How do you treat vulvodynia

How is vulvodynia diagnosed? If a cause for your pain is not found, you may have vulvodynia. How is it treated? Treatment may include: Medicines. Some examples are antidepressants, seizure medicines, nerve blocks, and medicated creams. These can help make the tissues of the vulva less sensitive. And antihistamines can help relieve itching. This treatment can help you learn how to control and relax your pelvic muscles.

Tightness or spasms in these muscles can make vulvar pain worse. Physical therapy. Specific exercises can help you strengthen your pelvic muscles. Estrogen creams. Putting this cream on your skin can help relieve pain.

Lidocaine jelly. Lidocaine jelly is sometimes used to relieve pain. In rare cases, surgery is done to remove tissue that is very sensitive. There are other things you can try to relieve your symptoms: Always clean your vulva gently. Avoid soaps and other products, such as vaginal sprays or douches, that irritate your skin.

Wear loose-fitting cotton clothes. Avoid nylon and other fabrics that hold moisture close to the skin. This may cause irritation and allow an infection to start. Avoid hot baths, and don't use soaps or bath products to wash your vulva. Rinse with water only, and gently pat the area dry. Relieve itching and pain with a cold water compress or cool baths. Don't scratch the area. Try using a vaginal lubricant, such as Astroglide or K-Y Jelly, to reduce irritation from having sex.

Stay active. But limit exercises that can irritate the vulva, such as bike riding or horseback riding. How can you live better with vulvodynia? See a counselor. Cognitive-behavioral therapy allows you to express your emotions and concerns and to learn new ways of coping with vulvar pain.

Sex therapy can also help you and your partner find ways to be intimate that don't cause pain. Keep a pain diary. You can track moods, thoughts, activities, and medicines that affect pain.

Having a record of pain can help you and your doctor find the best ways to treat it. Your health care professional may use a diagram to visually note where you feel discomfort, as well as the degree and nature of the pain, such as burning, throbbing or stabbing. A positive cotton swab test one that causes significant pain, especially in the vestibule most strongly suggests the diagnosis of vulvodynia.

Your doctor may use a large magnifying instrument called a colposcope to take a closer look at the vulvar skin. While there may be redness and inflammation, vulvar skin usually appears normal in women with vulvodynia, despite the occurrence of pain. Any abnormal appearing areas may need biopsy to rule out other disorders. Explain how chronic vulvar pain impacts your daily life. Are there certain activities you avoid, such as exercise, use of tampons or sex? You may want to keep a pain diary with detailed information about your pain—when it occurs and for how long, things that make it better or worse and any other symptoms.

This can provide important clues and will help your health care professional make a diagnosis. There are treatments available to provide symptom relief. Adjunct therapies, such as acupuncture, massage therapy and cognitive behavioral therapy, are also being explored. There is no known cure for vulvodynia. The main goals of treatment are to manage your pain, improve your quality of life e. The chronic nature and complexity of vulvodynia often require multiple treatment strategies.

Finding the right treatment or combination of therapies may take some time, especially because each woman's symptoms and response to treatment are different. Your health care provider will recommend a treatment approach based on your condition s , level of pain and preferences. The following section provides a snapshot of available treatments that have been beneficial in reducing pain symptoms listed in no particular order :.

Basic vulvar care. These suggestions will be helpful in all women, not just those with vulvar pain. Some common suggestions for vulvar care include:. Topical anesthetic ointments provide quick, temporary pain relief and comfort and may be used overnight or applied 15 to 20 minutes before sexual activity or throughout the day as needed. Ice packs also provide temporary relief and may be helpful when you can't avoid sitting for long periods, such as lengthy car rides.

Topical estrogens, and occasionally testosterones, may be used in women who are estrogen deficient, such as women who are postmenopausal or those who are premenopausal and take certain medications that lower estrogen levels. Low doses of tricyclic antidepressants may be recommended to treat vulvodynia because of their pain-blocking properties, particularly amitriptyline Elavil , desipramine Norpramin and nortriptyline Pamelor.

Gabapentin, an antiseizure medication, is effective for pain relief in some women and offers an alternative to women who are unable to use tricyclic antidepressants or have side effects from them.

Pregabalin Lyrica , which is used to treat nerve and muscle pain, also may be considered. A newer class of antidepressants, known as SSNRIs Effexor, Cymbalta , have also demonstrated benefit with fewer side effects for some women than the tricyclic antidepressants; however their use in women with vulvodynia has not been well studied.

Like the older tricyclic class of antidepressants, these medications can also help relieve symptoms of depression. Ask your health care professional about various medications and their common side effects. When using certain medications, keep in mind it can take up to six to eight weeks for symptoms to improve, and that you will not necessarily achieve complete relief.

Physical therapy and biofeedback training. Some women have associated spasms or weakness of the pelvic floor muscles that may either contribute to the vulvar pain or develop due to the pain. Your health care professional will evaluate your pelvic floor muscles and may refer you to a pelvic floor physical therapist for full evaluation of the muscles, joints and nerves in the pelvic area.

Treatments may include exercises, education and manual therapies, such as massage. Biofeedback, which helps you enter a relaxed state to reduce pain and teaches you control of the contraction and relaxation of the pelvic muscles, is an integral part of the physical therapy. Learned control of these muscles will aid in situations where pain may occur, such as intercourse or a pelvic exam, by allowing conscious relaxation of these muscles to occur. Relaxation and breathing techniques. Like biofeedback, learning to recognize when you are tensing your pelvic floor muscles due to stress and then learning specific relaxation techniques to reduce stress and anxiety can help alleviate pain.

Diet modifications. Talk with your provider about the pros and cons of eliminating certain types of foods from your diet, such as those high in oxalates or sugar.

To test for food sensitivity and to determine which foods, if any, are affecting you, eliminate one food or food group at a time. Use a food diary to record your results—you might begin to notice an association between your symptoms and certain foods you wouldn't have otherwise suspected.

This may be especially helpful in women who also have interstitial cystitis. Nerve blocks. Injections of lidocaine or lidocaine plus a steroid may provide at least temporary and sometimes long-term relief from vulvar pain.

These injections may be local into trigger points or especially tender areas at the entrance or a short distance in the vagina, or they may be aimed at the larger, pudendal nerve, which carries most of the nerves from the vulvar area to the spinal cord. The pudendal block can be performed through the vagina with the injection into the area at the top of the vagina, near the cervix or through the buttocks this is usually done by an anesthesiologist trained in pain control, not a gynecologist.

Women who have a muscle spasm as the primary contributing cause to the vulvar pain may benefit from Botox injections into the affected muscle. Neurostimulation and spinal infusion pump.

If other treatment forms haven't helped and your pain is severe, your health care professional may have you consult with a professional skilled in neurostimulation or in the use of a spinal infusion pump. With neurostimulation, an electronic device delivers low-voltage electrical stimulation to a targeted nerve or the spinal cord in an attempt to substitute a tingling sensation for pain.

A spinal infusion pump is an implanted device that constantly administers a small dose of medication to the spinal cord and nerve roots to help dull pain. Experience treating vulvodynia with these interventions is limited. Women with severe vulvodynia localized in the vestibule who have failed to find relief with other remedies may consider vestibulectomy, a surgical procedure that removes the painful tissue of the vulvar vestibule. This surgery is usually reserved only for women with vulvar vestibulitis who have not responded to more conservative therapies and understand that, despite the surgery, the pain may not resolve afterward.

Vulvodynia can limit daily activities, interfere with interpersonal and intimate relationships and diminish quality of life. Women who suffer with chronic vulvar pain may also experience depression and feelings of low self-worth. Regardless of what strategies are being employed to manage the vulvar pain, psychological counseling can help women develop coping strategies and deal with sexual intimacy issues.

For many, it is a valuable part of their overall treatment plans. Cognitive behavioral therapists or individual, marriage or sex therapists may be considered. Because we don't know what causes vulvar pain, we really don't know how to prevent it. But there are some things you can do to help minimize your pain. As always, talk with your health care provider about what's best for you. Check your environment and follow basic vulvar skin care. If your vulvar pain symptoms come and go, think about what that area is exposed to.

Do you use a lubricant during intercourse? Have you switched laundry detergents? Are symptoms worse when you wear a certain kind of underwear or use a certain brand of sanitary pad?

Try changing one thing at a time and see if it helps. Keeping a symptom calendar may help uncover a pattern of pain. Don't miss your annual exam. Routine pelvic exams—once a year for women age 18 and older—are very important to ensure early intervention for problems, including chronic pelvic and vulvar pain. Annual gynecologic appointments may include breast exams, Pap tests and other important preventive screenings, such as cholesterol screening and thyroid tests. These visits give you the opportunity to discuss any gynecological concerns or symptoms with your provider.

If you experience vulvar pain, don't wait. Make an appointment to discuss your symptoms with your health care professional. If you don't think your pain is being recognized or managed, find a local specialist in vulvar disorders. Review the following Questions to Ask about vulvodynia so you're prepared to discuss this important health issue with your health care professional.

For information and support on coping with Vulvodynia, please see the recommended organizations and books listed below. Director issvd. Glazer, Gae Rodke. The most lead-contaminated neighborhoods in cities are often the poorest and home to the highest percentage of nonwhite children. Female Patient. Pagano R. Vulvar vestibulitis syndrome: an often unrecognized cause of dyspareunia.

Nyirjesy P, Halpern M. Medical management of vulvar vestibulitis: results of a sequential treatment plan. Infect Dis Obstet Gynecol. Calcium citrate for vulvar vestibulitis. A case report. Urinary oxalate excretion and its role in vulvar pain syndrome. Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med. Ben-David B, Friedman M. Gabapentin therapy for vulvodynia. Anesth Analg.

Effect of dietary oxalate and calcium on urinary oxalate and risk of formation of calcium oxalate kidney stones. J Am Diet Assoc. Vulvar pain syndrome: a review. Obstet Gynecol Surv. Vulvar vestibulitis: significant clinical variables and treatment outcome. A randomized comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis.

Cromolyn cream for recalcitrant idiopathic vulvar vestibulitis: results of a placebo controlled study. Sex Transm Infect. Clinical management of vulvodynia. Rev Gynaecol Pract. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature.

Physical therapy for vulvar vestibulitis syndrome: a retrospective study. J Sex Marital Ther. Vulvar vestibulitis syndrome: care made to measure. J Psychosom Obstet Gynaecol. Edwards L. New concepts in vulvodynia. Pure versus complicated vulvar vestibulitis: a randomized trial of fluconazole treatment. The vulvodynia guideline. Submucous infiltration of betamethasone and lidocaine in the treatment of vulvar vestibulitis. Intralesional alpha interferon. Cost-effective therapy for vulvar vestibulitis syndrome.

Intramuscular beta-interferon treatment for severe vulvar vestibulitis. Modified vulvar vestibulectomy: simple and effective surgery for the treatment of vulvar vestibulitis. Evaluation of the surgical treatment of vulvar vestibulitis. Kandyba K, Binik YM. Hypnotherapy as a treatment for vulvar vestibulitis syndrome: a case report. Sand Petersen C, Weismann K. Isoprenosine improves symptoms in young females with chronic vulvodynia.

Acupuncture for the treatment of vulvar vestibulitis: a pilot study. Acta Obstet Gynecol Scand. Powell J, Wojnarowska F. Acupuncture for vulvodynia. J R Soc Med. Over-the-counter and alternative medicines in the treatment of chronic vaginal symptoms. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.

Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. 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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Purchase Access: See My Options close. Best Value! To see the full article, log in or purchase access. 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.