Vulva pain

Vulva Pain / Vulvodynia

  by Dr Funmi Odusoga DFRSH MRCOG

Table of Content

Vulva Pain

1. Aetiology

2. Clinical features

3. Complications

4. Diagnosis

5. Management

6. Alternative regimen

7. Follow up

Unprovoked Vulvodynia

1.  Aetiology

2. Clinical features

3. Complications

4. Diagnosis

5. Management

6. Reference

Vulval pain

International Society for the Study of Vulvovaginal Diseases [ISSVD] defines vulvodynia as ‘vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder’.

• Categorised as generalised or localised
• Provoked, unprovoked or a mixture of the two.
• Localised provoked vulvodynia [vestibulodynia]

Aetiology

• Likely to be multifactorial
• History of recurrent vulvovaginal candidiasis

Clinical Features

• Symptoms -Vulval pain – frequently felt at the introitus at penetration during sexual intercourse or on insertion of tampons.
• Long history.
• Signs -Focal tenderness elicited by gentle application of a cotton wool tip bud at the introitus or around the clitoris
•  There are no signs of an acute inflammatory process

Complications

• Sexual dysfunction
• Psychological morbidity

Diagnosis

• Based on history and examination

Management

• Exclude treatable causes
• Multidisciplinary approach to patient care
• Avoidance of irritating factors
• Use of emollient soap substitute
• Topical local anaesthetics e.g. 5% lidocaine ointment or 2% lidocaine gel
• The application should be made 15-20 minutes prior to penetrative sex and washing off the lidocaine just before sex or the use of condom by the partner can reduce the risk of transfer resulting in penile numbness. Avoid oral contact
• Pelvic floor muscle biofeedback
•  Vaginal transcutaneous electrical nerve stimulation
• Vaginal trainers
• Cognitive behaviour therapy

Alternative Regimens

• Pain modifiers – the benefit of drugs such as tricyclic antidepressants, gabapentin and pregabalin is not clear.
• Amitriptyline gradually titrated from 10mg up to 100 mg according to response and side effects may be beneficial in some women
•  Surgery – Modified vestibulectomy may be considered in cases where other measures have been unsuccessful. Patients who have responded to topical lidocaine prior to sex have a better outcome.

Follow-up

• Long-term follow-up and psychological support may be needed

Unprovoked Vulvodynia

Aetiology

• unknown
• best managed as a chronic pain syndrome.

Clinical Features

• Symptoms -Pain that is longstanding and unexplained.
• May be associated with urinary symptoms such as interstitial cystitis54
• Signs -The vulva appears normal.

Complications

• Sexual dysfunction
•  Psychological morbidity

Diagnosis

• Clinical diagnosis made on history and examination
• Exclude other causes

Management

• Multidisciplinary approach to patient care and that combining treatments can be helpful in dealing with different aspects of vulval pain.
• Treatment resistant unprovoked vulvodynia may require referral to a pain clinic
• Use of emollient soap substitute
• Pain modifiers – tricyclic antidepressants are well established in chronic pain management.
• Amitriptyline is frequently first line treatment; dosage should be increased by small increments starting at 10mg up to 100mg daily according to the patient’s response
• If unresponsive or unable to tolerate the side effects, gabapentin or pregabalin may be used
• Alternative regimens -Topical local anaesthetic e.g. 5% lidocaine ointment or 2% lidocaine gel.
• A trial of local anaesthetic may be considered although irritation is a common side effect
• Cognitive behavioural therapy and psychotherapy
• Acupuncture

Follow up– As clinically required

Reference

2014 BASHH UK National Guideline on the Management of Vulval Conditions