Provoked vestibulodynia — structured SAQ (15 marks)

(a) Diagnosis and definition (3 marks)

1 mark for the diagnosis, 2 marks for the verbatim definition. ^[1]

• Diagnosis: provoked vestibulodynia (localised provoked vulvodynia).
• Definition (verbatim): vulvodynia is vulvar pain of at least 3 months' duration, without a clearly identifiable cause, which may have potential associated factors (the 2015 ISSVD / ISSWSH / IPPS consensus).^[1][2]

(b) Multidimensional classification (3 marks)

1 mark for each correct axis pair, up to 3. ^[1]

• Location: localised — to the vestibule (vestibulodynia).^[1]
• Provocation: provoked — pain on touch or attempted intercourse; no spontaneous pain.^[1]
• Onset: secondary / acquired (no information given on lifelong pattern).^[1]
• Temporal pattern: persistent, with episodic flares provoked by intercourse or tampon use.^[1]

(c) Bedside manoeuvre and meaning of a normal examination (3 marks)

• Manoeuvre: the cotton-swab (Q-tip) test — gentle application of a cotton swab at six sites around the vulvar vestibule (typically the 2, 4, 6, 8, 10 o'clock positions) with the patient rating pain on a 0-10 numerical rating scale. Localised allodynia reproducing her insertional pain at the 5 and 7 o'clock positions (8/10) confirms provoked vestibulodynia.^[2]
• Meaning of a normal examination: a normal examination does NOT invalidate the diagnosis. Vulvodynia is a clinical diagnosis based on the history with localised allodynia on cotton-swab testing after exclusion of identifiable causes; the surrounding skin is typically normal.^[2]

(d) Four-step multidisciplinary stepped-care plan (4 marks)

1 mark per step with correct evidence. ^[1][2]

• Step 1 — General care measures and education: validate the pain; gentle cleansing, soap substitute, emollient, cotton underwear, lubricants; education about the chronic neuropathic / nociplastic pain framework.
• Step 2 — First-line topical and physical therapy: topical lidocaine 5% ointment applied to the vestibule before intercourse; pelvic floor physiotherapy (the Morin 2017 systematic review supports this as an effective first-line intervention); topical oestrogen in postmenopausal women.^[4]
• Step 3 — Second-line psychological and oral therapy: cognitive-behavioural therapy — ideally couple therapy (the Bergeron 2021 RCT showed cognitive-behavioural couple therapy outperformed overnight lidocaine for provoked vestibulodynia); oral neuromodulators (amitriptyline starting 10 mg nightly titrated to 50-75 mg, gabapentin, pregabalin).^[3]
• Step 4 — Specialist intervention: vestibulectomy as a last-resort surgical option for refractory disease, after exhaustion of medical, physical and psychological therapy; pudendal nerve block where pudendal neuralgia coexists.^[2]

(e) Two treatments that have no role (2 marks)

1 mark each, up to two. ^[2]

• Chronic opioid therapy — has no role in vulvodynia; worsens central sensitisation, carries dependence and overdose risk.
• Topical corticosteroids in the absence of a steroid-responsive dermatosis — steroids do not treat vulvodynia and may cause atrophy.
• Repeated courses of clotrimazole without positive swabs — antifungals treat candidiasis, not vulvodynia.
• Prophylactic or first-line vestibulectomy — surgery is a last resort, not a first-line therapy.

Common errors that lose marks

• Calling the pain "vulvar vestibulitis" — the -itis suffix was retired because inflammation is not present histologically.
• Failing to exclude infection, dermatosis, neoplasia and atrophy before labelling the pain as vulvodynia.
• Recommending chronic opioids — they have no role.
• Recommending first-line vestibulectomy — surgery is a last resort.
• Saying the diagnosis requires an abnormal examination — a normal examination is the typical finding.
• Missing the multidimensional classification (location, provocation, onset, temporal pattern).^[1][2]

Examiner notes

A high-scoring candidate defends the 3-month definition, the multidimensional classification, the cotton-swab test with the meaning of a normal examination, and the multidisciplinary stepped-care plan with the Bergeron 2021 RCT and Morin 2017 systematic review as evidence. The candidate must state explicitly that chronic opioids have no role and that vestibulectomy is a last resort.^[1][2][3]