Subset of vulvodynia	Typical history	Physical findings	Treatment
Cyclic vulvovaginitis	Pain is worse just before or during menses Pain is exacerbated by intercourse (especially on the next day) Some relatively symptom-free days Frequent use of antibiotics for other conditions	Variable erythema and edema Minimal vaginal discharge	Refer to support group Fluconazole (Diflucan), 150 mg weekly for 2 months, then twice monthly for 2 to 4 months Physical therapy with biofeedback Low-oxalate diet Oral calcium citrate (Citracal)
Vulvar vestibulitis syndrome	Usually premenopausal Entry dyspareunia or pain with insertion of tampon Possible history of carbon dioxide laser therapy, cryotherapy, allergic drug reactions or recent use of chemical irritants	Positive swab test (vestibular point tenderness when touched with cotton swab) Focal or diffuse vestibular erythema	Refer to support group
			Topical estradiol cream, 0.01% (Estrace Vaginal Cream) twice daily
			Intralesional interferon injection
			Physical therapy with biofeedback
			Low-oxalate diet
			Oral calcium citrate
Dysesthetic vulvodynia (essential vulvodynia)	Usually postmenopausal or perimenopausal Diffuse, unremitting burning pain that is not cyclic Less dyspareunia or point tenderness than in vulvar vestibulitis	Usually no erythematous cutaneous changes	Refer to support group Tricyclic antidepressants in gradually increasing amounts (6 or more months of therapy) Physical therapy with biofeedback
Papulosquamous vulvar dermatoses	Itching is prominent Variable chronic symptoms	Erythema Thick and/or scaly lesions May have additional skin lesions elsewhere on body Biopsy required	Topical corticosteroids (2.5% hydrocortisone ointment or 0.1% triamcinolone ointment) for psoriasis, lichen planus, contact dermatitis, lichen simplex chronicus Topical 2% testosterone propionate for lichen sclerosis Topical imidazole creams for tinea cruris
Vesiculobullous vulvar dermatoses	Itching or burning Variable chronic symptoms	Blisters or ulcers that are not related to scratching Biopsy may be required	Depends on condition
Neoplastic vulvar lesions	Variable persistent lesion	Variable; possible white plaques, ulcers or erythema	Refer to gynecologic oncologist
		Biopsy required
Vestibular papillomatosis	Normal anatomic variant Variable history of human papillomavirus infection Many are asymptomatic	Papillomatous appearance of mucosal surfaces Biopsy to rule out koilocytosis or human papillomavirus infection if symptomatic or questionable	No treatment required Treat for human papillomavirus infection only if biopsy is positive