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Questions and Answers
What is the duration of vulvar pain required for a diagnosis of vulvodynia?
What is the duration of vulvar pain required for a diagnosis of vulvodynia?
What is the approximate percentage of women in the reproductive age group affected by vulvodynia?
What is the approximate percentage of women in the reproductive age group affected by vulvodynia?
What is a possible contributing factor to vulvodynia?
What is a possible contributing factor to vulvodynia?
What is the name of the canal through which the pudendal artery, vein, and nerve pass?
What is the name of the canal through which the pudendal artery, vein, and nerve pass?
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What is the classification of vulvodynia based on the location of pain?
What is the classification of vulvodynia based on the location of pain?
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What is a differential diagnosis to rule out in a patient with vulvodynia?
What is a differential diagnosis to rule out in a patient with vulvodynia?
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What is an important aspect of the physical examination in a patient with vulvodynia?
What is an important aspect of the physical examination in a patient with vulvodynia?
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What is a conservative treatment option for vulvodynia?
What is a conservative treatment option for vulvodynia?
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What is a medication commonly used to treat vulvodynia?
What is a medication commonly used to treat vulvodynia?
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What is a type of intervention that may be used to treat vulvodynia?
What is a type of intervention that may be used to treat vulvodynia?
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At what level is abdominal pain located in pelvic pain?
At what level is abdominal pain located in pelvic pain?
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What is the typical duration of chronic pelvic pain in females?
What is the typical duration of chronic pelvic pain in females?
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What percentage of patients with chronic pelvic pain have an improper or wrong diagnosis?
What percentage of patients with chronic pelvic pain have an improper or wrong diagnosis?
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Which of the following conditions is a common cause of chronic pelvic pain in females?
Which of the following conditions is a common cause of chronic pelvic pain in females?
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What is the term for pain caused by musculoskeletal disorders in the pelvic region?
What is the term for pain caused by musculoskeletal disorders in the pelvic region?
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Which of the following is a psychological condition that can contribute to chronic pelvic pain?
Which of the following is a psychological condition that can contribute to chronic pelvic pain?
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What is the term for pain caused by abnormal muscle contractions in the pelvic floor?
What is the term for pain caused by abnormal muscle contractions in the pelvic floor?
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What is the average time period from presentation to diagnosis of chronic pelvic pain?
What is the average time period from presentation to diagnosis of chronic pelvic pain?
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What is the primary location of pelvic pain?
What is the primary location of pelvic pain?
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Which of the following is a common condition associated with chronic pelvic pain in females?
Which of the following is a common condition associated with chronic pelvic pain in females?
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What is the prevalence of chronic pelvic pain in females compared to?
What is the prevalence of chronic pelvic pain in females compared to?
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What is the term for pain caused by abnormal muscle contractions in the pelvic floor?
What is the term for pain caused by abnormal muscle contractions in the pelvic floor?
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Which of the following is a neurological condition that can contribute to chronic pelvic pain?
Which of the following is a neurological condition that can contribute to chronic pelvic pain?
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What is the percentage of patients with chronic pelvic pain who have an improper or wrong diagnosis?
What is the percentage of patients with chronic pelvic pain who have an improper or wrong diagnosis?
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What is the time period from presentation to diagnosis of chronic pelvic pain?
What is the time period from presentation to diagnosis of chronic pelvic pain?
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Which of the following is a musculoskeletal condition that can contribute to chronic pelvic pain?
Which of the following is a musculoskeletal condition that can contribute to chronic pelvic pain?
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Study Notes
Definition and Diagnosis
- Vulvodynia is defined as vulvar pain of at least 3 months' duration without a clear identifiable cause, which may have potential associated factors.
- It is a diagnosis of exclusion and an idiopathic pain disorder.
- Only 1.4% of women seeking medical advice are correctly diagnosed, despite affecting 3-7% of the reproductive age group.
Aetiology
- The cause of vulvodynia is unknown.
- Contributing factors include:
- Neuropathy (increased nerve fibers in the region or spinal nerve injury)
- Chronic vaginal dryness
- Sjögren's syndrome
- Genetic predisposition to inflammation
- Allergy or sensitivities
- Pelvic floor dysfunction
Anatomical Correlation and Pathophysiology
- The vulva is innervated by:
- Anterior labial branch of the IIN
- GFN
- Branches of pudendal nerve
- The pelvic floor muscles are divided into three groups:
- Superficial (urogenital diaphragm)
- Middle
- Deep pelvic floor muscles (anal triangle muscles and associated pelvic and hip muscles)
- The pudendal artery, vein, and nerve passing through Alcock's canal provide neurovascular function of the pelvic floor.
Classification
- Vulvodynia can be classified as:
- Generalized or localized
- Primary or secondary
- Provoked or unprovoked
- Intermittent, persistent, or constant
- Immediate or delayed
Differential Diagnoses
- Infections:
- Candidiasis
- Trichomoniasis
- Herpes
- Human papillomavirus
- Inflammatory conditions:
- Lichen planus
- Lichen sclerosus
- Lichen simplex
- Contact dermatitis
- Neurologic disorders:
- Pudendal nerve, IIN, or GFN injury, entrapment, or neuropathy
- Tarlov cysts
- Trauma:
- Straddle injury
- Female genital mutilation
- Accidents
- Sexual abuse
- Neoplastic conditions:
- Squamous cell carcinoma
- Oestrogen deficiencies
- Iatrogenic:
- Persistent post-surgical pain
- Nerve injury
- Surgical positioning: lithotomy, laparoscopic trocar injury
History and Physical Examination
- Detailed pain history, including psychosocial and sexual history, should be taken.
- Complete gynaecological examination, including external genitalia, per vaginal, and per rectal examination.
Examination
- Cotton sensory test
- Neurosensory check—cotton vs pin prick
- Pelvic floor muscle examination
Pain Comorbidities
- Interstitial cystitis
- Endometriosis
- Chronic headache
- Hypermobility syndrome
- Temporomandibular dysfunction
Treatment
- Multidisciplinary and multimodal approach is crucial for success of therapy.
- Conservative/self-management:
- Exercise and physical therapy
- Healthy diet (especially low-oxalate diet)
- Stress management
- Psychotherapy (including mindfulness and CBT)
- Sexual therapy
- Acupuncture
- Medications:
- Simple analgesics
- TCAs (commonly amitriptyline and nortriptyline)
- SNRIs (commonly duloxetine and venlafaxine)
- Anticonvulsants (commonly gabapentin, pregabalin, topiramate, lamotrigine, and carbamazepine)
- Topical (antifungal, corticosteroids, lidocaine, oestrogen, testosterone, ketamine, and gabapentin)
- Interventions:
- Nerve blocks (GFN, IIN, or pudendal nerve block)
- Pulsed RF of nerves
- Neuromodulation:
- TENS
- Peripheral nerve neuromodulation
- SCS
- Surgery:
- Reserved for provoked vestibular vulvodynia
Chronic Pelvic Pain
- Chronic pelvic pain is defined as abdominal pain located below the umbilicus, including lower back pain with or without radiation into the thighs, which may be acute, chronic, or intermittent.
- In females, chronic pelvic pain is defined as intermittent or constant pain in the lower abdomen or pelvis of at least 6 months' duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
Incidence
- Chronic pelvic pain is more prevalent in females, affecting 14-40% of women in the reproductive age group.
- The prevalence of chronic pelvic pain is comparable to that of asthma and low back pain.
- 20-70% of patients have an improper or wrong diagnosis.
- The time period from presentation to diagnosis varies between 6.7 ± 6.2 years.
Anatomical Correlation of Pain Generators
- One or more anatomical structures can be pain generators in most cases.
- Female pelvic pain generators include:
- Urethra
- Bladder
- Vulva
- Vagina
- Uterus
- Ovaries
- Pelvic floor
- Peritoneum/endometriosis
- Bowel
- Post-surgical/neuropathic
- MSK
- Psychosocial
- Male pelvic pain generators include:
- Urethra
- Bladder
- Penis
- Scrotum
- Prostate
- Pelvic floor
- Peritoneum
- Bowel
- Post-surgical/neuropathic
- MSK
- Systemic
- Psychosocial
Causes
- Gynaecological conditions:
- Endometriosis
- Adhesions
- Chronic pelvic inflammatory disease
- Pelvic congestion syndrome
- Ovarian remnant syndrome
- Recurrent haemorrhagic ovarian cysts
- Myomata uteri (degenerating)
- Adenomyosis
- Uterine retroversion
- Pelvic floor and hip muscle pain
- Visceral hyperalgesia
- Neoplasms
- Urological conditions:
- Urinary retention
- Urethral syndrome
- Interstitial cystitis
- Pyelonephritis
- Neoplasms
- Abdominal conditions:
- Neuropathies
- Porphyrias
- IBS
- Bowel obstruction
- Diverticulitis
- Hernia
- Neoplasms
- Neurological conditions:
- Nerve entrapment syndromes
- Generalized myofascial pain syndrome
- Fibromyalgia
- Musculoskeletal conditions:
- SIJ pain
- Hip pain
- Pubic dysfunction
- Spine pathology
- Psychological conditions:
- Depression
- PTSD (history of abuse/trauma)
- Anxiety disorders
- Personality disorder
Chronic Pelvic Pain
- Chronic pelvic pain is defined as abdominal pain located below the umbilicus, including lower back pain with or without radiation into the thighs, which may be acute, chronic, or intermittent.
- In females, chronic pelvic pain is defined as intermittent or constant pain in the lower abdomen or pelvis of at least 6 months' duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
Incidence
- Chronic pelvic pain is more prevalent in females, affecting 14-40% of women in the reproductive age group.
- The prevalence of chronic pelvic pain is comparable to that of asthma and low back pain.
- 20-70% of patients have an improper or wrong diagnosis.
- The time period from presentation to diagnosis varies between 6.7 ± 6.2 years.
Anatomical Correlation of Pain Generators
- One or more anatomical structures can be pain generators in most cases.
- Female pelvic pain generators include:
- Urethra
- Bladder
- Vulva
- Vagina
- Uterus
- Ovaries
- Pelvic floor
- Peritoneum/endometriosis
- Bowel
- Post-surgical/neuropathic
- MSK
- Psychosocial
- Male pelvic pain generators include:
- Urethra
- Bladder
- Penis
- Scrotum
- Prostate
- Pelvic floor
- Peritoneum
- Bowel
- Post-surgical/neuropathic
- MSK
- Systemic
- Psychosocial
Causes
- Gynaecological conditions:
- Endometriosis
- Adhesions
- Chronic pelvic inflammatory disease
- Pelvic congestion syndrome
- Ovarian remnant syndrome
- Recurrent haemorrhagic ovarian cysts
- Myomata uteri (degenerating)
- Adenomyosis
- Uterine retroversion
- Pelvic floor and hip muscle pain
- Visceral hyperalgesia
- Neoplasms
- Urological conditions:
- Urinary retention
- Urethral syndrome
- Interstitial cystitis
- Pyelonephritis
- Neoplasms
- Abdominal conditions:
- Neuropathies
- Porphyrias
- IBS
- Bowel obstruction
- Diverticulitis
- Hernia
- Neoplasms
- Neurological conditions:
- Nerve entrapment syndromes
- Generalized myofascial pain syndrome
- Fibromyalgia
- Musculoskeletal conditions:
- SIJ pain
- Hip pain
- Pubic dysfunction
- Spine pathology
- Psychological conditions:
- Depression
- PTSD (history of abuse/trauma)
- Anxiety disorders
- Personality disorder
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Description
Assess your knowledge about vulvodynia, a chronic and idiopathic pain disorder affecting the vulva, its diagnosis, incidence, and contributing factors.
