Vulvodynia

Introduction

Vulvodynia describes the sensation of vulval burning and soreness in the absence of any obvious skin condition or infection. The vulva is the term for the external genital area in women. It includes skin, the clitoris, lots of glands and the small and large labia. The vestibule is just inside the labia minora.

The discomfort can be continuous (unprovoked vulvodynia) or on light touch eg. sexual intercourse or tampon use (provoked vulvodynia). Vestibulodynia occurs when this affects the vestibular area. Some women have symptoms which overlap between both.

Vulval unprovoked pain:

spontaneous pain
pain is burning and sore in nature
itching not usually a problem
can be generalised around the vulva or localised

Vulval provoked pain:

pain with light touch eg tampon use or sexual intercourse
usually no symptoms atother times
can be generalised around the vulva or localised

Unprovoked Vulval Pain

This is often a consequence of irritation or hypersensitivity of the nerve fibres in the skin. This is felt as pain by the woman. This type of pain can occur even when the area is not touched. A similar example of nerve-type (neuropathic) pain often occurs after an attack of shingles; once the rash has disappeared the area of skin where the rash was can be intensely painful.

The intensity of pain can vary from mild discomfort to a severe constant pain which can even prevent women from sitting down comfortably. It is usually there most of the time. It can interfere with sleep and many daily activities. There can be good days and bad days and the pain can have an effect on sexual activity.

In some women the burning sensation can be generalised over the whole genital area. Alternatively it can be localised to just the clitoris or just one side of the vulva. These symptoms are not infective, not related to cancer, and they cannot be passed to your partner.

Usually there is nothing to see as the problem lies with the nerve fibres themselves which are not visible to the skin. Vulvodynia can be diagnosed in the clinic by your doctor based on a history and examination.

Provoked Vulval pain

The pain experienced by women with provoked vulval pain is very individual. It relates to excessive sensitivity on light touch, such as during intercourse and the insertion of tampons. For some women touch or pressure to the vestibule area causes symptoms of soreness and tenderness. This can also have an effect on sexual activity.

Vulval pain should be diagnosed by a healthcare professional who should rule out infections and vulval skin conditions which may cause similar symptoms. There is often excessive pain on light touch to specific areas.

What causes it?

In the majority of women with vulvodynia no cause is found. Around one third of women can pinpoint the time the symptoms developed. This was usually around the time of thrush or a urinary tract infection. Once this settled they were left with sensitivity on the nerve endings.

Medical Treatments

As an initial treatment, local anaesthetic gel is often used. This can ‘numb’ the nerve fibres in the skin temporarily and may be used safely on a regular basis, including prior to sexual intercourse.

Tablets such as amitriptyline and gabapentin alter the way nerve fibres transmit the sensation of pain. It is usual to start at a low dose and then increase gradually until the pain improves. The response may take several weeks. It is often necessary to continue for 3 to 6 months.

With tablets some women experience side-effects such as tiredness, a dry mouth and constipation. However, these usually settle within the first few weeks and are not usually made worse by increasing the dose. Medication can be taken at night-time to reduce drowsiness.

Physiotherapy treatments

The pelvic floor muscles are a sling of muscles in the pelvis which support the pelvic organs. As a protective mechanism, these muscles can go into spasm if there is pain in the genital area – this is a normal response. Physiotherapy treatments offer the opportunity to recognise and overcome some of the muscle tension in the pelvic area.

Physiotherapy includes:

Biofeedback treatment

Biofeedback is useful for women with vulval pain to demonstrate the increased muscle tone and learn how to overcome it. This helps the woman take some control over her body. Although there is little scientific evidence of its benefits, it may complement other treatments.

Pelvic floor muscle trigger points

These are localized bands of tight muscle that can cause pain. A specialist women’s health physiotherapist will be able to release these for you, and show you how to do this yourself if appropriate.

De-sensitisation / use of vaginal dilators

A protective guarding response of the muscles at the entrance to the vagina can occur in women with vulval pain. This can be overcome by gradually and progressively inserting bigger dilators into the vagina (such as one finger, then your partners finger, then a small vaginal dilator) to de-sensitise the area.

Relaxation

Many women with vulval pain find that introducing an element of “whole body” relaxation into their routine helps them to relax their pelvic floor muscles more easily. Your physiotherapist can teach you a technique called the Mitchell Method of simple physiological relaxation, or you can download a leaflet from the Association of Chartered Physiotherapists in Women’s Health website.

Holistic treatments and stress management

Holistic treatments are a crucial part of the ‘package’ as stress and anxiety that follow chronic pain can also be a barrier to getting better. Tackling vulvodynia in a holistic way can even mean coming off drugs.

Being holistic, open-minded and engaging may help you cope with your pain. Chronic pain can affect many aspects of your life including general physical activities, social and work life, relationship with family and friends, mood and thoughts – the list goes on. Examples of holistic treatments include acupuncture, yoga, meditation, Pilates, walking and painting.

Sexual dysfunction and Vulval pain

Vulval pain syndrome often impacts on sexual functioning. Problems such as vaginismus, painful sex, low libido (sex drive) and poor arousal are common. For some women, referral to a Psychosexual Counsellor is necessary.

The cycle of pain caused by vulval conditions may ultimately lead to avoidance of sexual activities, and relationship difficulties. Pain on touching leads to fear and apprehension about penetration.

Trying to relax and desensitize the pelvic floor/lower vaginal muscles can be achieved by using either digital massage of the tender area, or vibration. Vaginal trainers can be inserted to relax the muscles around the entrance to the vagina and to gently stretch the area. They have a role in helping to relax the pelvic floor muscles in women with any type of vulval pain, particularly when the thought of sex is associated with pain and spasm in these muscles. They are frequently prescribed by a psycho-sexual counsellor or a doctor but can easily be bought over the counter or on the internet. They usually come as a set of different sizes and must be used with good lubrication.

The smallest trainer is used first, gradually moving up in size until the largest can be easily and comfortably inserted.

Massage

Vulval massage helps. Imagine you have had a back or joint injury, then massage, stretch, and pressure can all help relax and de-sensitise the area. A similar principle applies to the vulval area. Try gently rubbing the skin of the tender area with a finger coated in lubricants. If it is too painful try a smaller area initially.

Vibration against the area is another option and some women buy a small simple vibrator to hold against the skin. This can be used instead of massage.

General Care of the Vulva

‘The blander the better’ is the usual teaching when it comes to applying products to the vulval skin. Vulval skin is less of a barrier than other skin surfaces and is more liable to irritation. Many products, even so-called ‘low-allergy’ products can irritate skin.

Perfumed products should be avoided. Follow the advice below if you have vulval symptoms.

Avoid soaps, bubble-baths, deodorants, baby wipes, antiseptics and vaginal wipes from coming into contact with the vulval area.

Shower rather than bathe and clean the vulval area only once a day. Over-cleaning can aggravate vulval symptoms.

Washing with water on its own tends to cause dry skin. Use a soap substitute to clean the vulval area e.g. aqueous cream, emulsifying ointment, Dermol 500.

Avoid scrubbing with flannels/sponges. Gently dab the vulval area dry with a soft towel or use a hairdryer on a cool setting held away from the skin.

If passing urine makes your symptoms worse, then wash the urine away from the vulval area using a jug of warm water whilst on the toilet. Urine is an irritant to the skin.

Wear loose-fitting silk or cotton underwear.

Wear white or light-coloured underwear. Dark textile dyes may irritate the skin

Avoid coloured toilet paper.

Avoid wearing nail varnish on finger nails if you tend to scratch.

Fabric conditioners and washing powders contain potential irritants to the skin. Hypo-allergenic products are available in chemists and supermarkets.

Try low allergy sanitary products but avoid wearing towels on a regular basis.

Sleep without underwear.

Some over-the-counter products may contain possible irritants e.g baby/nappy creams, herbal creams and thrush treatments.

Emollients

These soothe the skin and will rehydrate dry areas. They are a vital part of most chronic skin conditions. They are usually fragrance-free and less likely to irritate. Using one of these moisturisers every day can help relieve symptoms. They are also useful when you have no symptoms to protect the skin and prevent flare-ups.

Products include aqueous cream BP, Emulsifying ointment, soft paraffin, Epaderm and Dermol 500. It is important to find the moisturiser that suits you best. Even if the first one you try doesn’t work well, it is worth trying another one.

Aqueous cream can also be kept in the fridge and dabbed on to cool and soothe the skin as often as you like.

What to do with severe vulval pain

Advice for a bad day

Some of you will have good days where the pain is bearable and bad days where the pain can be particularly severe and difficult to manage. Some of the following steps may help.

Are there any trigger points that occurred that you might be able to avoid again? Are you stressed? Are you upset? Lots of events in your life can be responsible for pain to worsen – try and think what factors may be responsible and how they can be avoided. Stress does have an important role in vulval pain and many women with vulval pain do have worse symptoms when under stress. Trying to relax during a bad spell of pain can help. Try aromatherapy, massage or acupuncture.

Try not to feel isolated. If you have a close friend, then call them. Sharing that you have pain with other women can help. Resist using anti-thrush treatments (or other old creams in your bathroom cabinet). The best way to clean the vulval area is with a soap substitute or emollient only once or twice a day.

If the pain is particularly severe then go and seek help from your doctor.

Useful contacts

The Vulval Pain Society