Vulvodynia (vulval pain)

Definition
Vulvodynia is a chronic discomfort or pain of the vulva lasting for at least 3 months, without an identifiable infectious, inflammatory, neoplastic, or neurologic cause. The pain may be constant or intermittent and can significantly affect quality of life, sexual function, and mental health.

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Classification

1. By location

   • Generalized vulvodynia – affects the entire vulval region

   • Localized vulvodynia – confined to a specific area, often the vestibule (vestibulodynia)

2. By provocation

   • Provoked – pain occurs when the area is touched or pressure is applied (e.g., intercourse, tampon insertion, tight clothing)

   • Unprovoked – spontaneous pain without physical contact

   • Mixed – both provoked and unprovoked pain

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Possible Contributing Factors
While the exact cause is unknown, several factors may contribute:

• Nerve injury or irritation in the vulval region

• Hypersensitivity of nerve endings (neuropathic pain)

• Pelvic floor muscle overactivity or spasm

• Chronic inflammatory responses (without obvious infection)

• Hormonal changes (e.g., low estrogen from menopause or hormonal contraceptives)

• History of recurrent vulvovaginal candidiasis or other infections

• Genetic susceptibility affecting inflammatory response

• Psychosocial factors (stress, anxiety, depression)

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Symptoms

• Burning, stinging, irritation, rawness, or throbbing of the vulva

• Pain during intercourse (dyspareunia)

• Pain when inserting tampons or during gynaecological exams

• Discomfort with prolonged sitting, cycling, or wearing tight clothes

• Pain can be constant or occur only with provocation

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Diagnosis

• Clinical history: Onset, duration, triggers, previous treatments, psychosocial impact

• Physical examination:

  • Visual inspection of vulva (usually appears normal)

  • Cotton-swab test to localize and assess pain sensitivity

  • Pelvic floor muscle assessment for tenderness/spasm

• Exclusion of other causes:

  • Vaginal swabs for infection (e.g., Candida, bacterial vaginosis, STIs)

  • Skin biopsy if dermatoses suspected (e.g., lichen sclerosus)

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Treatment
Management is multimodal and tailored to the individual, focusing on symptom relief and improving quality of life.

1. Education and lifestyle measures

• Avoid irritants: fragranced soaps, bubble baths, synthetic underwear

• Wear loose cotton underwear; avoid prolonged tight clothing

• Use gentle, non-soap cleansers or just water for vulval hygiene

• Lubricants during intercourse (water-based or silicone-based, avoid irritating additives)

2. Pelvic floor physical therapy

• Relaxation and stretching exercises

• Biofeedback to reduce muscle overactivity

• Trigger point release techniques

3. Medications

• Topical:

  • 5% lidocaine ointment or gel applied nightly or before intercourse

  • Topical estrogen (if atrophy is present in postmenopausal women)

• Oral neuropathic pain agents:

  • Tricyclic antidepressants (e.g., amitriptyline 10–25 mg at night, titrate as tolerated)

  • Gabapentin or pregabalin for neuropathic pain modulation

• Other: Selective serotonin–norepinephrine reuptake inhibitors (SNRIs) in some cases

4. Psychological support

• Cognitive–behavioural therapy (CBT)

• Sex therapy for individuals/couples to address intimacy concerns

5. Interventional options

• Nerve blocks in refractory cases

• Vestibulectomy (surgical removal of painful vestibular tissue) for severe localized provoked vestibulodynia not responding to other treatments

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Prognosis

• Vulvodynia can persist for months or years

• With a tailored, multidisciplinary approach, many patients experience significant symptom improvement

• Early intervention and psychological support improve outcomes