Vaginal Discharge

Chapter 87
VULVAR AND VAGINAL PAIN, DYSPAREUNIA,

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

VULVAR AND VAGINAL PAIN, DYSPAREUNIA,

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