Types
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.
Causes
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.
Clinical presentation
Diagnosis
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 from 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.
Management
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.
| Recommended | Comments |
|---|---|
| Dermatitis treatment if needed | MSHC fact sheet on genital skin care provides useful information |
| Candida treatment | 6-8 weeks of suppressive fluconazole if uncertain whether recurrent/chronic candida is a trigger |
| Herpes Simplex Virus suppression | If history is suggestive of HSV |
| Local anaesthetic gel | If the woman can touch her vulva: 2% xylocaine gel 2-3 times a day to the introital area (to aid desensitisation), up to 3 months, and massage the vestibule/PFMs at same time with her fingertip. Xylocaine commonly has an initial burn that settles quickly |
| Referral to pelvic floor physiotherapist | Continence Foundation of Australia for Women’s Health Physiotherapists |
| Pelvic floor muscle re-training |
Pelvic floor muscle re-training 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. |
| Change in 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. If comfortable, patient and partner can negotiate limits around the amount of time that vulval and vaginal touch lasts and whether sexual penetration will occur and when to stop. |
| Cortisone ointment | If there is an associated dermatitis a mild cortisone ointment may help |
| Candida treatment | If chronic thrush is suspected a trial of candida treatment for at least 2 months may help . Sometimes the diagnosis of subtle chronic candida is difficult and tests can be negative. |
| 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. |
| 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. |
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.
References
It is important for patients and partners to have a good understanding of the drivers of pain and chronic pain theory.
- www.vulvovaginaldisorders.org An algorithm for basic adult diagnosis and treatment
- www.noigroup.com is the best chronic pain website for patients and practitioners.
- Henzell H, Berzins K, Langford J. Provoked vestibulodynia: current perspectives. International Journal of Women's Health. 2017; 9: 631–642.
- Henzell H, Berzins K. Localised provoked vestibulodynia (vulvodynia): assessment and management. Australian Family Physician, Volume 44, No.7, 2015 Pages 460-466
- 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
Disclaimer
We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines.
The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.