The diagnosis of vulvodynia is made after taking a careful history, ruling out infectious or dermatologic abnormalities, and eliciting pain in response to light pressure on the labia, introitus, or hymenal remnants. Several treatment options have been used, although the evidence for many of these treatments is incomplete. Treatments include oral medications that decrease nerve hypersensitivity (e.g., tricyclic antidepressants, selective serotonin reuptake inhibitors, anticonvulsants), pelvic floor biofeedback, cognitive behavioral therapy, local treatments, and (rarely) surgery. Most women experience substantial improvement when one or more treatments are used.

Vulvodynia is characterized by chronic discomfort in the vulvar region; the discomfort may range from mild to severe and debilitating. The diagnosis depends on a consistent history, lack of a documented infectious or dermatologic cause, and in most women, tenderness when gentle pressure is applied by a cotton swab to the vulva, introitus, or hymenal areas. The pain usually is present during and after intercourse, and other factors may exacerbate the pain (e.g., bicycle riding, tampon insertion, prolonged sitting, wearing tight clothes) (Table 1). (1) In some women the pain is spontaneous.

Although vulvodynia was described in 1889 as “excessive sensitivity” of the vulva, (2) it rarely was referred to in the medical literature until the 1980s. Recognition of this disorder and its effects on the lives of women worldwide led to the adoption of the term “vulvodynia” by the International Society for the Study of Vulvovaginal Diseases (ISSVD) in 1983. At the time, it was defined as “chronic vulvar discomfort that is characterized by the complaint of burning, stinging, irritation, or rawness” in the absence of skin disease or infection. (3) The ISSVD recently revised the definition to include two subgroups: localized and generalized vulvar dysesthesia. (4) Each of these subgroups is further categorized as provoked, spontaneous, or mixed. It is unclear whether these groups are separate disorders or different presentations of the same disorder. (1) The term “vulvar vestibulitis” is no longer used because inflammation is not a prominent component of the disorder; it is now referred to as localized vulvar dysesthesia (or vestibulodynia). (4)

Prevalence

Three studies (5-7) that systematically addressed prevalence in different settings found vulvar pain to be much more common than previously thought, with rates of 15 percent in one gynecologist’s practice, (5) 1.7 percent in an Internet survey, (6) and 8.6 percent in a population-based study of symptomatic women in the Boston area. (7) These findings would extrapolate to more than 2.4 million women in the United States and approximately 15 affected women in a family practice of 2,000 patients.

Characteristics of Women with Vulvodynia

Women presenting with vulvodynia typically are white; are in stable, long-term relationships; have had the pain for several years; and have been examined several times by multiple physicians before receiving the diagnosis. (6-9) The age range is broad, from children (rarely) to women 80 years and older, (6) but most women with this disorder are between 20 and 50 years of age.

Vulvodynia is not associated with sexually transmitted diseases (STDs) or STD risk factors, (8,10) but affected women often have been treated repeatedly for candidal vulvovaginitis. (8,10,11) In the past, it was theorized that the pain of vulvodynia was due to psychological issues. (12,13) However, recent data indicate that women with vulvodynia are psychologically comparable to women without the disorder (14-16) and are no more likely to have been abused. (8,14,17) Marital satisfaction levels also are similar. (14)

Although women with vulvodynia report that the quality and quantity of their sexual activity has decreased since the onset of symptoms, more than one half have had intercourse and have had an orgasm in the previous month. (18) These women were just as likely as women without pain to participate in other sexual activities (e.g., masturbation, receiving oral sex). (18)

Pathophysiology

Although research is ongoing, little is known about the causes of vulvodynia. Affected women are more likely to have altered contractile characteristics of the pelvic floor musculature (19); biofeedback therapy designed to address these alterations often results in improved muscle function and decreased vulvar pain. (20,21) Although women with vulvodynia were known to be sensitive to touch in the vestibular region, it has only recently become clear that women with vulvodynia also have increased sensitivity at peripheral sites, such as the upper arm or leg. (22,23) Whether these muscular changes and increased systemic sensitivity are primary or secondary to the pain disorder is unknown.

Several studies have identified minor immunologic changes in women with vulvodynia, such as altered levels of interleukin-1 and tumor necrosis factor-a in vestibular tissue (24); increased production of interleukin-1[beta] and decreased production of interleukin-1 receptor antagonist by lymphocytes following stimulation (25); decreased production of interferon-a26; and changes in the gene associated with interleukin-1 receptor antagonist. (27,28) These changes could result in a decreased ability to downregulate the inflammatory response, which in turn may be associated with neuropathic changes.