The diagnosis of vulvodynia is clinical, based on characteristic findings on history and physical examination. It is largely one of exclusion: other causes of vulvar pain must be ruled out.
History
A complete medical, surgical, and sexual history should be obtained to look for specific conditions that could be causing vulvar pain. A complete pain history should be taken to determine the cause of pain, inciting factors, and its impact on the patient. Is the pain is nociceptive, neuropathic, or both?
Appropriate questions include:
- How and when did the pain begin?
- The onset of vulvodynia is often sudden and without precedents.
- It is important to ask whether there was a precipitating event, such as trauma, childbirth, or surgery that may have injured the pudendal nerve, or did the pain begin spontaneously in an acute or gradual fashion?
- Does the woman participate in hobbies or occupational activities that may have injured the pudendal nerve?
- Are there long periods of sitting at work with poor posture and a non-ergonomic chair?
- Does she frequently ride in a car for long periods?
- Does she participate in sports or exercise that may aggravate nerve or muscles?
- Is there a history of inflammatory insult such as recurrent Candida infections that might have sensitized the nerves?
- How is the pain described?
- Allow the patient to verbalize the painful symptoms.
- Where is the location of the pain?
- Is it focal or generalized?
- Provoked or unprovoked? Generalized unprovoked pain suggests vulvodynia.
- Does the pain seem to have a point of emanation, suggesting a specific source?
- What is the intensity of the pain?
- Is there a component of itching suggestive of vulvar dermatitis?
- Are there other signs or symptoms associated with the pain?
- Are there specific skin complaints (pruritus, localized burning, pressure, throbbing) and/or lesions (mass, ulcer, change in color) suggesting dermatitis, lichen sclerosus, lichen planus, or vulvar intraepithelial neoplasia?
- Vulvodynia is more likely if there are no skin lesions or skin complaints, but uncontrolled lichen planus is a significant source of vulvar pain.
- Is there anything relevant in the past medical history?
- Are there medical disorders (herpes simplex or zoster), medications, surgeries, or trauma that could have affected the vulva or referred pain to the vulva?
- Are common comorbid conditions, such as fibromyalgia and irritable bowel syndrome, present?
- Ask about past psychological history, particularly with regard to depression, anxiety, and posttraumatic stress disorder.
- A sexual history is important to confirm that the relationship is loving and there is no history of abuse, but abused women can develop vulvodynia.
- A history of allergies suggests the possibility of vulvar dermatitis.
- Are there urinary tract symptoms?
- Vulvodynia can be associated with urinary tract symptoms in the setting of a negative urine culture.
- Vulvodynia can often be mistaken for interstitial cystitis.
- Does she have chronic constipation, poor bowel habits, frequent straining and pushing to evacuate?
- What are her hygienic practices?
- Women often erroneously regard their personal practices (eg, use of panty liners, feminine and contraceptive products, tight lycra garments, perfumed or deodorant soaps) as innocuous since they have engaged in them for a long time.
- Does she have significant orthopedic problems?
- Any history of degenerative disc disease with possible nerve root impingement in the lumbo-sacral region?
- Any hip disease that may distort gait?
- What previous evaluations have occurred?
- What improves the pain?
- How does the pain impact upon the patient's life?
- Most women with vulvodynia report a substantial impact on their quality of life.
- Has the patient experienced sexual dysfunction before or subsequent to onset of vulvodynia?
Physical examination
Vulvar erythema, especially at the vestibule, may be the only significant visual finding in vulvodynia, but may not be present. Discomfort upon separation of the labia minora is one of the most common physical findings.
The vulva should be inspected for visible lesions that could be a source of pain. Bulbocavernosus (gently stroking the labia majora) and anal wink reflexes should be checked, as changes in these reflexes, hyper- and hypesthesia, suggest peripheral neuropathy. Loss of the bulbocavernosus reflex and anal wink require further neurologic evaluation. Bilateral tenderness and trigger points at the insertion of the levator ani suggest vulvodynia may represent myalgia referred from the levators.
Spontaneous or elicited pain at the lower third of the anterior vaginal wall suggested bladder-related comorbidities (painful bladder syndrome/interstitial cystitis).
The patient should be asked to demonstrate the location of painful areas and identify if there is tenderness to touch. The area from mid thigh to the mons should be checked for allodynia, hype-, or hyperesthesia. The location(s) of pain can be mapped on a diagram, with a description of severity (mild, moderate, or severe) at each location.
A Q-tip test of the vestibule can be performed by untwisting the end of the Q-tip to make a cotton wisp and using this to check for intact sensation to light touch or allodynia (ie, Q- tip wisp feels like a pinch, knife, or sandpaper). Allodynia may be present in both nociceptive and neuropathic pain. The stick of the Q-tip should then be broken to form a sharp point that can be used to test for areas of hype- or hyperesthesia. Provoked pain localized to the vestibule suggests vestibulodynia, while the pain of vulvodynia is unprovoked. Findings in the vestibule and outside the vestibule suggest a mixed pain picture of both vulvodynia and vestibulodynia.
In addition, the skin and mouth should be examined for lesions suggestive of lichen sclerosus or lichen planus, which also occur on the vulva.
Laboratory tests
There are no laboratory abnormalities associated with vulvodynia. Laboratory studies are indicated to exclude specific causes of vulvar pain, such as vulvovaginal infection, inflammatory vulvar disorders, and neoplasia when physical findings suggest one of these disorders.
We suggest obtaining a vaginal pH, wet mount, and yeast culture to exclude vaginitis.
Testing for varicella-zoster virus (VZV) and herpes simplex (HSV) is performed if there are ulcers or vesicular eruptions. Direct fluorescence antibody testing can detect both VZV and HSV. Herpes serology is helpful if there is a question of herpes, but negative cultures.
Biopsy
A biopsy of the skin is performed if there are signs suggestive of vulvar dermatoses or neoplasia or in patients refractory to therapy. In one study of 90 women with vulvodynia refractory to treatment, 61 percent had clinically relevant dermatoses diagnosed on dermatopathologist-analyzed vulvar biopsy. The diagnoses included the disorders listed below in differential diagnosis.
DIFFERENTIAL DIAGNOSIS
The most common infection that causes vulvar pain is candida; rare infectious etiologies include dermatophytes (tinea cruris) and bacteria (Group A streptococcus). Vulvar dermatologic conditions that may cause pain include lichen sclerosus, allergic/irritant dermatitis, lichen planus, and vulvar intraepithelial neoplasia, as well as other rare inflammatory or neoplastic conditions. Any of these disorders may be associated with secondary bacterial infection.
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