Vulval pain

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WHAT IS IT?

“Vulvodynia” means “vulval pain”. There are 2 types which can overlap.
Localized provoked vestibulodynia (vulvodynia) is discomfort when the vaginal opening (the “vestibule”) is touched or anything is put into the vagina, including a tampon. It occurs in the absence of an obvious ongoing cause and the skin looks normal. Pressure is felt as pain, and touching with a cotton bud may produce a ‘cut glass’, burning or tearing feeling. Sometimes the clitoral area is involved as well. Uncommonly, vestibular pain may be felt during arousal before any direct touching happens. Urinary burning and frequency can accompany vulval discomfort or occur alone with the same triggers. Discomfort tends to persist minutes – days afterwards. It may occur with the first ever vaginal touch or penetration, or after years of comfortable touch and intercourse.

Spontaneous generalized vulvodynia . This pattern of discomfort affects the whole vulva, or changing areas of it, without any direct pressure or anything being in the vagina. This is pain that is usually felt as a burning sensation, but can also be a sensation of prickling, dryness or mild itch. In this case, when something is put in the vagina it is usually painfree, or if there is burning nearby then it is not aggravated by penetration. Again the skin looks healthy,

Both patterns of symptoms are treated as “chronic pain”, and may be associated with pain conditions affecting other parts of the body, eg. Irritable bowel, irritable bladder, migraine, fibromyalgia, back and jaw pain and chronic fatigue syndrome.

Importantly, chronic vulval pain does not usually interfere with pregnancy or the method of childbirth.

WHAT CAUSES IT?

The exact cause of vulvodynia and other chronic pain is not known. However there is no single cause.

Persistent triggers causing inflammation, other painful conditions of the pelvis or hip and back, genetic predisposition to pain, mood problems, poor sleep and chronic stress contribute to chronic pain.
There is altered sensitivity of nerve endings and associated pelvic “floor” muscle overactivity. Recent research using brain scans shows that there are also changes in brain function associated with chronic pain and so the sensations of pain continue despite the absence of an obvious cause. The nerves in the area that is painful can also produce their own pain impulses, so pain increases. Treatment aims to reverse these changes. It is important to remember that the vulva and vagina are healthy, but that the sensations are altered. Mostly these improve with treatment and time.

Common triggers are frequent skin inflammation, most often candida (thrush), urinary infections or a difficult to control dermatitis. Thrush needs to be considered, especially if there is a worsening of symptoms near the period, even if itch and discharge are subtle. Very occasionally genital herpes may be involved. All infections need prompt and accurate treatment. Wart virus (HPV) doesn’t cause vulvodynia, although its treatments often irritate, and the skin nearby is often dry.

SYMPTOMS
  1. Discomfort may range from none unless the area is touched, to frequent vulval awareness whilst sitting, walking or especially bicycling and horseriding. Tight clothing may aggravate it too. There may be times of improvement and worsening. Intercourse may be possible, with discomfort only at the very initial stage, or may be too uncomfortable to attempt at all. Often the pelvic floor muscles will learn to tense as a protective behaviour, and this will worsen the pain.
  2. “Afterburn” may occur after intercourse, lasting minutes - hours - days. This type of burning or tenderness that persists after sex is typical of chronic pain when there are no irritants or infections present. Burning or discomfort will similarly happen after medical examination with a cotton tip or internal exam. Relief is often gained by a cool compress or saltwater soak. You can then apply a bland moisturiser (dermeze). Urinary symptoms often occur in vulval pain conditions, even without true bladder infection. This is because the bladder and urethra and vulva develop from the same type of tissue and share their nerve supplies. There is also “cross talk” between the pelvic organs and muscles, so pain in one can cause symptoms in the other.
  3. Anxiety and Depression are common consequences of any chronic painful condition. Pre-existing stressors, fear of the anticipated pain, consequent poor arousal and poor lubrication, may worsen the experience of pain. Sexual relationships invariably suffer even when both partners have a good understanding of the condition and are mutually supportive. Professional counselling is often very helpful in sorting through these natural reactions, and they help to find an effective way of expressing some of the inevitable frustrations most partners feel.
HOW IS IT DIAGNOSED?

Diagnosis is made by carefully detailing your symptoms and an examination. Skin disease and infection are excluded. A swab may be taken particularly to exclude thrush. A cotton wool bud is used to map out the area of discomfort. Pelvic floor muscle function and tenderness will be assessed during a gentle examination. In almost all cases the skin and vulva look normal but sometimes there can be a degree of redness that is not an infection or skin problem.

BIOPSY

Biopsy is not recommended routinely, even when the area looks red. Biopsy findings in women with symptoms have often been similar to women without symptoms.

TREATMENT

Most cases will eventually resolve spontaneously, though this can take months or years. Treatments include:

  • Local anaesthetic gel - in very mild cases this may be sufficient. Unless there is irritation, the usual prescription is 2% lignocaine gel 3-5 times daily at the vaginal opening only, for up to 3 months. If tolerated, a 5% ointment can be used for the 2nd and 3rd months.
  • Sexual Practices. We often suggest no intercourse until both partners have an understanding of vulvodynia and improvements begin. Otherwise there is a risk of prolonging the symptoms from repeated anticipation and experience of pain. However if comfortable, agree to limit the amount of time that vulval and vaginal touch lasts. There needs to be enough sensual touch to feel aroused and you should feel able and confident to give a clear indication on whether to proceed or stop. Talk about this with your partner and agree beforehand whether sexual penetration will occur and when to stop. 
  • Cortisone ointment: a mild cortisone ointment may help if there is an associated dermatitis.
  • Diets: there is no strong evidence to support the role of particular diets.
  • Candida treatment: a trial of candida treatment for at least 2 months may help if chronic thrush is suspected. Sometimes the diagnosis of subtle chronic candida is difficult and tests can be negative.
  • Pelvic floor muscle retraining: with biofeedback techniques is the single most helpful treatment. A referral to a specialist women’s health physiotherapist should be made. Women are usually unaware of chronic tension in their pelvic floor, as well as in their abdomen and upper legs. Physiotherapy will help to “downtrain” these muscles. Later, vaginal “downtrainers” of graduated sizes are used under the guidance of the physiotherapist, to release the tone and action of the muscles. They are not used to stretch the vagina, as the elasticity of the tissues will be normal.
  • Neuromodulating medications. Low dose tricyclic antidepressants and the anticonvulsants pregabalin and gabapentin can be very effective, combined with physiotherapy and counselling. These medications adjust pain perception, rather than treat depression. The dose used is NOT an effective antidepressant. If significant depression is present, this should be treated on its merits. However sleep and anxiety may be improved with the low dose and this itself will help pain. See the Genital Pain Medication factsheet.
  • Counselling for the impact of pain: a woman’s and her partner’s responses to her pain is very important to assess. It is natural and common to be significantly affected by the symptoms. Partners often have different knowledge and fears about the implications of longstanding symptoms. Counselling both alone and together can be very helpful.
  • The role of surgery: very occasionally surgical removal of an isolated tender area can be very successful. Widespread areas of pain are not suitable for surgery. Referrals are made to highly skilled gynaecologists, and a very thin portion of the tender area is removed and covered over with a small section of the back vaginal wall. It is often difficult to visually detect the surgery after healing. 

General Advice.

  • Genital Skin care – see the Genital Skin Care fact sheet. Lifestyle and pain: see www.paintoolkit.org

Specific resources for vulvodynia

Strategies for anxiety management
Consider online resources such as:

Books
Good Loving, Great Sex (by Dr. Rosie King) is an excellent resource for desire discrepancy in relationships, whatever the cause of the discrepancy.

Disclaimer:
This fact sheet is designed to provide you with information on Vulval pain. It is not intended to replace the need for a consultation with your doctor. All clients are strongly advised to check with their doctor about any specific questions or concerns they may have. Every effort has been taken to ensure that the information in this pamphlet is correct at the time of printing.

Last Updated November 2017