Penodynia and vulvodynia are nociplastic pain conditions frequently associated with specific psychological profiles. In both conditions, management should be multimodal, combining psychological and body-based interventions, education, and topical treatment as first-line therapy, with systemic options used cautiously when initial measures fail. The disease course is often prolonged and requires sustained clinical support.

Jean Noël Dauendorffer, MD, dermatologist-venereologist and attending physician in the Dermatology Department at Hôpital Saint-Louis, Paris, France, and Gaëlle Quéreux, MD, PhD, dermatologist at Centre Hospitalier Universitaire de Nantes, Nantes, France, outlined key principles of care during the Dermatology Days of Paris conference, held from December 2 to 6, 2025, in Paris.

Penodynia Management

Penodynia refers to neuropathic pain that should be suspected, particularly in the presence of paresthesias, often unilateral, when genital skin and neurologic examination findings are normal. This remains a diagnosis of exclusion.

“Men who consult us for genital skin pain or burning sensations are often anxious because of fear of a sexually transmitted infection,” Dauendorffer said. “We therefore need to rule out this differential diagnosis, particularly urethral involvement with pain radiating to the glans.”

Diagnostic evaluation includes first- and second-void urine cultures and testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium. Assessment should also exclude urologic or urethral causes through vesicoprostatic, scrotal, and penile ultrasonography, urologic evaluation, and, in selected cases, pelvic MRI or neuro-urologic investigations.

“The clinical and paraclinical workup should not be conducted all at once but rather progressively, depending on response to initial management,” Dauendorffer said.

Among the common differential diagnoses, including Peyronie disease, posttraumatic pain, and referred pain, Dauendorffer emphasized two entities:

• Pudendal neuralgia results from the compression of one or both pudendal nerves and is characterized by pain in the anatomic territory extending from the anus to the penis. Pain predominates in the sitting position and is relieved when sitting on a toilet seat. It does not wake patients at night and is not associated with superficial perineal sensory deficits, suggesting sacral root or plexus involvement.
• Dorsal penile nerve compression syndrome occurs more frequently in the presence of predisposing factors such as diabetes or intensive cycling. It is characterized by penile pain, reduced sensitivity of the glans or shaft, genital paresthesia, and, sometimes, erectile dysfunction. There is no associated scrotal or anorectal pain, urinary symptoms, or constipation. Pain resolution following anesthetic block of the dorsal nerve in the pubic region supports the diagnosis.

Initial treatment relies on topical therapies such as lidocaine-prilocaine cream and lidocaine. When these are ineffective, neuropathic analgesics, including tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, gabapentin, and pregabalin, may be considered.

Multidisciplinary care may also include perineal physiotherapy, osteopathy, cognitive-behavioral therapy, medical hypnosis, and sophrology. Transcutaneous neurostimulation should be considered in selected cases.

“It is essential to reassure the patient in the absence of sexually transmitted infection or cancer,” said Dauendorffer. “These chronic pain conditions are often discouraging after prolonged medical wandering. The first step is to validate the complaint even without an obvious cause in order to establish a strong therapeutic alliance.”

The diagnostic workup should remain rational and gradual in approach. Patients should understand that no single treatment is consistently effective and that therapeutic goals focus on progressive improvement rather than on immediate resolution.

Vulvodynia Profile

Vulvodynia is common, affecting 1 in 6 women during their lifetime. However, only approximately 60% of patients seek medical care, often after several years of symptoms. The impact on the daily quality of life is frequently substantial.

“Vulvodynia is not limited to simple vulvar pain,” Quéreux said. Pain persisting for more than 3 months without an identifiable cause, localized most commonly as vestibulodynia, spontaneous or provoked, primary or secondary, and continuous or intermittent, occurs within a broader constellation of complaints.

Affected women more frequently report urinary tract infections, fungal infections, depression, chronic fatigue syndrome, and other chronic pain syndromes such as migraine or fibromyalgia.

Pathophysiology is complex and multifactorial:

• Physical contributors include chronic inflammation, recurrent infections, hormonal factors, pelvic floor dysfunction, and peripheral hyperalgesia, which are often associated with a family history of vulvodynia.
• Psychological factors also play important roles. “These women more often present with insecurity, pessimism, vulnerability in intimate relationships, greater catastrophizing in response to pain, kinesiophobia, anxiety, and depression,” Quéreux said.

However, it remains unclear whether chronic pain causes these features or vice versa. Higher rates of childhood sexual violence have also been reported.

Symptoms typically include burning sensations, tingling, discomfort, and dyspareunia, with no visible vulvovaginal abnormalities on examination. Light touch of the vestibule with a cotton swab usually reproduces the characteristic pain.

The approach is based on several key areas:

• Topical treatments include local anesthetics such as lidocaine, vulvovaginal estrogen therapy when not contraindicated in peri- and postmenopausal women, and moisturizers and lubricants, with medical prescriptions to encourage adherence.
• Psychological support may involve eye movement desensitization and reprocessing, medical hypnosis, or supportive cognitive therapies, with the aim of reducing the dominance of pain in daily life.
• Perineal rehabilitation with biofeedback should be conducted by a physiotherapist or midwife trained in the management of vulvodynia.
• Systemic therapies, when needed, include low-dose amitriptyline and gabapentin.

Here again, a personalized, progressive, and multidisciplinary approach is essential to maintain a therapeutic relationship throughout the care pathway, which may be prolonged and initially unsatisfactory.

This story was translated from Univadis France, part of the Medscape Professional Network.