What Is Vulvodynia

Overview

Vulvodynia is characterised as a persistent and unexplained pain in the vulva lasting at least three months. The vulva is all the external structures of female genitalia. Vulvodynia is the most common cause of pain during sexual intercourse for premenopausal women.¹² Treatment for vulvodynia often follows a multidisciplinary approach using medications alongside physiotherapy, therapy, and counselling. It is important to see a doctor if you experience consistent vulval pain.

Types of vulvodynia

Vulvodynia can be classified in various ways:

• Localised (pain at one vulvar site)
• Generalised (pain in multiple vulvar sites and can extend to the perineum and inner thighs)
• Provoked (pain is provoked e.g. vaginal contact)
• Spontaneous (pain is spontaneous)
• Primary onset (pain occurs at time of trigger)
• Secondary onset (pain occurs some time after the trigger)
• Constant (frequency)
• Transient (frequency)
• Rhythmic (frequency)

It is possible that a patient may show mixed types e.g. have both localised and generalised pain or have both provoked and spontaneous pain.³

The most common vulvodynia experienced by women is localised and among these women, provoked vestibulodynia (where the pain is in the tissues surrounding the vulva) is most common.⁴

Causes of vulvodynia

Like many chronic pain conditions, it remains unclear the exact cause of vulvodynia and, for some patients, the cause will never be found. However, researchers have put forward several theories that may cause or contribute to vulvodynia.⁵

• Problems with nerves that transmit pain information from the vulva (could be caused by surgery, childbirth, trapped nerves, severe history of vaginal thrush)⁶
• Genetic susceptibility
• Abnormal hormonal response in vulvar tissue
• Abnormal levels of inflammatory substances in vulvar tissue
• Hypersensitivity to vulvovaginal organisms
• Weakness in the pelvic floor muscles

It is important to note that not all pain in the vulva is vulvodynia. A doctor may want to rule out some of these conditions before diagnosing and progressing onto vulvodynia treatments:⁷

• Sensitivity to cosmetic products
• Persistent vaginal infections
• Abnormal hormonal levels 
• Skin conditions
• Behçet’s disease (rare)
• Sjögren’s syndrome (rare)

It is possible to have a combination of vulvodynia alongside another health problem.

Symptoms of vulvodynia

The vulva usually looks normal in vulvodynia. The main symptom is pain in the vulva which can be described as an itching, burning, or stabbing pain. Commonly, the pain is in combination with dyspareunia (genital pain before/after/during sexual intercourse).⁹

Vulvodynia may cause a low mood. Women often find vulvodynia embarrassing to talk about and it may also affect sexual relationships, reduce sex drive, and cause depression.¹⁰

Management and treatment for vulvodynia

Because the underlying cause of vulvodynia tends to be unknown, it makes the treatment of this condition more difficult. A combination of treatments for vulvodynia tends to be most effective at relieving symptoms and improving quality of life. A biopsychosocial framework has been established for treating women with vulvodynia, which focuses on treating the vulvar pain, improving the pelvic floor muscles, and improving the education surrounding the condition for both oneself and for those sexually involved with the patient.¹¹. Keeping a pain diary is useful to monitor treatment progress for the patient and doctor when beginning a new treatment. 

Is is also common for patients to experience ‘pain flare’ which is a sudden increase in their pain symptoms. It is possible that doctors may prescribe patients a different treatment to use during these times.¹²

Topical vulval treatments

Topical anesthetics (lidocaine) can be applied up to 20 minutes before sex or throughout the day. 5% lidocaine cream can be purchased from a pharmacy but it is advised to speak to a doctor before using it. Note that latex condoms are damaged by lidocaine.¹³ A study found that nightly use of lidocaine resulted in sustained pain relief.¹⁴

Vaginal lubricants and creams can be purchased from a pharmacy and can soothe and moisturize the vulva. 

Topical hormonal creams can improve vulva health, particularly for thin and dry tissue.¹⁵

Prescription medicine

You will need to see a doctor to get these medications prescribed. Often the doses will be increased with time until the pain subsides. However, these medications often have to be taken for an extended period of multiple months.¹⁶

Oral pain-blocking medications:

• Antidepressants (e.g. TCAs, SNRIs) 
• Anti-epilepsy medications
• Opioids

It is possible that these typically oral medications may be available as a cream.¹⁷

For localized vulvodynia, injections into certain nerves can provide a temporary solution:¹⁸

• Local anesthetic
• Steroids

Physiotherapy

Various forms of physiotherapy can be used: 

• Pelvic floor exercises
• Vaginal trainers
• TENS (transcutaneous electrical nerve stimulation)
• Heat/cold
• Ultrasounds
• Massage
• Soft-tissue work

A vaginal insertion with biofeedback machine attachment may be used to visualize where the pelvic floor muscles are most weak.^{19 20}

Therapy and counseling

Cognitive behavioural therapy (CBT) is the major type of therapy used for women with vulvodynia.²¹

Psycho-sexual counselling may be recommended for the patient and their sexual partner(s).²²

Surgery

Surgery is not usually recommended because it does not guarantee a pain-free result. Overall success rates are between 60-96%.²³ Only in very rare instances, surgery is performed where part of the vulva is removed. 

There are two types of surgery:²⁴

• Vestibulectomy with vaginal advancement
• Modified vestibulectomy

Neurostimulation and spinal infusion pump: This is only recommended when other forms of treatment have failed. Either an electronic device, which delivers low voltage electrical stimulation, or an infusion pump, which continuously delivers small amounts of medication, is fitted to the spinal cord and nerve roots to reduce pain.25

Diagnosis

Multiple healthcare professionals may be involved in the diagnosis of vulvodynia. Unfortunately, vulvodynia is often misdiagnosed and is underdiagnosed.²⁶ It is important to rule out conditions that mimic vulvodynia; the gynaecologist and urogynecologist are important at this step.²⁷ It is common for the vulva to appear normal.

Firstly, a patient interview and medical history will be performed and taken. After this, a physical examination of the vulva, vagina, and vaginal secretions will be done to rule out conditions mimicking vulvodynia and it is possible that a biopsy and blood test will be performed to assess for infection and hormonal levels. During the physical examination, a pressure test is performed at various sites to assess the severity of the pain.²⁸

Complications

Vulvodynia may cause low mood. Women often find vulvodynia embarrassing to talk about and it may also affect sexual relationships, reduce sex drive, and cause depression.²⁹

FAQs

How can I prevent vulvodynia

Simple changes to your lifestyle can also help to reduce and prevent the pain:^{30 31 32} 

• Wear cotton underwear, sanitary products, and loose-fitting bottoms
• Avoid irritants (e.g. scented hygiene products)
• Reduce stress
• Use a doughnut-shaped cushion for sitting
• Protect the vulva from chlorine whilst swimming, by using petroleum jelly
• Apply cool packs to the vulva
• Try not to avoid vulva touch completely
• Modify the diet to reduce intake of foods that make the pain worse
• Avoid exercise which puts pressure on the vulva

Who are at risk of vulvodynia

Vulvodynia is not contagious, nor is it associated with personal hygiene or cancer.

People at risk of vulvodynia may have some underlying genetic predisposition. However, many other environmental factors can contribute such as adverse childhood experiences.³³

How common is vulvodynia

Vulvodynia can affect women of all ages and may affect between 7% to 16% of women.^{34 35 36} 

When should I see a doctor?

You should see a GP or go to a local sexual health clinic if you have persistent vulval pain. This is because the pain associated with vulvodynia is unlikely to get better without medical intervention. Also there are conditions that mimic vulvodynia but are treatable - it is important to rule these out or get treatment for them.

Summary

Vulvodynia is a chronic pain condition. It is, therefore, important to manage. A doctor can advise on suitable treatment options, which may include prescription medication. A combination of treatment methodologies may be most beneficial, especially since this condition has no known cause. It may be useful for patients with vulvodynia to reach out to a support network as chronic pain conditions can greatly influence mood; the Vulval Pain Society and Pelvic Pain Support Network are two of the main support groups for women with vulvodynia.³⁷