Provoked vestibulodynia in a 25-year-old — structured oral station (12 minutes)

Opening prompt — "How do you frame this woman's presentation?"

Model response — the definition plus the descriptor set: ^[1][2]

• "This is vulvodynia by the 2015 ISSVD consensus — vulvar pain of at least 3 months' duration without a clearly identifiable cause, with potential associated factors."
• "I have excluded infection (negative swabs), and there is no dermatosis, neoplasia or atrophy on examination. The cotton-swab test reproduces her insertional pain at the 5 and 7 o'clock positions of the vestibule."
• "On the multidimensional classification: localised (vestibulodynia), provoked (pain only with touch or intercourse), secondary / acquired, persistent."^[1]

Probe 1 — "Describe the cotton-swab test and what it tells you."

• "I apply a cotton swab gently at six sites around the vulvar vestibule (the 2, 4, 6, 8, 10 o'clock positions), asking the patient to rate the pain on a 0-10 numerical rating scale at each site. Localised allodynia reproducing her insertional pain at the 5 and 7 o'clock positions (8/10) confirms provoked vestibulodynia."^[2]
• "A normal surrounding examination is the typical finding — vulvodynia is a clinical diagnosis based on the history and localised allodynia after exclusion of identifiable causes. A normal examination does not invalidate the diagnosis."^[2]

Probe 2 — "Defend your multidisciplinary stepped-care plan."

• "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."^[2]
• "Step 2 — first-line topical and physical therapy: topical lidocaine 5% ointment before intercourse; pelvic floor physiotherapy, which the Morin 2017 systematic review supports as an effective first-line intervention for provoked vestibulodynia."^[4]
• "Step 3 — second-line psychological and oral therapy: cognitive-behavioural couple therapy — the Bergeron 2021 RCT of 108 women showed CBCT outperformed overnight lidocaine for provoked vestibulodynia; oral neuromodulators such as amitriptyline, gabapentin or pregabalin."^[3]
• "Step 4 — vestibulectomy is a last resort for refractory disease after exhaustion of medical, physical and psychological therapy; not first-line."^[2]

Probe 3 — "She is already on escalating oral morphine from a previous clinician. What do you do?"

• "Chronic opioids have no role in vulvodynia — they worsen central sensitisation and carry dependence and overdose risk. I would refer her to a pain specialist for a structured opioid deprescribing pathway and apply a multidisciplinary stepped-care plan."^[2]

Probe 4 — Communication: "How do you explain a normal examination to a woman who is in pain?"

• "I would say: 'Your pain is real. The examination shows that the surrounding skin is healthy, which is the typical finding in vulvodynia. The cotton-swab test confirmed that the pain is localised to the vestibule, and that the nerves and muscles in that area are amplifying the signal. The plan is to retrain those nerves and muscles with physiotherapy and psychological therapy, and to use a numbing ointment when you need it — without resorting to opioid painkillers, which actually make this kind of pain worse.'"^[2]