Vulval pain

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WHAT IS IT?

Vulvodynia is typically pain when the vaginal opening is touched or anything is put in the vagina. It occurs in the absence of an obvious ongoing cause i.e. no obvious infection or dermatitis, and the skin looks normal. Pressure is felt as pain, and touching with a cotton bud may produce a ‘cut glass’, burning or tearing feeling. Sometimes the clitoral area is involved as well. Uncommonly, vestibular pain may be felt before any direct touching happens.

A less common pattern of pain affects the whole vulva, or changing areas of it, without any direct pressure or anything being in the vagina. This is pain that is usually felt as a burning sensation, but can also be a sensation of prickling, dryness (despite the tissues being moist) or mild itch, .In this case, when something is put in the vagina it is usually painfree, or if there is burning nearby then it is not aggravated by penetration. Again the skin looks healthy, but examination and tests need to be performed to exclude dermatitis and infections.

Both patterns of symptoms are treated as chronic pain, and may be associated with pain conditions affecting other parts of the body, eg. Irritable bowel, irritable bladder, migraine, fibromyalgia and possibly chronic fatigue syndrome.

Importantly, chronic vulval pain and tenderness usually do not interfere with pregnancy or the method of childbirth. 

WHAT CAUSES IT?

The exact cause of vulvodynia and other chronic pain is not known.  However there is no single cause.
There is altered sensitivity of nerve endings and associated muscle spasm.  Recent research using brain scans shows that there are also changes in brain function associated with chronic pain and so the sensations of pain continue despite the absence of an obvious cause.  The nerves in the area that is painful can also produce their own pain impulses, so pain escalates. Treatment aims to reverse these changes. It is important to remember that the vulva and vagina are healthy, but that the sensations are altered. Mostly these improve with treatment and time.

Vulval pain is sometimes triggered by frequent or severe skin inflammation, most commonly candida (thrush) or urinary infections. Thrush needs to be considered especially if there is a worsening of symptoms near the period, even if itch and discharge are not present. However it is well known that many pain conditions are often worse near period time. Very occasionally genital herpes may be involved. All infections need prompt and accurate treatment. Wart virus has little effect, although its treatments often irritate, and the skin nearby is often dry.

Persistent pain can occur even after years of enjoyable and painfree sexual activity. Sometimes it is noticed with the first attempt at putting something into the vagina, like using a tampon.

SYMPTOMS

Symptoms may range from none unless the area is touched, e.g. by attempted use of a tampon, or by having sex, to frequent vulval awareness whilst sitting, walking or especially bicycling and horseriding. Tight clothing will aggravate it also. There may be times of improvement and worsening.

Intercourse may be possible, with discomfort only at the very initial stage, or may be too uncomfortable to attempt at all. Often the pelvic floor muscles will learn to tense as a protective behaviour, and this will worsen the pain.

Afterburn may occur after intercourse, lasting minutes - hours - days. This can be from friction or pressure, or occasionally from irritation from lubricants, condoms or semen. (as distinct from an allergy). It can be associated with candidal infections also. However, this type of burning or tenderness that persists after sex is typical of chronic pain when there are no irritants or infections present.  Burning or tender discomfort will similarly happen after medical examination with a cotton tip or internal exam.

Relief is often gained by a cool compress or saltwater soak. You can then apply a bland moisturiser (especially good if refrigerated). Urinary symptoms often occur in vulval pain conditions, even without true bladder infection. This is because the bladder and urethra and vulva develop from the same type of tissue and share their nerve supplies. The bladder sometimes feels ‘irritable’. Bowel irritability is also a common association.

Anxiety and Depression are common consequences of any chronic painful condition. Pre-existing stressors (including poor sleep), fear of the anticipated pain, consequent poor arousal and poor lubrication, may worsen the experience of pain. Sexual relationships invariably suffer even when both partners have a good understanding of the condition and are mutually supportive.  Professional counselling is often very helpful in sorting through these natural reactions, and they help to find an effective way of expressing some of the inevitable frustrations and anger most partners feel. People often bury their negative feelings out of consideration for their partner.. We acknowledge this impact of pain and will offer you counselling services.

How is it diagnosed?

Diagnosis is made by carefully detailing your symptoms and an examination. Skin disease and infection  are excluded. A swab may be taken particularly to exclude thrush. A cotton wool bud is used to map out the area of discomfort. Pelvic floor muscle function and tenderness are will be assessed during a gentle examination. In almost all cases the skin and vulva look normal but sometimes there can be a degree of redness that is not an infection or skin problem, 

BIOPSY

Biopsy is not recommended routinely, even when the area looks red. Biopsy findings in women with symptoms have often been similar to women without symptoms. 

Treatment

Most cases will eventually resolve spontaneously, but this can take years.

  • Local anaesthetic gel - in very mild cases this may be sufficient. Unless there is irritation, the usual prescription is 2% lignocaine gel 3-5 times daily at the vaginal opening only, for up to 3 months. If tolerated, a 5% ointment can be used for the 2nd and 3rd months.
  • Sexual Practices. Lubricants - If condoms are used, water based lubricant will not weaken the condom but may produce irritation. Try various types as they will differ regarding irritation. Therefore rinse off  and moisturise after. 

Condom use for less than 5 minutes is usually OK if vegetable or almond oil is used. Note the availability of the morning after pill within 48-72 hours.  However, the amount of time that the penis or finger is in the vagina usually needs to be brief in pain syndromes and be preceded by enough sensual touch to feel well aroused.  Be confident about this with your partner beforehand and agree BEFOREHAND whether sexual penetration will occur. (see below “Sex and Pain”)

  • A mild cortisone cream or ointment may help if there is an associated dermatitis.
  • There is no strong evidence to support the role of particular diets.
  • A trial of long-term anticandida treatment may help (minimum of 2 months of topical or oral medication) if chronic thrush is suspected. Sometimes the diagnosis of subtle chronic candida is difficult and tests can be negative.
  • PELVIC FLOOR MUSCLE RETRAINING with biofeedback techniques is the single most helpful treatment. A referral to a physiotherapist can be made  Women are usually unaware of chronic tension in their pelvic floor, as well as in their abdomen and upper legs. Activities such as dance and pilates will train these muscles to be strengthened but sometimes their tone is excessive and can worsen pain. Sufficient relaxation doesn’t occur. Physiotherapy will help to “downtrain” these muscles.  Exercises for the trunk, legs and the pelvic floor are taught. Later, vaginal dilators of graduated sizes are used as “downtrainers” under the guidance of a physiotherapist, to improve the tone and action of the muscles. They are NOT used to stretch the vagina, as the elasticity of the tissues will be normal.
  • Low dose antidepressants are often very effective .(usually used with physiotherapy). The more correct term is nerve modulators, as the action of these medications is to adjust pain perception, not to treat depression. The dose used is NOT an effective antidepressant. (Higher doses actually are less effective in chronic pain). If significant depression is present, this should be treated on its merits. However sleep and anxiety may be improved with the low dose, and this itself will help pain.

The ‘tricyclic’ antidepressants also have a powerful antihistamine action, so will reduce itching and often improve sleep. Daytime sedation often is an initial side-effect but mostly reduces with time, and the dose can gradually be increased to 50 - 75 mg.  Dry mouth or eyes, and slight slowness of the urinary stream may occur. Newer antidepressants have recently been tried. The usual length of treatment is 6 months at the dose that has been effective, then gradually weaning. However, it is common for treatment at some level to be needed for several years (see the Pain Medication pamphlet).

The role of surgery.

Very occasionally surgical removal of an isolated tender area can be very successful. Widespread areas of pain are not suitable for surgery. Referrals are made to highly skilled gynaecologists, and a very thin portion of the tender area is removed and covered over with a small section of the back vaginal wall. It is often difficult to visually detect the surgery after healing. Psychological and sexual counselling are generally offered at the same time. Physiotherapy will usually continue as well.

SEX AND PAIN.

The following is kindly reproduced from the Vulval Pain Society UK (www.vulvalpainsociety.org), 

Courtesy from author Dr. Gundi Keimle, Consultant Clinical Psychologist, Royal Bolton Hospital UK.
Standard psychosexual couple-therapy known as “sensate focus”, pioneered by Masters & Johnson (1970) is very useful in the treatment of a range of sexual problems. In essence, the couple are instructed to set “protected” time aside on a regular basis during which they are encouraged to explore and touch each other in a mutually pleasurable way. Initially, this starts off with touching only the non-sexual parts of the body, and as the couple progresses, the sexual parts are included gradually. Throughout all this time, there is a “ban” on sexual intercourse, in order to allow the woman to relax and enjoy “safe” touching without tensing up (physically and/or emotionally) at the thought of “what might follow” (i.e. penetrative intercourse and pain). It is also important for the couple to alternate between being the “active” and “passive” partner during each pleasuring session, and to take it in turns to initiate (who goes first as the “active” one, i.e. the one to start touching/stroking/massaging their partner). Gradually, over a number of weeks, the woman can hopefully move from safe, physical, non-sexual closeness to sexual/erotic intimacy and ultimately to sexual intercourse, whilst experiencing an increase in libido, arousal, vaginal expansion and lubrication.
For women with vulval pain during penetration, “sensate focus” psychosexual therapy with her partner is best combined with pelvic floor exercises, biofeedback, and the use of graded vaginal dilators (“downtrainers”) to use during additional solo practice. Women who experience painful sex are likely to suffer from impaired libido and arousal, as described earlier. Therefore, concentrating more on foreplay and non-penetrative forms of sexual pleasuring should help to increase enjoyment and reduce pain. “Sensate focus” is a good way of “re-educating” partners in the art of sensuous pleasuring without merely perceiving this to be a “means to an end”! However, where penetrative intercourse does occur, it is important to use also plenty of additional vaginal lubrication.

General Advice.

Skin care.
see Genital skin care pamphlet for advice (soap substitutes especially) and the avoidance of irritants as described.
      e.g. 

  • tight clothing/Gstrings
  • pantyhose
  • unlubricated sexual activity
  • pads without barrier ointments
  • prompt testing and treatment of infections if worsening symptoms

Lifestyle and pain: see www.paintoolkit.org

Specific resources for vulvodynia

Strategies for anxiety management
Consider online resources such as:

  • www.anxietyonline.org.au (auspiced by Swinburne University Melbourne).
  • YouTube   Dr. Lori Brotto reviews the development of how mindfulness-based programs have come to be applied to sexual difficulties and sexual dysfunction.
    .

Books
Good Loving, Great Sex (by Dr. Rosie King) is an excellent resource for desire discrepancy in relationships, whatever the cause of the discrepancy.

Disclaimer:
This fact sheet is designed to provide you with information on Vulval pain. It is not intended to replace the need for a consultation with your doctor. All clients are strongly advised to check with their doctor about any specific questions or concerns they may have. Every effort has been taken to ensure that the information in this pamphlet is correct at the time of printing.

Last Updated August 2012