Medical Advice

Vulval Pain

What is vulvodynia?

If you have been searching the internet looking for answers about vulval pain you will have come across the term "vulvodynia" and have probably been confused about what it means. Basically, it is a term that simply means vulval pain. Vulvodynia is a very vague term and you will find that different doctors have different ideas about what it means. It is a bit like the term "headache". We all know what that means, but we also know that there are many causes: anything from stress to a brain tumour!

Vulvodynia is also known as the "burning vulva syndrome".

What is vulval pain like?

The nerve supply to the vulva is different to other parts of the body. Therefore vulval pain is often not at all like the sort of pain we experience if we cut our finger. Patients often describe it in the following way:

  • burning
  • stinging
  • ripping
  • tearing
  • stabbing
  • ants crawling
  • pulsing
  • throbbing
  • rawness
  • itch that does not make you want to scratch, or a "pre-itch"
  • itch that does make you want to scratch
  • inability to wear tight clothes without an uncomfortable feeling
  • irritation
  • just awareness that you have a vulva

Often these feelings are not there first thing in the morning. They build up during the day and get worse when you are active. They are often worse when you are standing or sitting, than lying down. They often get better when you are in bed at night and tend not to wake you up although many people say they have trouble going to sleep.

What are the conditions that can cause vulval pain?

There are many conditions that cause pain of the vulva. In fact just about any skin condition that involves the vulval and vagina can be painful at times. Even common conditions like dermatitis can become painful if the skin splits or becomes raw from scratching.

If we want to treat vulval pain, we need to know what caused it.You need to know WHY. Some of the conditions that can cause vulval pain are:

  • Lots of common skin conditions can become painful if the skin splits or becomes raw from scratching. These conditions include dermatitis, psoriasis and lichen sclerosus which also commonly involve the vulva.
  • Anything that causes blistering or rawness of the vulva, which includes rare diseases such as lichen planus.
  • Allergic reactions to things that have been applied and to medicines that you might be taking by mouth.
  • Vaginal and vulval infections such as thrush and genital herpes.
  • Bladder infections can be experienced as vulval pain.
  • Back problems, particularly the kind that results in sciatica, can be experienced as pain in the vulva.
  • Hip pain can be felt in the vulva.
  • Nerve disease and damage can cause vulval pain.
  • Pelvic floor muscle spasm can cause vulval pain, especially the kind that is experienced during intercourse.

How do we make a diagnosis?

By very careful history taking, examination and tests to check for infection and skin disease.

How do we treat vulval pain?

This depends entirely on the diagnosis. There is no one treatment. If you have a skin disease or infection, treatment of the underlying condition will cure the pain. However medications and physical therapies such as acupuncture, chiropractic and physiotherapy are also used. In some cases psychological help is needed.

What if it is not a skin disease or infection?

If your vulva looks normal and your tests are normal, then it does not mean you do not have a genuine problem. Pain can be felt in the vulva as a result of dysfunction or disease of the lower back,pelvis,hip,bladder or because of nerve disease or injury. These problems can also be effectively treated.

Treatment for this type of vulval pain usually involves physiotherapy and exercises. There are a number of medications that will relieve it as well. For example some of them are:

  • Amitryptyline
  • Nortryptyline
  • Gabapentin
  • Pregabolin
  • Amitryptyline and nortyrptyline are both also used as antidepressants

    Gabapentin and pregabolin are both also used to treat epilepsy

Many drugs have more than one use. If you are given an antidepressant drug for vulval pain, it does not mean the doctor just thinks you are depressed and is not being honest with you about why he or she is prescribing it. It is just that these drugs are often used to treat nerve pain.

All drugs that are used to treat nerve pain can have some side effects, particularly when you first start on them. The commonest are drowsiness, dizziness, listlessness and just feeling "spaced out". Nortryptyline and amitriptyline can give you a dry mouth and some people also find they get constipated or have blurry vision. If you have a heart condition or glaucoma(increased pressure in your eyes) you should not take them. Starting with a low dose and increasing this gradually will help to overcome the initial side effects. These usually wear off with time.

It can take several weeks for these medications to become really effective and it is important to persevere.

A benefit many patients mention is that you sleep really well.

Many people with vulval pain are just happy to have an explanation and don't want treatment. Because the pain is not very severe, they would rather just live with it knowing that it is harmless.

What if I just have pain with intercourse and/or tampon insertion and nothing else?

This is usually the result of painful pelvic floor muscle spasm. It often starts with something that makes the vagina sensitive (like skin inflammation or an infection), but sometimes it can be triggered by psychological stress as well.

Just about anyone who has had a painful vulval condition for any reason is at risk to develop pelvic floor muscle spasm. It is a protective reflex, a bit like shutting your eyes if something is coming at your face or pulling your hand off a hotplate. You cannot help it because it is an automatic thing your body does to protect you from harm. Fixing pelvic floor muscle spasm starts with fixing whatever caused it. If the spasm doesn't stop after the trigger has been fixed a pelvic floor physiotherapist will usually be able to help you.

I have heard Botox® can help

This is true. Botox® is a medication that paralyses your muscles temporarily. It is being widely used to treat many conditions that are due to muscle spasm and of course to get rid of wrinkles!

If you have vulval pain that is caused by pelvic muscle spasm and you are having trouble overcoming it with exercises, then Botox® may help. It may give you a bit of space to get the exercises going effectively.

There is a down side: it is expensive, it only lasts about 3 months and it must be injected with a needle. It can be very helpful but try exercises first.

I have heard there is an operation to widen my vagina. Will this help?

We think this operation should only be used as a last resort. This is something you should discuss with your doctor. It needs very careful consideration before you agree to it.