(105) Recognizing Complex Regional Pain Syndrome of the Vulvar Vestibule: Are We Missing the Mark?

Abstract Introduction Complex regional pain syndrome (CRPS) is a chronic pain condition diagnosed by the Budapest criteria (Harden et al. 2007) that has classically been described as affecting the extremities. Although it is historically described in orthopedics as occurring in the extremities, the same pathophysiology may also occur in the pelvis where the presentation may be overlooked by clinicians outside of orthopedic specialties who are unfamiliar with the pattern outlined by the Budapest criteria. Recognition of CRPS pathophysiology may be further complicated due to the affected pelvic anatomy containing mucosa and visceral tissue in addition to bone and connective tissue found in joints where it is classically described. Given its rich somatic and autonomically innervation, the vulvar vestibule may be an under-recognized locus for CRPS-type mechanisms-yet this has not previously been characterized in gynecology literature. Building on the neuroanatomical and pathophysiologic insights previously outlined in the interventional pain literature (Hunter et al. 2018), we describe CRPS localized to the vestibule to highlight its clinical presentation and implications for management in otherwise intractable pelvic pain. Objective To describe the clinical and pathophysiologic framework of CRPS of the vulvar vestibule and to call for standardized terminology that bridges gynecology, sexual medicine, pain medicine, orthopedics, neurology and neurosurgery. Recognition of CRPS pathophysiology will provide a roadmap for treatment of a subset of intractable pelvic pain. Methods We retrospectively reviewed cases from a multidisciplinary sexual medicine clinic (2021–2025). Inclusion criteria were pain confined to the vestibule and were fulfillment of Budapest diagnostic criteria for CRPS, with absence of infection, dermatosis, or other explanatory pathology, and documented sensory, sudomotor, vasomotor, and motor/trophic changes. Data collected included symptom profiles, diagnostic testing, and treatment outcomes. Results We propose that a subset of patients currently diagnosed with “refractory vestibulodynia” exhibit hallmarks of CRPS: disproportionate burning pain, dynamic allodynia, temperature or color change, and responsiveness to sympathetic nerve blocks. These features suggest an underlying process of neurogenic inflammation and maladaptive sympathetic–sensory coupling and possible central sensitization rather than a purely mucocutaneous pain disorder. Recognizing vulvar vestibular CRPS reframes these cases within an established pain taxonomy, enabling precise communication across specialties and guiding the use of targeted interventions such as sympathetic blockade, neuromodulation, and graded desensitization. Conclusions We describe the first conceptualization of vulvar vestibular CRPS-a distinct, localized expression of complex regional pain syndrome within the female genital tract. Awareness of vestibular CRPS allows for appropriate targeted therapy-including multimodal and interventional pain management. Adoption of this terminology across gynecology, sexual medicine, and interventional pain disciplines will provide a unifying diagnosis for what are can be seen as co-existing but discrete diagnoses in gynecology (high pelvic floor tone disorder, vulvodynia/vestibulodynia, pelvic congestion), facilitate collaborative research, and potentially increase access to care through insurance coverage to improve therapeutic outcomes for women with this disabling but underrecognized condition. Disclosure No.