Vulvodynia

Specialty: Gynecology and breast.

• Chronic vulvar pain of unknown cause
• vulvar allodynia
• vulvar burning syndrome
• idiopathic vulvar pain

Why it occurs

• Pelvic floor dysfunction (hypertonia of the levator ani muscles)
• Peripheral and central nociceptive sensitization
• Pudendal nerve neuropathy
• History of repeated vulvovaginal infections treated aggressively
• Psychosexual factors and chronic stress

Initial workup

Systematic vulvar physical examination using the "cotton-swab test" to delimit the areas of allodynia and hyperalgesia. Systematic rule out active infections through repeated vaginal and vulvar cultures. Evaluation by a physiotherapist specialized in pelvic floor to assess muscle tone and trigger points. Psychological and sexological assessment.

Standard management

• Amitriptyline orally starting with 10 mg at night and gradually increasing to 50-75 mg/break as tolerated
• Gabapentin 300 mg orally daily, gradually adjusting to 900-1800 mg/day divided into three doses
• Pregabalin 75 mg orally at night, increasing according to clinical response
• Topical 2% Amitriptyline cream combined with 2% Baclofen applied locally to the introitus twice a day
• 5% lidocaine cream applied 20 minutes before sexual intercourse or at night (note: avoid repeated empirical antifungal treatments that worsen mucosal irritation).