Physical Exam
The Essentials

The Physical Exam is Essential

When vulvodynia is suspected, it is important to rule out other potential causes of vulvar pain. Even though valuable information can be gathered from the patient history, a physical exam is key to ruling out other conditions.

Action Steps

1.  Vulvar Pain: What to Rule Out
2. The Physical Exam
3. Making the Diagnosis

1. Vulvar Pain: What to Rule Out

Vulvodynia is a Diagnosis of Exclusion

For a patient experiencing vulvar pain (either provoked or spontaneous) it is important to rule out the following conditions. Keep in mind that patients may have both a specific disorder AND vulvodynia.

Infections
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Neurologic
Consider a pelvic nerve condition if patient has constant unprovoked pain
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Hormonal Skin Changes
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Neoplastic
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Inflammation
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‍★ Did you know that a subset of people on the birth control pill, or other anti-androgens like spironolactone, will develop atrophy and subsequently provoked pain of the vulvar vestibule?

See treatment section to learn more about what we know about this association.

2. Physical Exam

Tips for Trauma Informed Care

Patients with vulvar pain will likely have significant anxiety or fear about having a vulvar exam.  They may or have experienced sexual, physical, or emotional trauma during their lifetime.  Many will have had traumatic experiences with the medical system. The following techniques will help the physician navigate the physical exam through a trauma informed lens, helping to create a safe environment that supports a sense of self-efficacy, dignity, and personal control.

Empower

Make it clear the patient is in control

Remind them that they can take a break any time; ask the patient what has made exams easier for them in the past & facilitate those things if possible (e.g., having a support person in the room, having a fidget toy, or deep breathing).

Use

Visual aids

Consider using a diagram to describe the steps the exam and point to the areas of the vulva that will be palpated prior to performing the exam.

Encourage

relaxation Techniques

Many patients have their own breathing techniques and relaxation techniques. Encourage them to use their own, or suggest techniques that have been effective for your patients in the past.

Allow

For extra time for the exam

Make sure you have time to incorporate aspects of trauma-informed care. If you do not, schedule the exam for a different day. Ask the patient if they are comfortable having exam today, or give them the option to book for a follow-up.

Say

Use trauma-informed language

Use language like, “move your knees to either side" instead of “spread your legs.”

Avoid

Words like “normal”

Use words like “healthy” instead.

Explain

The purpose of the physical exam

The purpose is to rule out other conditions, pain mapping, and assess the contribution of elevated pelvic floor tone) and the steps of the physical exam.

Consent

Break the exam into steps

Ask for consent to perform the exam. Explain each step of the exam prior to performing it. Ask for permission to touch before each step.

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Exam Set Up


1. Equipment needed:  No special equipment is required for an exam for vulvar pain. Have a Q-tip ready to perform the light touch component of the exam. Note that a speculum is not used during an exam for vulvar pain.

2. Exam Table: Consider placing the patient into a semi-reclined position rather than fully reclined. This setup can aid with patient feelings of control and visibility with a handheld mirror.
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3. Handheld Mirror: The patient can be encouraged to use a mirror so they can observe what the physician is doing and also to see where all the examined parts are.

Components of the Exam for Vulvar Pain


1. Inspection: Check for signs of inflammation or changes to the anatomy. Assess for hypoestrogenization of the vulvar vestibule.

2. Pain Mapping: Introduce a neutral touch with the back of a gloved hand on the inner thigh - palpate the genitocrural fold, labia majora, interlabial folds, labia minora, and vestibule.  Start in a spot where palpation is pain-free. Have patient identify where, when, and how intensely the pain is experienced.

3. Q-Tip Test for provoked vulvodynia: Apply light touch with the Q-tip to multiple sites of the vestibule adjacent to the hymen as shown in the diagram below (red circles ⭕ indicate Q-tip touch sites). Ask patient to rate pain on a scale from 1 to 10. Greater than 3/10 is considered a positive Q-tip test and is consistent with provoked vulvodynia.

4. Pelvic Floor: Note any involuntary tensing of the buttocks, thighs, and pelvic floor.

5. At initial visit, do a vaginal swab to rule out a yeast infection. Offer the option for the patient to perform a self-swab, which may reduce anxiety.

3. Making the Diagnosis

Diagnosing vulvodynia is challenging. How do you know your patient has vulvodynia?

  • The patient’s report of pain is a reliable diagnostic indicator.
  • The pain may be present all the time (spontaneous) or only with touch (provoked). Many words can be used to describe the vulvar pain from pressure to burning.
  • Q-Tip Test result is greater than 3/10. This is considered a positive Q-Tip Test and is consistent with provoked vestibulodynia. However, note that if the patient has pain that is not above a 3, it is still possible that they have vulvodynia.
  • All other conditions are ruled out or managed.

Once the diagnosis has been confirmed

the physical exam findings should be reviewed with the patient and an overview of vulvodynia provided using the following checklist:

Inform

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Educate


Sometimes vulvodynia is caused by central sensitization, a pain-sensitization condition. Pain is like an alarm system that alerts us to a potential threat. Sometimes that brain gets it wrong and sets off the alarm when there is no actual threat and the tissues are healthy, or when the threat has passed and the tissues have healed. This is what is happening in the case of vulvodynia caused by central sensitization.

Sometimes vulvodynia is caused by peripheral sensitization. After there has been injury or inflammation to an area (e.g., the vulva), there is a normal sensitization response intended to help prevent additional harm. However, sometimes these nerve fibres remain highly sensitive and send pain signals in response to innocuous touch or even no touch at all, resulting in vulvodynia.
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Prevent

📄 Vulvar Skincare Recommendations ⬇
📄 Outercourse Ideas Handout⬇
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Invite

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4. What is Vulvodynia

Have your patient watch this video to help them understand what vulvodynia is

Making the diagnosis of vulvodynia is an important step in your patient's journey.

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‍Approximately 2/3 of people seeking treatment will see three or more clinicians before receiving a diagnosis. Sadly, many will go undiagnosed. Decreasing delays in the diagnosis of vulvar pain is an important goal of this Toolkit.

★ At this point, you can refer your patient to a gynaecologist or a specialist family physician. You can also continue to the next steps of addressing psychosexual impact and implementing an individualized treatment plan.

End of Physical Exam. Proceed to the Psychosexual Impact below.

Proceed to Psychosexual Impact
1. What to Rule Out
2. Physical Exam
3. Making the Diagnosis
4. What is Vulvodynia
handouts