Guideline sources The following summarized guidelines for the evaluation and management of vulvodynia are prepared by our editorial team based on guidelines from the European Academy of Dermatology and Venereology (EADV 2017). 1 Guidelines 1. Screening and diagnosis Clinical presentation: Recognize that: vulvodynia is a chronic pain condition lasting months or years before the diagnosis B intensity of the discomfort is often variable over time B significant improvement or complete remission may occur following treatment or spontaneously B candidiasis is frequently an initiating event B any acute painful vulval, urinary or anal condition, such as infection or surgical procedure, may precede the occurrence of vulvodynia, especially if these physical events occur in a context of emotional stress. B Differential diagnosis: Suspect neurological conditions responsible for perineal pain in patients with sphincter disturbances and objective neurological abnormalities. B https://web.pathway.md/diseases/recrHmr1ZYIUgrOGz 1/3 6/29/23, 3:45 AM Vulvodynia Pathway Obtain pelvic and lumbosacral MRI in patients with spontaneous generalized vulval pain resistant to treatments. B 2. Medical management Lidocaine: Prescribe local anesthetics such as lidocaine 5% ointment or 2% gel, applied 15-20 minutes before penetrative sex and washing off just before penetration, mostly in patients with introital dyspareunia resulting from provoked vestibulodynia. B Offer long-term daily use of lidocaine in patients with vulvodynia. A Other topical analgesics: Consider offering the following topical analgesics in patients with vulvodynia: gabapentin 2-6% cream amitriptyline 2% cream capsaicin 0.025-0.05% cream, recognize that its use is limited by topical side effect (burning). C Antidepressants and anticonvulsants: Offer oral pain modifiers mostly in patients with unprovoked vulvodynia, B recognizing that: low-dose amitriptyline 5-25 mg daily is widely used B gabapentin 300-1,200 mg daily is another option. B Insufficient evidence to support the use of pregabalin in patients with vulvodynia. I 3. Nonpharmacologic interventions Vulval care: Advise avoiding irritating factors in patients with vulvodynia. B Advise using emollient soap substitutes in patients with vulvodynia. B Cognitive behavioral therapy: offer CBT B over supportive psychotherapy in patients with vulvodynia. B Show 2 more Physiotherapy: Consider offering perineal manual therapy and biofeedback in patients with vulvodynia, preferably delivered by physiotherapists experienced in the management of chronic vulval pain and its sexual impact. C Consider offering vaginal trainers in patients with vulvodynia. C Acupuncture: offer acupuncture in patients with vulvodynia. B 4. Therapeutic procedures Transcutaneous electrical nerve stimulation: consider offering self-administered transcutaneous electrical nerve stimulation in patients with vulvodynia. C https://web.pathway.md/diseases/recrHmr1ZYIUgrOGz 2/3 6/29/23, 3:45 AM Vulvodynia Pathway Nerve block: consider performing multilevel anesthetic nerve blocks (caudal, pudendal) in patients with vulvodynia. C Botulinum toxin injections: insufficient evidence to support the use of botulinum toxin in patients with vulvodynia. I 5. Surgical interventions Vestibulectomy: consider performing vestibulectomy (posterior or total, with or without vaginal advancement to cover the defect) as a last resort in patients with vulvodynia, after failure of all available therapeutic options. C 6. Follow-up and surveillance Follow-up: follow-up patients with vulvodynia every 3 months until improvement. Ensure multidisciplinary long-term follow-up. B References 1. van der Meijden WI, Boffa MJ, Ter Harmsel WA et al. 2016 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol. 2017 Jun;31 6 925 941. Open https://web.pathway.md/diseases/recrHmr1ZYIUgrOGz 3/3