Expert Commentary

Vulvar pain syndromes: Making the correct diagnosis


 

Although condyloma is generally a painless condition, many patients complain of pain following treatment for it, whether treatment involves topical medications or laser surgery.

Chancroid is a painful vulvar ulcer. Trichomonas can sometimes be associated with vulvar pain.

Dr. Lonky: What terminology do we use when we discuss vulvar pain?

Dr. Haefner: The current terminology used to describe vulvar pain was published in 2004, after years of debate over nomenclature within the International Society for the Study of Vulvovaginal Disease.5 The terminology lists two major categories of vulvar pain:

  • pain related to a specific disorder. This category encompasses numerous conditions that feature an abnormal appearance of the vulva (Table 1).

TABLE 1

Terminology and classification of vulvar pain from the International Society for the Study of Vulvovaginal Disease

SOURCE: Moyal-Barracco and Lynch.5 Reproduced with permission from the Journal of Reproductive Medicine.
  1. Vulvar pain related to a specific disorder

    1. Infectious (including candidiasis, herpes)

    2. Inflammatory (lichen planus, immunobullous disorders)

    3. Neoplastic (Paget’s disease, squamous cell carcinoma)

    4. Neurologic (herpes neuralgia, spinal nerve compression)

  2. Vulvodynia

    1. Generalized

      1. Provoked (sexual, nonsexual, or both)

      2. Unprovoked

      3. Mixed (provoked and unprovoked)

    2. Localized (including vestibulodynia, clitorodynia, hemivulvodynia)

      1. Provoked (sexual, nonsexual, or both)

      2. Unprovoked

      3. Mixed (provoked and unprovoked)

  • vulvodynia, in which the vulva appears normal, other than occasional erythema, which is most prominent at the duct openings (vestibular ducts—Bartholin’s and Skene’s).

As for vulvar pain, there are two major forms:

  • hyperalgesia (a low threshold for pain)

  • allodynia (pain in response to light touch).

Some diseases that are associated with vulvar pain do not qualify for the diagnosis of vulvodynia (Table 2) because they are associated with an abnormal appearance of the vulva.

TABLE 2

Conditions other than vulvodynia that are associated with vulvar pain

Acute irritant contact dermatitis (e.g., erosion due to podofilox, imiquimod, cantharidin, fluorouracil, or podophyllin toxin)
Aphthous ulcer
Atrophy
Bartholin’s abscess
Candidiasis
Carcinoma
Chronic irritant contact dermatitis
Endometriosis
Herpes (simplex and zoster)
Immunobullous diseases (including cicatricial pemphigoid, pemphigus vulgaris, linear immunoglobulin A disease, etc.)
Lichen planus
Lichen sclerosus
Podophyllin overdose (see above)
Prolapsed urethra
Sjögren’s syndrome
Trauma
Trichomoniasis
Vulvar intraepithelial neoplasia
WHAT NEEDS TO BE RULED OUT FOR A DIAGNOSIS OF VULVODYNIA?

Dr. Lonky: What skin diseases need to be ruled out before vulvodynia can be diagnosed?

Dr. Edwards: Skin diseases that affect the vulva are usually pruritic—pain is a later sign. Lichen simplex chronicus (also known as eczema) is pruritus caused by any irritant; any pain that arises is produced by visible excoriations from scratching.

Lichen sclerosus manifests as white epithelium that has a crinkling, shiny, or waxy texture. It can produce pain, especially dyspareunia. The pain is caused by erosions that arise from fragility and introital narrowing and inelasticity.

Vulvovaginal lichen planus is usually erosive and preferentially affects mucous membranes, especially the vestibule; it sometimes affects the vagina and mouth, as well.

Desquamative inflammatory vaginitis is most likely a skin disease that affects only the vagina. It involves introital redness and a clinically and microscopically purulent vaginal discharge that also reveals parabasal cells and absent lactobacilli.

Dr. Lonky: You mentioned that neurologic diseases can sometimes cause vulvar pain. Which ones?

Dr. Edwards: Pudendal neuralgia, diabetic neuropathy, and post-herpetic neuralgia are the most common specific neurologic causes of vulvar pain. Multiple sclerosis can also produce pain syndromes. Post-herpetic neuralgia follows herpes zoster—not herpes simplex—virus infection.

Dr. Lonky: Any other conditions that can cause vulvar pain?

Dr. Haefner: Aphthous ulcers are common and are often flared by stress.

Non-neoplastic epithelial disorders are also seen frequently in health-care providers’ offices; many patients who experience them report pain on the vulva.

It is always important to consider cancer when a patient has an abnormal vulvar appearance and pain that has persisted despite treatment.

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