Vulval pain: clinical review

Vulval pain is a relatively common condition. Dr Abdelmageed Abdelrahman discusses causes, the distinction between provoked and unprovoked vulval pain, and the evidence base for available treatments.

Section 1: Epidemiology and aetiology
Section 2: Making the diagnosis
Section 3: Treatment 
Section 4: Prognosis
Section 5: Case study


Section 1: Epidemiology and aetiology

Vulvodynia (vulval pain) in women is defined as the sensation of vulval burning and soreness in the absence of any obvious skin condition or infection.

Incidence

It is estimated that around 16% of women have suffered from vulval pain for at least three months at any time in their life. The average age of occurrence of vulvodynia is around 30 years of age. A high prevalence is observed in all decades of life until age 70. Despite the high prevalence, it is still an underestimated condition, as it can potentially be dismissed as a psychological condition.1

Summary of the classification of vulval pain 2, 3, 4
Vulvodynia (unprovoked pain) Vestibulodynia (provoked pain)
Can be generalised around the vulva or localised Pain with light touch (such as with tampon use or sexual intercourse)
Pain is burning and sore in nature Usually no symptoms at other times
Itching is not usually a problem Can be generalised around the vulva or localised

Aetiology of vulvodynia

The cause tends to be multifactorial. As with other pain syndromes, finding a specific cause remains a challenge. A history of vulvovaginal candida is the single most consistently reported feature in women with vestibulodynia. Confirmed microbiology is rarely present to support this aetiology and use of multiple inappropriate topical antifungals may also contribute to symptoms.4

Psychological morbidity has been found to be high in women with vulval pain syndromes. Studies have confirmed profound psychosexual ramifications such as anxiety, depression and disruption of interpersonal relationships prevalent among women with vulvodynia.5


Section 2: Making the diagnosis

History

It is important to distinguish between the two main types of pain - provoked and unprovoked pain. Triggering events for provoked pain include coitus, tampon insertion, cycling, long periods of sitting at work or infections. As part of the history, you must ask about the nature of the pain (burning/sharp stinging), alleviating features and, as discussed, relation to sexual intercourse.

Ask about associated symptoms such as itch, skin lesions, interstitial cystitis, low back pain, irritable bowel syndrome or fibromyalgia. A psychosexual history is crucial as many women have significant dysfunction and may need a psychosexual specialist input. With regard to the psychosexual history, it is important to ask the following:

  • Do you have any concerns about your sex life?
  • Is sex painful?
  • Is sex enjoyable?
  • Do you feel the lower vaginal muscles tightening up during sexual intercourse?

Past medical and surgical history such as exposure to herpes simplex or herpes zoster, pelvic or hip surgery and pudendal nerve injury must also be elicited.

Treatment history, duration of therapy, dosage, side effects, compliance and reason for discontinuation of treatment are also important to ascertain.

Clinical examination

Clinical examination is essential to exclude vulval conditions that could have similar symptoms. Lichen sclerosus and seborrhoeic dermatitis can cause vulval pain through excoriation, splitting of the vulval skin and itching.

Other conditions such as apthous ulceration, erosive lichen planus and herpes simplex infection should be sought for.

In erosive lichen planus the mucosal surfaces are eroded. At the edges of the erosions the epithelium is mauve and a pale network (known as Wickham’s striae) is occasionally seen. The lesions consist of friable telangiectasia with patchy erythema which are responsible for the common symptoms of postcoital bleeding, dyspareunia and a variable discharge which is often serosanguinous. This type is also seen in the oral mucosa.4 

Herpes is characterised by painful ulceration of the anogenital region, dysuria and vaginal discharge. Systemic features of fever and myalgia are more common with primary infection.

Investigations

Infection screening involves wet smears, vaginal pH and fungal and bacterial cultures to exclude vulvovaginal infections. Bacterial vaginosis is a significant risk factor for localised vulvodynia.

Colposcopy aims to exclude subclinical HPV and localised fungal infection. However, colposcopy and acetic acid adds little or nothing to the naked eye examination of the vulva.

There is paucity of evidence for suggesting HPV testing and hence testing is not indicated.

Routine vulval biopsy is not supported. There is no routine indication for MRI in unprovoked vulvodynia as sacral cysts as a cause of referred pain to the vulva is very rare.

Unprovoked vulvodynia

Women with unprovoked vulvodynia are typically peri- or postmenopausal. They present with a longstanding history of inappropriate use of topical steroids/creams. Many of the women tend to be sexually inactive. They may also complain of rectal, perineal and urethral irritation. Understandably, there is a lot of psychological morbidity.

The diagnosis of vulvodynia is based on clinical assessment after excluding vulvovaginal infections, inflammatory disorders and vulval conditions. Evaluation of medical, surgical, and previous treatments together with sexual history will assist in identifying the specific conditions that cause vulval pain. Visual analogue pain scales and pain diaries are useful in assessing the degree of pain.1

Clinical examination of the vulva tends to be normal. Importantly, no investigations are of benefit.

Provoked vulvodynia (vestibulodynia)

Provoked vulvodynia is frequently found in the context of superficial dyspareunia and is characterised by vestibular tenderness on light touch.

Women are usually white European aged between 20 and 40 years. Their symptoms are exacerbated by sexual intercourse, tampon insertion and pain during gynaecological examination. There tends to be a delay between onset of symptoms to receiving a diagnosis, typically six months.

Women with this condition tend to be prone to stress and anxiety. They also experience reduced sexual arousal, negative sexual feelings and less spontaneous interest in sex. These are risk factors for significant psychosexual dysfunction, hence the importance of involvement of psychosexual specialists.

Clinically, vestibular tenderness can be demonstrated using a Q-tip applicator. No investigation is usually necessary as the clinical examination points to a diagnosis.


Section 3: Treatment

Unprovoked vulvodynia

It is vital that women with unprovoked vulvodynia are given reassurance and an explanation of the condition.

Tricyclic antidepressants and neuroleptics are first-line treatments. Due to side effects, compliance with treatment may be a problem. Three to six months of treatment has been suggested as optimum. Surgery is contraindicated in this group of patients.

Acupuncture has also been used as a treatment. However, it has shown limited efficacy in those women refractory to medical treatments. A study by Powell et al. including only 12 patients with unprovoked vulvodynia showed that two were completely cured. Acupuncture is time-consuming and a large part of the beneficial effect in this study may have come from the regular specialist contact. However, in view of the patients' lack of response to other measures, their satisfaction with the acupuncture was surprisingly high.6

Provoked vulvodynia (vestibulodynia)

Counselling women is essential in the management of provoked vulvodynia. Psychosexual counselling offers basic sexual function assessment and provides education, information and support groups for individuals or indeed couples. A comprehensive treatment approach therefore includes combined psychological and sexual therapy addressing the issues of both psychological and somatic symptoms.

The patient is preferably counselled alongside her partner in improving physical non-coital sexual contact, and overcoming pelvic floor muscle hypertrophy with sensate focus therapy. A referral to a psychosexual counsellor may be made by the GP or a gynaecologist (with a special interest in psychosexual medicine) who has exhausted treatment options.7,8

It is very important to note that good evidence for effective treatments is lacking.1 Treatment includes:

  • Local anaesthetic gel (particularly useful prior to sex); this temporarily numbs the area of hyperaesthesia.
  • Vaginal dilators; these help sensitive pelvic floor muscles.
  • Biofeedback training of the pelvic floor; this helps sensitive pelvic floor muscles.
  • Vestibulectomy; this is surgical removal of hyperaesthetic skin.

Section 4: Prognosis

It is important to obtain a good history and perform a clinical examination to be able to distinguish between provoked and unprovoked vulvodynia.

Good evidence for effective treatment is lacking. Tricyclic antidepressants may be helpful in those with unprovoked pain. Surgery is only suitable in certain women with localised provoked pain.


Section 5: Case study

Ms Allen is a 26 year old woman with an 18-month history of vulval pain referred by her GP.

She has used multiple treatments in the past including topical antifungals, amitryptyline and steroid ointments.

The pain level she experiences is 8 out of 10 on a pain scale each day and described as a burning sensation in the vulval area generally. She is very anxious and believes she has vulvodynia after reading about it on the internet.

She took the amitriptyline for six days and stopped this because of tiredness. She is not currently in a relationship. On examination, the vulva looks normal and is generally tender on light touch.

Ms Allen has unprovoked vulvodynia. Unprovoked vulvodynia can include tenderness on light touch, and younger women are not immune to unprovoked pain.

Initial management of Ms Allen was with good skin care to minimise vulval irritation. This includes avoidance of direct application of perfumes, dyes, chemicals or soaps on the vulva or clothes that touch the vulva, and avoiding tight and synthetic underwear (use 100% cotton).

She was also prescribed tricyclic antidepressants with clear instructions for use. She was informed about the side effects, which usually occur in the first 10 to 14 days then settle. The key here is to persevere with treatment as side effects are usually of short duration. She could also consider acupuncture though this is unlikely to be available on the NHS. Written information for Ms Allen is available at www.vulvalpainsociety.org.

  • Dr Abdelmageed Abdelrahman is a trainee in obstetrics and gynaecology in Northern Ireland Deanery

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References

  1. Nagandla K et al. Vulvodynia: integrating current knowledge into clinical practice. The Obstetrician and Gynaecologist. 2014;16:259–67
  2. Bergeron S, Binik YM, Khalifé S, Pagidas K. Vulvar vestibulitis syndrome: a critical review. Clin J Pain 1997;13:27–42 .
  3. Mandal D, Nunns D, Byrne M, McLelland J, Rani R, Cullimore J et al. Guidelines for the management of vulvodynia. Br J Dermatol 2010;162:1180–5.
  4. British Association for Sexual Health and HIV. Clinical Effectiveness Group. UK National Guideline on the Management of Vulval Conditions. February 2014
  5. Danby CS, Margesson LJ. Approach to the diagnosis and treatment of vulvar pain. Dermatol Ther 2010; 23: 485–504.
  6. Powell J, Wojnarowska F. Acupuncture for vulvodynia. J R Soc Med 1999;92:579–81.
  7. Masheb RM, Kerns RD, Lozano C, Minkin MJ, Richman S. A randomised clinical trial for women with vulvodynia: cognitive-behavioral therapy vs. supportive psychotherapyPain 2009;141:31–40.
  8. Backman H, Widenbrant M, Bohm-Starke N, Dahlof LG. Combined physical and psychosexual therapy for provoked vestibulodynia – an evaluation of a multidisciplinary treatment model. J Sex Res 2008;45:378–85.

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