Vulval pain is a complex and poorly understood area of vulval disease, which as a result is often inadequately managed, or not even recognized. The majority of women who have some form of vulval pain may be labelled as chronic thrush sufferers for many years or be labelled as mad as they don’t have any obvious physical signs. Assessment of vulval pain is particularly difficult in primary care, as any physical changes are often subtle and not easily seen with a naked eye. The term vulvodynia is defined as chronic vulval discomfort, especially that characterized by the patient’s complaint of burning, stinging, irritation or rawness (McKay).
Table ISSVD classification of vulval pain
In 1991 the ISSVD classified vulvodynia in six categories, as shown in Table ISSVD classification of vulval pain. This classification is currently under review and a revised classification is expected.
As the vulval dermatoses have already been discussed earlier in this chapter and vestibular papillomatosis refers to the papillae present on the labia minora, which are now considered to be a normal variant, we will consider a simplified, broader classification of vulval pain. In general terms, vulval pain can be divided into three categories:
- infective causes
- dysaesthetic vulvodynia
- vulval vestibulitis syndrome.
Vaginal infections and sexually transmitted infections are covered separately and so will not be dealt with in great detail. Less common causes of vulval pain include BehГ§et’s syndrome, Crohn’s disease of the vulva, benign mucous membrane pemphegoid, Stevens – Johnson syndrome, and pemphigus, but these will not be covered in detail in this chapter.
It is important to take a thorough history. As previously mentioned, the majority of vulval disease will either present with pruritus or pain as the primary complaint. True vulvodynia does not have a pruritic component. It is a persistent raw, burning sensation that throbs, and may last for many hours, if not days. Vulval pain has been compared to glossodynia or post-herpetic neuralgia and the similarities persist in some of the treatments available.
Infective causes of vulval pain
Vulval candidiasis does not usually present with the classic curd-like discharge and itching of vaginal candida, although it is probably the most common misdiagnosis within vulval disease.
It is more common in older women, often in those who are using a steroid-based preparation for a vulval dermatosis. Immunocompromised patients are prone to this infection, as are diabetics. The management at initial consultation should include urine analysis for glucose.
The classic presentation is symmetrical erythematous, swollen labia majora, with sharply demarcated borders. The area is hot to touch and has a beefy appearance. Vaginal swabs will not always yield a positive result as laboratories usually look for Candida albicans and not for other subgroups of the Candida species.
The treatment of choice is oral fluconazole 150 mg twice, at weekly intervals, plus vaginal nystatin pessaries and topical nystatin cream. If the patient were using a steroid-based preparation and experiencing fungal overgrowth, it would be advisable to change to a preparation which has a combination of steroid and antifungal, e.g. Dermovate NN.
Candida may be a cause of cyclic vulvodynia where episodes of pain are related to a point in the menstrual cycle. If such a relationship can be identified, then prophylactic treatment can be implemented before symptoms occur.
Herpes simplex virus (especially a primary attack), syphilis, chancroid, and Trichomonas vaginalis may also present with severe vulval pain.
This condition classically affects older women. It presents with a persistent burning of the genital area, which is unremitting and often worse at night. In patients who are sexually active, coitus does not have any effect on the symptoms and is not a precipitating factor.
Multiple topical creams do not cause relief and many resort to applying ice to the vulval area. On examination, there is no physical abnormality and even under detailed colposcopic examination the vulva has a normal appearance.
First-line treatment is usually tricyclic antidepressants as, although they act centrally, they also have a modifying effect on peripheral nerves, which may relieve the burning. Amitryptiline is commonly used but as the affected population tends to be older women, it is prudent to start with a low dose of 10 mg at night, and increase as necessary up to maximum doses of 100 – 150 mg. This regimen minimizes the antimuscarinic side effects, although the patient should be warned that these might occur.
The pain is often compared to post-herpetic neuralgia and carbamazepine may be of use with a starting dose of 100 mg/day, which may be increased sequentially as with the tricyclic antidepressants.
Vulval vestibulitis syndrome
Vulval vestibulitis syndrome (VVS) was described by Friedrich in 1987, although the condition appears to have existed under a variety of different names for over a century. It is defined by a triad of signs and symptoms:
- severe pain on vestibular touch or attempted vaginal entry;
- tenderness to pressure localized within the vestibule;
- physical findings confined to vestibular erythema of varying degrees.
Even among gynaecologists this is a little known condition, but its incidence, or certainly its recognition, is increasing and now accounts for 10 – 15% of referrals to specialist vulval clinics.
The diagnosis is particularly difficult in general practice as often there does not appear to be any abnormality to the naked eye. Even under colposcopic examination, the changes seen within the vestibule may be subtle. Classically this condition affects young Caucasian women in the twenties and thirties, although it has been observed in postmenopausal women. It never appears to affect the black population. The aetiology of this condition is still unknown, but is now thought not to be an infective cause.
The history is of sudden onset vulval pain precipitated by intercourse. Prior to this the woman has been able to achieve penetration, often for many years without difficulty. The pain is superficial dyspareunia, often so severe that it leads to cessation of sexual activity. It is not unusual to experience difficulty with tampon insertion and removal. The pain caused is burning in nature and may persist postcoitally for hours, if not for days. Some women find this discomfort sufficient that it has stopped them from wearing tight jeans or participating in activities such as horse riding or cycling. Occasionally, the woman may be able to identify a precipitating event, such as a particularly nasty bout of thrush, but more usually there is no particular event that can be recalled. Often these women will have self-treated for candida, but obviously with no effect.
As previously mentioned, physical examination is difficult, but on close inspection erythema of the openings of the vestibular glands can be identified. If any pressure is applied to these areas, the patient will experience reproduction of the pain felt at attempted intercourse. Traditionally this “Q-tip tenderness” was achieved by rolling a cotton bud over the entrance to the glands, but more recently other methods have been developed to quantify the tenderness and record this level more accurately.
Treatment of this condition is still difficult and treatment strategies vary throughout the world. Topical steroid preparation such as Trimovate can be first-line treatment. This is applied over the affected area nightly for 2 months. Some women do not respond to steroid and a proportion respond to topical oestrogen cream. Use of local lignocaine gel may be of use short term to allow penetrative intercourse and may be used prior to surgery. About 80 – 90% of women will respond to medical treatment; however, a small proportion require surgical management in the form of vestibulectomy, which involves removal of the skin of the vestibule. Success of this procedure is usually quoted at about 85%, but success rates can be increased by careful selection of patients suitable for surgery, which should only be used as a last resort if all medical treatment fails.