Vulvodynia, also known as vulvar vestibulitis syndrome (VVS), is a vulvar disorder described as spontaneous or generalized pain in the vulvar region. It may or may not be associated with pain from intercourse, also known as dyspareunia. Two types of vulvodynia exist: localized and generalized.
Generalized vulvodynia, pain in the entire vulvar area, may be provoked or non-provoked and primary or secondary.
Localized vulvodynia in the vestibular region (the entry point into the vagina) is referred to as vulvar vestibulitis or vestibulodynia. Vestibulodynia is pain at the vulvar vestibule or opening of the vulva. It may be provoked (PVD), which demonstrates pain upon touch, especially during penetration or intercourse, or non-provoked, which is pain at the vestibule at all times that occurs without provocation. Some women have had pain since their first penetration (primary vulvar vestibulitis) while some develop pain after being pain free for a period of time (secondary vulvar vestibulitis).
The exact cause of vestibulodynia remains to be determined. It is not a sexually transmitted disease and not a precursor to cancer. However, some preliminary thoughts that link vulvodynia to these conditions include:
- Past recurrent or chronic yeast infection
- Allergies or hypersensitivity (for example to oxalates in urine)
- Autoimmune disorder that may be similar to lupus erythematosus
- Injury to vulva
- Neuropathy including increased number of nerve endings in the vulvar and vaginal area
- Linkage to lowered dose oral contraceptives
- Genetic inheritance of increased nerve fibers in the vulvar region, or predisposition to inflammation
Some women with vulvodynia have a history of sexual abuse though these syndromes are not perceived to be psychological in nature.
The word "vulvodynia" means "painful vulva." Pain may be diffused in nature and in the entire vulvar region. It may occur on one or both sides of the vulva and can be burning or raw. A person suffering from vulvodynia may also suffer from painful intercourse.
The main symptoms of vestibulodynia include pain localized in the vulvar region, burning, itchiness, stinging, rawness, and throbbing. You may also experience painful intercourse
Pain is often characterized as constant or intermittent; it can last for hours, days, months or years. The pain may be provoked by contact with an object, such as with the insertion of a tampon or penis, or even with the pressure from sitting on a bicycle seat (provoked vestibular vestibulitis). The pain may also be constant, as in the case of generalized vulvodynia. The pain of vulvodynia may extend into the clitoris; this is referred to as clitorodynia. In addition, the symptoms may be considered primary or secondary.
In addition to pain, the vulva may appear to look inflamed or swollen but at times it can also look normal.
Women with clitorodynia may experience pain localized to the clitoral area, increased discomfort with orgasm and engorgement. They may report a discomforting achiness in the clitoral area.
Since vulvodynia can be confused with other vulvovaginal problems, it is important to develop a comprehensive history and have a physical examination to distinguish what problems, if any, are occurring in the genital pelvis.
As part of the detailed evaluation, your health care professional will perform an examination of the external genitals and vaginal mucosa or lining. Genital cultures may be preformed to rule out underlying sexually transmitted diseases or vaginitis. Vulvodynia may be caused by injury to the pudendal nerve, which may be caused by surgical injury or trauma, orthopedic or sports injury, childbirth, and a variety of other causes.
A cotton swab test may also be preformed, where the provider will take a moistened cotton swab and check for specific localized pain as he or she progressively touches specific areas of the vulvar vestibule. The vestibule is often labeled similarly as a face of a clock. Pain from a Q-Tip test may be specifically localized to a certain region, often at 5 and 7 o’clock, which coincides with the area of the glands.
Some vulvar specialists may even do a vulvoscopy where they look at the vulvar tissues with a microscope. Sometimes they can see inflammation and redness in the vestibule at the areas of 5 and 7 o’clock (where the vestibular glands are located).
In selected cases, an MRI (Magnetic Resonance Imaging) or CT scan may be performed to assess the spinal cord and rule out underlying anatomical problems that could be impacting the nerves that supply the vulvar region.There is a link between vulvodynia and painful bladder syndromes like interstitial cystitis, and some women may need a urological evaluation to address both syndromes concurrently.
Prescription medications: Tricyclic antidepressants that may help lessen chronic pain include amitriptyline, desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor). Gabapentin (Neurontin) and Tegretol may also help decrease the chronic pain. Antihistamines such as hydroxyzine (Vistaril®) and Montelukast Sodium (Singulair®) can reduce itching. Patients have some success using topically applied creams and gels, including those which contain estrogen and/or testosterone. Some of these topical creams may need to be made from a compounding pharmacy.
Biofeedback/Physical Therapy/Relaxation: This therapy, often done by a specially trained physical therapist, can help women learn to control their pain response and relax tense pelvic floor muscles. Specifically trained genitopelvic floor therapists can do internal vaginal manipulation to help stretch out and relax tense muscles. It is not uncommon that some women who have vulvar vestibulitis may also have vaginismus. Treatment for vaginismus may also be warranted. Read more about treatments for vaginismus.
Local anesthetics: Medications such as lidocaine ointment can be applied on a regular basis or as needed to decrease some of the symptoms associated with vulvodynia and vulvar vestibulitis. Some women find it helpful to use it approximately 30 minutes before intercourse to decrease pain. Read more about treatments for dyspareunia.
In some specialized refractory cases, some specialist advocate injection of Botulinum toxin into the hypertonic pelvic floor muscles and vestibulodynia. Other specialists recommend pudendal nerve blocks to decrease pain transmission.
Surgery:In severe cases where pain is uncontrollable and local treatments have failed, some women may choose to have surgical removal of the area where the pain is localized. A vestibulectomy or removal of the affected skin and tissue is very successful and should only be performed by a vulvar expert. According to a recent article from the Journal of Sexual medicine, success rates from vestibulectomies are variable and range from 60-90 percent.
Vulvar hygiene:Vulvar hygiene is important to the overall treatment for vulvodynia. In addition to good vulvar care and avoidance of irritants, lubricants without caustic additives, such as glycerin or parabens, should be used during intercourse. Some women also find natural oils, like vitamin E, almond or extra virgin olive oil helpful. Good Clean Love®, Yes® and Pjur® water-based lubricants are helpful.
Counseling and therapy:Sexual counseling and therapy may be helpful for women and their partners who are suffering from sexual complaints as a result of vulvodynia. Alternatives to penetration can be encouraged and help may be needed in order to preserve the lines of communication. Sexual counselors and therapists will help maintain couple intimacy and improve sexual self image as treatment progresses. Some women may also suffer from anxiety, depression and frustration concerning their chronic condition, and a mental health care professional may be especially helpful.
Educational resources:Educational materials and resources are also essential for a woman and her partner so they can have accurate information concerning the disease process and cutting edge treatment options.
Some women may begin their quest for treatment at their local gynecologist or internal medicine specialist office. Most, however, require a vulvar specialist who is experienced in vulvar disease, vulvoscopy and the new treatments. It is advisable to seek out a specialist. A vulvar specialist may be located at The National Vulvodynia Association (www.nva.org). This organization has a comprehensive database of health care providers who treat vulvar conditions. It provides web addresses and additional information concerning specialty, type of practice and number of cases seen on a monthly basis. It can be searched by geographical area as well.
The International Society for the Study of Vulvovaginal Disease (www.issvd.org) may also be an excellent resource for up to date information, research and providers who specialize in vulvovaginal disorders.
Other specialists you may need include genitopelvic physical therapists, and a mental health professional. A person with vulvodynia may also see a neurologist, pain management specialist and an urogynecologist if there are bladder or urinary concerns.
If you are suffering from sexual complaints associated or caused by vulvar conditions, a good therapist or counselor who specializes in sexual pain may be located at the International Society for the Study of Women’s Sexual Health (www.isswsh.org) or American Association of Sexual Educators, Counselors and Therapists (www.aasect.org). The International Society for Sexual Medicine (www.issm.info) and the European Society for Sexual Medicine (www.essm.org) are also excellent resources.