Dysesthetic Vulvodynia

Generally considered a diagnosis of exclusion, it presents commonly in perimenopausal and postmenopausal women as nonspecific superficial vulvar burning or perineal discomfort with intermittent, deep, aching pain. Patients deny entry dyspareunia. Physical examination is normal, with no tenderness on palpation. Pudendal nerve tenderness, hyperesthesiae, or hypoesthesiae in a saddle distribution extending from the mons pubis to the upper inner thighs and posteriorly across ischial tuberosities may be noted on examination.187 The etiology may be secondary to an aberration in cutaneous nerve perception (pudendal nerve distribution S2-S4) at either the central or peripheral level. Tricyclic antidepressants starting at 10 mg q.d. to 40-60 mg q.d. may be of benefit in this condition.188 Topical 5 percent lidocaine may provide additional benefit. Other reported treatments, although of unproven effectiveness, include acupuncture, pelvic floor muscle, physical therapy, TENS, regional nerve blocks, and anticonvulsants.188

Table 41.3 Etiologies of vulvodynia.

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