Vulvovaginitis may be due to allergic reaction (eg, contact vaginitis), infection (eg, bacterial, parasitic, fungal), or hypoestrogenism (ie, atrophic). Symptoms include burning, discomfort, dyspareunia, and abdominal vaginal discharge. Localizing the pain is important in order to determine the diagnosis.

Contact vulvitis
The patient usually complains of itching or burning that involves the vulva but not the vagina. Elimination of the possible agent and administration of topical steroids for 7-10 days usually result in resolution of symptoms.

Atrophic vaginitis
Primary complaints include burning, dyspareunia, and vaginal spotting. The patient may also experience burning during micturition, urinary urgency, and urinary frequency. Topical estrogen cream is the first-line treatment. Incidence of systemic absorption is low with low-dose topical estrogens. Estradiol-releasing vaginal rings have the highest continuance and efficacy rates among all topical preparations.

Microbial vaginitis
The usual complaints are accompanied by vaginal discharge. Appropriate treatment results in resolution of symptoms.

Vulvodynia
Vulvodynia is defined as chronic vulvar burning and/or pain without clear medical findings. Specific treatable causes, such as dermatoses or group B streptococci infection, should be ruled out in the first instance. Essential (dysesthetic) vulvodynia is a diffuse unremitting vulval burning that may radiate to the inner thigh, buttocks, and perineum. Associated complaints include urethral and rectal burning or discomfort. This condition is commonly found in postmenopausal women. Physical examination reveals findings of hyperalgesia in the affected areas. Pudendal nerve damage or compression is a possible contributory factor. Urinary frequency, urgency, and incontinence may develop as a consequence, and chronic constipation may also develop. Vulvar vestibulitis (provoked vulvodynia) is severe pain upon vestibular touch or attempted vaginal entry during coitus, tenderness to pressure localized within the vulvar vestibule, and physical examination findings limited to vestibular erythema of variousdegrees.

Because both the vestibule of the vulva and the bladder are derived from the urogenital sinus, a common etiology has been suggested for these conditions. Standard therapy for vulvodynia includes amitriptyline and, more recently, gabapentin. Additional therapies include estrogen cream, nitroglycerin cream (0.2%), interferon-alpha, and pelvic floor rehabilitation with surface electromyography (EMG) biofeedback.

Vestibulodynia is an entity that may be a combination of vestibulitis and constant spontaneous vulvodynia. Patients have a higher incidence of dysuria, and even the contact of urine on the vestibular skin evokes a sensation of pain. Perineoplasty is associated with a higher failure rate in these patients. Further, a higher frequency of human papilloma virus DNA is found in tissue samples of patients with vestibulodynia.

Author: Dharmesh Kapoor, MD, MBBS, MRCOG, Subspecialty Fellow, Department of Gynecology, Derriford Hospital

Coauthor(s): Gamal Mostafa Ghoniem, MD, FACS, Fellowship Program Director, Clinical Professor of Surgery, Head, Section of Voiding Dysfunction, Female Urology and Reconstruction, Cleveland Clinic Florida; Willy Davila, MD, Head, Section of Urogynecology and Reconstructive Pelvic Surgery, Chairman, Department of Gynecology, Cleveland Clinic Florida

Editors: Jordan G Pritzker, MD, Assistant Professor of Obstetrics, Gynecology, and Women’s Health, Women’s Comprehensive Health Center, Albert Einstein College of Medicine; Physician-In-Charge, Dept of Obstetrics and Gynecology, Long Island Jewish Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine