Vulvar Pain

Reassuringly, there is treatment for this condition and at WHRIA we have developed targeted treatment protocols and use a multidisciplinary team approach to manage this condition.

Common causes for vulvar pain include:

• Dermatological (skin) conditions
• Infection
• Trauma
• Pudendal nerve entrapment (this is the nerve supplying the vulval region)
• Neuropathic (nerve related) pain

However, in many cases the problem may be multifactorial or the specific cause may be difficult to identify.

Management is focused on:

• Treating any underlying cause
• Addressing Vaginismus (associated over contraction of the muscles in the vulvo-vaginal area)
• Targeting any nerve/neuropathic dysfunction
• Drawing on the expertise of a psychologist to place and deal with the condition in the context of the affected person’s life

Commonly used terms to describe vulvar pain are:

• Vestibulodynia – localized provoked vulvar pain
• Generalised Unprovoked Vulvodynia

Vestibulodynia

Previously known as Vestibulitis.

What is Vestibulodynia?

Pain or discomfort (stinging, burning or ‘inflammation’) in the ‘vestibule’ area of the vulva and vagina. This is where the skin of the vulva (the outside genital skin) meets with the inside skin of the vagina. This very sensitive skin includes the skin surrounding the vaginal entrance and the urethra (where urine passes out). The area contains glands (Bartholin’s and vestibular) which are responsible for lubrication in the area.

Approximately 15% of women have this condition.

Symptoms include:

• Hypersensitivity of the skin in the area – increased sensation from minimal touch eg. Inability to tolerate underwear
• Inability to use tampons
• Inability to have sexual intercourse
• The area feels sore, tender or painful
• The area may appear red
• Can be associated with vaginismus (over contraction of the muscles in the area, which act as a barrier during sexual intercourse or tampon use)
• May be associated with chronic pain in other parts of the body

What causes Vestibulodynia?

In some cases we are able to identify a trigger.

These may include:

• Bad ‘thrush’ infection
• Dermatological disorder
• Trauma to the area
• Childbirth
• Surgery
• Painful episode of sexual intercourse

In many cases there is no identifiable trigger and the symptoms develop for no obvious reason.

How is Vestibulodynia diagnosed?

It is essential to take a thorough history and discuss the nature of the symptoms, the timing of onset and identify any treatable conditions. It is also important to find out what treatments have already been trialed, which were successful and those that weren’t or exacerbated the condition. The impact of the condition on lifestyle and relationships also needs to be appreciated.

Examination involves looking at the area (inspecting for any evidence of infection, dermatological conditions or trauma). The area often has a specific red appearance, but may look normal. The sensitivity of the skin in the area is assessed with a cotton tip swab. The muscles in the area are also assessed with regard to tone and bulk. A speculum examination is sometimes performed.  The examination is often tailored to the specific needs and the ability of the individual to tolerate the examination.

How is Vestibulodynia treated?

At WHRIA we have an experienced multidisciplinary team, consisting of a Gynaecologist, Physiotherapist and Psychologist. Acupuncture and Osteopathy may be a useful adjunct for any musculoskeletal pain.

The aims of treatment are:

• Education about the problem
• Reassurance that it is not uncommon and improvement is highly likely
• Identify and treat any underlying disorder eg infection, dermatological condition
• Attention to vulval care/hygiene
• Treat any neuropathic component (tablets and creams) to the condition
• Treat the associated vaginismus with physiotherapy, and consider use of Botox to reduce over contraction of the muscles
• Psychotherapy – develop strategies to manage pain
• Surgery – where the hypersensitive skin in the area is removed. This is rarely required.

In most cases the symptoms will improve, but it does require patience and education about the condition.

Useful Website:

• http://issvd.org/patient-education/

Generalised Unprovoked Vulvodynia (GUP)

What is it?

Pain or chronic vulvar discomfort (burning, stinging, ‘irritation’) that affects the vulva. The vulvar region is the area extending from the skin over the pubic bone at the front to the skin in front of the anus. It is bordered by the inner thighs.

This condition may affect women of any age, but often women 40 years and older.

Classification

Vulvodynia has previously been classified as such:

• Provoked – the symptoms are triggered, usually by touch eg during sexual intercourse, with use of tampons or wearing tight clothing
• Non-provoked – the symptoms are present at random or most of the time with no identifiable trigger.
• Mixed – mix of both provoked and non provoked.
• Generalised/localized

The following information is focused on Generalised Unprovoked Vulvodynia.

Symptoms

It is often an ongoing spontaneous pain or discomfort (e.g. burning) affecting a large part of the vulva. It may also occur with sitting, bike riding or sexual intercourse. The symptoms are often worse at the end of the day.

What causes Generalised Unprovoked Vulvodynia?

The cause is unknown. Some theories suggest that the nerve system supplying the vulvar area is abnormal, resulting in increased pain messages being sent or felt by the brain.

There may be a history of problems with the pelvic musculoskeletal system, previous trauma to the area or pudendal nerve entrapment.

The Diagnosis and Treatment is similar to that of Vestibulodynia.

In addition extra investigations to exclude pudendal nerve entrapment may be performed if suggested by the clinical history or examination.

More Information

If you’d like more information you can view this Conversation article ‘Does your vulva hurt? You could have vulvodynia’ written by Jane Chalmers & Lorimer Moseley or browse our Health Information page.