Guidelines for Management of Vulvodynia Issued
Vulvodynia has been defined by the ISSVD as vulval discomfort, described as a burning pain occurring in the absence of visible findings or a neurologic disorder. Classification has been by anatomic site and whether pain is provoked or unprovoked.
This is a report from the BSSVD that presents evidence-based guidelines for the diagnosis and management of vulvodynia, but the authors noted many limitations in published research, including poor patient selection, limited follow-up, and a paucity of randomized trials.
- The BSSVD group consists of gynecologists, dermatologists, genitourinary specialists, and patients who conducted a search of the literature to identify evidence for the guidelines.
- 12 recommendations emerged with evidence levels after literature review:
- Recommendation 1:
- An adequate pain history should be taken to assess pain severity and impact on the woman’s life and to categorize the subgroup of vulvodynia involved.
- The ISSVD classification divides types of vulvodynia into generalized vs localized and provoked vs unprovoked.
- Localized vulvodynia includes vestibulodynia, cliterodynia, and hemivulvodynia.
- Provoked vulvodynia can be sexual, nonsexual, or both.
- Mixed vulvodynia can be provoked or unprovoked.
- Recommendation 2:
- Patients with dyspareunia should have a sexual history taken to identify psychosexual morbidity and dysfunction, with a focus on provoked pain that reduces arousal and interest in sex.
- High degrees of anxiety, depression, somatization disorders, and hypochondriacal symptoms have been associated with vulvodynia.
- Recommendation 3:
- The diagnosis of vulvodynia is clinical; therefore, biopsies, patch testing, and magnetic resonance imaging are not necessary for diagnosis.
- Recommendation 4:
- A team approach may be necessary with a lead clinician to refer patients to physiotherapy, psychosexual medicine, and pain management. o Recommendation 5:
- Combining treatments (eg, medical, psychological, physiotherapy, and dietary advice) should be encouraged to address different facets of pain.
- Surgical vestibulectomy has a better outcome when psychosexual dysfunction is present.
- Recommendation 6:
- Patients should receive an adequate explanation of symptoms and medication instructions.
- Recommendation 7:
- Topical agents may cause irritation and should be prescribed with caution.
- Topical lidocaine gel may aid penetration for intercourse, but potential effects on the partner should be addressed.
- Other topical agents such as capsaicin, nifedipine, and ketoconazole cream have unproven effects and mixed results.
- Recommendation 8:
- Tricyclic antidepressants are an initial treatment option for unprovoked vulvodynia, and other agents such as gabapentin and pregabalin may be considered as additional agents.
- Gabapentin can be started at 300 mg daily increasing every 3 days to a maximum of 3600 mg daily, but the optimal medication is still unclear.
- Recommendation 9:
- Surgical excision of the vestibule can be considered for local provoked vulvodynia if other measures have failed, but only a minority of patients will benefit.
- Compared with behavioral measures, 1 study found similar results with patients preferring the behavioral approach (pain management, sex education, partner education).
- Laser vaporization of the vestibule is not recommended.
- Recommendation 10:
- Pelvic floor muscle dysfunction should be addressed in women with sex-related pain, and self-help exercises and physical therapy may be of benefit, with self-massage, biofeedback, and trigger point pressure being alternative strategies.
- Recommendation 11:
- Acupuncture may be considered for treatment of provoked pain, but the long-term outcomes and mechanism are still unclear.
- Recommendation 12:
- Intralesional injections of methylprednisolone and lidocaine may be of help in those with provoked vulvodynia; a 32% remission rate has been reported.
- In conclusion, these guidelines act as a starting point to help clinicians increase their education and awareness of vulvodynia.
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Evidence-based guidelines for management of vulvodynia were issued by the British Society for the Study of Vulval Diseases Guideline Group and reported online in the March 16 issue of the British Journal of Dermatology.
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