Vulvodynia

What is vulvodynia?

The International Society for the Study of Vulvovaginal Disease (ISSVD) defines vulvodynia as a chronic discomfort involving the vulva in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder.^{1 2} It is usually described by women experiencing it as a burning or soreness rather than a pain. It is a diagnosis of exclusion and in the case of a cause being found, the diagnosis would not be vulvodynia.

Classification of vulvodynia³

ISSVD classifies vulvodynia by location (generalised vs localised) and then subclassifies these two groups into whether symptoms are provoked or not as follows:

• Generalised vulvodynia - affecting the whole vulval area:

  • Provoked - for example, by touch, sexual intercourse or tampon insertion.

  • Unprovoked - present even without touch.

  • Mixed (provoked and unprovoked).

• Localised vulvodynia - affecting a specific area of the vulva. This includes clitorodynia (where the clitoris is affected), vestibulodynia (where the vaginal vestibule is affected, previously known as vulval vestibulitis), hemivulvodynia, etc:

  • Provoked.

  • Unprovoked.

  • Mixed.

There may be overlap between these categories. Vulval pain caused by recognised conditions is not categorised as vulvodynia but rather as "vulval pain related to a specific disorder".

Causes of vulvodynia (aetiology)²

Aetiology is not understood and is likely to be multifactorial. There are a number of theories which include:

• A trigger causing inflammation or injury, causing stimulation of pain receptors, and receptor/nerve damage. Triggers possibly involved could be infections, skin conditions, allergies, trauma or hormonal factors.

• General urogenital hypersensitivity.

• Disordered central pain processing.

• Somatoform pain disorder.

Risk factors

Associations with other chronic pain conditions are common, with one study finding 45% of women with vulvodynia also having one of the following:⁴

• Fibromyalgia

• Irritable bowel syndrome

• Chronic fatigue syndrome

• Interstitial cystitis

• Endometriosis

A history of recurrent vulvovaginal candidiasis is commonly associated.⁵

Women with a past history of anxiety and/or depression are more likely to get vulvodynia.⁶

How common is vulvodynia? (Epidemiology)²

• Vulvodynia affects women of all ages and ethnicity.

• Lifetime prevalence has been estimated at 8% and is constant across all decades up to the age of 70.

• Provoked vestibulodynia is the most common presentation.

Diagnosis of vulvodynia^{2 3}

The diagnosis of vulvodynia requires a careful history and confirmatory physical examination. Failure to achieve a satisfactory diagnosis can result in increasing frustration and worsening psychological problems along with phobia about sexually transmitted infections and cancer.

History

The vulval discomfort is often described as burning, stinging, irritation or rawness.⁷

A thorough history should be taken to include:

• Duration of pain.

• Location of pain and radiation.

• Severity of pain.

• Type of pain, relieving factors. Whether pain is provoked and, if so. what by (touch, tampons, sexual intercourse, clothes, sitting, etc).

• Sexual history where appropriate - to include questions about vaginismus, lubrication, arousal, anorgasmia, relationship issues, whether pain is provoked by intercourse.

• Previous treatments.

• Medical, surgical and gynaecological history.

• Allergies.

• Impact of pain on life.

• Presence of mood disorders.

Examination

• Little or nothing abnormal is apparent on inspection.

• The purpose of examination is to localise the pain and to exclude other diagnoses.

• A moist, cotton tip applicator can be used to touch the vestibulum lightly in order to "pain map". A mirror may be helpful so the woman can visualise the area being touched and ascertain which areas are affected.

• Inspect/palpate for signs which indicate other diagnoses:

  • Skin changes (lichen sclerosis, neoplasia, rashes, inflammation).

  • Atrophic change.

  • Changes to normal anatomy.

  • Signs of infection - discharge, inflammation.

  • Abnormal muscle tone.

  • Ischial spine tenderness (sign of pudendal neuralgia rather than vulvodynia).

  • Bladder neck tenderness.

Investigation

• A vaginal swab may be useful to rule out infection.

• A biopsy may be required if there are abnormalities on inspection, in which case vulvodynia has already been excluded as a diagnosis.

Differential diagnosis²

Alternative causes of vulvovaginal discomfort or dyspareunia include:

• Infection, including candidal vulvovaginitis, genital herpes, chlamydia, gonorrhoea, trichomoniasis, tinea.

• Cystitis.

• Lichen planus.

• Lichen sclerosus.

• Pudendal neuralgia.

• Vaginismus.

• Vulval atrophy.

• Vulval intraepithelial neoplasia.

• Psoriasis.

• Contact dermatitis.

• Fissures.

• Vaginal septa or adhesions.

Management of vulvodynia^{2 3 5}

General

• Vulvodynia has many possible treatments; however, very few controlled trials have been performed to verify efficacy of these treatments.⁸

• The British Society for the Study of Vulval Disease (BSSVD) guidelines recommend a multidisciplinary approach and advise that combining treatments can be helpful in dealing with different aspects of vulval pain. Specialities which may be involved include psychosexual medicine, physiotherapy, clinical psychology and pain management teams.

• Furthermore, these guidelines encourage patient education and reassurance as being vital to good management. Patient information leaflets and explanation that this is a recognised pain condition may be helpful. Women often fear pathology such as sexually transmitted infection or cancer; understanding the nature of the condition goes some way to alleviating distress.

• Avoidance of contact irritants should be advised. This includes wearing cotton underwear, not wearing underwear at night, avoiding perfumed products such as soaps and sanitary towels, etc.

• Avoidance of unnecessary topical preparations such as antifungals should be advised.

• Advise use of emollient soap substitutes.

Topical

Topical applications of local anaesthetics such as 5% lidocaine ointment or 2% lidocaine gel may be helpful, particularly in allowing intercourse. This should be applied 20 minutes before intercourse and washed off prior to penetration, or a condom used or it may cause penile numbness. These treatments should be used with caution due to the risk of contact irritation.

Medical

Conventional analgesics and narcotics are not helpful in vulvodynia. Instead, medications used in other neuropathic disorders have been borrowed, including:

• Tricyclic antidepressants (TCAs) - frequently used as first-line therapy. Side-effects are common and there is insufficient evidence of efficacy at this time.⁹ Other antidepressants such as paroxetine and venlafaxine have been used in patients who could not tolerate TCAs.¹⁰

• Gabapentin is commonly tried but the evidence base for this and other anticonvulsants such as pregabalin remains poor.¹¹

Physiotherapy

• Pain in the vulva can cause spasm of the adductor muscles of the thigh and other muscles in that region and physiotherapy can be beneficial.

• Pelvic floor exercises allowing relaxation of vaginal muscles may be useful.

• Biofeedback training has also been used to improve strength and relaxation of the pelvic floor musculature.

• Transcutaneous electrical nerve stimulation (TENS) and vaginal trainers are also used.

• Devices to make sitting more comfortable may also be helpful.

Psychological therapies

• Cognitive behavioural therapies (CBT) and psychotherapy have been used successfully to improve reported vulval pain.¹²

• Mindfulness-based CBT is thought to improve sexual function and satisfaction in women with vulvodynia.¹³

• Additional support may be required - including reassurance of the partner.

• Sexual, individual or relationship counselling may also be appropriate. Advice about ensuring adequate arousal (and therefore lubrication) prior to intercourse, use of different sexual positions and good communication may be helpful.

Surgical

Occasionally a modified vestibulectomy is a treatment option:

• The aim is to remove hypersensitive tissue and replace with the advancement of normal vaginal mucosa.

• It is only appropriate for provoked vestibulodynia and tends to be reserved for patients who have had limited success with other therapies.

• Those who respond to topical lidocaine have a better outcome.

• High success rates have been reported where patients are carefully selected.¹⁴

Complementary and alternative medicine

Where conventional medicine proves unsatisfactory, patients frequently turn to alternative practitioners. Few data are available on which to base recommendations for or against such treatments.

A GP should be able to provide empathy and education. Give the patient the opportunity to discuss her problems. Encourage perseverance with treatment. Refer to a specialist where diagnosis is in doubt or for multidisciplinary treatment. A first-line approach should include education, reassurance and general advice, perhaps followed by referral for physiotherapy and/or psychosexual counselling where appropriate.

Complications

Vulvodynia can have a significant detrimental effect on quality of life.¹⁵ Affected women may experience frustration, chronic stress, depression and sexual and relationship problems. It may have an adverse effect on the psychosexual health and quality of life of her partner.

Prognosis²

The natural history of this disorder is not clear. There is a high placebo effect in trials, suggesting high rates of spontaneous improvement in symptoms. Many treatment options have shown good success rates. However, improvement may take time and a combination of therapies.