In the absence of a histologic abnormality, vulvar pruritus, discomfort, and pain (vulvodynia) may or may not respond to a variety of treatments including improved hygiene, oral or topical medications, injections, or surgery (50). Most clinicians finding local inflammatory conditions of the vulva without a target lesion for biopsy will try to improve the local environment with attention to clothing and cleanliness (51), but if simple measures do not lead to rapid improvement, biopsies are necessary. Although irritant contact dermatitis is more common than allergic contact dermatitis, both the original irritant and the secondary sensitization to topical medications should be considered both in established vulvitis and in the initial treatment of a new complaint (52,53). As in similar complaints on other parts of the body, vulvodynia may persist after the original offending agent is long gone, with continued ineffective and irritating treatment used by the patient in an effort to control local symptoms while exacerbating them. It has been suggested that previous Candida albicans infection may predispose patients to a subsequent hypersensitivity response, which may be related to the complaint of discomfort or pain (54).
Vulvar vestibulitis syndrome (VVS) has been cited as the pathologic cause for occasionally intractable pain. Treatment options may include surgery (55) but without a guarantee of good result. With the potential for new or more severe symptoms, extreme caution is necessary before embarking on a surgical attack. The psychological aspects of VVS rank as high as the physical findings in deciding on a management plan (56), although the psychological characteristics as well as the local pathology are inconsistent. It has been suggested that some clinicians encounter, recognize, and treat more cases of VVS than are seen in general gynecologic experience. It is unclear whether referral patterns or diminished threshold for making the diagnosis lead to clustering of patients with this diagnosis.
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