Terminology & Classification

“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.