You seem to have generalized vulvodynia which is a type of vulvar pain syndrome usually characterized by unprovoked, constant, burning pain involving most of the vulva (labia majora, labia minora, clitoris, and often the vestibule). It occurs in the absence of relevant visible infectious, inflammatory, or neoplastic findings and in the absence of a specific clinically identifiable, neurologic disorder. Patients frequently experience great difficulty describing and localizing their pain and often believe they have a constant yeast infection. Other symptoms include constant irritation, a raw sensation, the feeling of grating or sandpaper, the sensation of continual swelling, or feeling as if they are sitting on a hard ball or knot.
For women with provoked localized vulvar pain, with or without pelvic floor hypertonicity, we suggest pelvic floor muscle rehabilitation and topical lidocaine ointment as first-line therapy.
For women with unprovoked vulvar pain, we suggest tricyclic antidepressants as first line pharmacologic therapy. We start at 10 mg once a day at bedtime and increase the dose by 10 mg every five days to 100 to 150 mg at bedtime. A dose of nortriptyline 100 to 150 mg for three months without improvement would prompt us to taper and then discontinue the drug, and switch to another agent.
Our second-line choice is gabapentin. Using combinations of drugs may be effective when single-agent therapy fails, but must be done cautiously, given the significant side effects of these drugs. Our preference is to start with topical lidocaine and gabapentin.
Local nerve block may be effective for women who have not achieved adequate pain relief from pharmacologic therapy.