Vulval Pain

The Vulva is the area of skin between your legs. It includes the labia, which are the flaps of skin that surround the opening of the vagina. There are many different conditions that can make this area painful or irritated. It may be painful due to an infection such as thrush. It may be painful due to a skin condition like dermatitis or lichen sclerosis.

However, sometimes it can be painful without any infection or skin condition being present.

To make it even more complicated, sometimes all these conditions are present at the same time – or at different times in the same woman. It’s also common for her to have other types of pelvic pain as well.

Your doctor will check for infection, and skin conditions such as dermatitis. They may take a swab or possibly a biopsy (tiny sample of skin) looking for infection or skin conditions. A bladder infection can also give this type of pain.

If these are normal, but you have pain, then you may have a ‘Vulval Pain Syndrome’. This means that you have pain in the Vulva, but no abnormality can be found. Your pain is real, but it is a pain that can’t be seen by others. This pain can feel just the same as pain from an infection or skin condition.

Sometimes, it is previous infections or skin problems that can trigger the Vulval Pain Syndrome. Sometimes the Vulval pain starts for no known reason.

Vulval pain syndromes are not a sign of a dangerous health problem.

It can be embarrassing to talk about vulval pain, but is important to discuss vulval pain symptoms with a doctor experienced in this area of medicine – there are treatments available. Don’t just try to ‘put up with it’!

Doctors and women’s health physiotherapists use different names to describe different types of vulval pain syndromes:

• Vestibulodynia or vestibulitis. This means pain at the opening of the vagina. The pain usually comes on after touch or pressure during sex, medical examinations or inserting tampons. For some women, it can last for hours after sex.

• Vulvodynia. This means pain in the outside skin of the female genitals. The pain can be present all the time, or it can come and go. The pain may be felt all over the vulva, or just on one side, or one or two spots. Touch does not usually trigger the pain, but it can make it worse.

• Clitorodynia. This means pain around the clitoris, often brought on by touch or sexual arousal.

Women with vulval pain use words like:

• burning, tearing, splitting, stabbing, feeling raw, and sometimes itchiness or stinging.

The exact cause of Vulval Pain Syndromes are unknown, but researches believe that pain can occur as a result of:

• chronic inflammation from recurrent thrush infections or chronic skin conditions, such as Lichen sclerosus and Irritant Contact Dermatitis,
• hormonal changes. For example, the changes at menopause or during breastfeeding,
• abnormal inflammatory responses to trauma,
• overactive pelvic floor muscles in a woman with chronic pelvic pain conditions such as endometriosis,
• misfiring of the vulval nerves – with a message of pain sent to the brain, when the message should mean touch, pressure, heat or stretch.

Some women with vestibulodynia have an area of redness at the vaginal opening, but this not a reliable sign as every woman’s vulva looks different. In most cases of vulval pain, the vulva looks completely normal.

There is no single test that diagnoses vestibulodynia or vulvodynia. To being with, your doctor will need to talk to you about your symptoms and your medical history in detail. The ‘Q-tip test’ can be used to map areas of pain – this involves touching a cotton bud to the skin at the opening of the vagina.

It is important to exclude other causes for vulval pain so your doctor may need to take swabs from inside the vagina to test for infections and perform a vulval biopsy to test for skin conditions. A women’s health physiotherapist can assess for over-activity of the pelvic floor muscles by performing an internal examination.

• Treatment for vulval pain syndromes often involves multiple strategies, and a little bit of time and adjustment to find what suits you best. Because the pain often has more than one cause, successful treatment often involves more than one approach.For example, you may find that a combination of gentle care of the vulval skin, medication to reduce nerve pathway pain and pelvic physiotherapy to relax the pelvic floor muscles is the most effective.
  • Gentle Care of the Vulva Skin involves:
    • washing the vulva only with water
    • using a soap alternative such as QV, Cetaphil or Dermaveen for the body
    • avoiding feminine hygiene sprays, wipes or powders
    • using unscented toilet paper, pads and tampons,
    • wearing comfortable cotton underwear – try to minimise wearing G-strings, tight jeans and pantyhose
    • using water-based lubricants during intercourse. If these cause irritation then coconut, olive or almond oil can be used instead.
    • don’t wax, shave or laser the hair on the labia – limit hair removal to the ‘bikini-line’.
  • Common medications used include amitriptyline (as a tablet or cream), duloxetine (Cymbalta), venlafaxine (Effexor), gabapentin (Neurontin) or pregabalin (Lyrica). There is information on how to take these medications on this website under ‘Information’ – ‘How to take Medications’.
  • Physiotherapy for Vulval Pain is particularly helpful for women with pain triggered by sexual intercourse. An experienced women’s health physiotherapist can teach women how to relax the sore, tight muscles of the pelvis.
  • Pain Psychology.
    • Living with a vulval pain syndrome can have a negative impact on self-esteem, mood and anxiety. Research shows us that depression and anxiety make pain more difficult to manage and can even intensify feelings of pain.
    • An experienced pain psychologist can help women to learn how to better manage their pain, improve their relaxation techniques reduce anxiety and improve their mood and feelings of well-being.
  • Sex Therapy
    • Women with vulval pain syndromes often struggle with sexual and relationship problems as a consequence of their pain. Low libido, pain with arousal or decreased arousal and lack of orgasm can be a cycle that sex therapists can help women and their partners to break.
    • Sex therapists can help couples to find ways to engage in non-painful sexual activity and improve intimacy. The good feelings that such intimacy and pleasure generate can also help to reduce pain.
  • Nerve blocks and Botulinum Toxin Injections
    • Some women respond well to ultrasound-guided injections of local anaesthetic into entrapped nerves.
    • Botulinum Toxin (Botox or Dysport) injections to the pelvic floor muscles can help women to progress with physiotherapy and thereby reduce their vulval pain.

• Don’t despair if your pain comes back after a period of improvement – these problems can come and go. With time, these flares will last for shorter periods of time and you’ll get on top of them more quickly. Improvement can take weeks and sometimes months, so be patient and kind to yourself and your body.Be wary of practitioners who offer you a ‘quick fix’, or non-evidenced based therapies. Only a doctor or a women’s health physiotherapist is appropriately trained to examine your genital area.

• The International Society for the Study of Vulval Disorders – www.issvd.org
• The Australia New Zealand Vulvovaginal Society – www.anzvs.org