The author reports no financial relationships relevant to this article.
CASE: No relief, despite multiple therapies
A 20-year-old woman is referred to your practice for evaluation of persistent dyspareunia. She describes the pain as “excruciating” and reports that it occurs with attempted penile insertion.
Her symptoms began 1 year ago when she noted some postcoital soreness at the introitus, as well as external dysuria. The symptoms have become so pronounced that she now avoids sexual intercourse altogether. She experiences similar pain when she inserts a tampon, wears tight jeans, or rides a bicycle. She has no history of recurrent vaginitis.
So far, she has tried, sequentially, topical steroids, vitamin D ointment, topical gabapentin, and oral amitriptyline—without improvement.
What is the differential diagnosis? And what can you do to ease her pain?
Although vulvar pain has many causes, women who have a chronic vulvar pain syndrome generally fall into one of three diagnostic categories (i.e., McKay’s patterns):
- cyclic vulvovaginal candidiasis
- essential vulvodynia.1
In this case, the diagnosis is vestibulitis, which is marked by focal erythema and, in some cases, focal erosion at the junction of the hymen and vestibule. Clinical findings in women who have vestibulitis are often subtle, but can be detected with careful examination.
This article outlines the diagnosis and management of vestibulitis and essential vulvodynia, including a basic classification of vulvar pain (TABLE). In the process, it also sheds light on the tricky diagnosis of cyclic vulvovaginal candidiasis, which can provoke vestibulitis in some cases.
A careful history, focused physical examination of the vulva and vagina, and microscopy of the vaginal secretions are the foundation of diagnosis of any vulvar pain syndrome.
How vulvar pain is classified
Involvement of the entire vulva
Involvement of a portion, or component, of the vulva, e.g., vestibulodynia, clitorodynia, hemivulvodynia, etc.
|International Society for the Study of Vulvar Diseases13|
Anatomy of the vulva
The first step in adopting a practical approach to vulvar pain is developing familiarity with vulvar anatomy. I find it useful to divide the vulvovaginal anatomy into three discrete areas:
The vulvar integument is keratinized and contains hair follicles and apocrine glands. The epithelium of the vestibule, on the other hand, is similar to the buccal mucosa: nonkeratinized and usually moist, with no adnexal structures. This highly innervated area extends from the hymenal ring to Hart’s line (FIGURE 1) and is the primary site of concern in women who have a vulvar pain syndrome.
The vagina begins at the hymenal ring and extends proximally to the cervix. The vagina is uniformly normal in patients who complain of chronic vulvar pain unless yeast vaginitis is one of the causes.
Women who have cyclic vulvovaginal candidiasis initially complain of symptoms of yeast vaginitis, e.g., vulvovaginal itching and a cheesy white vaginal discharge. Most women experience infrequent episodes of yeast vaginitis, but those who have cyclic candidiasis relapse after a short course of topical or systemic antifungal therapy. When they relapse, they tend to experience mild irritative symptoms and de novo entry dyspareunia.
Many of these women will have been treated with intermittent antifungal medication and antibiotics because their clinician assumed that a bacterial infection was present when the antifungal therapy did not solve the problem. Another challenge in evaluating these women is the inability of point-of-care testing to guide the diagnosis—or the omission of such testing altogether.
The basic profile of these patients remains the same, however: relapsing introital symptoms that are relatively mild but lead to worsening entry dyspareunia, a sign of vestibulitis. The patient may also report postcoital soreness and burning after micturition when the urine drops onto the vestibule (“splash dysuria”). These symptoms may reflect the presence of small vestibular fissures.
As an official entity, the term vulvodynia has been around only 25 years. The International Society for the Study of Vulvar Diseases (ISSVD) defined vulvodynia in 1984 as chronic vulvar discomfort, noting that it is characterized in particular by the patient’s complaint of burning, stinging, irritation, or rawness.
Vulvodynia didn’t originate in 1984, of course. But its definition was an important first step in identifying a clinical entity that had long been ignored by clinicians, primarily because of their inability to determine a cause, establish a diagnosis, and recommend a specific course of therapy. In addition, the magnitude of the problem was woefully underestimated.
A population-based study of 4,915 women in Boston found that 16% of respondents reported either chronic vulvar burning or pain with contact.11 Hispanic women were more likely than Caucasian and African-American women to acknowledge such a complaint.
Similarly, Goetsch found that 15% of patients in her gynecologic practice had vestibular pain and tenderness on examination.12