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Vulvodynia: A Common and Under-Recognized Pain Disorder in Women and Female Adolescents -- Integrating Current Knowledge into Clinical Practice

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As shown on the left, most women with Generalized Vulvodynia report spontaneous pain in multiple areas of the vulva. Pain tends to be constant, but may be intermittent in some women. Although symptoms are spontaneous, they tend to worsen with provocation. Periods of unexplained pain relief and/or flares can occur. Erythema may or may not be present. This subtype affects 20 percent of those reporting chronic vulvar pain symptoms (Harlow 2003).

 As shown on the right, women with Provoked Vestibulodynia report provoked pain only within the vulvar vestibule. Erythema may co-occur. This subtype affects 80 percent of those with vulvar pain (Harlow 2003).

 A subset of women report spontaneous widespread vulvar pain, as well as provoked pain localized to the vestibule. The above subtypes may coexist in some women (Reed 2003, Edwards 2004).    

 

 

Women may present with marked introital erythema, as seen in patient #1, or the tissue may appear relatively normal, as seen in patient #3. Although patient #3 presented with minimal erythema, she had severe pain, which prevented her from engaging in sexual intercourse or inserting a tampon. Recent studies have also shown that pain severity and subsurface inflammation do not consistently correlate with the severity of erythema observed. The relevance of this criterion is disputed. 

 

 

Current guidelines recommend that a cotton-swab test be performed (Haefner 2005). The 11 sites shown on this diagram should be tested for allodynia and hypo- or hyperalgesia by applying gentle pressure with a dry cotton-swab (just enough to slightly indent the skin). If symptoms are provoked and localized to the vestibule, a more thorough evaluation of the vestibule is warranted and is described in the next slide.

 

 

Sites to be tested within the vulvar vestibule can be visualized using a clock face (1-12 o’clock) with one vertical and one perpendicular (black) line through the center of the vaginal opening. The 2 and 5 o’clock positions are equidistant to both lines, as are the 7 and 10 o’clock positions. The anterior vestibular sites (2, 10 and 12) are typically assessed first, followed by the posterior sites (5, 6 and 7). Again, gentle pressure is applied to each of these sites and women are asked to rate the pain severity and describe the character of the pain they experience (Zolnoun 2012).  

 

 

NIH-funded foundational work at the University of North Carolina at Chapel Hill is currently ongoing to refine a vulvovaginal neurosensory examination (described in this slide). Current prospective patient-reported outcomes studies are underway to delineate the exam components that are clinically relevant and predictive of treatment response (PI Zolnoun, NIH Grant 5K23HD053631, description available at: https://projectreporter.nih.gov/project_info_results.cfm?aid=7927135&icde=0). 

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