pain is generalized to multiple areas of the vulva and spontaneous, but exacerbated by touch/pressure, the diagnosis is likely Generalized Vulvodynia. Twenty percent of women suffer from this subtype or a mixture of both.
* The two subtypes can coexist (Reed 2003, Edwards 2004).
Based on data from an NIH-funded population-based study, the above four questions have been found to be highly predictive of an office-based diagnosis of vulvodynia (Harlow 2009). These questions were validated against clinical examination with 80% specificity and 95% sensitivity. They should be included on screening forms to help health care practitioners identify women and adolescents who may be suffering from the condition.
For more than a decade, gynecologists, dermatologists, vulvar pain specialists, and researchers have used the 2003 ISSVD terminology as a guide to diagnosing vulvar pain.This terminology evolved over years of discussion on the nature of idiopathic vulvar pain, especially that occurring during sexual activity and vaginal penetration. The 2003 terminology divided vulvar pain into two overarching categories: vulvar pain related to a specific disorder, and vulvodynia, defined specifically as “vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder.” Therefore, the term vulvodynia was reserved for those cases in which the pain could not be attributed to an identifiable “visible” cause.
Since 2003, the category of identifiable causes of vulvar pain has evolved substantially, as have the potential factors associated with vulvodynia. These developments are based on the results of numerous studies examining a wide range of possible etiological factors (e.g., inflammatory, genetic, musculoskeletal, neurosensory, neuropathic) and treatment avenues (e.g., oral medication, pelvic floor physical therapy, surgical intervention, psychological intervention). These studies have also led to the conclusion that vulvodynia is likely not one disease but a constellation of symptoms of several (sometimes overlapping) disease processes that benefits most from a range of treatments based on individual presentation. These studies have widened the scope of etiological considerations and have resulted in the need to update the description and nomenclature of persistent vulvar pain. In addition, several important pain characteristics of vulvodynia have been introduced (e.g., primary and secondary status; intermittent and constant pain pattern).