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Treatment Options for Persistent Vulvar Pain

Obset Gynecol; ePub 2016 Sep; ACOG Committee on Gynecologic Practice

The American College of Obstetricians and Gynecologists (ACOG) and the American Society for Colposcopy and Cervical Pathology offer recommendations and conclusions for the diagnosis and treatment of persistent vulvar pain though an updated committee opinion drafted by the ACOG Committee on Gynecologic Practice. Recommendations and conclusions include:

• Vulvar pain can be caused by a specific disorder or it can be idiopathic. Idiopathic vulvar pain is classified as vulvodynia.

• The classification of vulvodynia is based on the site of the pain; whether it is generalized, localized, or mixed; whether it is provoked, spontaneous, or mixed; whether the onset is primary or secondary; and the temporal pattern (whether the pain is intermittent, persistent, constant, immediate, or delayed).

• A thorough history should identify the patient’s duration of pain, medical and surgical history, sexual history, allergies, and previous treatments.

• Cotton swab testing is used to identify the areas of pain (classifying each area of pain as mild, moderate, or severe) and to differentiate between generalized and localized pain.

• The vulva and vagina should be examined, and infection ruled out when indicated using tests, including wet mount, vaginal pH, fungal culture, and Gram stain, or other available point-of-care testing or polymerase chain reaction testing.

• A musculoskeletal evaluation would help rule out musculoskeletal factors associated with vulvodynia, such as pelvic muscle overactivity and myofascial or other biomechanical disorders.

• Medications used to treat vulvar pain include topical, oral, and intralesional medicinal substances, as well as pudendal nerve blocks and botulinum toxin. Tricyclic antidepressants and anticonvulsants also can be used for vulvodynia pain control.

• Choosing the proper vehicle for topical medications is important because creams contain more preservatives and stabilizers than ointments and often produce burning on application, whereas ointments are usually better tolerated.

• Women with vulvodynia should be assessed for pelvic floor dysfunction.

• An emerging treatment for vulvodynia is transcutaneous electrical nerve stimulation.

• When other nonsurgical management options have been tried and failed, and the pain is localized to the vestibule, vestibulectomy may be an effective treatment.

• Although optimal treatment remains unclear, consider an individualized, multidisciplinary approach to address all physical and emotional aspects possibly attributable to vulvodynia.

• It is important to begin any treatment approach with a detailed discussion, including an explanation of the diagnosis and determination of realistic treatment goals.


American College of Obstetricians and Gynecologists. Persistent vulvar pain. Committee Opinion No. 673. Obstet Gynecol. 2016;128:e78–84.