During a pelvic exam, your doctor inserts two gloved fingers inside your vagina. While simultaneously pressing down on your abdomen, he or she can evaluate your uterus, ovaries and other pelvic organs. Before diagnosing vulvodynia, your doctor will ask you questions about your medical, sexual and surgical history and to understand the location, nature and extent of your symptoms.
Vulvodynia treatments focus on relieving symptoms. No one treatment works in every case. For many, a combination of treatments works best.
It can take time to find the right treatments, and it can take time after starting a treatment before you notice relief. Stress tends to worsen vulvodynia and having vulvodynia increases stress. Although there's little evidence that alternative techniques work, some women get some relief from yoga, meditation, massage and other stress reducers.
You might find talking to other women who have vulvodynia helpful because it can provide information and make you feel less alone. If you don't want to join a support group, your doctor might be able to recommend a counselor in your area who has experience helping women cope with vulvodynia. Sex therapy or couples therapy might help you and your partner cope with vulvodynia's effect on your relationship.
The machine provides visual feedback on the strength of pelvic floor muscles while performing exercises to normalize their function. This type of biofeedback is conducted by specially trained providers and some physical therapists. Nerve Blocks Courtesy of Dawn Danby and Paul Waggoner The pudendal nerve, located in the pelvis, carries sensations from the vulva to the brain.
A pudendal nerve block injection uses local anesthetic and a steroid to numb the nerve and interrupt the transmission of pain signals. In many cases, a series of injections, spaced days or weeks apart, is administered intravaginally pictured to the right or in the epidural space in the lower back same technique used during childbirth.
Many women experience short-term relief with this procedure and some experience long-term relief. One recent study found that women with vulvodynia who underwent a series of different nerve blocks vulvar, pudendal and spinal experienced sustained pain relief. Diet Modification: Some women find that eating a certain food increases their pain and that elimination of the food alleviates it.
For example, some eliminate acidic or high-sugar foods. If you want to test for food sensitivity, eliminate one item or food group at a time, so you can determine which ones, if any, are affecting you. Neurostimulation involves the implantation of an electronic device that delivers low voltage electrical stimulation to the spinal cord, or a targeted peripheral nerve, with the intent of substituting a tingling sensation for pain.
Spinal infusion pumps continually administer very small amounts of medication to the spinal cord and nerve roots. Complementary or Alternative Medicine: Women with vulvodynia, as with all forms of chronic pain, may benefit from using alternative therapies in conjunction with traditional medical treatments. There are many complementary therapies available, such as acupuncture, massage therapy, relaxation techniques and cognitive behavior therapy. Surgery for women with Provoked Vestibulodynia formerly known as Vulvar Vestibulitis Syndrome : Surgery is contraindicated for women with Generalized Vulvodynia.
Two surgical procedures are used for women with PVD. Vestibulectomy with vaginal advancement involves the removal of a portion or all of the vestibule, including the hymen, followed by vaginal advancement.
In a modified vestibulectomy , only the superficial painful tissue is removed and there is no vaginal advancement. Most published results are based on vestibulectomy with vaginal advancement. It is difficult to compare the results of surgery studies because different outcome measures are used and the length of follow-up time differs. Overall success rates for both procedures range from percent.
After surgery, physical and dilator therapy are often recommended and may help alleviate any remaining pelvic floor muscle abnormalities. Careful patient selection is essential because it increases the likelihood of success with a surgical procedure. Researchers are studying factors that may predict surgical treatment success or failure; however, no conclusions can be drawn at this time. The treatments described above are, by far, the most common ones, but your provider may recommend another approach for your specific case.
These might include:. In addition to your long-term treatment strategy, it is important to discuss with your provider how to handle a pain flare. It is important to keep in mind that research on vulvodynia is ongoing, with current studies investigating both its causes and the efficacy of different treatments. Vulvodynia Treatments « Prev Next ». Discontinuation of Irritants: Health care professionals recommend eliminating over-the-counter feminine products such as perfumed bubble baths, soaps, sprays and douches that can irritate vulvar tissue.
Eliminating irritants is typically the first step in treatment. Please see Self-Help Strategies for additional information. Until the s, TCAs were one of the most common treatments for vulvodynia because of their widespread use in treating other chronic pain conditions. Then a large NIH-funded study found that the TCA desipramine was no more effective than a placebo for relieving vulvodynia.
They are not widely used today, because of this study and the fact that TCAs have more undesirable side effects than newer pain-relieving medications.
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Next: Herniated Lumbar Disk. Apr 1, Issue. Vulvodynia: Diagnosis and Management. B 6 , 7 Tricyclic antidepressants should be considered for the treatment of vulvodynia. B 9 , 39 , 42 , 47 Selective serotonin reuptake inhibitors and gabapentin Neurontin should be considered for symptomatic relief of vulvodynia. B 9 , 63 Cognitive behavioral therapy should be used to decrease vulvar pain with intercourse. B 47 Biofeedback and physical therapy should be considered to help patients regain control of the pelvic floor musculature.
B 14 , 47 , 51 Perineoplasty should be reserved for women with severe vulvodynia. Diagnosis of Vulvar Pain and Dyspareunia Figure 1. Pudendal canal syndrome Unilateral genital pain, often increased with sitting Vaginismus Pelvic floor muscle spasm present and accentuated with examination Vulvar atrophy Pale, thinning mucosa; possible tears or petechiae. White blood cells and parabasal cells present in vaginal discharge Vulvar intraepithelial neoplasia White or multicolored, elevated lesions, possibly warty.
TABLE 2 Differential Diagnosis of Dyspareunia at the Vaginal Introitus Diagnosis Clinical findings Allergic vulvitis Pruritus, irritation, burning History consistent with allergen exposure; lack of infectious cause Chronic candidal vulvovaginitis Variable erythema, edema, or thick white discharge; pruritus is common Potassium hydroxide microscopy or culture positive Lichen planus White reticulate lesions, vaginal discharge, pruritus, burning, dyspareunia, and bleeding with intercourse; may have erosions, erythema, buccal lesions, or papulosquamous plaques Lichen sclerosis Vulvar thinning, whitening, and wrinkling; agglutination of labia.
Case reports 9 , 38 , 39 Retrospective reports 9 , 39 Calcium citrate Decreases oxalate deposition in tissues 2 tablets twice daily 2 to 4 tablets twice daily Minimal Used in conjunction with other treatments. Case reports 40 Anecdotal evidence when used in conjunction with a low-oxalate diet 41 Desipramine Norpramin Decreases neuronal hypersensitivity 25 mg at bedtime for 10 days, then 50 mg at bedtime daily 50 to mg at bedtime higher dosages to mg occasionally are successful Same as amitriptyline but less common Start at lower dosages in older patients.
Based on similarity to amitriptyline and use in other painful neuropathies 42 Gabapentin Neurontin Decreases neuronal hypersensitivity mg daily, increasing every five days by mg per day to three-times-per-day dosing mg three times daily, to maximum of mg three times daily 2, mg Headaches, nausea, vomiting, fatigue, and dizziness often transient or mild 43 — Case reports suggest benefit.
Case reports 9 Venlafaxine Effexor Decreases neuronal hypersensitivity Used in other painful neuropathies Dietary changes Low-oxalate diet Decreases the possible role of oxalate deposition in vulvar tissue Ranges from a highly oxalate-restrictive diet to avoidance of a short list of foods that increase oxalate levels significantly 44 — A low-oxalate diet is very restrictive.
Surgical therapy Perineoplasty and vestibulectomy Removal of hypersensitive tissue and replacement with vaginal mucosa advancement — — Acute discomfort and job absenteeism. Rarely, bleeding, infection, hematoma, wound separation, vaginismus, vaginal stenosis Only useful in localized vestibular cases. Continue three-times-daily application to introitus. Avoidance of irritants e. Cognitive behavioral therapy Increases understanding of the disorder and encourages patients to find ways to minimize symptoms Eight two-hour group sessions over 12 weeks — — Recommended duration can be up to 1.
TABLE 3 Treatment Options for Women with Vulvodynia Therapy Proposed mechanism Beginning dosage Continuing dosage Side effects Precautions Evidence Oral therapies Amitriptyline Decreases neuronal hypersensitivity 25 mg at bedtime for 10 days, then 50 mg at bedtime daily 50 to mg at bedtime higher dosages to mg occasionally are successful Dry mouth, fatigue often transient , constipation, weight gain uncommon Start at lower dosages in older patients.
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Author disclosure: Nothing to disclose. More in Pubmed Citation Related Articles. Email Alerts Don't miss a single issue. Sign up for the free AFP email table of contents. Navigate this Article. Perineoplasty should be reserved for women with severe vulvodynia. Not wearing underwear Applying ice to the area Riding a bicycle Being distracted Prolonged sitting Pruritus, irritation, burning.
History consistent with allergen exposure; lack of infectious cause. Chronic candidal vulvovaginitis. Variable erythema, edema, or thick white discharge; pruritus is common. Potassium hydroxide microscopy or culture positive. Pudendal canal syndrome. Unilateral genital pain, often increased with sitting. Pelvic floor muscle spasm present and accentuated with examination. Vulvar intraepithelial neoplasia. Oral therapies. Decreases neuronal hypersensitivity.
Dry mouth, fatigue often transient , constipation, weight gain uncommon. Start at lower dosages in older patients. Decreases oxalate deposition in tissues. Used in conjunction with other treatments. Case reports Desipramine Norpramin. Same as amitriptyline but less common. Gabapentin Neurontin.
Rarely fatigue, anorgasmia, or weight gain. Discontinuation should be gradual. Case reports 9. Venlafaxine Effexor.
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