Vulval pain is a common gynecologic complaint. Studies of the general population have estimated that chronic vulvar pain is present in 8% to 15%1–3 of reproductive-aged women. It is neuropathic pain of at least 3 months duration that has recognised associated factors but the underlying cause of the condition is unclear.
The International Society for the Study of Vulvar Disease (ISSVD) along with the International Society for the Study of Women’s Sexual Health, and the International Pelvic Pain Society adopted a new classification system for vulval pain in 2015. This system acknowledges the complexity of making these diagnoses and broadly divides the vulval pain conditions into 2 main groups: vulval pain caused by a specific disorder and vulvodynia.
Vulvodynia is an important women’s health issue that significantly affects sexual function and quality of life. Women will benefit from a multidimensional approach to therapy and it may be useful to help set realistic expectations about treatment time course and outcome. More data are urgently needed around management options for vulvodynia. A systematic review of the medical literature highlights the fact that vulvodynia is a complex disorder that can be difficult to treat. It is associated with poor therapeutic outcomes and has a negative impact on patient quality of life. Although many treatment options are available, no single treatment is effective for all patients, and management must therefore be individualized. Measures such as gentle vulvar care, medication, biofeedback training, physical therapy, sexual counselling and surgery, as well as complementary and alternative therapies, can be used to treat the condition with varying degrees of success. Concurrent emotional and psychological support is often of great value.
Vulvodynia is defined as vulval pain that has been present for at least 3 months, with no clear identifiable cause. It is described by the following key characteristics:
The 2 most common subtypes of vulvodynia are:
Vulval pain caused by a specific disorder (Secondary vulval pain):
The cause of vulvodynia is not well understood; however, most experts agree that it is most likely multifactorial and differs by subtype. Epidemiologic studies suggest a link between a history of vulvovaginal infection, particularly recurrent or severe infections, and the subsequent development of vulvodynia. Histologic studies in women with PVD compared with controls have demonstrated neuron proliferation of the vestibule, increased lymphocytes and mast cells, and increased proinflammatory cytokines, though results have not been consistent across all studies. GD is considered a centrally mediated pain condition similar to other chronic pain conditions (eg, fibromyalgia) by many experts and there have not been any histologic studies to date. Some have suggested hormonal alteration (oral contraceptive pill use, menopause) as part of the etiologic pathway in vulvodynia. Genetic predisposition is suggested by the observation that PVD clusters in families.
The diagnosis of vulvodynia is primarily based on clinical history coupled with physical examination and is largely a diagnosis of exclusion. It is important to identify and treat specific disorders that may be contributing to pain before making a diagnosis of vulvodynia. A thorough evaluation of the patient’s pain history, sexual history, psychosocial situation, medical history, and physical examination are key aspects to correctly diagnosing and managing vulvodynia. Recently, a tool called the Vulvar Pain Assessment Questionnaire (VPAQ) was developed as a disease-specific set of measurement scales designed to capture the biopsychosocial nature of vulvodynia.
Characterizing the patient’s pain by performing a detailed pain history is crucial to the diagnosis of vulvodynia. The interview should elicit the location, quality, intensity, and duration of pain episodes.
Women with PVD will frequently report pain at the opening to the vagina with vaginal penetration (eg, tampon use, intercourse), whereas women with GD will often report constant soreness, burning, or irritating pain throughout the entire vulva.
The sexual history is an important part of the assessment of vulvodynia. Patients experiencing relationship issues may have difficulty discussing sexuality and may benefit from discussion of related issues such as avoidance behaviours, conflict, or negative partner responses. Patients who have a history of sexual abuse or negative sexual experiences, particularly any childhood trauma, may need additional time to discuss this history. Many women with vulvodynia will feel distressed around issues of sexuality and may have a significant psychological impact as a result. Anxiety, depression, hypervigilance, fear of pain, and catastrophizing are examples of common psychological issues that women with vulvodynia may face, and addressing these can help women in the healing process.
Research shows that women with vulvodynia have higher rates of comorbid pain conditions and show substantial alterations in pain pathways peripherally and centrally. Many patients with vulvodynia have suffered from their condition for many years and previous treatment attempts and outcomes should be documented.
Optimal management of vulvodynia varies by subtype but, in general, requires a multidisciplinary approach that includes promotion of vulval health, psychological treatment, physical therapy, and medical therapy. Data are limited on the efficacy of many of the most common therapies and treatment decisions are, therefore, guided by clinical experience or expert opinion, and tailored to individual patients. Before starting any new treatments, it may be wise to have the patient stop all topical vulvar therapies because they may be contributing to vulvar irritant dermatitis. Some practitioners start with less invasive treatments (eg, counselling, physical therapy) and move toward more invasive treatment (eg, medications, surgery), depending on response. Many consider concurrent multidisciplinary therapy the best approach because the woman affected by vulvodynia often is suffering physically, emotionally, relationally, and sexually. A multidisciplinary approach is a holistic approach that considers all the different ways that vulvodynia has affected her life.
The current British guidance from the British Society for the Study of Vulval Disorders (BSSVD) was published in 2010. It offers 12 recommendations on diagnosis and management. These recommendations are of evidence levels B and C.
Contact with some products can cause irritation and pain of the vulva. These may include soaps, creams, fragrances, tight-fitting clothing, douches, deodorants, synthetic lubricants, tampons, pads, and commercial vaginal wipes. Avoidance of these irritants is supported by the American College of Obstetricians and Gynaecologists and can lead to improved symptoms for some patients. In addition, patients can be encouraged to wash the vulva with water alone, wear loose-fitting cotton undergarments during the day and none while asleep, use a nonirritating lubricant for intercourse (eg, coconut oil if not using condoms for contraception), avoid the use of hairdryers, pat the area dry after bathing, and switch to all-cotton menstrual pads.
The goals of psychotherapy include decreasing pain, strengthening romantic relationships, and restoring sexual function by focusing on the thoughts, emotions, behaviours, and ways that couples interact in the setting of genital pain. Counselling may take an individual, couple, or group format, and there are advantages with each. The most commonly used form of psychotherapy is cognitive-behavioural therapy (CBT). Group-based CBT has been evaluated in several clinical trials, shown to significantly decrease pain during intercourse at 6-month follow-up, and this effect was sustained over long-term follow-up at 2.5 years.
Vulvodynia can have a devastating impact on a woman’s sex life and may lead to the breakdown of relationships or reluctance to form new relationships. In combination with other treatment strategies, a course of therapy with a sexual therapist or psychosexual therapist may be the right choice for some women and their partners. The aim depending on the woman’s wishes may be for them to be able to achieve penetrative intercourse with their partners or it may be to allow them to explore other ways to be sexual within their relationship that does not necessarily include penetration. This approach is particularly beneficial when vaginismus (an involuntary spasm of the pelvic floor musculature) has developed together with vulvodynia.
Pelvic floor physical therapy is a cornerstone of treatment of women with vulvodynia because most women have concomitant pelvic floor muscle dysfunction (vaginismus) as a compensatory mechanism to avoid pain. Failure to address pelvic floor dysfunction in patients with vulvodynia is likely to result in suboptimal treatment.
The 3 main local therapy types that have been used for PVD are antinociceptive agents (anaesthetics such as lidocaine, capsaicin, and botulinum), anti-inflammatory agents (corticosteroids, interferon, cromolyn, and lysate), and compounded neuromodulators or combinations (tricyclic antidepressants [TCAs], gabapentin, and baclofen). Although many case series have suggested promising results, clinical trials of topical agents to date have shown limited or no long-term efficacy and these agents are not recommended for curative treatment of PVD. Recently, hormonal topical therapy (0.01% estradiol and 0.1% testosterone) was reported to significantly decrease pain for women with PVD who were on oral contraceptive pills when their pain started, but this was a case series and further data are needed from RCTs before this can be strongly recommended.
|Lidocaine 5% (cream or ointment)||Applied daily||No clear benefit vs placebo in 2 RCTs; both groups improved
Descriptive study showed improved pain and frequency of sex
|Gabapentin 2%–6%(cream)||Applied daily||No RCTs
Descriptive study showed improvement in pain and increased frequency of intercourse
|Amitriptyline 2% or baclofen 2% (cream)||Applied daily||No RCTs
Descriptive study reported improved pain
|Estrogen 0.01% and/or testosterone 0.05%(cream)||Applied daily||No RCTs
Case series demonstrated significant decrease in pain
|Capsaicin 0.025%–0.05%(cream)||Applied daily||No RCTs.
Observational studies demonstrated decreased pain
Use of a topical anaesthetic such as lidocaine can provide the patient with temporary relief of pain. Lidocaine can be used as needed and many patients will apply this before or after intercourse, when exercising, or anytime that they experience increased pain. Preferred formulations are a 4% viscous lidocaine solution, a 5% lidocaine ointment, and a 2% lidocaine gel. There are many different formulations of lidocaine. Topical lidocaine application is very safe, though there are reports of toxicity in patients who have applied copious amounts of topical lidocaine to a large surface area of the body. Care should be taken to use the appropriate amount to cover only the painful region (vestibule). The maximum recommended amount is 4.5 mg/kg every 3 hours, which is much higher than the amount needed to cover the vestibule.
When using topical therapy it is important to consider the vehicle for medication application because many creams contain preservatives and stabilizers that can produce burning and hence an ointment or liquid may be better tolerated.
These include tricyclic antidepressants (eg, amitriptyline, nortriptyline, and desipramine), serotonin or norepinephrine reuptake inhibitors (SNRIs; eg, duloxetine), and anticonvulsants (eg, gabapentin, pregabalin). Treatment with any of these agents requires attention to side effects and potential drug interactions. In general, doses should be started low and titrated up gradually to allow tolerance to the side effects.
Transcutaneous electrical nerve stimulation (TENS) is a commonly used nonpharmacologic noninvasive treatment, to relieve pain for several different types of illnesses and conditions. Prior reports show that TENS reduces pain through both peripheral and central mechanisms. Centrally, sites in the spinal cord and brainstem that utilize opioid, serotonin, and muscarinic receptors are activated by TENS. Peripherally, at the site of TENS application, opioid and a-2 noradrenergic receptors are involved in TENS-induced analgesia.
Dionisi et al. administered weekly intravaginal TENS sessions combined with pelvic floor rehabilitation and biofeedback, observing an improvement in vulvar pain in 75.8% of all cases. In addition, Murina et al. in a double-arm randomized placebo-controlled trial showed improvement in all main outcome measures in 40 women with vestibulodynia. The authors also stressed that intravaginal TENS treatment is simple and safe and improves pain and dyspareunia at 3 months. Nappi et al.183 performed an open study in women with vestibular pain, inducing dyspareunia and vaginismus. The results were positive in the improved contractile ability of pelvic floor muscles, VAS, and FSFI pain scores.
The usual pattern of stimulation is through a symmetrical biphasic waveform. The patient is stimulated through a vaginal probe, 20 mm in diameter and 110 mm long, with 2 metallic transverse rings that act as electrodes. The therapeutic scheme and according to Murina et al. is in 2 steps: (1) 15 minutes, 10 Hz frequency, and pulse duration of 50 microseconds and (2) 15 minutes, 50 Hz frequency, and pulse duration of 100 microseconds. The intensity slowly increased until it reaches a level of sensation described as the maximum tolerable without pain. Nevertheless, there is still the need for better-designed randomized trials to further clarify standardized stimulation protocols according to the severity of pain and the long-term clinical effects of TENS.
The literature includes few reports of pelvic pain treatment at pain clinics using minimally invasive interventional procedures. Lately, however, interest has arisen in specialized pain management techniques, such as multilevel local anaesthetic, botulinum toxin A, radiofrequency nerve blockade, and neuromodulation using different modalities of electrical stimulation. Interventional therapeutic approaches in patients with vulvar pain have additional benefits and could therefore be placed somewhere between medical treatment and surgery.
McDonald and Rapkin attempted several treatments with infiltration at various levels: caudal epidural, pudendal nerve block, and vulvar infiltration with local anaesthetic agents. The authors concluded that these treatments may be effective. Rapkin et al.have also used multilevel nerve blockades with local anaesthetics: caudal, pudendal nerve block, and vestibular infiltration with local anaesthetic agents. Significant improvements were obtained in the vulvar pain in both sensory and affective components of the MPQ as well in depression as assessed by the BDI, without changes in sexual functioning on the Female Sexual Function Index (FSFI).
Trigger point steroid and bupivacaine injections have been successful in some patients with localized vulvodynia. It is recommended not to inject more than 40 mg of triamcinolone monthly, combined with bupivacaine. The combined drugs are injected into specific areas or used as a pudendal block.
The ganglion impar, a single structure usually found on the anterior aspect of the sacrococcygeal joint, is the lowest ganglion of the paravertebral sympathetic chain. Its blockade is indicated in visceral pain syndromes and/ or sympathetic pain syndromes of the perineal region. Diagnostic blocks are recommended, especially when diagnosis and further management plans are dependent on response to the block.
Treatment with botulinum toxin A is widely reported for vulvodynia treatment, but unfortunately, the majority of the published studies were case series or individual case reports.
Pelletier et al.showed the benefit of high doses of botulinum toxin A (50 IU botulinum toxin A bilaterally in the bulbospongiosus muscle. After 3 months, 80% of the patients improved in terms of pain (VAS score improvement from 8 to 2) and sexual function. Abbot and Med reviewed published cases of treatment with botulinum toxin and established the gynaecological indications for its use in women with chronic pelvic pain, concluding that the use of botulinum toxin in the vulva may provide benefit up to 3 to 6 months after an injection of 20 to 40 IU in women with vestibulodynia. They proposed initiating rehabilitation therapy first, with botulinum toxin therapy for refractory cases. Yoon et al. reported 7 cases treated with botulinum toxin (40 IU) in each site of pain: vestibule, levator ani, or perineum. The pain disappeared in all cases (VAS reduction from 8.3 to 1.4). Brown et al.applied injections of botulinum toxin (20 and 40 IU) into the levator ani muscles, with good results, suggesting that vestibulodynia may be a variant of chronic regional pain syndrome. In spite of these positive results, the methodology used in the previously cited articles is insufficient to describe the size of the effect with confidence.
Radicular pain is a complex phenomenon involving a major divergence of the afferent nociceptive signal, which leads to sensitization of the dorsal root ganglion (DRG) and probably the dorsal horns at more than one level. In general, the mechanism of action of radiofrequency treatment is based on the premise that an RF lesion will stop nociceptive (A-delta and C fibres) input into the central nervous system without having a destructive effect on motor or sensory (A-delta) fibres. Pulsed RF uses relatively high voltage applied near a neural tissue in short pulses, which avoids a significant rise in temperature, and should be more selective for C fibre denervation, so as to decrease the chances for sensory or motor deficit. According to previously published studies, pulsed radiofrequency (PRF) might interfere with normal cell function at the DRG that is induced through changes in myelin and changes in the intracellular axonal components of the pain afferents,179 with an early and late increase in the c-Fos expression being observed at central spinal levels in the dorsal horn.
The use of radiofrequency on the ganglion impar has shown to be effective in visceral pain syndromes and/or sympathetic pain syndromes of the perineal region. Placement of a radiofrequency electrode through the sacrococcygeal ligament has been effective in relieving perianal pain when the latter is sympathetically mediated via the ganglion impar.
Pulsed radiofrequency neuromodulation to the S2, S3, and S4 sacral nerve roots, at a frequency of 2 Hz and a pulse width of 20 milliseconds, for 120 seconds at 42°C has been used in patients with vulvodynia.
Surgery usually consists of vulvar excision and vestibulectomy, and should be reserved for patients who have had pain for over 6 months, and are partly or fully incapable of sexual intercourse, or patients who have failed all previous medical attempts. Other procedures have been attempted, including modified vestibulectomy, vestibuloplasty, and perineoplasty. Pudendal nerve decompression is another surgical option when the aetiology is clearly related to the pudendal nerve.