Vulvodynia is chronic vulvar pain without a visible cause that has been present for at least 3 months. It is classified as localized or generalized. Localized vulvodynia involves pain in the vulvar vestibule, while generalized vulvodynia causes stinging or burning anywhere in the vulva. Diagnosis involves ruling out other causes through history, exam, and tests. Treatment is multimodal and includes behavioral changes, pelvic floor physical therapy, psychological interventions, various medications, and sometimes surgery. The goal is to set realistic expectations as improvement may take months and different treatments may need to be tried.

1. vulvodynia
Dr Samia Mohamad Eid
Prof of ob & gyne Al Azhar University Damietta

2. Vulvodynia
International Society for the Study of Vulvovaginal Disease (ISSVD) 2015
2
Chronic, intractable vulvar pain in the absence of any
visible, physical finding or any objective abnormalities
such as infections or dermatosis

3. Skene 1889
Treatise on the disease of women
Esther Weisfogel 1976
She discrbe the condition as one in
which, I smill nothing, I hear nothing
I see nothing. (BVS)
Kelly 1928
Sensitive deep spot in the mucosa of
hymenal ring
4
Battle with
a Unicorn:
the burning
vulva
International Society for the Study of Vulvovaginal Disease (ISSVD)

4. “Burning valva syndrome.
Vulvodynia
44
7th
ISSVD
ISSSVD
2015

5. Vulvar pain caused by a specific
disorder
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Vulvodynia
International Society for the Study of Vulvovaginal Disease (ISSVD) 2015
Classification of vulvar pain

6. Vulvar pain caused by a specific disorder
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7. Vulvodynia
A complex & multifactorial syndrome, the
exact pathophysiology remains unkown.
A wide variety of ttt is prescribed & most
women shop from doctor to dector
becouse of high faliure rate of most
treatment
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8. Incidence &
prevalence
3 - 15 %
Assessing prevalence is challenging
because the condition is frequently
misdiagnosed when they are seen
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9. Valvodynia classification
Localized vulvodynia
 Provoked
 spontaneous,
 mixed
Generalized vulvodynia
▰Provoked
▰spontaneous,
▰mixed
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10. DIAGNOSTIC CRITERIA OF
LOCALIZED VULVODYNIA
▰ Pain localized to the vulvar vestibule,
with or without the clitoris
▰ Absence of identifiable cause
▰ Duration of at least three months
▰ Pain elicited with pressure-point testing
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11. CLINICAL PRESENTATION
The hallmark symptom in
women with localized
valvodynia is significant pain
upon contact with the vulvar
vestibule.
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PAIN:
 Sexual intercourse,
 Tampon insertion,
 Gynecologic exam
 Prolonged sitting,
 Wearing fitted pants.
Real women, real pain

12. DIAGNOSTIC CRITERIA Of
GENERALIZED VULVODYNIA
▰Episodic unprovoked stinging, burning, or
rawness anywhere in the vulva.
▰ Absence of identifiable cause
▰ Duration of at least three months
▰ Pain cannot elicited with pressure-point
testing
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13. CLINICAL PRESENTATION
The hallmark symptom in women with generalized
valvodynia is :
hyper aesthesia over a wide area of the external
genitalia
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Real women, real pain

14. Pathophysiology
Localized vulvodynia
Neuro-inflammatory pain from
nociceptors in the vulval
vestibule that has been
sensitized by inflammation or
trauma.
Generalized
▰A neuropathic pain due to
damage to the pudendal
nerve.
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15. Most affected women are between 20 and 60 years
of age ,but symptoms can begin in childhood or
adolescence.
Additionally, the pain is sufficiently severe to limit
sexual function, cause psychological distress,
impair relationships, and/or adversely affect routine
activities
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DIAGNOSTIC EVALUATION

17. Vulvodynia syndrome is a diagnosis of exclusion;
detailed history and physical examination that includes focal
pressure-point testing of the vulvar vestibule
▰ OB/GYN history
▰ Detailed pelvic exam to exclude pathology
▰ Vaginal culture (in selected cases)
▰ Pap smear
Diagnosis
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18. “▰Physical examination
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19. Physical examination
localized vulvodynia
▰This Women will have
pain out of proportion to the
pressure from the touch of
the cotton swab, particularly
in the areas between four
and eight o’clock.
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20. Physical examination
generalized vulvodynia
▰This Women will have
pain out of proportion to the
pressure from the touch of
vulva.
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21. Generalized vulvodynia
▰pain occurs spontaneously and is relatively
constant, but there can be some periods of
symptom relief.
▰Activities that apply pressure to the vulva,
such as prolonged sitting or sexual
intercourse, typically exacerbate symptoms.
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22. ▰Vulvodynia syndrome does not cause laboratory or
imaging abnormalities.
▰ However, laboratory tests such as microscopy;
testing for gonorrhea, chlamydia, and trichomonas;
and urinalysis or urine culture can be useful to
exclude infectious causes.
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23. “Treatment of vulvodynia
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24. ▰vulvodynia is a chronic condition, characterized by
periods of remission and flare, one goal of treatment
is to set realistic expectations.
▰Women should understand that improvement can
be a slow process and, because there is not a "one
size fits all" treatment, that finding the correct
therapy for them can take some trial and error, time,
and patience.
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25. ▰ Successful treatment programs are
multimodal and involve the interdisciplinary
team of a medical clinician, a physical
therapist, and a psychobehavioral and/or
sex therapist.
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26. ▰BEHAVIOR MODIFICATION
▰PELVIC FLOOR PHYSICAL THERAPY
▰PSYCHOLOGICAL INTERVENTION
▰MEDICATION
▰SURGERY
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27. BEHAVIOR MODIFICATION
▰Vulvar hygiene – Good vulvar hygiene is the first and easiest
step alleviate irritation .
▰Symptom relief: Soaking in warm baths with Epsom salt,
application of ice packs for 10 to 15 minutes at a time every four
to six hours.
▰Lubrication: Over-the-counter personal lubricants can be both
helpful and harmful.
▰Stress reduction & relaxation
▰Exercise
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28. PELVIC FLOOR PHYSICAL THERAPY
▰Women with vulvodynia exhibit myofascial trigger points
and increased muscle tension in the pelvis, The hyper
tonicity results from increased tissue inflammation,, and
abnormal neural patterns, all of which contribute to muscle
restriction and decreased mobility in these areas.
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29. PSYCHOLOGICAL INTERVENTION
▰Cognitive behavioral therapy
▰Sex therapy and couple-based therapy
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30. MEDICATION
First tier:
▰ Topical lidocaine ointment: 2%-5%
▰ Topical estrogen cream: 0.01%
Second tier:
▰ antidepressants, anticonvulsants,
▰ Capsaicin cream: desensitization to burning
and decreased pain
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31. ▰Third tier
▰Botulinum neurotoxin-A
▰It blocks the release of substance-P from
nociceptive neurons
▰Benefits typically last from 3 to 12 months
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32. ▰Vaginal prasterone:
▰a synthetic dehydroepiandrosterone
(DHEA) used in the treatment of moderate
to severe dyspareunia related to vulvar or
vaginal atrophy of menopause
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33. COMPLEMENTARY AND ALTERNATIVE
TREATMENTS
▰ Acupuncture
▰ Hypnosis
▰ Transcutaneous electrical nerve
stimulation
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34. ▰LASER THERAPY: Laser therapy for the
treatment of vulvodynia is an area of
developing research
▰SURGERY: Surgery is generally considered
a treatment of last resort, particularly for
women with localized, provoked vulvodynia
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35. Conclusion
▰Vulvar pain is a symptom of a set of complex
disorders and is often a frustrating experience for
patients and their providers.
▰Rapid resolution of symptomatic chronic
vulvodynia is unusual. Improvement of pain may
take months. The expected level of improvement
needs to be addressed realistically with patients.
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THANKS!
Dr Samia Mohamad Eid
dr.samia@azharobgyndomyat.edu.eg.