Vulvodynia treatment guidelines

What is Vulvodynia:

Vulvodynia is a common chronic pain condition, estimated to affect between 8-10% of women of all ages, and defined as being of at least 3 months duration with no identifiable infectious, neoplastic or neurological cause sufficient to explain the pain.

Women may not describe their discomfort as pain, but as burning or rawness, or a sharp, stabbing or tearing sensation, or an unpleasant itch.

Pain can be localised to the vaginal entrance (vestibulodynia) or clitoris (clitorodynia), or generalised (affecting other parts of the vulva, often the whole vulva), or mixed.

Pain can be provoked by touch, pressure or vaginal penetration, or spontaneous, occurring in the absence of touch. Pain can be mixed.

Provoked pain occurring in the vestibule with touch or sexual activity is the more common presentation, often referred to as provoked vestibulodynia (PVD) or localised provoked vulvodynia (LPV), formerly vulvar vestibulitis.

Onset may occur with first sexual activity (primary) or occur after a period of pain free sexual activity (secondary).

Pain maybe constant or fluctuate, can remit spontaneously, and can recur.

Vulvodynia is now regarded as a chronic pain disorder involving altered neural processing in the peripheral and central nervous system (sensitisation). The peripheral and central nervous system become sensitised resulting in non-painful stimuli being felt as pain (allodynia) and mildly painful stimuli causes more pain (hyperalgesia).

Peripheral sensitisation can be driven by persistent skin inflammation, such as with recurrent vulvovaginal candidiasis (RVVC) or chronic contact dermatitis.

There is often associated pelvic floor dysfunction, resulting in overactive, tense and tender 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. Genetic variations, hormonal factors, 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) are implicated in pain sensitisation.

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.

If consenting, carefully examine the vulva to check for skin lesions, dermatitis or fissures that can be a source of pain. Gentle cotton tip testing to map vulval pain and vaginal swabs for microscopy and culture, particularly for yeasts, are helpful if tolerated. Avoid repeated examinations as this can wind up pain (hyperpathia). Gentle single digit palpation of the pelvic floor to check for increased resting tone and muscle tenderness is helpful if tolerated.

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.  Pelvic floor muscles are often tense and tender with gentle palpation of the lower vagina, 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. Likewise, chronic dermatitis/dermatosis need to be managed before a diagnosis of chronic pain can be made.

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 to vulval touch. Do warn the woman that xylocaine can sting transiently after application.

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.

Sexual function. Painful intercourse often results in fear, avoidance and loss of intimacy. 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. 

Referral to pelvic floor physiotherapist    Continence Foundation of Australia for Women’s Health Physiotherapists

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 reflex pelvic floor contraction. There is good evidence of benefit with reduced pain and improved sexual function. The physiotherapist may recommend vaginal dilators when appropriate.

Psychological support. Vulvodynia can have a profound negative effect on intimacy, relationships, self-image and mood. Anxiety and fear increase pain. Fear of pain leads to avoidance and loss of intimacy. Psychological therapies, both cognitive-behavioural and supportive therapies, have shown evidence of benefit.

Touch therapy. 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.

Neuromodulating medication can be compounded and applied topically. Amitriptyline, gabapentin, baclofen, ketamine or PEA (palmitoylethanolamide) can be compounded in a cream or ointment base (such as Lipoderm) and 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. 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) are 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.

Botulinum toxin injections into the pelvic floor muscles may be considered in selected women with refractory pelvic floor hypertonicity. This is not first line therapy and usually restricted to women managed in specialist centres. Evidence remains limited.

Outcome:

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

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

Reassure women that vulvodynia does not affect fertility. Explain that pain can change during pregnancy (it can improve, stay the same or deteriorate) but can be managed.

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 early referral to a tertiary centre where they can access multidisciplinary care.

It is important for patients and partners to have a good understanding of the drivers of pain and chronic pain theory.

1. www.vulvovaginaldisorders.org An algorithm for basic adult diagnosis and treatment
2. www.noigroup.com is the best chronic pain website for patients and practitioners.
3. Henzell H, Berzins K, Langford J. Provoked vestibulodynia: current perspectives. International Journal of Women's Health. 2017; 9: 631–642. 
4. Henzell H, Berzins K. Localised provoked vestibulodynia (vulvodynia): assessment and management. Australian Family Physician, Volume 44, No.7, 2015 Pages 460-466
5. Alicia M Thornton and Catherine Drummond. Current concepts in vulvodynia with a focus on pathogenesis and pain mechanisms. Australasian Journal of Dermatology (2016) 57, 253–263
6. National Vulvodynia Association (US site). Available at: https://nva.org
7. DermNet NZ. Vulvodynia. 
8. DermNet NZ. Vestibulodynia.
9. British Association of Dermatologists. Vulvodynia and vestibulodynia patient information leaflet. 
10. International Society for the Study of Vulvovaginal Disease (search for vulvodynia).
11. International Association for the Study of Pain. IASP terminology: chronic primary pain. Washington (DC): IASP; 2021
12. 2015 Consensus Terminology and Classification of Persistent Vulvar Pain. Low Genit Tract Dis. 2016; 20:26-30
13. Pukall CF, Goldstein AT, Bergeron S, et al. Vulvodynia: definition, prevalence, impact and pathophysiological factors. J Sex Med. 2016; 13(3):291-304