by Sara Hover, RPh, FAARM, PCCA Director of Clinical Services

Signs and Symptoms of Vulvodynia

Persistent vulvar pain, burning sensations and discomfort define the landscape of vulvodynia, affecting everyday activities — including intimacy. Although many patients will report symptoms of recurring vaginitis, laboratory results prove negative. Often, these patients will experience pain triggered by undergarments or tight-fitting pants in contact with their vulva, or even when sitting for prolonged periods of time. It is essential to rule out other potential causes of vulvar pain before confirming vulvodynia, as it is a diagnosis of exclusion.¹

Pelvic Floor Dysfunction and Vulvodynia

The intricate interplay between vulvodynia and pelvic floor dysfunction underscores the complexity of this condition. Chronic tension or weakness in the pelvic floor muscles can exacerbate vulvar pain, creating a cycle of discomfort that necessitates comprehensive management.³

Pelvic Floor Physical Therapy

A cornerstone in vulvodynia management should include physical therapy protocols, such as vulvar desensitization, pelvic floor muscle stretching, myofascial release, conjunctive tissue manipulation and neuromuscular re-education. There are also similar techniques to help release the hip and abdominal muscles. This therapy has been found to alleviate pain and promote overall pelvic health. There are physical therapists that specialize in pelvic floor disorders.³

Topical Medications for Vulvodynia

Topical medications, including local anesthetics like lidocaine or compounded creams with medications such as amitriptyline, baclofen and gabapentin, play a crucial role in reducing vulvodynia symptoms. Amitriptyline is a tricyclic antidepressant which may relieve neuropathic pain by its unique ability to inhibit presynaptic reuptake of serotonin and noradrenaline.⁴ Baclofen is a gamma-aminobutyric acid type B (GABA-B) receptor agonist and may also produce anti-glutamate action, both of which inhibit nociceptive signaling in cutaneous nerve fibers. It is most appropriate for use in patients with concurrent pelvic hypertonia.⁵ Gabapentin works on the voltage‐dependent calcium ion channels, which results in reduced neuropathic pain. In a retrospective chart review, gabapentin cream was well tolerated and significantly reduced vulvar pain.⁶

Acupuncture: A Holistic Approach

Acupuncture, a traditional Chinese practice where needles are skillfully applied to specific acupoints to harmonize the body's energy flow, offers a holistic approach to vulvodynia management. Acupuncturists target specific acupoints on the abdomen — suprapubically —and the extremities, avoiding direct application to the vulva. The ancient art of acupuncture is believed to move blocked qi (energy), relax pelvic floor muscles, and reduce pain and heat in the vulvar region.¹ While more research is needed, the anecdotal evidence and some studies suggest that acupuncture may play a valuable role in alleviating vulvodynia symptoms.

Multidimensional Approach

Vulvodynia demands a multidimensional approach to treatment, encompassing an understanding of its signs and symptoms, acknowledging the connection with pelvic floor dysfunction and exploring diverse management options. From topical medications to pelvic floor physical therapy and the holistic embrace of acupuncture, women navigating the challenges of vulvodynia have an array of tools at their disposal. If you suspect a patient may have vulvodynia, discuss their management options and recommend that she seek guidance from a healthcare professional.

References

1. Schlaeger, J. M., Glayzer, J. E., Villegas-Downs, M., et al. (2023). Evaluation and Treatment of Vulvodynia: State of the Science. Journal of midwifery & women's health, 68(1), 9–34. https://doi.org/10.1111/jmwh.13456
2. Bornstein J., Goldstein A.T., Stockdale C.K., et al. 2015 ISSVD, ISSWSH and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. Obstet Gynecol. 2016;127(4):745‐751. https://doi.org/10.1097/AOG.0000000000001359
3. Morin, M., Dumoulin, C., Bergeron, S., et al. (2021). Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia: a multicenter, randomized trial. American journal of obstetrics and gynecology, 224(2), 189.e1–189.e12. https://doi.org/10.1016/j.ajog.2020.08.038
4. Sindrup, S. H., Otto, M., Finnerup, N. B., et al. (2005). Antidepressants in the treatment of neuropathic pain. Basic & clinical pharmacology & toxicology, 96(6), 399–409. https://doi.org/10.1111/j.1742-7843.2005.pto_96696601.
5. Keppel Hesselink, J. M., Kopsky, D. J., & Sajben, N. L. (2014). Vulvodynia and proctodynia treated with topical baclofen 5 % and palmitoylethanolamide. Archives of gynecology and obstetrics, 290(2), 389–393. https://doi.org/10.1007/s00404-014-3218-4
6. Boardman, L. A., Cooper, A. S., Blais, L. R., et al. (2008). Topical gabapentin in the treatment of localized and generalized vulvodynia. Obstetrics and gynecology, 112(3), 579–585. https://doi.org/10.1097/AOG.0b013e3181827c77

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care or encourage its abandonment.