Chapter 87
VULVAR AND VAGINAL PAIN, DYSPAREUNIA,
AND ABNORMAL VAGINAL DISCHARGE
Andrea J. Rapkin and Monica Lee
DEFINITION OF VULVODYNIA AND
CURRENT NOMENCLATURE
The purpose of this chapter is to outline the anatomy and physi-
ology of vulvar and vaginal pain syndromes and to explore the
differential diagnosis and management of vulvar and vaginal pain
and dyspareunia (Tables 87-1 and 87-2), including the roles of
medication, surgery, psychotherapy, and multidisciplinary pain
management. The differential diagnosis and management of
abnormal vaginal discharge is also discussed.
Vulvar pain syndromes are characterized by unexplained
burning or any combination of stinging, irritation, itching, pain
or rawness anywhere from the mons pubis to the anus that causes
physical, sexual, and psychological distress. A multitude of terms
have been used in the literature to describe vulvar pain syn-
dromes. Vulvodynia was first described in 1889 by A. J. C. Skene1
but received little attention until the 1970s. The International
Society for the Study of Vulvovaginal Diseases (ISSVD) aban-
doned the term “burning vulva syndrome,” first described in
1984,2 and introduced a classification wherein the two principal
divisions were vulvar vestibulitis syndrome (VVS) and dyses-
thetic or essential vulvodynia.3 The most recent classification of
vulvar pain, which was agreed on at the October 2003 Congress
of the ISSVD, consists of two major categories4:
1. Vulvar pain related to a specific disorder
a. Infection
b. Inflammation
c. Neoplasm
d. Neurologic disease
2. Vulvodynia: vulvar discomfort, usually described as burning
pain, occurring in the absence of a specific disorder
a. Generalized (involving the entire vulva) or localized
(involving a portion or component of the vulva, such as
the vestibule, clitoris, or hemivulva)
b. Provoked (i.e., by sexual and/or nonsexual contact),
unprovoked (i.e., spontaneous), or mixed (provoked and
unprovoked).
The term vestibulitis signifies the presence of inflammation,
which was thought to be misleading because much evidence sug-
gests no such presence. Therefore, the ISSVD voted to discon-
tinue use of this term.
INCIDENCE AND EPIDEMIOLOGY OF VULVODYNIA
The typical patient with vulvodynia used to be described as a
nulliparous woman in her 20s or early 30s who often may have
developed symptoms suddenly.5 The true prevalence of vulvo-
dynia is uncertain due to its recent recognition; however, a 1991
study of 210 consecutive patients seen at a private practice for
general gynecology found that 37% had some degree of positive
testing for vulvar discomfort, and 15% met full criteria.6 A survey
of more than 4900 women aged 18 to 64 years reported that 16%
of the 3000 respondents had experienced vulvar pain lasting at
least 3 months; 7% had vulvar pain at the time of the survey, and
many had seen up to five different doctors for this problem.7
Unexplained vulvar pain was found to be of similar incidence
among white and African American women. Hispanic women
were 80% more likely than white women to have experienced
chronic vulvar pain.
ANATOMY OF THE VULVA AND VAGINA
The vulva is the part of female anatomy located between the
genitocrural folds laterally and between the mons pubis anteri-
orly and the anus posteriorly (Fig. 87-1).8 It is composed of the
labia majora, labia minora, mons pubis, clitoris, vestibule, urinary
meatus, vaginal orifice, hymen, Bartholin’s glands, Skene’s ducts,
and vestibulovaginal bulbs.
The labia majora form the lateral boundaries of the vulva
and consist of two large folds of adipose and fibrous tissue.
Anteriorly, the labia majora fuse into the mons pubis; posteriorly,
they become narrower and flatter and terminate 3 to 4 cm
anterior to the anus, where they are united by the posterior
commissure or fourchette. The skin of the labia majora is usually
darker than the adjacent skin. The skin has an outer lining
of stratified squamous epithelium. Within the dermis are
numerous hair follicles and sebaceous, sweat (eccrine), and
apocrine glands.
The labia minora lie between the labia majora and consist of
two flat folds of connective tissue containing little or no adipose
tissue. They are covered by skin on their lateral aspects and par-
tially so on their medial aspects. Hart’s line separates the medial
boundary of the minora from the vestibule and is the line of
demarcation between the skin and mucous membrane; it runs
along the base of the inner aspect of each labia minora, passes
into the fossa navicularis, and separates the skin boundary of the
fourchette from the mucous membrane of the hymen. The labia
minora are 4 to 5 cm in length and 0.5 cm in thickness. Anteri-
orly, each divides into two parts, one passing over the clitoris to
form the prepuce and the other joining the clitoris to form the
frenulum. Posteriorly, they tend to become smaller and blend
with the medial surfaces of the labia majora or unite anterior to
the posterior commissure to form the fourchette. The skin and
mucosa of the labia minora are extremely rich in sebaceous
glands. During sexual excitement, the labia minora frequently
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