Expert Commentary

Vulvar pain syndromes: Making the correct diagnosis


I screen every patient for depression using a Patient Health Questionnaire (PHQ-9); I also screen for anxiety. I find that a significant percentage of patients in my clinic are depressed or have an anxiety disorder. Failure to address these comorbidities makes treatment very difficult. I typically prescribe citalopram (Celexa), although there is some question whether it can safely be combined with a tricyclic antidepressant. We also offer stress-reduction classes, teach every patient the value of diaphragmatic breathing, offer mind-body classes for anxiety and stress, and provide intensive programs where the patient can learn important self-care skills, such as pacing (spacing activities throughout the day in a manner that avoids aggravating the pain), and address her anxiety and stress in a more guided manner. We also have a psychologist who specializes in pain for any patient who may need one-on-one counseling.

Dr. Edwards: The presence of comorbidities is somewhat useful in making the diagnosis of vulvodynia. I question my diagnosis, in fact, when a patient who has vulvodynia does not have headaches, low energy, depression, anxiety, irritable bowel syndrome, constipation, fibromyalgia, chronic fatigue, sensitivity to medications, TMJ dysfunction, or urinary symptoms.


Dr. Lonky: How prevalent is a finding of pudendal neuralgia?

Dr. Edwards: The prevalence and incidence of pudendal neuralgia are not known. Those who specialize in this condition think it is relatively common. I do not identify or suspect it very often. Its definitive diagnosis and management are outside the purview of the general gynecologist, but the general gynecologist should recognize the symptoms of pudendal neuralgia and refer the patient for evaluation and therapy.

Dr. Lonky: What are those symptoms?

Dr. Haefner: Pudendal neuralgia often occurs following trauma to the pudendal nerve. The pudendal nerve arises from sacral nerves, generally sacral nerves 2 to 4. Several tests can be utilized to diagnose this condition, including quantitative sensor tests, pudendal nerve motor latency tests, electromyography (EMG), and pudendal nerve blocks.20

Nantes Criteria allow for making a diagnosis of pudendal neuralgia (Table 3).21


Nantes Criteria for pudendal neuralgia by pudendal nerve entrapment

SOURCE: Labat et al.21 Reproduced with permission from Neurology and Urodynamics.
Essential criteria
  • Pain in the territory of the pudendal nerve: from the anus to the penis or clitoris

  • Pain is predominantly experienced while sitting

  • The pain does not wake the patient at night

  • Pain with no objective sensory impairment

  • Pain relieved by diagnostic pudendal nerve block

Complementary diagnostic criteria
  • Burning, shooting, stabbing pain; numbness

  • Allodynia or hyperpathia

  • Rectal or vaginal foreign body sensation (sympathalgia)

  • Worsening of pain during the day

  • Predominantly unilateral pain

  • Pain triggered by defecation

  • Presence of exquisite tenderness on palpation of the ischial spine

  • Clinical neurophysiology findings in men or nulliparous women

Exclusion criteria
  • Exclusively coccygeal, gluteal, pubic, or hypogastric pain

  • Pruritus

  • Exclusively paroxysmal pain

  • Imaging abnormalities able to account for the pain

Associated signs not excluding the diagnosis
  • Buttock pain on sitting

  • Referred sciatic pain

  • Pain referred to the medial aspect of the thigh

  • Suprapubic pain

  • Urinary frequency or pain on a full bladder, or both

  • Pain occurring after ejaculation

  • Dyspareunia or pain after sexual intercourse, or both

  • Erectile dysfunction

  • Normal clinical neurophysiology

Initial treatments for pudendal neuralgia should be conservative. Treatments consist of lifestyle changes to prevent flare of disease. Physical therapy, medical management, nerve blocks, and alternative treatments may be beneficial.

Pudendal nerve entrapment is often exacerbated by sitting (not on a toilet seat, however) and is reduced in a standing position. It tends to increase in intensity throughout the day.22 The final treatment for pudendal nerve entrapment is surgery if the nerve is compressed. By this time, the generalist is not generally the provider who performs the surgery.

Dr. Gunter: I believe pudendal neuralgia is sometimes overdiagnosed. EMG studies of the pudendal nerve, often touted as a diagnostic tool, are unreliable (they can be abnormal after vaginal delivery or vaginal hysterectomy, for example). In my experience, bilateral pain is less likely to be pudendal neuralgia; spontaneous bilateral compression neuropathy at exactly the same level is not a common phenomenon in chronic pain.

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