Vulvodynia

Overview

Vulvodynia is a chronic pain condition that affects the vulvar area, occurring without an identifiable cause. It is characterised by a sensation of burning or irritation that must persist for at least three months to meet the diagnostic criteria established by the International Society for the Study of Vulvovaginal Disease (ISSVD).

The causes are not fully understood, but sub-types of vulvodynia may arise from factors like excess nerve fibres, hormonal imbalances, inflammation, and muscular dysfunction. Diagnosis is by exclusion of other possible causes, and treatment varies, as no single therapy has proven universally effective.

Signs and Symptoms

Pain is the hallmark symptom of vulvodynia, described as burning, stinging, irritation, or sharp pain in the vulva and vaginal entrance. It may be constant, intermittent, or triggered by touch, such as during sexual activity, tampon insertion, or prolonged pressure from sitting or biking. The pain can be either localised to one area or generalised across the entire vulvar region. Specific sub-types of vulvodynia include:

• Vestibulodynia: Localised to the vestibular region, often described as a burning or cutting pain. It is the most common subtype, affecting 10%-15% of women seeking gynaecological care.
• Clitorodynia: Pain extending to the clitoris, sometimes related to clitoral adhesions. Symptoms may include pain, hypersensitivity, hyposensitivity, and altered sexual function.

Causes

Vulvodynia is a highly idiopathic condition with multiple possible causes. Sub-types like vestibulodynia have known causes such as neuroproliferation, hormonal mediation, and inflammation. Neuroproliferative vestibulodynia involves an increased number of nerve endings, while hormonally-mediated types may result from hormonal contraceptives. Inflammatory vestibulodynia can develop from immune responses.

Other potential causes include genetic predispositions, autoimmune disorders, chronic infections, injury, and pelvic floor dysfunction. Co-morbidities commonly associated with vulvodynia include fibromyalgia, irritable bowel syndrome, interstitial cystitis, and depression.

Diagnosis

Diagnosis is primarily by exclusion of other conditions. Typical patient complaints, normal physical findings, and the absence of identifiable causes are key to diagnosis. Cotton swab testing helps differentiate between localised and generalised pain, mapping pain locations and severity.

Vaginal examinations and tests such as wet mounts, vaginal pH, fungal cultures, and Gram stains may be performed. Surveys indicate that many women meeting the criteria for vulvodynia do not seek medical help, and misdiagnosis is common due to a lack of familiarity among gynaecologists.

Differential Diagnosis

1. Infections: UTIs, candidiasis, herpes, HPV, vaginitis
2. Dermatological Diseases: lichen sclerosus, lichen planus
3. Neoplasms: Paget's disease, vulvar carcinoma
4. Neurologic Disorders: neuralgia secondary to herpes, spinal nerve injury, pudendal nerve entrapment

Treatment

There is no single effective treatment for vulvodynia; various approaches are used based on the subtype and cause.

Medications

Creams and ointments containing lidocaine, oestrogen, or tricyclic antidepressants may be used, although evidence is often poor. Oral antidepressants and anticonvulsants have been tried with limited success. Injectable medications such as steroids and botulinum toxin have also shown limited effectiveness.

Physical Therapy

Patients with high-tone pelvic floor muscles may benefit from pelvic floor physical therapy, which can help reduce pelvic floor dysfunction and associated pain.

Surgery

Vestibulectomy, the surgical removal of the vulval vestibule, may be recommended, especially for neuroproliferative vestibulodynia. While it has successful long-term outcomes, it is typically considered after other measures have failed.

Lifestyle Changes

Recommendations include wearing cotton underwear, avoiding irritants, and using lubricants during sex. However, alternative medicine lacks sufficient study to make concrete recommendations.

Counselling

Group educational seminars led by gynaecologists can significantly improve psychological symptoms and sexual function in women with provoked vestibulodynia.

Epidemiology

The prevalence of vulvodynia ranges between 10-28% of women. Many conditions that are not truly vulvodynia might be confused with it, making accurate estimates challenging. Vulvar pain is a frequent complaint in women’s health clinics.

Patient Communities

Patient communities play a very important role in supporting individuals with vulvodynia, given the challenges in diagnosis and treatment. The National Vulvodynia Association (NVA) and Tight Lipped are prominent organisations offering support, advocacy, and educational resources. Online communities on platforms like Facebook and Reddit provide valuable peer support and information sharing.

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Self-assessment MCQs (single best answer)

What is the primary characteristic symptom of vulvodynia?

How long must the pain persist to meet the diagnostic criteria for vulvodynia?

Which subtype of vulvodynia is most commonly reported?

What is a common diagnostic tool used to differentiate between localised and generalised vulvodynia pain?

Which of the following is NOT a potential treatment for vulvodynia?

Which condition is commonly associated as a co-morbidity with vulvodynia?

Which of the following is NOT a potential cause of vulvodynia?

What is the role of the National Vulvodynia Association (NVA)?

Which of the following treatments is considered only after other measures have failed for neuroproliferative vestibulodynia?

What is the estimated prevalence range of vulvodynia among women?