Vulvodynia and Vestibulodynia

What are the aims of this leaflet?

This leaflet has been written to help you understand more about vulvodynia and vestibulodynia. It tells you what it is, what causes it, what can be done about it, and where you can find out more about it.

What is vulvodynia?

Vulvodynia means pain in the vulva, the female genital area.
Many conditions affecting the vulva may be painful (e.g. infections such as thrush or herpes, as well as skin diseases such as eczema). In vulvodynia, pain is felt in the vulva when there is no obvious visible cause for it and other diagnoses have been ruled out by examination and investigation.

Whilst vulvodynia is the term used for pain felt in the vulva, there is another similar condition, known as vestibulodynia, which is sometimes described as localised provoked vulvodynia. Vestibulodynia is a term used for pain arising at the entrance of the vagina, in the area known as the vestibule (the area of the openings to the vagina and the urethra), when any pressure, be it a touch or friction, is applied. As with vulvodynia, there is no obvious visible cause for the pain in vestibulodynia.

What causes vulvodynia?

The precise cause is unknown. The nerve endings in the skin of the vulva appear to become over sensitive and send abnormal signals which are felt as a sensation of pain. Stress can make it worse. The exact incidence is not known but believed to be about 15%. It is not contagious or related to hygiene or hygiene products.

Is vulvodynia hereditary?

No.

What are the symptoms of vulvodynia?

Pain occurs in the vulva, and occasionally involves the bottom or even the inner thighs. It is typically felt as a burning, stinging or raw discomfort and may be constant or intermittent. Symptoms may occur only in a small area or become generalised to involve the entire vulva. The pain can occur spontaneously or when the vulva is touched

What does vulvodynia look like?

The skin of the vulva looks normal. This is important as other skin problems, such as infections, can cause the vulva to look abnormal as well as feel sore.

How will vulvodynia be diagnosed?

Your doctor will make the diagnosis by taking the history of your complaint and then examining you to exclude other causes of pain in the area. Taking swabs or a biopsy (removal of a small sample of skin under a local anaesthetic to confirm the diagnosis under the microscope) may occasionally be needed to rule out other causes.

Can vulvodynia be cured?

There is no simple cure, but most patients will respond to one or more of a variety of treatments, to the point at which it is no longer a problem.

How can vulvodynia be treated?

Various treatments can be tried. Some of them may suit some women better than others, so it is worth trying different things to see which will help you. The following are sensible lines of treatment:

Avoid soap, bubble baths, shower gels, shampoos, special wipes and deodorants in this area. Wash with a soap substitute, as this will keep your skin soft and provide a barrier against irritation. Emulsifying ointment (a moisturiser) is a good soap substitute, and can be bought over the counter from chemists and at supermarkets without a prescription. Use petroleum jelly to protect the area from chlorine when you are swimming.
A local anaesthetic ointment can be used to numb the area, reducing discomfort. Five-percent (5%) Lidocaine ointment can be bought over the counter from your chemist. It may sting a little when first applied, but this will settle. Those with mild symptoms can use it as and when it is required. Those with more severe symptoms can apply it more regularly. The ointment may also be applied 10 minutes before intercourse but must be wiped off fully if a condom is being used as it can interfere with its protective ability.

If these measures do not give you enough relief, then oral medication may be needed. Three types are commonly used:

Amitriptyline or Nortriptyline. This was developed as an anti-depressant but is now used for many pain problems (e.g. for migraine and post-shingles neuralgia). The dose should start at 10mg at night, and gradually increase each week by an extra 10mg per night. The effective dose varies from patient to patient but is usually between 20 and 80mg. Once the effective dose has been reached, you should stay on it for 3 months before gradually reducing it.
Gabapentin. This is an anti-epileptic drug, which is also used for pain. The dose should start at 300mg at night and gradually increase to 300mg three times a day. If necessary it can be increased to 600mg, 3 times daily.
Pregabalin. This is similar to Gabapentin but is used at the dose of 75-300mg, taken twice daily.

Other treatments include:

Surgical excision. Surgery is an option for a minority of patients when other treatments do not produce satisfactory relief. It may be considered only in patients with severe localised vulvodynia.
Pelvic floor exercise. Pelvic floor refers to a group of muscles which are in the shape of a sling between the legs. These muscles are responsible for keeping the pelvic organs (bladder, uterus, and rectum) in place. Patients with vulvodynia who have sex related pain frequently have pelvic floor muscle dysfunction.

Techniques to desensitize the pelvic floor muscles are likely to be helpful.

Acupuncture. Acupuncture may be a treatment option for unprovoked vulvodynia.
Intralesional injections. Intralesional (into the vulva or the cestibule) injections may be considered in patients with vulvodynia triggered by touch.

What can I do?

Do not worry, as this condition is not life threatening or contagious. Follow the guidelines given above, and find what works best for you. Look at the stresses in your life (e.g. from your job, family, money, or partner) and try to reduce them as far as possible. High levels of stress will increase pain. Occasionally referral by your doctor to a ‘Pain management clinic’ may be helpful.

If intercourse is painful this may have emotional and psychological effects on your relationships. It is important to understand this, and to communicate fully with your partner, discovering techniques that are comfortable and suit you both. Occasionally psychosexual counselling from an expert may help.

Where can I get more information?

Web links to detailed leaflets:

http://dermnetnz.org/site-age-specific/vulvodynia.html
http://dermnetnz.org/site-age-specific/vulvar-vestibulitis.html