Vulvodynia is the medical term used to describe vulval pain. It is not a new condition, having been described over 100 years ago. It is a common symptom with many causes. While the majority of cases are not life-threatening, there can be life-ruining consequences, with women frequently suffering for many years. All too often it is assumed that the pain is caused by candidiasis. In general, vulval pain can be divided into four categories:

1. microbial ()
2. vulvar vestibulitis
3. dysaesthetic vulvodynia
4. others ()

The importance of a thorough history cannot be over-emphasized, as physical abnormalities are often absent. In addition to the vulva, examination should include the mouth and non-genital skin.

Symptoms

Depending on the cause, symptoms can include the following:

  • • stinging
  • • shooting pains
  • • hypersensitivity — hyperpathia
  • • allodynia — e.g. feeling a light touch as if it was burning
  • • rubbing
  • • cracking/splitting
  • • tenderness
  • • dryness
  • • burning/heat
  • • swelling
  • • painful walking
  • • painful sitting
  • • painful sex.

Causes

Microbial

Microbial causes of vulval pain include candidiasis, trichomoniasis and herpes simplex. See the relevant section of the book for information about these conditions.

Vulvar vestibulitis

The aetiology of this condition is unknown. Women often report that the symptoms follow a specific event, e.g. a severe attack of thrush. There is an association with interstitial cystitis, fibromyalgia and irritable bowel syndrome. Subsequent psychosexual problems are common.

Assessment

Women presenting with vulvar vestibulitis are usually Caucasian and under 40 years of age. They typically describe severe pain and discomfort of the vestibule (the region where the vulva meets with the vagina, including the Bartholin’s and vestibular glands and the urethra). Pain is experienced when pressure is applied to the vestibule during sexual intercourse or insertion of tampons. The pain often continues for a variable period (hours to days) after sex. For some, even tight clothes or a light touch can cause symptoms. Itching is not usually present.

On examination, there is focal tenderness of the vestibule, usually worst near the Bartholin’s ducts and Skene’s glands (near the urethral meatus). There may be red areas (erythema) at the sites of tenderness, but often there are no signs of inflammation.

Diagnosis is made on clinical grounds, especially if vulval pain, focal tenderness and erythema are present. However, infections, particularly of Candida, should be screened for and a biopsy may be warranted to exclude other skin conditions.

Management

Spontaneous remission can occur in up to 50% of patients. General advice on vulval care (see appendix to this section) should be followed. Non-prescribed creams, e.g. over-the-counter thrush therapy, can cause vulval irritation and are best avoided. The treatment approach should address both the pathophysiological and psychological components of the condition, but treatment approaches lack the backing of well-designed trials.

Treatment options include:

1. Medication

  • • Soothing agents — aqueous cream, emulsifying ointment, Emulsiderm bath lotion.
  • • Topical local anaesthetic preparations — either applied half-an-hour prior to sexual intercourse or regularly.
  • • Pain modifiers — amitriptyline/nortriptyline or gabapentin. The starting dose of amitriptyline is 10 mg nocte. The dose should be increased by 10 mg every 2 weeks, titrated against the response, to a maximum of 50 mg nocte. However, while amitriptyline is often used, there is no randomized-trial evidence to support this. Gabapentin can be used if the woman is intolerant to the side effects of tricyclics.
  • • Topical steroids — alone and in combination with other agents, e.g. trimovate, if there is a coexisting inflammatory dermatosis, eg. eczema.
  • • Oestrogen cream.

2. Therapy

  • • Psychosexual counselling.
  • • Behavioural therapy to train the introital muscles to relax:
  • - vaginal trainers are graded in size
  • - electromyographic biofeedback from a vaginal probe
  • - perineal massage,
  • • Pelvic floor muscle physiotherapy.

3. Surgery

  • • The most common surgical procedure is a vestibulectomy. The amount of tissue removed is variable, depending on symptoms. Post-operative management may include the use of creams (steroid creams, emollients), vaginal trainers, or review by a pain management team or psychosexual counsellor. Reported success rates are extremely variable, ranging from 20% to over 90%. Surgery is effective only in well-selected patients and should be reserved for when non-invasive treatments fail. Complications include scar tissue formation, granulation tissue formation and infection.

Dysaesthetic vulvodynia

Dysaesthesia means altered sensation. This can include hyperpathia (where an otherwise mildly unpleasant stimulus can be agonizing) and allodynia (where a different sensation is felt from the one usually experienced, e.g. pressure may be perceived as burning). Again, the aetiology of dysaesthetic vulvodynia is unknown. It is hypothesized that vulval nerve fibres get irritated or damaged and fire abnormal nerve signals back to the spinal cord, resulting in pain. A similar clinical picture is seen in post-herpetic neuralgia.

Assessment

Women tend to be Caucasian, peri- or post-menopausal, and complain of long-standing vulval burning and soreness. The pain can vary from mild discomfort to severe pain that prevents comfortable sitting or sleeping. The pain may also affect the inside of the thighs, the upper legs, anus and urethra, Foreplay and penetration may also be painful. Itching is rarely a feature. Examination is often unremarkable, but it is helpful to delineate the affected area since this can clarify which nerve is affected.

Diagnosis is made on clinical grounds. Remember, however, that a minority will have referred vulval pain secondary to back problems causing spinal nerve compres sion, bladder and bowel pathology, and rectovaginal endometriosis.

Management

As with vulval vestibulitis, treatment options lack the backing of well-designed trials. Options include:

  • • vaginal lubricants — Sensilube, Astroglide
  • • soothing agents — aqueous cream, emulsifying ointment, Emulsiderm bath lotion
  • • topical local anaesthetic preparations — either applied half-an-hour prior to sexual intercourse or regularly
  • • pain modifiers — amitriptyline (up to 50 mg nocte), nortriptyline, carbamazapine, gabapentin or dothiepin
  • • complementary medication — aloe vera gel, Calendula, Dr Bach Rescue Cream, hypercal creams, Aveeno ()
  • • complementary treatments — acupuncture and chiropractic
  • • Others — a combination of a low-oxalate diet and the drug calcium citrate (which removes oxalate from the body) is widely used in America, but less so in the UK. As the pain is more continuous, surgery is usually unsuccessful.

Other causes of vulval pain

These include, vulval intra-epithelial neoplasia, dermatitis, lichen sclerosus and lichen planus. See the relevant chapter for more information.

Pregnancy and vulval pain

Women who are pregnant are more prone to thrush infections. Some studies have suggested that among women with vulval vestibulitis, one-fifth noticed that their pain started following delivery. It is not clear whether this is a result of true vulval vestibulitis or pain from stitches, oestrogen deficiency while breast feeding or due to vaginal infections.

Sex and vulval pain

Sex that produces hymenal or posterior fourchette fissures can mimic vulval vestibulitis. The fissures can usually be seen if the woman is examined within 48 hours of intercourse.

Vulval pain impacts on sexual functioning, affecting both quality and frequency. Fear of pain or anticipation of pain during sex can result in vaginismus (involuntary spasm of the pelvic floor muscles surrounding the vagina, making penetration impossible), decreased libido and arousability, problems with orgasm and aversion to sex. Relationship difficulties inevitably result. Treatment approaches include biofeedback and behavioural and psychosexual therapy. Research suggests that these non-invasive approaches should be used before contemplating surgery. Sexual therapy is available privately and on the NHS. A list of accredited and registered sexual and relationship therapists is available from BASRT (British Association of Sexual and Relationship Therapy) and the IPM (Institute of Psychosexual Medicine). Relate (formerly Marriage Guidance) counsellors may also provide psychosexual therapy. Finally, qualified clinical psychologists may provide a service addressing both pain and sexual/relationship difficulties.

Conclusion

Women with vulval pain frequently suffer for many years. Early diagnosis in primary care with appropriate treatment and, if required, referral to a specialist vulval clinic, will expedite appropriate management. Supportive therapy in the form of explanation and reassurance is essential. Recent collaboration between gynaecologists, dermatologists, genitourinary medicine physicians, psychologists and psychosexual counsellors means that both physical and psychological aspects can now be addressed. However, specialists need to urgently direct their attention to proper evaluation of the plethora of unproven treatment options available and in use.

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