Vulvodynia

General vulvar skin care: wash the vulva with water only (or a plain emollient as a soap substitute), avoid feminine hygiene sprays/wipes, avoid tight synthetic underwear, avoid irritant hair-removal products or methods. Refer for pelvic floor physiotherapy where history or examination suggests pelvic floor muscle hypertonicity, and for psychosexual counselling where sexual function is affected. Reassure the patient that vulvodynia is not an infection and not a marker of cancer. - Ongoing; reassess at 4-6 weeks and add the medical treatments below if pain persists

Not a prepubertal presentation. An adolescent presenting with this pattern should be referred to a gynaecologist with adolescent experience rather than managed in primary care alone.

NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain (2024)

Vulvodynia is defined as vulval discomfort, often burning, in the absence of a relevant clinical finding or an identifiable neurological disorder - it is a diagnosis of exclusion. History and examination must first rule out candidiasis, dermatoses (lichen sclerosus, lichen planus, dermatitis), and, for any atypical skin change, vulval neoplasia, before treating as vulvodynia. General vulvar care and physiotherapy/psychosexual referral apply to every patient regardless of which medical treatment, if any, is added on top.

10 mg once daily at night initially, titrated by 5-10 mg every 2 weeks as tolerated to a usual effective dose around 60 mg nightly (maximum 100 mg nightly) - Trial for at least 2-3 weeks at an adequate dose before judging effect; continue long-term if effective, reviewed periodically

Not established in children for this indication; refer rather than prescribing in an adolescent with this pattern.

NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain for the pathway, with the figures from Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683): "The initial dose should be 10 mg - 25 mg in the evening... Recommended doses are 25 mg - 75 mg daily in the evening. Doses above 100 mg should be used with caution... A single dose above 75 mg is not recommended." The SmPC states no 60 mg step, and it asks that anything above 75 mg be split into two doses rather than given as one nightly dose.

Named in this guidance as an appropriate initial oral treatment for unprovoked/persistent vulvodynia; the source document draws this recommendation from the British Society for the Study of Vulval Disease (BSSVD) 2010 guideline and ACOG Committee Opinion No. 673: Persistent Vulvar Pain (2016), both cited by name within it. Reserve for pain persisting despite vulvar care, physiotherapy, and topical lidocaine - it is not a first-contact treatment.

300 mg once daily initially, increasing in steps of 300 mg every 2-3 days as tolerated (in 2-3 divided doses) to an effective dose, typically in the range 900-1800 mg daily (maximum 3600 mg daily) - Titration over 3-8 weeks; continue if effective, reviewed periodically

Not established in children for this indication.

Gabapentin 300 mg capsules SmPC sections 4.2 and 4.4 (eMC product 4122)

The vulvodynia-specific source names gabapentin (with pregabalin) as an option for persistent pain, but states this is usually undertaken with specialist pain-service involvement rather than started independently in primary care - listed here as the next step after amitriptyline has failed or is not tolerated, best arranged together with a pain-service or gynaecology referral rather than as a routine primary-care first move. The vulvodynia-specific source does not publish a titration schedule, so the mg steps come from the gabapentin SmPC (eMC 4122) cited for the dose, which for peripheral neuropathic pain gives a 300 mg day-1 start and says "the dose can be further increased in 300 mg/day increments every 2-3 days up to a maximum dose of 3600 mg/day".

Apply 5% lidocaine ointment thinly to the affected vulvar area; can be used as regular treatment or applied approximately 20-30 minutes before intercourse to reduce entry pain. An ointment base is generally better tolerated than a cream, which tends to sting more on application. - Trial for 4-6 weeks before judging effect

Not indicated in children.

NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain (2024)

This guidance states a topical local anaesthetic can be trialled in all patients with vulvodynia, alongside - not instead of - the general vulvar care and physiotherapy/psychosexual referral above.