Terminology and History

One of the earliest references to chronic vulvar pain in the medical literature is credited to T. Galliard Thomas, who described hyperesthesia of the vulva in A Practical Treatise on the Diseases of Women in 1891 (4). He noted an extreme sensitivity of the nerves supplying the vulva that was distinct from other gynecologic conditions, such as vaginismus. With the exception of redness, there were no physical abnormalities, and symptoms were triggered by friction, air, bathing, and/or pressure. Dyspareunia, or pain with intercourse, was cited as the most devastating symptom and often the reason a woman consulted a physician. Thomas attributed the origins of this vulvar pain to menopause or a "morbid mental state" (4). Because surgical removal of the labia minora and other vulvar tissues did not cure the patient, opium, chloroform, tannin, nitric acid, and local sedatives were recommended as potential treatments. Although this disorder was highlighted again by Skene in 1899 in Treatise on the Diseases of Women (5), there is little published literature until the late 1970s.

In 1975, the International Society for the Study for Vulvovaginal Disease (ISSVD) formally recognized a series of symptoms related to unexplained vulvar discomfort and termed the disorder "burning vulvar syndrome" (BVS). An ISSVD task force was established in 1982 to further investigate the condition. The findings were presented at the 1983 BVS Congress, where the term "vulvodynia" was coined (6) and defined as "chronic vulvar discomfort, especially that characterized by the woman's complaint of burning (and sometimes stinging, irritation, or rawness). Vulvodynia can have multiple etiologies, and use of this term for a patient's problem should prompt a thorough diagnostic evaluation" (6).

Just as there are many subsets of depression (7), not all vulvodynia is the same; duration, location, and nature of symptoms can vary greatly among patients. The past three decades have seen much controversy regarding the classification and description of this condition. In 1989, McKay proposed five categories of vulvodynia: vulvar vestibulitis, essential vulvodynia, vulvar dermatoses, cyclic vulvitis, and vulvar papillomatosis (8). Ten years later, the 1999 ISSVD World Congress encouraged clinicians to replace the term "vulvodynia" with "vulvar dysesthesia" and argued that the disorder be classified as "generalized" or "localized," based upon the location of symptoms. Within the localized forms of disease, there were three proposed subclassifications: vesti-bulodynia (formerly vulvar vestibulitis), clitoridynia, and "other" (9). A 2001 review by Graziottin, et al. (10) described seven subtypes of vulvodynia; the terminology and classification presented were not in agreement with the ISSVDs report.

When vulvodynia was revisited by the 2001 ISSVD World Congress, the terminology was again revised. "Vulvar dysesthesia" remained the preferred term, and two major categories—"provoked" and "spontaneous"—were recognized based upon the nature of pain stimulus; each of these was subdivided based upon the location of pain (generalized vs. localized) (11). Yet, this classification system was not accepted universally by clinicians and researchers. In April 2003, attendees of the National Institutes of Health Conference on Vulvodynia continued to debate the issue and resolved that two major subtypes of vulvodynia be recognized: dysesthetic vulvodynia and vulvar vestibulitis.

In early 2004, the National Vulvodynia Association supported this terminology and promoted it as follows (12):

• Dysesthetic Vulvodynia (generalized). Diffuse pain that is constant or intermittent; vestibular pressure does not always cause symptoms but may exacerbate existing symptoms.

• Vulvar Vestibulitis Syndrome (dysesthesia localized in the vestibule). Localized pain that occurs when pressure is applied to the vestibule; a burning sensation is the most common symptom.

In October 2003, the ISSVD World Congress reinstated the word "vulvodynia" to describe unexplained vulvar pain and recommended eliminating the term "vestibulitis." They again divided vulvodynia into two subtypes— generalized versus localized—as defined by symptom location; each of these is further classified into three categories—provoked, unprovoked, or mixed— based upon inciting factors. The 2003 ISSVD World Congress recommended universal acceptance and promotion of these terms, bringing uniformity and clarity to the way the disease is recognized, diagnosed, and discussed by health-care professionals (3).

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