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Vulvodynia

Abstract

Vulvodynia is a condition that occurs in 8–10% of women of all ages and is characterized by pain at the vulva that is present during sexual and/or non-sexual situations. Diagnosis is established through careful medical history and pelvic examination, including the cotton-swab test. The onset and maintenance of vulvodynia involves a complex interplay of peripheral and central pain mechanisms, pelvic floor muscle and autonomic dysfunction, anxiety, depression and childhood maltreatment as well as cognitive–affective, behavioural and interpersonal factors. Given the absence of empirically supported treatment guidelines, a stepwise approach of pelvic floor physical therapy and cognitive behavioural therapy as well as medical management is suggested, with surgery as the last option. Vulvodynia has a negative effect on the quality of life of women and their partners, and imposes a profound personal and societal economic burden. In addition, women with vulvodynia are more likely to report other chronic pain conditions, which further alters their quality of life. Future efforts should aim to increase girls’, women’s and healthcare professionals’ education and awareness of vulvodynia, phenotype different subgroups of women based on biopsychosocial characteristics among more diverse samples, conduct longitudinal studies and improve clinical trial designs.

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Fig. 1: Anatomy of the female lower genital tract.
Fig. 2: Factors associated with the development and maintenance of vulvodynia.
Fig. 3: Pelvic floor innervation in females.
Fig. 4: Diagnostic algorithm for vulvodynia.

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Acknowledgements

This review paper was supported in part by grants from the Canadian Institutes of Health Research and a Tier I Canada Research Chair awarded to S.B. Work by U.W. on vulvodynia has been supported by the National Institutes of Health grant HD39699 (NICHD and Office of Research on Women’s Health), and her research programme on chronic pain in women at the University of Alabama at Birmingham is supported by the William A. Lell, M.D.–Paul N. Samuelson, M.D. endowed professorship in anaesthesiology.

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Contributions

Introduction (S.B. and U.W.); Epidemiology (S.B.); Mechanisms/pathophysiology (S.B. and U.W.); Diagnosis, screening and prevention (B.D.R.); Management (S.B. and N.B.-S.); Quality of life (B.D.R.); Outlook (S.B., B.D.R., U.W. and N.B.-S.); Overview of the Primer (S.B.).

Corresponding author

Correspondence to Sophie Bergeron.

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Competing interests

U.W. serves on the External Consultant Board for the NIH Preclinical Screening Platform for Pain, a novel preclinical pain therapy screening platform that has been launched at the National Institute for Neurological Disorders and Stroke as part of the NIH Helping to End Addiction Long-term Initiative. In her capacity as a special government employee of the FDA, U.W. has served as a voting member of the FDA Anaesthetic and Analgesic Drug Products Advisory Committee. U.W. has served as a consultant for Grünenthal GmbH and Ironwood Pharmaceuticals, Inc. All other authors declare no competing interests.

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Nature Reviews Disease Primers thanks M. Goetsch, F. Murina, P. Smith and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Related links

VPAQ supplemental digital content: http://links.lww.com/PAIN/A324

World Health Assembly of the WHO approves 11th version of the ICD-11: http://s3.amazonaws.com/rdcms-iasp/files/production/public/ICD11%20Press%20Release_3June2019.pdf

World Health Assembly update: https://www.who.int/news-room/detail/25-05-2019-world-health-assembly-update

Glossary

Dyspareunia

Pain during sexual intercourse.

Provoked vestibulodynia

Pain elicited via pressure to the vulvar vestibule or attempted vaginal penetration.

Allodynia

Pain due to a stimulus that does not normally provoke pain.

Hyperalgesia

Intensified pain from a stimulus that normally provokes pain.

Central sensitization

Also known as central pain mechanisms. Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.

Pain catastrophizing

Tendency to hold exaggerated negative thoughts and feelings about the pain, that is, rumination, helplessness and magnification.

Pain self-efficacy

The degree to which a woman believes she can manage the pain effectively.

Tampon test

Standardized research technique of insertion of a tampon of standardized size by the patient to assess discomfort. Can be used repetitively over time to assess changes.

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Bergeron, S., Reed, B.D., Wesselmann, U. et al. Vulvodynia. Nat Rev Dis Primers 6, 36 (2020). https://doi.org/10.1038/s41572-020-0164-2

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