Navigating vulvodynia

Vulvodynia, part of vulval pain syndromes, involves enduring exterior vaginal or vulvar pain for over three months, defying clear causes. This enigmatic condition often leads to misdiagnoses like recurrent thrush. In her latest online article, Dr Emily Lord explores its symptoms, causes, diagnostics, and treatment.

What is vulvodynia?

Vulvodynia falls under the category of vulval pain syndromes, with another related condition called vaginismus, characterised by the involuntary tightening of vaginal muscles in response to vaginal insertion.

Unlike vaginismus, vulvodynia involves pain primarily on the exterior of the vagina or vulva, persisting for over three months without any identified alternative causes. It is essentially a diagnosis of exclusion, often complicating clinical assessments. Many women, over years, might have been misdiagnosed with conditions like recurrent thrush or urinary tract infections (UTIs), undergoing various treatments with varied responses.

What are the symptoms of vulvodynia?

It's important to note that patients frequently don't explicitly report experiencing pain or vulvodynia. Instead, they tend to describe other sensations when seeking medical help, such as recurrent thrush, persistent vaginal irritation, itching, or burning.

Crucially, the patient's history plays a vital role in understanding their condition. They might mention avoiding tampons due to irritation, attributing the use of pads to recurrent thrush. Activities like bike riding may be avoided due to discomfort. Additionally, patients often express discomfort during sexual intercourse, indicating that they don't find it enjoyable. This aspect can pose challenges for both the individuals and their partners in comprehending the underlying reasons.

What are some of the possible causes of vulvodynia?

Various factors contribute to vulvodynia, making it a complex, multifactorial condition where the exact cause is often elusive. Sometimes, it manifests suddenly without any apparent history of discomfort. However, in many cases, there's a triggering event, such as a severe episode of thrush. Subsequently, individuals may experience ongoing issues or have concurrent vulvar conditions, like lichen sclerosis, even after addressing the initial problem. Despite managing these conditions, persistent pain and irritation may continue to be a concern.

How is vulvodynia diagnosed?

The process involves dedicating time to sit down with the woman, understanding when her symptoms began, exploring the information she has received, her attempted remedies, what alleviates or exacerbates her condition, and identifying her preferences and limitations in terms of comfort.

This comprehensive approach helps in gaining insight into whether vulvodynia might be the underlying issue. However, given that it's a diagnosis of exclusion, it's imperative to rule out other potential causes. A thorough examination by a seasoned professional is essential, focusing on the vulva itself to check for dermatological conditions and excluding infections such as thrush, STIs, and bacterial vaginosis. This step is crucial in providing reassurance to the woman, especially considering previous instances where clinicians may have suggested ongoing infections.

During the examination, a Q tip or an ear stick is used to assess different areas of the vulva, aiming to identify any altered sensations. It's noteworthy that the experience may not necessarily be pain but could involve heightened sensitivity on one side compared to the other. This mapping process also involves checking for conditions like vaginismus, the involuntary tightening of the vagina. Importantly, these aspects are not mutually exclusive, and there can be an overlap between them. In essence, the history-taking and thorough examination, coupled with the exclusion of other potential causes, form the core of the diagnosis.

How is vulvodynia treated?

The initial step is to reassure women that vulvodynia is a recognised condition, not rooted in psychology, and not indicative of a chronic infection. It is crucial for them to understand this and communicate it to their partners if applicable. Practical measures include seeking information about the condition and learning from the experiences of other women. Practicing good vulvar care, such as washing with an emollient instead of irritants like fem fresh, and opting for cotton, non-irritating underwear can be beneficial.

In my treatment approach, I emphasise information and careful self-care. I often initiate with topical treatments containing local anaesthetics, aimed at dampening nerve fibre sensation. This may provide sufficient relief for some, while others might report partial improvement or intolerance due to irritation.

Oral medications, including tricyclic antidepressants like amitriptyline, commonly used in neuropathic pain conditions, can be effective. These medications not only offer analgesic effects but also anti-anxiety benefits, significantly improving symptoms for women. If these are not well-tolerated or if there are medical contraindications, alternative medications are considered, taking the broader health context into account.

Addressing the holistic picture is crucial. In some cases, referral to psychosexual medicine may be beneficial for both the individual and their partner to navigate the impact on their intimate life. Simultaneously, addressing the medical aspects involves referring individuals to gynaecological physiotherapists who specialise in pelvic floor control. Surgical procedures exist, though I have not found the need to recommend them in my practice. This comprehensive approach encompasses the various aspects of treatment for vulvodynia.

How long does vulvodynia usually last?

Vulvodynia varies widely among women, and providing a realistic yet positive perspective is crucial. Most women can fully overcome it over time, and even if it recurs, recognising the symptoms enables quick and effective treatment. In the vast majority (90%), symptoms subside with time. While a small number (about 10%) may experience ongoing symptoms, it's important to emphasise that effective treatment is available, offering a positive outlook and assistance.

Dr Emily Lord is an esteemed consultant in sexual and reproductive health. You can schedule an appointment with Dr Lord on her Top Doctors profile.