Vulval Pain

Vulval Pain

This information is intended to provide those experiencing symptoms of vulval pain  with a summary of diagnosis and management as well as other possible diagnoses.

The vulva is the tissue outside of the vagina including the vaginal opening ( vestibule ), the labia, the clitoris, urethral opening and the mons pubis.

 

Vulval pain can affect any woman of any age and the condition can last anything from three months to several years. For some the pain may resolve by itself but others may battle with symptoms for a long time.

Vulval pain may be related to several causes including infections such as  candidosis or herpes, skin conditions (dermatosis) and occasionally  precancerous or malignant conditions. In such cases there are visible lesions explaining the pain.

The 2015 consensus terminology and classification of persistent vulvar pain definition is "vulvar pain of at least 3 months duration, without clear identifiable cause, which may have potential associated factors" (Bornstein J 2015). Neuropathic pain arising from nerve damage is rare:it should be excluded by a careful history and appropriate clinical examination, and, if necessary,by imaging or other investigations.

Some data suggest that this pain may arise from persistent inflammatory damage to tissue. Some women may make more chemicals that increase or cause inflammation. Irritation causes the release of chemicals (cytokines) which make nerve endings sensitive. When nerves are sensitized, normal touch or pressure can create pain in excess of what would be normally be expected for that level of pressure or touch  This is known as allodynia. There is research indicating an increase in the number of nerve fibres in the vulva in women with this condition (Bohm-Starke et al 1998). An increase in the number of nerves could lead to an increased inflammatory response. In addition tissue samples from women with this condition have higher levels of substances that cause inflammation (Sloane et al 1999). Biopsies show an increase in the number of mast cells (Bornstein 2001) which could lead to hyperalgesia (excessive sensitivity to a painful stimulus meaning that sufferers feel more pain than normal).

Persistent infections may cause irritated vulvar tissue. The use of over-the-counter preparations may make the condition worse as anti-fungal creams may irritate the skin and may play a role in the onset of vulvodynia. Women may also have other so called "medically unexplained symptoms" such as irritable bowel syndrome (IBS), interstitial cystitis (IC), fibromyalgia, complex regional pain syndrome (CRPS) and other autoimmune/inflammatory diseases.

Unprovoked vulvodynia

The pain in this condition usually affects the whole vulva. The pain is spontaneous, ie not triggered by pressure or local contact (clothing, intercourse etc). Unprovoked vulvodynia should be differentiated from pudendal neuralgia by appropriate investigations. See neurological information

Provoked vulvodynia

The vestibule is the most frequently affected site of provoked vulvodynia ( previously called vestibulitis). The pain is provoked by sexual or non sexual touch on the vestibule such as: sexual intercourse (dyspareunia), inserting tampons, tight clothing or cycling.

Provoked and unprovoked vulvodynia may be associated.

Urinary or bowel disorders such as interstitial cystitis or irritable bowel syndrome are frequently associated with provoked vestibulodynia.

Most doctors, including some gynaecologists,  may never have heard of vulvodynia. There is a lack of knowledge in the medical community and many health professionals have not learnt much about the disorder (Glazer H, Rodke G, 2002, Updike et al, 2005 ). Consequently, some professionals may not take an integrated, appropriate medical and multi-disciplinary approach. This can be similar to other pelvic pain conditions. Vulvodynia may cross several fields of medicine: gynaecology, urology, gastroenterology, neurophysiology, rheumatology, immunology, pathology and psychology. Often a particular specialist will see what they know most about the condition and use the treatments they are most familiar with, for example with interstitial cystitis, a urologist may concentrate on urinary symptoms of urgency and frequency while a neurologist may be more likely to find pain caused by nerve damage or pudendal neuralgia. In our opinion this is not a reason to stop seeking support but women may want to find out about who may be best placed to help them or try to access a network of health professionals who are familiar with the different aspects of the condition.

The management of vulval pain should follow the principles of chronic pain management. (Mandal D et al 2010). This includes a detailed pain history. The International Pelvic Pain Society questionnaire may be helpful. The use of a pain scale and a diary may be useful in assessing the degree of pain. A team approach may be necessary with involvement of physiotherapists, psychologists, sexologists as well as pain specialists. ( Wesselman U, 1997).A randomized controlled trial of transcutaneous electrical nerve stimulation ( TENS) using a vaginal probe in provoked vulvodynia concluded that it is a simple and effective short term treatment ( Murina F et al, 2008). A combination of medical treatment as well as psychotherapy and physiotherapy appears to be more successful than isolated treatment approaches. (Munday P et al, 2007)

Those with vulvodynia, either spontaneous or provoked by touch, usually have pelvic floor muscle dysfunction. Integrated with other therapies there are various self-help physical therapies, which if appropriate for your symptoms, can be learned e.g., pelvic floor muscle relaxation exercises, internal and external soft tissue massage, trigger point pressure, biofeedback and use of vaginal trainers in provoked pain. It is crucial to find a physiotherapist who is familiar with taking care of those with vulvodynia.

It is sensible to avoid irritants in everyday products as far as possible.   A local anaesthetic 5% lidocaine cream was found to have helped some women with vulvodynia in a study by Zolnoun et al (2003). Appropriate moisturization of the vulva is desirable (oestrogen cream  moisturizers, lubricant for sexual intercourse) .Very low doses of tricyclic antidepressants eg. amitriptyline or nortriptyline may be used for unprovoked vulvodynia, the doses used for pain are far lower than the doses used for depression. Side effects may include dry mouth and constipation and should be considered when contemplating this type of medication. If this is unsuccessful gabapentin or pregabalin may be considered, however those with long-standing symptoms are less likely to benefit  (Boardman LA et al, 2008 ).

Botulinum toxin A injections have been used and a recent study suggests that higher doses than used previously may be  effective. ( Petersen CD et al 2009, Pelletier F et al 2011). In a recent randomized controlled trial enoxaparin reduced vestibular sensitivity and painful intercourse in women with localized provoked vulvodynia. ( Farajun , 2012 )

Surgical removal of the tissue around the opening of the vagina (vestibulectomy) is not generally beneficial in women with provoked vulvodynia (Andrews JC, 2011). Women who respond to lidocaine gel before intercourse may have a more successful outcome than those who gain no benefit. The use of vaginal dilators may be helpful ( Nunns D, 1997, Abramov  L 1994). In our opinion anyone considering surgery should find out as much as possible about it before making a decision.

Many women worry that they may not be able to create or maintain intimate relationships in their lives due to their vulval pain. However, many women with vulval pain are able to maintain long term stable relationships. The Pelvic Pain Support Network Health Unlocked message board  provides support and a way to connect with others who may have succeeded in this. Please see the link below.

Nunns D, Mandal D, Byrne M et al. Guidelines for the management of vulvodynia. BSSVD Guideline group. Br J Dermatol, 2010 Jun:162 (6) 1180-5

The International Association for the Study of Pain (IASP)  produced a factsheet on Vulvodynia for the global year against Pain in Women.

The HealthUnlocked website

PPSN-WEB-010 v2

Issue date: February 2013

Updated: April 2016

Review date: April 2019

 


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