Vulvodynia refers to a group of painful conditions of the vulva, the most common sub-type being vulvar vestibulitis syndrome (VVS).
Vulvar pain is the main symptom in all of these conditions which tend to be chronic and affect up to 20% of all women (Arnold, Bachmann, Rosen, Kelly, & Rhoads, 2006; Bachmann et al., 2006). White and African American women experience vulvodynia but it is probably more common in women of Hispanic background.
Symptoms of vulvodynia
The type of vulvar pain experienced is often described as burning or stabbing, and upon investigation, is found in the absence of other disorders. Complaints range from a burning sensation of the perineum to stinging and rawness, but the most common complaints are dyspareunia (painful intercourse), severe point tenderness when touched, perineal irritation and inflammation (erythema) of the vestibule (ACOG Committee on Gynecologic Practice, 2006). The pain may occur at regular intervals (often premenstrually) or may be chronic or irregularly intermittent. Certain stimuli may induce the pain as well; the most common examples include wearing tight clothes, sitting for long periods, inserting a tampon or riding a bicycle.
STDs (sexually transmitted diseases) and risk factors for SDIs are not associated with vulvodynia but women with these syndromes often experience repeated yeast infections (candidal vulvovaginitis). Candida, which may a cause of vulvodynia, is a microorganism commonly found in the vagina that is responsible for most infections of the vulva and vagina.
Vulvodynia pain is not traceable to previous sexual abuse, marital problems or other psychological issues. Women with the syndrome tend to have abnormal pelvic floor muscle activity that often responds to specialized biofeedback therapy with a decrease in vulvar pain as the muscle function improves. Sudden onset of pain may occur when provoked or triggered by intercourse or a pelvic examination but it might dissipate slowly over hours or days. Vulvar pain that results from a normal painful stimulus (allodynia) along with pain that seems greater than would be expected (hyperpathia) from a specific stimulus suggest that the pain of vulvodynia may have a neuropathic cause.
How is vulvodynia diagnosed?
Patient history is part of the diagnosis and will include consistent vulvar pain in the absence of a yeast infection (documented by a negative yeast culture) or such other dermatological signs as an abnormal pH. Vulvar pain, pain during intercourse, and pain while inserting a tampon are the most common symptoms reported.
One or more inflammatory areas in the vestibule may be visible on physical examination. When gentle pressure is applied with a cotton swab to the vulva, introitus, or hymen, women with vulvodynia report various degrees of tenderness. In addition, many complain of urinary symptoms including urgency, frequency and painful urination (dysuria), all of which may also been seen with interstitial cystitis (painful bladder syndrome). In some cases, women may believe that the pain is deep in the vagina or pelvis when, in fact, the sensitivity is in the area of the entrance to the vagina or introitus (Reed, 2006). Vulvodynia may be accompanied by an increased risk for UTIs in perimenopausal and postmenopausal women (Foxman et al., 2001).
Treatments for vulvodynia
Since the pain of vulvodynia appears to have a neuropathic origin, medications that have been used successfully for other neuropathic disorders have been helpful in women with vulvodynia. (Goldstein, Marinoff, & Haefner, 2005). Medications that have been useful as incontinence therapies fall into three major groups and may be used topically or orally:
- Medications used to treat thinning of vaginal tissues (estrogen),
- Medications to treat inflammation (corticosteroids),
- Medications to treat pain (lidocaine [Xylocaine], tricyclic antidepressants, gabapentin [Neurontin].
Trycyclic antidepressants such as amitriptyline (Elavil) are often tried first to treat vulvar pain. Gabapentin (Neurontin), an antiepileptic drug, may also have some benefit.
Fluconazole (Diflucan) may be prescribed for long term treatment to control possible candidal infections contributing to vulvodynia, although the results of this treatment have been inconsistent. It should only be used in patients whose candida infections have been documented.
Biofeedback treatments and physical therapy may alter and improve contractile characteristics of the pelvic muscle. They might also improve muscle control, strength and relaxation (Glazer, 2000).
Self-care in the form of washing the vulvar area with mild, non-perfumed soaps and wearing of 100% cotton underwear may improve symptoms.
Other treatments have had mixed results:
- Women with specific issues (estrogen deficiency or lichen sclerosus, for examples) may find relief from topical corticosteroids and estrogens; but these have not been generally successful.
- Local injection of steroids and interferon has shown conflicting results.
- Xylocaine applied at tender points as needed, up to three or four applications per day, or applied nightly to the entrance of the vagina, has been used with some success.
- Some women have experienced pain relief from topical cromolyn sodium.
- In women with severe symptoms that have not responded to other therapies, surgery may be indicated as a treatment of last resort.
Refernences
- ACOG Committee on Gynecologic Practice. (2006). ACOG Committee Opinion: Number 345: Vulvodynia. Obstetrics and Gynecology, 108, 1049-1052.
Arnold, L.D., Bachmann, G.A., Rosen, R., Kelly, S., & Rhoads, G.G. (2006). Vulvodynia: Characteristics and associations with comorbidities and quality of life. Obstetrics and Gynecology, 107, 17-24. - Foxman, B., Somsel, P., Tallman, P., Gillespie, B., Raz, R., Colodner, R., et al. (2001). Urinary tract infection among women aged 40 to 65: Behavioral and sexual risk factors. Journal of Clinical Epidemiology, 54, 710-718.
- Glazer, H.I. (2000). Dysesthetic vulvodynia: Long-term follow-up after treatment with surface electromyography-assisted pelvic floor muscle rehabilitation. Journal of Reproductive Medicine, 45, 798-802.
- Goldstein, A.T., Marinoff, S.C., & Haefner, H.K. (2005). Vulvodynia: Strategies for treatment. Clinical Obstetrics and Gynecology, 48, 769-785.
Reed, B.D. (2006). Vulvodynia: Diagnosis and management. American Family Physician, 73, 1231-1238.
Posted June 2010
Last Updated November 2011
