“ Vulvodynia” is a well-recognised chronic pain condition. There are 2 main subtypes.
This guideline focusses on the commonest and most distressing subtype, “Localized Provoked Vestibulodynia “(LPV). It affects the vulval vestibule (around the vaginal opening), and presents with painful sexual intercourse.
Pain sensitivity is in part genetically determined but also influenced by psychological and environmental factors.
Chronic pain occurs with greater frequency in women with a past history of sexual or physical abuse.
There is chronic vulval discomfort, most often described as a burning pain, occurring in the absence of a specific, clinically identifiable infections, dermatological, or neurologic disorders. The affected skin has a normal appearance, which can include nonspecific reddening.
It is diagnosed when other causes of vulvar pain have been excluded or when pain persists despite adequate management of these conditions (eg dermatitis, thrush).
- Localised (to the vestibule +- clitoris), and provoked by touch/penetration
- Generalised and spontaneous – whole vulva may be affected, usually by a spontaneous burning sensation. Direct touch may not be painful.
- Mixed pattern
FEATURES OF LOCALIZED PROVOKED VESTIBULODYNIA
Typically, pain is provoked by sexual intercourse, use of tampons and tight clothing.
Pain or burning characteristically continues after intercourse, often lasting a few hours but sometimes several days (“afterburn”).
Afterburn can include vulval dysuria, and “irritable bladder”, often mistaken for a UTI.
Afterburn is often mistakenly attributed to thrush. Alone it may precede penetration pain by up to 1 year.
Pain may be so severe as to preclude sexual intercourse.
In the absence of touch or pressure, women are often symptom-free.
- Primary LPV: intercourse and tampons have always been uncomfortable.
- Secondary LPV: typically have previously had years of pain-free sex. In this latter group, there may sometimes be an identifiable pain-sensitising genital condition.
Burning or rawness with vaginal penetration (including tampons), but also a stinging, tearing, stabbing or “dry” sensation.
Penetration is always uncomfortable to some degree, even if at other times there is no pain.
If there are clear episodes of painfree intercourse, then an episodic disorder should be searched for eg episodic candida, dermatitis, irritants or herpes. Repeated examinations and
microbiological swabs (when no antifungals have been used in the month prior) are often necessary.
The skin is normal in texture . Mild redness near the introitus is usually normal.
Light palpation of the vulva with a cotton tip produces tenderness and altered sensation “allodynia” (eg pressure is felt as “burn/itch/stinging”). There may be an “aftersensation” when palpation ceases.
1 or 2 fingertip palpation of the pelvic floor, if possible, is usually tender. Pelvic floor spasm (vaginismus) may preclude examination.
- Exclude and treat concurrent dermatitis and yeast infections. Exclude HSV if skin splits are present.
- Explain chronic pain theory and give reading resources – these are provided on the MSHC website under “Sexual Health Information” patient fact sheet “Vulval Pain – Vulvodynia”. Encourage the partner to read these too.
- Refer to a specialised pelvic floor physiotherapist for “downtraining” of the pelvic floor and trunk muscles.
- 2% lignocaine gel 2-3 times daily to the introitus for some months may be a useful adjunct. (there is often an initial sting for about 30 seconds that subsides).
- Refer for counselling regarding the “impact” of the pain.
- Medication for 6 months or more – a low dose tricyclic antidepressant (TCA) may be needed. Nortriptyline started at 5-10mg nocte, increasing slowly to 30-50mg over 1-2 months, is useful.
Amitriptyline is very sedative and the most predictably anticholinergic, but may be useful where sleep is a problem.
TCAs must not be combined with SSRIs or SNRIs.
Pregabalin is now PBS listed and is useful as an alternative or in conjunction with a low dose TCA.
With all medications, “start low, go slow” as for other chronic pain conditions.
Specialist pain physician advice may be necessary.
Validation of the symptoms and experience is a key factor in clinical improvement.
As with any chronic pain syndrome, complete cure may not be the outcome. However improvement over some months is usually very significant. Planned reviews over 1-2 years are very helpful.
Identifying and treating triggers of pain will help to reduce flares of symptoms.
Look for other types of chronic pain – chronic bladder pain (“interstitial cystitis”), irritable bowel, dysmenorrhoea, musculoskeletal pain are often associated.
Migraine and fibromyalgia may also be present.
Depression and anxiety need specific management, and are a priority in management.
An Enhanced Primary Care plan can facilitate a multidisciplinary approach to care.
Link to additional PDF -Australian journal of dermatology, by AM Thornton and C Drummond.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.
Last Updated October 2015