An underdiagnosed syndrome with pain and associated burning of the female external genital organs. Up to 15% of women admit having experienced vulvar pain at some stage of their lives.
May cause significant physical incapacity and psychological distress as well as sexual and marital problems.
There is little evidence-based research data on the condition.
Multiprofessional skills are utilized in the treatment.
Symptoms and diagnosis
General points
A patient with vulvodynia will find a gynaecological examination painful. A speculum examination, taking a sample or bimanual palpation may be difficult or impossible to perform, but they are either not always necessary for the diagnosis.
Vulvodynia is often associated with vaginismus which refers to involuntary muscle spasms or tension of the pelvic floor muscles, which often may even occur chronically.
Vulvodynia can often be diagnosed only after other causes of pain in the genital area have been excluded. Because of this, one should not hesitate in referring the patient to a specialist.
Vulvar vestibulitis syndrome
Subtype of vulvodynia where the vestibule, i.e. the vaginal opening, is painful to touch. Pain during intercourse is the main symptom.
The pain is easy to localize with the aid of a cotton-tipped swab.
The swab test typically invokes a withdrawal reaction and demonstrates a sharp pain at the 5 and 7 o'clock positions in the posterior vestibule, often also in the paraurethral area at the 1 and 11 o'clock positions in the anterior vestibule.
The sites of point tenderness in the posterior vestibule may coincide with erythema which correspond to the position of vestibular glands.
The aetiology of vulvar vestibulitis syndrome is unknown. Some cases seem to be provoked by recurrent, chronic yeast infection, a bacterial infection or thinning of the mucosa due to the use of low-dose combined contraceptives.
Dysaesthetic vulvodynia (essential vulvodynia)
Differs from the above condition in that the patients are usually older (typically over 40 years of age), the pain is continuous and diffuse around the entire vulvar region, and the pain may radiate to the anal area, lower back and thighs. The condition is usually not associated with dyspareunia.
The pain is aggravated towards the evening.
Also known as pudendal neuralgia.
Palpating with a cotton-tipped swab will not elicit pain in the vestibule only, but pain may be felt throughout the vulvar region and even in areas outside the vulvar region.
Hyperaesthesia is believed to result from altered innervation of the skin and mucous membranes. The pain is neuropathic in origin.
Differential diagnosis
Genital herpes Genital Herpes, other ulcerative vulvar conditions
Endometriosis if dyspareunia is the main symptom Endometriosis
Treatment
Good doctor-patient relationship is essential.
Help the patient to understand the condition and the variable nature of the symptoms. Many patients learn to find methods to cope with their symptoms.
Explain the relevant anatomy, with the aid of a mirror and drawing if needed.
Talk about possible dyspareunia. Has the condition affected the couple relationship or the patient's mood?
Multiprofessional support is often necessary.
The patient should be referred to a physiotherapist familiar with pelvic floor rehabilitation, and often also to a sex therapist. It is advisable to include the patient's partner in the sex therapy.
Treatment to be carried out at home:
Basic care: wash the genital area only once or twice a day using water alone, loose clothing.
Skin oil (from a pharmacy) to be applied to the painful areas at bedtime, with the aid of a mirror at the beginning.
Emollients 1-2 times daily to keep the skin and mucosa in good condition
Regular touching of the sensitive areas after washing is important (desensitization), as are also pelvic floor exercises (provide the patient with local patient education materials). It is important that the patient learns to identify the pelvic floor muscles and how to relax them. A physiotherapist with expertise in the pelvic floor rehabilitation is able to advise and offer guidance; biofeedback training will improve results.
Lubricants or anaesthetic gels may be helpful in sexual intercourse.
Set simple and realistic goals. Healing will take time, emphasize the importance of following instructions.
Follow-up appointments at 3-6 month intervals may be initially necessary to support the patient.
Vulvar vestibulitis syndrome
The condition may remain unchanged for years, but the severity of the symptoms will vary.
Few effective treatment choices are available. Good guidance, counselling and education form an integral part of the treatment and will help the patient to cope with her condition.
Suggest temporary withdrawal of combination oral contraceptives (e.g. for 6 months) or change them over to minipills.
Pelvic floor physiotherapy is often beneficial, especially if pelvic floor muscles are tightened or there is clear vaginismus.
If there is poor response to the above treatments, refer the patient to a gynaecological outpatient clinic for an assessment regarding further treatment.
If yeast infection is diagnosed or there is a history of recurrent yeast infections, consider prophylaxis, e.g. fluconazole 150 mg once weekly for 6 months.
Dysaesthetic vulvodynia
Treatment of pain consists of amitriptyline, initially 10 mg at bedtime, or other tricyclic antidepressant. The dose is increased every couple of weeks until the pain is relieved.
Amitriptyline 10-40 mg at bedtime is usually a sufficient maintenance dose.
Since response is slow to develop treatment should be continued for several months after which dose reduction could be attempted.