Vulvodynia treatment guidelines

Vulvodynia, like other chronic pain conditions, is thought to be due to neuroinflammatory changes with peripheral and central sensitisation resulting in pain in the absence of painful stimuli. 

There are associated factors implicated in pain sensitisation, such as skin persistent inflammation with recurrent vulvovaginal candidiasis (RVVC), or inflammatory dermatoses.

There is often associated pelvic floor dysfunction that results in overactive and tense pelvic floor muscles, and pain with vaginal penetration.  Pelvic floor dysfunction can cause muscle spasm, or vaginismus, with attempted vaginal penetration, often reported as a feeling of the vagina being blocked.

There are other associated factors that appear to increase a person’s vulnerability to developing chronic pain, that include genetic, hormonal or psychosocial factors (in particular, anxiety, distress and childhood trauma) and co-existent chronic pain conditions (in particular, chronic pelvic pain/endometriosis, chronic bladder pain, irritable bowel disorder).
Of note: human papilloma virus (HPV) does not cause vulvodynia.

Diagnosis is based on a history. Typically, the vulva looks normal. There are no specific tests to diagnose vulvodynia, but tests to exclude vulval or vaginal inflammatory conditions (predominantly candidiasis) are important. Biopsy is only indicated if there are visible skin abnormalities or lesions.

In provoked vestibulodynia, there is increased sensitivity to gentle cotton tip touch over the inner vestibule adjacent to the hymenal rim, often maximal from 5 to 7 o’clock. There can be non-specific erythema of the mucosa at sites of tenderness. Speculum examination should be avoided if possible as it can cause significant pain.  Vaginal swabs can also cause pain but, if tolerated, are helpful to collect samples for microscopy and culture, particularly for yeasts. Pelvic floor muscles are often tense and tender with gentle palpation of the lower vaginal, but PV exam should be avoided if there is tense spasm and pain.  

Generalised vulvodynia is less common, often sexual activity is pain free. There is variable discomfort with gentle cotton tip touch affecting part or all of the vulva, and usually no pelvic floor overactivity.

Inflammatory skin conditions can co-exist with vulvodynia and need to be identified and managed before a diagnosis of pain can be made, in particular RVVC. Candida, particularly C. albicans, is highly inflammatory and frequently implicated in the onset of vulvodynia. Vulvodynia becomes apparent when thrush is suppressed, evidenced by repeated negative cultures, and pain continues.

It is helpful to use a mirror with the examination to show where the pain is (vulvodynia can be hard to localise), to show that the painful skin looks normal, to demonstrate that gentle touch is enough to elicit pain, and to show that pain does not mean damage. It can also be helpful to apply topical local anaesthetic (2% lignocaine or similar) to the inner vestibule during this examination to demonstrate the numbing effect and help reduce reflex involuntary pelvic floor contraction with vulval touch. Do warn the woman that xylocaine can sting transiently after application.

A diagnosis of vulvodynia is largely based on history.

Examination and investigations are necessary to exclude other conditions and treat associated conditions.

Uncomplicated provoked vulvodynia

• Skin and anatomy look normal
• No history or investigations to suggest candida or HSV
• Typical history – mild-moderate pain provoked by any penetration or pressure rom items such as tampon, fingers, intercourse or tight clothing
• No symptoms if not touched
• Patient may describe a feeling of “afterburn” following touch, pressure, penetration or examination
• Typical cotton tip discomfort: Provoked - maximal at 5 and 7 o’clock in vestibule, and usually PV cotton tip discomfort (without speculum)
• Introitus looks tight or 'sucked' in can be indication of pelvic floor muscle overactivity, and tenderness with fingertip palpation laterally mid to low vagina

Complicated provoked vulvodynia

• Severe and long duration of pain
• Associated chronic dermatitis, lesions, candida or lichen planus
• Other associated chronic pain conditions such as chronic bladder pain, irritable bowel syndrome, migraine, TMJ pain, fibromyalgia, back pain
• Associated PTSD, especially childhood and sexual abuse and fear of pain
• Anxiety and depression

Spontaneous generalised vulvodynia

• Skin and anatomy look normal
• Less common than provoked vulvodynia
• Tends to occur in older women
• Discomfort in the absence of touch or pressure
• Variable discomfort with gentle touch, affecting part or all of the vulva
• Can complicate provoked vulvodynia (mixed pattern)

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.

Provide patient with Melbourne Sexual Health Centre fact sheet on vulvodynia.

Suggest patient:

• discusses pain with her partner
• shares educational material
• avoids any sexual practice that triggers pain until a strategy is decided on. Otherwise the cycle of fear and more pelvic floor muscle overactivity reinforces the pain.

Refer patient to counselling service regarding the impact of pain. Normalise that there will be an impact on both partners.

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There are no standardised treatment guidelines for vulvodynia. The aim is to reduce pain, improve sexual function and quality of life. Treatment is multidisciplinary.  No one treatment works for all women, and treatment needs to be individualised. 

Patient-clinician relationship is an important aspect of care. Being heard, understood and validated is beneficial.

Education is therapeutic. There is evidence that neuroscience education does help reduce pain related anxiety and improve self-efficacy. To have a name for the pain, to know that it is common, and to know that most women with treatment do see significant improvement, is positive. To understand that pain can occur in the absence of damage, such as cancer or trauma or infection, can reduce fear. To understand that anxiety and distress wind pain up, and that reducing anxiety and distress can wind pain down. To understand why certain treatments help, improves therapeutic response.

Basic genital skin care should be encouraged for all – in essence, avoid potential irritants and increase moisture (link to genital skin care fact sheet).

Address background or persistent skin inflammation such as dermatitis or candidiasis. If RVVC is likely, suggest suppressive antifungal therapy (see candida treatment guidelines) as pain will not improve if there is persisting inflammation. 

There is good evidence that physiotherapy helps reduce pain. Pelvic floor physiotherapy helps down-train the pelvic floor and improve sexual related pain. It can help reset the pelvic floor resting tone and reduce reflexive pelvic floor contraction. 

Vulvodynia can have a profound negative effect on intimacy, relationships, self-image and mood. Psychological therapies, both cognitive-behavioural and supportive therapies, have shown evidence of benefit. 

Avoidance of sexual practices that cause pain is advisable and, if possible, engage in intimacy that does not trigger pain. Make sure there is good lubrication with any penetration. Partners can benefit from being able to access educational material to help them understand vulvodynia.  

If the woman catch touch her vulva, the simplest medical intervention is application of topical lignocaine (2 – 5%) to the vestibule that can be used daily or on an as needs basis (such as before sex or physiotherapy) to reduce vestibular pain and aid desensitisation. Do advise that lignocaine can sting transiently and to wipe it off before sexual contact. 

Other neuromodulating medications, such as amitriptyline, gabapentin or baclofen, can be applied topically once or twice daily to the vestibule (or whole vulva if there is generalised pain). The advantage is that regular application promotes repeated self-touch and if massaged with application, can help desensitise the vulva. Medications can be compounded individually or in combination, usually 2-5% strength, in a simple non-irritating base. Evidence for use is poor, but some women do have a good response.

Oral pain modifying medications, often used for chronic pain, have less evidence of benefit in vulvodynia. Anticonvulsants (including gabapentinoids) and antidepressants (tricyclics and SNRIs) usually prescribed in low dose. They are not recommended first line treatments and side effects can be troublesome.

Surgery is rarely indicated and reserved for women where other treatments have failed and pain is localised to the vaginal entrance and significantly interferes with quality of life.

Most women with mild to moderate provoked vestibular pain, respond well to basic interventions and can be managed in the community. 

Vulvodynia that is of longer duration, more severe (often preventing any genital touch), associated with other chronic pain conditions and significant psychological distress (including childhood trauma), will benefit from referral to a tertiary centre where they can access multidisciplinary care.

It is important to reassure women that the outlook is generally positive and she can expect improvement with reduction in pain. Advise women that pain can wax and wane, pain can resolve spontaneously, and can recur given the right triggers.

1. National Vulvodynia Association (www.nva.org )– USA site
2. www.dermnetnz.org/topics/vestibulodynia
3. www.dermnetnz.org/topics/vulvodynia 
4. ISSVD search vulvodynia – www.issvd.org 
5. Explain pain – D Butler and L Moseley 2n ed. 2013
6. Henzell H, Berzins K, Langford J. Provoked vestibulodynia: current perspectives. International Journal of Women
7. The Vulvodynia Guideline. Haefner