What is Vulvodynia?
Vulvodynia is a specific type of female genito-pelvic pain/penetration disorder (GPPPD) and can greatly affect the quality of sexual relationships, interfere with daily activities and affect psychological well-being (1). Vulvodynia is characterised by pain at the vulva that can occur both during sexual intercourse and outside of sexual activity (2). It occurs in approximately 7-15% of women (2). Vulvodynia is identified as vulvar pain for at least three months without any other identifiable cause (3). Vulvodynia can occur at any age and within in any ethnic group (5). The condition can be primary or secondary to other genital pain, localised or generalised and can occur spontaneously or provoked (5) (6). Pain can be intermittent, persistent, constant, immediate, or have a delayed onset (3)(5). The exact cause of vulvodynia remains unknown but possible contributing factors include injury or irritation to the nerves that transmit pain from the vulva to the spinal cord, increased number and sensitivity of nerve fibres in the vulva, localised vulval inflammation, low oestrogen, abnormal response to environmental factors, genetic susceptibility, and pelvic floor muscle disorders (1)(3)(6).
Diagnosis:
The diagnosis of vulvodynia is made by a medical professional such as a GP or gynaecologist under conditions of normal vulvar appearance, with or without vulval redness, normal vaginal walls and secretions, in association with sensitivity on cotton-swab testing. Pelvic floor muscle tenderness may also be present in some women (2). As vulvodynia is mostly a diagnosis of exclusion, a detailed medical and sexual history as well as pelvic examination is required to confirm diagnosis (2).
Management strategy:
Research in vulvodynia is ongoing and there is a lack of data about the effectiveness of various treatment options. Success can not be guaranteed. Treatment approach involves trialing of the non-pharmacological and minimally invasive therapies first. These treatments offer benefits with minimal risk. Other treatments with higher risk and side effect profile can be added as necessary. Many cases of vulvodynia resolve on their own, therefore the degree to which treatment is sought is dependant on patient choice and preference.
Vulval care: Initial management options focus on self care vulval practices which involve eliminating any potentially irritating substances such as shampoos, soaps, laundry detergents and intimate cleaning products (7). The use of non irritating cotton underwear and cotton sanitary pads is advisable while minimising use of potentially irritating sanitary products such as tampons (7)(8). Advise should be given to discontinue use of any intimate cleaning products as these are a known disruptor to the vaginal microbiome.
Discontinuation of hormonal birth control: Although not a causal factor for all women with vulvodynia, hormonal contraceptives may contribute to the pathophysiology of vulvodynia due its involvement in pain sensation at peripheral, spinal and supra-spinal levels. This may lead to a sensation of pain in the vulvovaginal tissue for some women (10). Hormonal contraceptives may also increase the likelihood of vaginal yeast infections which have an association with vulvodynia (11). It is important to note that findings are mixed and some studies have found no associated with vulvodynia and hormonal contraceptive use (12) therefore decision to discontinue or change hormonal contraceptives should be patient led.
Diet and lifestyle: New research shows an association between the vaginal microbiome, gut microbiome and vulvodynia (13). While this are of research is poorly understood, there is an association between candidal vulvovaginitis and vulvodynia in which the vaginal microbiome plays a critical role (11). Dietary and lifestyle advice such as smoking cessation and promoting a whole foods diet can help balance both gut and vaginal microbiomes. Assessment of long term antibiotic use and other medications such as non-steroidal anti-inflammatory drugs (NSAID’s) may also offer insight into potential causes of either chronic yeast infections or vaginal microbiome imbalances.
Sexual therapy: Education on sexual positioning and the relationship between pain and sexual experience may help improve sexual experience with vulvodynia. Referral to a psychosexual sex therapist required.
Psychological care: Vulva related perception of pain can be reduced by up to 30% with cognitive behavioural therapy (CBT) (9). CBT is accessed through psychologists trained in the method (7). A combination of psychological treatment through CBT and psyschosexual therapy may be particularly useful for vulvodynia manageemnt
Physical therapy: Pelvic floor dysfunction is associated with vulvodynia in some women and may cause painful intercourse and urinary, bowel, and sexual dysfunction (14). Physical therapy occurs under the guidance of a pelvic floor physiotherapist and includes assessment of the pelvic muscles, joints, fasciae, and ligaments as well assessment of the adjacent pelvic organs such as the urinary bladder and large intestine (7). Treatment includes exercises, massage, soft tissue work, and joint mobilisation (3). A few randomised control trails have showed promising results in the treatment of vulvodynia/vestibulodynia with electrical nerve stimulation via a tens device (16). Access to a tens machine can occur through a GP or physiotherapist.
Alternative and complementary therapies: Complementary therapies are common with 88% of women reporting trying at least one complementary approach in the treatment of vulvar symptoms. Effectiveness of complementary therapies is not well established due to minimal research, however massage, relaxation, yoga and mindfulness have all been suggested as useful in pain reduction (3)(7). Acupuncture has been shown to be an evidence based option for pain management of vulvodynia, although more evidence is needed (17). Acupuncture increases release of mu opioids and beta endorphins, both involved in downgrading the sensation of pain (17)(18). A randomised control trail showed significant reduction in vulvar pain and dyspareunia in vulvodynia compared with a waitlist control (17)(18).
Topical therapies: Topical therapies are commonly used for vulvodynia and involve a mixture of local anaesthetics, oestrogen creams, and tricyclic antidepressants in topical form (7). Topical steroid application has not shown improvements in vulvodynia however injectables with a combination of steroid and bupivacaine anaesthetic can be successful for localised vulvodynia (7). Botox injectables have also shown success in some cases of vulvodynia with relative safety (15). It is important to note that due to the frequent long term use of topical therapies, many women find relief with the discontinuation of all topical therapies (7). Effectiveness of topical therapies is not well established. Administration of appropriate topical therapies are provided by a GP or gynaecologist.
Oral medications: Oral pain blocking medications can be used for vulvodynia however these carry a significant risk of side effects. NSAIDs have not been shown effective in treating vulvodynia pain and should be avoided (7). Common medications used for vulvodynia require a prescription from the GP or gynaecologist and involve tricyclic antidepressants (TCAs), serotonin-norepinephrine re-uptake inhibitors (SNRIs) and anticonvulsants (3). TCAs are used as first line treatment due to lower side effects profile. Dosages should remain low and should be increased gradually due to risk of side effects (3). Polypharmacy should be avoided and careful considerations should be made regarding a desire to conceive as these drugs can be teratogenic (likely to cause birth defects or miscarriage) (3).
Laser therapy and surgery: Laser therapy of the vulvar epithelium is used as an alternative to surgery. The laser is used to promote collagen remodelling without altering normal structure. Results are similar to that of surgery with 62% of patients reporting complete remission of symptoms and 92% of patients reporting improvements in pain (7). Vestibulectomy surgery is considered a last resort when non-surgical methods have been tried and failed. Surgery is only appropriate when pain has been localised in the vestibule and provoked (3)(7). Surgery involves removing the vestibule and the involved area of the vagina. Physical therapy and the use of dilators after therapy are recommended. (3)(7). Success rates for surgery are 60-90% (7). Surgery is performed by a gynaecologist with interest in sexual pain disorders.
References:
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12. Reed B, Harlow S, Legocki L, Helmuth M, Haefner H, Gillespie B, et al. Oral contraceptive use and risk of vulvodynia: a population-based longitudinal study. BJOG : an international journal of obstetrics and gynaecology [Internet]. 2013 Dec 1;120(13):1678–84. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970290/
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14. Prendergast SA. Pelvic Floor Physical Therapy for Vulvodynia. Obstetrics and Gynecology Clinics of North America [Internet]. 2017 Sep;44(3):509–22. Available from: https://www.themamasphysio.com/wp-content/uploads/2018/02/physical-thearpy-for-vulvodynia-.pdf
15. Bhuiyan J, Habeshian KA, Booser AC, Gomez-Lobo V, Tazim Dowlut-McElroy. Botulinum Toxin Injections as a Treatment of Refractory Vulvodynia in Adolescents: A Case Series. Journal of pediatric & adolescent gynecology. 2023 Oct 1;36(5):497–500.
16. Filippo Murina, Recalcati D, S. Di Francesco, Cetin I. Effectiveness of Two Transcutaneous Electrical Nerve Stimulation (TENS) Protocols in Women with Provoked Vestibulodynia: A Randomized Controlled Trial. Medical Sciences [Internet]. 2023 Aug 2 [cited 2023 Sep 21];11(3):48–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10443369/
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