Vulvodynia

Case Study

Joanne, a 39-year-old lawyer, reported a constant tingling and burning sensation over her entire vulvar area, including her labia, perineum, vestibule, and clitoris, for the past 3 years. The sensations started progressively, initially with short periods of discomfort, but gradually became more frequent and intense to the point that she always felt some degree of pain during a 24-h period. The pain increased sharply with both sexual and nonsexual activities (e.g., walking or sitting for long periods of time), but she sometimes experienced these increases without provocation. She, like Sandra, underwent many invasive examinations and received numerous treatments, none of which helped. Joanne found that all aspects of her life were negatively affected; she had difficulties working, sleeping, and engaging in sexual activities. The pain was always on her mind, and although she obtained some relief from applying ice packs wrapped in towels to her vulva, this solution was only temporary and limited to her home environment. She lost interest in sex and began reducing her sexual activities, as they would exacerbate her pain. Desperate, she waited 1 year on a waiting list at a chronic pain service and was finally diagnosed with vulvodynia. She was prescribed a low dose of Elavil to help her sleep and to decrease the amount of pain she was experiencing, and was given a recommendation to join a vulvodynia support group to learn more about her condition and to meet others who experienced difficulties similar to hers.

Diagnosis

The diagnosis of vulvodynia is a diagnosis of exclusion, meaning that other causes for the pain (e.g., infections, inflammation, postherpetic neuralgia) must be ruled out, as in the case of vulvar vestibulitis syndrome. It is based on the description, quality, and location of the pain. Vulvodynia sufferers report chronic vulvar discomfort characterized by a burning sensation that is not contact-dependent. The pain is diffuse, often covering the vulvar area and including the perineum and may or may not lead to dyspareunia. Some vulvodynia sufferers also meet the diagnostic criteria for vulvar vestibulitis syndrome. It is crucial to rule out pruritus vulvae, which affects the same region as vulvodynia but is characterized by an itching sensation, and is often associated with skin changes, including excoriation and erythema (13,22). In addition, pudendal neuralgia must also be ruled out. In this condition, pain radiates from the vulva to the rest of the perineum, groin, and/or thighs and hyperesthesia is present in a saddle distribution. McKay (13) recommends the following evaluation for vulvodynia: examination of the skin for dermatoses and a careful search for infectious agents likely to cause inflammation. This is followed by nerve assessment, and by a careful anatomic distribution of involved areas, as locations and patterns of discomfort have been shown to be important in differential diagnosis (13).

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