Vulval Pain

My vulva hurts

Most women will experience vulval discomfort, soreness or pain at some time in their life and it is a very common reason for women to seek medical help. Sometimes, vulval pain may be cause by painful intercourse, however the vulva seems ‘pain prone’ and almost anything can cause the discomfort.

Too often women endure this pain and sexual dysfunction with no definite diagnosis. Management can often be challenging and sometimes require input from a number of clinicians. Because of this, It is important to have some basic knowledge and understanding of vulval pain to appreciate how we approach the management of it.

Vulval pain

As with all pain, vulval pain is divided into acute and chronic pain. Vulval pain that has lasted three months or longer is classified as chronic. Research has shown that 14% of women will experience a chronic vulval pain disorder in their lifetime. Because of this, vulval pain is considered to be quite common. The whole vulva may be affected, or only a part. In addition, many will experience pain during sex.

For most women with acute vulval pain, and some of those with chronic pain, the cause is readily identified and a firm diagnosis is made so thst a treatment may be facilitated. However, some women suffering from chronic vulval pain find it very difficult to get a diagnosis or can be misdiagnosed and thus do not get the correct treatment and support. This pain and discomfort can seriously impact one’s quality of life.

Vulval Pain

What causes vulval pain?
Vulval pain is caused by a spectrum of diagnoses. Various genitourinary, neuromuscular, gynaecological and gastrointestinal disorders may cause or contribute to vulval pain. Infections and inflammations are frequently the cause of acute pain. Chronic pain is much trickier and it can be difficult to pin point the underlying cause. Sometimes multiple contributing factors may be present in a single patient.

Some of the more common causes are listed below:

  • Genitourinary Infections and Inflammations
    • Thrush – often cyclical
    • Bacterial vaginosis
    • Genital herpes
    • Skin dermatoses
    • Desquamative inflammatory vaginitis
    • Fissuring
    • Aphthous ulceration
  • Musculoskeletal and Neurological Disorders
    • pelvic floor muscle dysfunction
    • Trauma and injury to bones and muscles e.g. coccyodynia
    • Osteoarthritis/degenerative joint disease
    • Pudendal Neuralgia
  • Gynaecological disease
    • Endometriosis
    • Chronic pelvic pain
  • Urological disease
    • Recurrent cystitis
    • Bladder Pain Syndrome e.g. interstitial cystitis
  • Gastrointestinal disease
    • Irritable Bowel Syndrome
    • Constipation
    • Inflammatory bowel disease e.g. Crohn’s
  • Vulvodynia, see more below

How will the cause of my vulval pain be identified?
For many patients, especially those with acute pain, a brief assessment will ascertain the cause of their pain. But diagnosis can be difficult and some women with chronic pain and complex issues will require a comprehensive work-up. Research has shown that 60% of women may see three or more doctors before getting an accurate diagnosis. However the most common cause of chronic vulval pain is a condition called vulvodynia.

How will my vulval pain be managed?
The first challenge is to make the correct diagnosis as this will inform the treatment that is right for you. One management strategy will not be appropriate for all women. The level and amount of care will depend on the diagnosis and the needs of each patient. Here at The McIndoe Centre, we have put together a group of expert clinicians all with a special interest in pain management which enables us to give you a very high level of care within a multidisciplinary team.

Chronic vulval pain requires;

  • 1) More time and effort, need to discuss the mechanisms of chronic pain
  • 2) Access to an integrated, specialist vulval clinic with a special interest in pain
  • 3) Pain mapping – site, intensity as defined by the history and examination
  • 4) A multidisciplinary team management programme

Read more about vulvodynia

The most common cause of chronic vulval pain is a condition called vulvodynia. Localized, provoked vulvodynia of the inner vulva (vestibulodynia), is the most common cause of painful sex in young women.

What is vulvodynia?
Vulvodynia is a pain syndrome characterised by ‘vulval discomfort, most often described as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder’. In other words – the vulva looks normal.

In the past, vulvodynia has been known by a number of different names which caused confusion. The International Society for the Study of Vulvovaginal Diseases currently recommends the following classification for vulval pain:

  • A. Vulval pain related to a specific disorder
    • 1. Infections
    • 2. Inflammations
    • 3. Neoplastic
    • 4. Neurological
  • B. Vulvodynia
    • 1. Generalised (the whole vulva is affected)
      • a) provoked
      • b) unprovoked
      • c) mixed
    • 2. Localized (a part of the vulva is affected)
      • a) provoked
      • b) unprovoked
      • c) mixed

How is vulvodynia diagnosed?
The diagnosis is one of exclusion and the challenge is to eliminate a recognisable cause (of which there are many) for your pain, before deciding that the diagnosis of vulvodynia is appropriate. Infections and skin inflammations are frequent causes of vulval pain. In some cases the diagnosis of vulvodynia is not even considered, while in others it is misdiagnosed. It is vital to take a detailed history and do a careful examination. Investigations often include swabs for infection and a biopsy to examine the tissue microscopically.

Vulvodynia and co-morbidities
Women with vulvodynia often have other chronic pain syndromes and medical problems. These include; a history of headache, irritable bowel syndrome, bladder pain syndrome, fibromyalgia, chronic fatigue syndrome, back pain, and temporomandibular joint disorder. These co-morbidities are not particularly helpful in establishing the diagnosis of vulvodynia, but they are an important consideration when choosing therapy.

A majority of women will also have pelvic floor muscle malfunction and this may contribute a significant amount to the overall pain level. Abnormalities commonly identified include; muscle spasm, poor contraction/relaxation and trigger points (hard tender spots in the muscles). It is important to be assessed by a physiotherapist who is familiar with vulval pain syndromes. Studies have also noted an increase in anxiety, stress, and depression among women who have vulvodynia.

How is vulvodynia managed?
Once the diagnosis of vulvodynia has been made, the challenge shifts to finding an effective treatment. However, this is not a quick fix, and often takes time. Simple measures include avoiding irritants and using emollients and moisturizers. Adequate lubrication at intercourse should be used. There are a number of drug treatments available and these include topical agents as well as oral ones. Both tricyclic and anticonvulsant medications are commonly used. Non-drug interventions include nerve blocks and pulsed radiofrequency of the pudendal nerves.

Physiotherapy can be very successful if there are pelvic floor muscle abnormalities. There are a number of good studies showing benefit from psychological input namely cognitive behavioural therapy and mindfulness based programmes. Surgery is an option in a small proportion of cases but needs very careful assessment.

Most patients will need to trial a number of treatment options to find the one that works best for them. Our dedicated, multidisciplinary team has expertise within in all relevant areas, and is committed to providing you with the highest quality of care.