Clinical Review

Vulvar pain syndromes: Making the correct diagnosis

OBG Manag. 2011 September;23(9):46-60

	Neal M. Lonky, MD, MPH, moderator of this discussion, is Clinical Professor of Obstetrics and Gynecology at the University of California–Irvine and a member of the Board of Directors of Southern California Permanente Medical Group. He serves as an OBG Management Contributing Editor.
	Libby Edwards, MD, is Adjunct Clinical Associate Professor of Dermatology at the University of North Carolina in Chapel Hill, NC, and Chief of Dermatology at Carolinas Medical Center in Charlotte, NC. Dr. Edwards is a Past President and Past Secretary General of the International Society for the Study of Vulvovaginal Disease.
	Jennifer Gunter, MD, is Director of Pelvic Pain and Vulvovaginal Disorders for Kaiser Permanente in San Francisco, Calif.
	Hope K. Haefner, MD, is Professor of Obstetrics and Gynecology at the University of Michigan Hospitals and Co-Director of the University of Michigan Center for Vulvar Diseases in Ann Arbor, Mich.

References

1. Thomas TG. Practical Treatise on the Diseases of Women. Philadelphia Pa: Henry C. Lea; 1874.

2. Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003;58(2):82-88.

3. Lavy RJ, Hynan LS, Haley RW. Prevalence of vulvar pain in an urban minority population. J Reprod Med. 2007;52(1):59-62.

4. Nyirjesy P, Peyton C, Weitz MV, Mathew L, Culhane JF. Causes of chronic vaginitis: analysis of a prospective database of affected women. Obstet Gynecol. 2006;108(5):1185-1191.

5. Moyal-Barracco M, Lynch PJ. 2003 ISSVD terminology and classification of vulvodynia: a historical perspective. J Reprod Med. 2004;49(10):772-777.

6. Yunas MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum. 2007;36(6):339-356.

7. Kahn BS, Tatro C, Parsons CL, Willems JJ. Prevalence of interstitial cystitis in vulvodynia patients detected by bladder potassium sensitivity. J Sex Med. 2010;7(2 Pt 2):996-1002.

8. Arnold JD, Bachman GS, Rosen R, Kelly S, Rhoads GG. Vulvodynia: characteristics and associations with comorbidities and quality of life. Obstet Gynecol. 2006;107(3):617-624.

9. Parsons CL, Dell J, Stanford EJ, et al. The prevalence of interstitial cystitis in gynecologic patients with pelvic pain, as detected by intravesical potassium sensitivity. Am J Obstet Gynecol. 2002;187(5):1395-1400.

10. Clemens JQ, Meenan RT, O’Keefe Rosetti MC, et al. Prevalence of interstitial cystitis symptoms in a managed care population. J Urol. 2005;174(2):576-580.

11. Engman M, Lindehammar H, Wijma B. Surface electromyography diagnostics in women with partial vaginismus with or without vulvar vestibulitis and in asymptomatic women. J Psychosom Obstet Gynecol. 2004;25(3-4):281-294.

12. Gunter J. Vulvodynia: new thoughts on a devastating condition. Obstet Gynecol Surv. 2007;62(12):812-819.

13. Gordon AS, Panahlan-Jand M, McComb F, Melegari C, Sharp S. Characteristics of women with vulvar pain disorders: a Web-based survey. J Sex Marital Ther. 2003;29(suppl 1):45.-

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15. Manchikanti L, Fellows B, Pampati V, et al. Comparison of psychological status of chronic pain patients and the general population. Pain Physician. 2002;5(1):40-48.

16. Banks SM, Kerns RD. Explaining the high rates of depression in chronic pain: a diathesis-stress framework. Psychological Bulletin. 1996;119(1):95-110.

17. Sadownik LA. Clinical correlates of vulvodynia patients. A prospective study of 300 patients. J Reprod Med. 2000;5:40-48.Editor found in PubMed: Sadownik LA. Clinical profile of vulvodynia patients. A prospective study of 300 patients. J Reprod Med. 2000;45(8):679–684. Could not find the citation listed. Please confirm.

18. Reed BD, Haefner HK, Punch MR, Roth RS, Gorenflo DW, Gillespie BW. Psychosocial and sexual functioning in women with vulvodynia and chronic pelvic pain. A comparative evaluation. J Reprod Med. 2000;45(8):624-632.

19. Landry T, Bergeron S. Biopsychosocial factors associated with dyspareunia in a community sample of adolescent girls. Arch Sex Behav. 2011;June 22.

20. Goldstein A, Pukall C, Goldstein I. When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain. Cambridge Mass: Da Capo Lifelong Books; 2011;117-126.

21. Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurol Urodyn. 2008;27(4):306-310.

22. Popeney C, Answell V, Renney K. Pudendal entrapment as an etiology of chronic perineal pain: Diagnosis and treatment. Neurol Urodyn. 2007;26(6):820-827.

Nantes Criteria allow for making a diagnosis of pudendal neuralgia (Table 3).²¹

TABLE 3

Nantes Criteria for pudendal neuralgia by pudendal nerve entrapment

Essential criteria Pain in the territory of the pudendal nerve: from the anus to the penis or clitoris Pain is predominantly experienced while sitting The pain does not wake the patient at night Pain with no objective sensory impairment Pain relieved by diagnostic pudendal nerve block
Complementary diagnostic criteria Burning, shooting, stabbing pain; numbness Allodynia or hyperpathia Rectal or vaginal foreign body sensation (sympathalgia) Worsening of pain during the day Predominantly unilateral pain Pain triggered by defecation Presence of exquisite tenderness on palpation of the ischial spine Clinical neurophysiology findings in men or nulliparous women
Exclusion criteria Exclusively coccygeal, gluteal, pubic, or hypogastric pain Pruritus Exclusively paroxysmal pain Imaging abnormalities able to account for the pain
Associated signs not excluding the diagnosis Buttock pain on sitting Referred sciatic pain Pain referred to the medial aspect of the thigh Suprapubic pain Urinary frequency or pain on a full bladder, or both Pain occurring after ejaculation Dyspareunia or pain after sexual intercourse, or both Erectile dysfunction Normal clinical neurophysiology
SOURCE: Labat et al.²¹ Reproduced with permission from Neurology and Urodynamics.

Initial treatments for pudendal neuralgia should be conservative. Treatments consist of lifestyle changes to prevent flare of disease. Physical therapy, medical management, nerve blocks, and alternative treatments may be beneficial.

Pudendal nerve entrapment is often exacerbated by sitting (not on a toilet seat, however) and is reduced in a standing position. It tends to increase in intensity throughout the day.²² The final treatment for pudendal nerve entrapment is surgery if the nerve is compressed. By this time, the generalist is not generally the provider who performs the surgery.

Dr. Gunter: I believe pudendal neuralgia is sometimes overdiagnosed. EMG studies of the pudendal nerve, often touted as a diagnostic tool, are unreliable (they can be abnormal after vaginal delivery or vaginal hysterectomy, for example). In my experience, bilateral pain is less likely to be pudendal neuralgia; spontaneous bilateral compression neuropathy at exactly the same level is not a common phenomenon in chronic pain.

I reserve the diagnosis of pudendal neuralgia for women who have allodynia in the distribution of the pudendal nerve with severe pain on sitting, and who have exquisite tenderness when pressure is applied over the pudendal nerve (at the level of the ischial spine on vaginal examination). Typically, the vaginal sidewall on the affected side is very sensitive to light touch. I do see pudendal nerve pain after vaginal surgery when there has been some compromise of the pudendal nerve or the sacral plexus. This is typically unilateral pain.

Dr. Lonky: Thank you all. We’ll continue our discussion, with a focus on treatment, in the October 2011 issue.

MORE TO COME

Part 2: A bounty of treatment options
(October 2011)
Part 3: Vestibulodynia
(November 2011)

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