May have additional skin lesions elsewhere on body Tricyclic antidepressants in gradually increasing amounts (6 or more months of therapy) Usually no erythematous cutaneous changes Less dyspareunia or point tenderness than in vulvar vestibulitis Topical estradiol cream, 0.01% (Estrace Vaginal Cream) twice dailyĭysesthetic vulvodynia (essential vulvodynia)ĭiffuse, unremitting burning pain that is not cyclic Positive swab test (vestibular point tenderness when touched with cotton swab) Possible history of carbon dioxide laser therapy, cryotherapy, allergic drug reactions or recent use of chemical irritants ![]() ![]() Pain is exacerbated by intercourse (especially on the next day)įrequent use of antibiotics for other conditionsįluconazole (Diflucan), 150 mg weekly for 2 months, then twice monthly for 2 to 4 monthsĮntry dyspareunia or pain with insertion of tampon Pain is worse just before or during menses During her last year of treatment, she experienced a 90 percent improvement in symptoms. The patient underwent a total of two and one half years of treatment. She also began biofeedback training and physical therapy for pelvic muscle relaxation and strengthening. Over the next year, she was treated with fluconazole, 150 mg once weekly for two months, and then once every other week for two months. She began taking calcium citrate three times daily, started a low-oxalate diet and was referred to a vulvar pain support group. She was referred to a third gynecologist, who instructed her to stop all topical medications. She was treated with triamcinolone-nystatin cream for two months and felt improvement in the first week but later developed further irritation of the vulvar and clitoral area. Over the following two months the patient saw two gynecologists and was diagnosed with vestibulitis. Conjugated estrogen vaginal cream gave no significant relief. Vaginal cultures grew various enteric organisms, and no yeasts were detected on KOH examination. Vulvar pain is frequently described as burning or stinging, or a feeling of rawness or irritation. In most cases, vulvodynia becomes a chronic problem lasting months to years. 5 Vulvar pain usually has an acute onset, at times associated with episodes of vaginitis or certain therapeutic procedures of the vulva (cryotherapy or laser therapy). Risk-taking sexual behavior is rare, and few patients have a history of sexually transmitted diseases. 2 Obstetric and gynecologic history is usually unremarkable. 1 Age distribution for the condition may range from the 20s to the 60s, and it is limited almost exclusively to white women. The incidence and prevalence of vulvodynia have not been well studied. 2 Originally suggested by McKay, 4 the term “vulvodynia” has also been suggested by the International Society for the Study of Vulvar Disease Task Force to describe any vulvar pain. Vulvodynia is a syndrome of unexplained vulvar pain that is frequently accompanied by physical disabilities, limitation of daily activities (such as sitting and walking), sexual dysfunction and psychologic disability. ![]() Since vulvodynia is often a chronic condition, regular medical follow-up and referral to a support group are helpful for most patients. Depending on the specific diagnosis, treatment may include fluconazole, calcium citrate, tricyclic antidepressants, topical corticosteroids, physical therapy with biofeedback, surgery or laser therapy. Proper treatment mandates that the correct type of vulvodynia be identified. Evaluation should include a thorough history and physical examination as well as cultures for bacteria and fungus, KOH microscopic examination and biopsy of any suspicious areas. Vulvodynia may have multiple causes, with several subsets, including cyclic vulvovaginitis, vulvar vestibulitis syndrome, essential (dysesthetic) vulvodynia and vulvar dermatoses. The pain is often described as burning or stinging, or a feeling of rawness or irritation. The patient's vulvar pain usually has an acute onset and, in most cases, becomes a chronic problem lasting months to years. It is a syndrome of unexplained vulvar pain, frequently accompanied by physical disabilities, limitation of daily activities, sexual dysfunction and psychologic distress. Vulvodynia is a problem most family physicians can expect to encounter.
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