Chronic Urogenital Pain

Vulvodynia – Bladder Pain Syndrome/Interstitial Cystitis


Definition and Classification of Vulvodynia


Definition. Vulvodynia is defined as vulvar pain of at least 3 months duration, without clear identifiable cause, which may have potential associated factors. Most women with vulvodynia will experience pain with any pressure application to the vulvar area. Tight clothing and tampons may be uncomfortable and sexual activity painful. Pain can be constant or occasional and affect the opening of the vagina, clitoris or either side of the vulva.

Vulvodynia is a chronic pain syndrome diagnosed on the basis of reported symptoms and physical examination of the vulvar area. Most common features assisting in the diagnosis of this condition include pain in the vulvar vestibule when palpated with a q-tip and reported pain of the vulvar area associated with sexual intercourse.

Classification. The classification of vulvodynia and other chronic vulvar conditions has recently been reviewed and slightly modified. The main changes reflect the recognition that vulvodynia can present with associated factors, such as muscle tension, and can co-exist with disorders such as lichen sclerosus. The new classification also provides the option of sub-classify vulvodynia as of primary (early) or secondary (later) onset. It is a diagnosis of exclusion, where medical causes have been excluded. Strictly speaking it should be stated that the term vulvodynia is more a descriptive term rather than a diagnostic label.

2015 Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia
Vulvar pain caused by a specific disorder*
  • Infections (e.g., recurrent candidiasis, herpes)
  • Inflammatory (e.g., lichen sclerosus, lichen planus, immunobullous disorders)
  • Neoplastic (e.g., Paget disease, squamous cell carcinoma)
  • Neurologic (e.g., postherpetic neuralgia, nerve compression, or injury, neuroma)
  • Trauma (e.g., female genital cutting, obstetrical)
  • Iatrogenic (e.g., postoperative, chemotherapy, radiation)
  • Hormonal deficiencies (e.g. genitourinary syndrome of menopause [Vulvovaginal atrophy], lactational amenorrhea)
Vulvodynia – vulvar pain of at least 3 months duration, without clear identifiable cause, which may have potential associated factors. The following are the descriptors:
  • Localized (e.g., vestibulodynia, clitorodynia) or generalized or mixed (localised and generalized)
  • Provoked (e.g., insertional, contact) or spontaneous or mixed (provoked and spontaneious)
  • Onset (primary or secondary)
  • Temporal pattern (intermittent, persistent, constant, immediate, delayed)
* Women may have both a specific disorder (e.g., lichen sclerosus and vulvodynia).

Past Terminology and Classification of Vulvodynia.

International Society for the Study of Vulvovaginal Disease (ISSVD)
Drs Peter J Lynch and Micheline Moyal-Barracco
ISSVD Terminology Committee on Vulvar Pain
At the 2003 ISSVD meeting, the following revised definition of vulvodynia was accepted:

“Vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific clinically identifiable, neurologic disorder.”

A classification of vulvodynia based on the site of the pain was also adopted. The new terminology is as follows:

A) Vulvar Pain related to a Specific Disorder
  1. Infectious (e.g. candidiasis, herpes, etc)
  2. Inflammatory (e.g. lichen planus, immunobullous disorders, etc.)
  3. Neoplastic (e.g.Paget’s disease, squamous cell carcinoma, etc.)
  4. Neurologic (e.g. herpes neuralgia, spinal nerve compression, etc.)
B) Vulvodynia
  1. Generalized
    • Provoked (sexual, nonsexual, or both)
    • Unprovoked
    • Mixed (provoked and unprovoked)
  2. Localized (vestibulodynia – previously known as vulvar vestibulitis, clitorodynia, hemivulvodynia, etc.)
    • Provoked (sexual, nonsexual, or both)
    • Unprovoked
    • Mixed (provoked and unprovoked)

For further clarification of the current terminology please visit –
International Society for the Study of Vulvovaginal Disease (ISSVD)

Libby Edwards, MD, Peter J. Lynch, MD
“Vulvodynia” has been the term of choice for the condition characterized by symptoms of vulvar burning, rawness, irritation, stinging, soreness, and/or pain occurring in the absence of an underlying, recognizable disease. Within the general category of vulvodynia, three subsets have been recognized:

  1. Vulvar vestibulitis syndrome: This condition was defined as pain localized to the vestibule elicited by touch, pressure, or friction, and usually accompanied by vestibular erythema. The suffix “itis” was used in the belief that this was an inflammatory process as demonstrated by the red color present on examination and the microscopic presence of mononuclear cells clustered around the rninor vestibular glands. When the redness and pain was confined to only a small area of the vestibule, the term “focal vulvitis” was sometimes substituted for vestibulitis.
  2. Dysesthetic vulvodynia (synonym essential or idiopathic vulvodynia): this condition was defined as vulvar pain, which was not necessarily confined to the vestibule and/or was migratory. Probing with a cottontipped applicator revealed somewhat inconsistent sites and intensity of pain. Minimal or no erythema was present upon examination and no significant number of inflammatory cells was found on biopsy. Typically, the pain of dysesthetic vulvodynia initially occurred only episodically as a direct result of touch, pressure or friction, but later on a background of low-grade, continuous pain was also described as being present. Some patients have no pain to touch.
  3. Cyclic vulvitis: this condition was defined as vulvar pain, which occurred in a cyclic fashion, generally in concert with the menstrual cycle. The pain could arise spontaneously or could be provoked by touch, pressure or friction. Redness might or might not be present on examination. Histologic findings were not well-established owing to the limited number of patients who had been biopsied. Intermittent, low-grade candidiasis (usually without the typical physical findings of vulvovaginal candidiasis) was thought to cause this condition. The problem often improved when chronic, suppressive oral or topical anticandidal agents were used.

Recently, problems with this terminology and classi­fication have been identified. First, detailed new information regarding the clinical appearance and biopsy findings of the vulva in normal, asymptomatic women has been reported. Many of these normal women were found to have vestibular redness, similar to that found in vulvar vestibulitis. Moreover, biopsies in these normal women often revealed some peri-glandular mononuclear cells, a histologic picture heretofore thought to be specific for vulvar vestibulitis. Second, many clinicians came to believe that cyclic vulvitis was in reality “atypical” (no vaginal discharge and no vulvar pustules) candidiasis. As such, these clinicians preferred to remove cyclic vulvitis from the classification of vulvodynia, because this is an underlying, recognizable disease, just as sclerosus and lichen planus are excluded because they are recognizable, specific diseases.
The problem of vulvodynia terminology and classification was discussed at the most recent meeting of the International Society of Vulvovaginal Disease (ISSVD) that was held in September, 1999 in Santa Fe, New Mexico. There was support to revise the terminology and to bring it in line with that used for other types of chronic pain syndromes as are contained in the cross­specialty, internationally used SNOMED nomenclature. After (largely revolving around the separation of vulvodynia into subsets of “provoked” versus “unprovoked” pain), the members voted to use the following terminology for a trial period of two years. This terminology will be discussed again at the ISSVD meeting in 2001 and a determination as to whether or not to make it permanent will be voted on at that time.

ISSVD 1999 Proposed Terminology and Classification for Vulvodynia Vulvar Dysesthesia (Formerly Vulvodynia)

  1. Generalized Vulvar Dysesthesia (formally dysesthetic vulvodynia). This condition refers to vulvar burning or pain that cannot be consistently, and tightly localized by point pressure “mapping” by way of probing with a cotton tipped applicator or similar instrument. The vulvar vestibule may be involved but the discomfort is not limited to the vestibule. Clinically, the pain may occur with or without provocation (touch, pressure or friction).
  2. Localized Vulvar Dysesthesia. This condition refers to pain that can be consistently and tightly, localized by point pressure mapping (see above) to one or more portions of the vulva. Clinically, the pain usually occurs as a result of provocation (touch, pressure or friction).
    • A) Vestibulodynia (formerly vulvar vestibulitis). This condition refers to pain that can be point pressure mapped to one or more portions of the vulvar vestibule. Redness (especially at the orifice east of the minor vestibular glands) may or may not be present at the sites of the point pressure mapping. A few mononuclear cells, usually located around the minor vestibular glands, may be present on biopsy.
    • B) Clitoridynia refers to pain that can be point pressure mapped to the clitoris. No information regarding clinical redness or histologic inflammation is available for this condition owing to the infrequency with which it has been reported.
    • C) Other localized forms of vulvar dysesthesia. Only a few instances of unexplained pain in other vulvar sites have been reported. For this reason, it is not clear as to, whether or not this category will prove to be clinically useful.

The lSSVD understands that the classification of vulvodynia will evolve as a better understanding of the etiology and pathophysiology of otherwise unexplained vulvar pain occurs. For this reason, the ISSVD views the proposed new classification as a “work in progress” and welcomes comments and questions regarding our approach.