Vulvodynia (Chronic Vulvar Pain)

Vulvodynia is a chronic pain condition that affects the vulva, the external female genital area. It's characterized by burning, stinging, irritation, or rawness in the vulvar region that lasts for at least three months and has no identifiable cause. There are two main types: generalized vulvodynia, where pain occurs throughout the vulvar area, and localized vulvodynia (often called vestibulodynia), where pain is limited to specific areas such as the vestibule around the vaginal opening. Pain may be constant or intermittent and can be provoked by physical contact or occur spontaneously. Vulvodynia significantly impacts quality of life, often affecting physical activities, sexual function, and emotional well-being. Although there is no cure, various treatments can help manage symptoms and improve quality of life.

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What Causes It?

Nerve irritation or damage - Compression or injury to nerves that supply the vulvar area.

Pelvic floor muscle dysfunction - Tightness, spasm, or weakness in the muscles supporting the pelvic organs.

Abnormal inflammatory response - The body's immune system may react abnormally to injuries or infections.

Hormonal changes - Fluctuations in estrogen levels, especially during menopause, may contribute.

Genetic factors - Some research suggests a genetic predisposition to pain conditions.

History of infections - Recurrent yeast or bacterial infections may trigger vulvodynia in some women.

Allergies or irritants - Sensitivity to soaps, detergents, feminine hygiene products, or clothing.

Comorbid pain conditions - Women with vulvodynia often have other pain syndromes like fibromyalgia or irritable bowel syndrome.

Previous trauma to the vulvar area - From childbirth, surgery, or other sources.

Psychological factors - Stress, anxiety, and depression may not cause vulvodynia but can worsen symptoms.

Dietary sensitivities - Some women report flares with certain foods, particularly those high in oxalates or acidic foods.

Signs & Symptoms

Burning sensation in the vulvar area - The most common symptom.

Stinging, rawness, or irritation of the vulva.

Aching, soreness, or throbbing pain.

Pain with light touch or pressure (allodynia).

Discomfort during sexual intercourse (dyspareunia).

Pain when inserting tampons or during gynecological examinations.

Discomfort when sitting for extended periods.

Pain with tight clothing or activities like bicycling or horseback riding.

Symptoms may be constant or intermittent.

Pain can range from mild discomfort to severe, debilitating pain.

Some women experience pain only with pressure or touch (provoked vulvodynia).

Others have constant background pain that worsens with pressure (mixed vulvodynia).

Some have unprovoked pain that occurs without any pressure or touch (spontaneous vulvodynia).

How We Diagnose

Our specialists use advanced diagnostic methods to accurately identify and assess your condition

Medical History and Physical Examination

Your doctor will ask detailed questions about your symptoms, their onset, duration, and factors that worsen or improve them. A gentle physical examination of the vulvar area will be performed to check for visible abnormalities and to map painful areas using a cotton swab test (Q-tip test).

Cotton Swab Test

A cotton swab is used to apply gentle pressure to different areas of the vulva to identify and map specific painful locations. This helps determine if pain is generalized or localized and how severe it is in different areas.

Cultures and Testing for Infections

Samples may be taken to rule out vaginal infections like yeast, bacterial vaginosis, or sexually transmitted infections that could cause vulvar symptoms.

Colposcopy

An examination using a special magnifying device to closely examine the vulvar skin for subtle abnormalities that might not be visible to the naked eye.

Vulvar Biopsy

If there are concerning areas or lesions on the vulva, a small tissue sample may be taken to rule out conditions like lichen sclerosus, lichen planus, or vulvar cancer.

Pelvic Floor Evaluation

Assessment of pelvic floor muscle function, which may be performed by a gynecologist or a physical therapist specializing in pelvic health. This can identify muscle tension, weakness, or abnormal patterns that may contribute to vulvar pain.

Neurological Assessment

Tests to evaluate nerve function in the pelvic and vulvar area, which may help identify neuropathic causes of pain.

Treatment Options

Personalized treatment plans tailored to your specific needs and condition

Lifestyle and Self-Care Measures

Changes to reduce irritation, including wearing loose-fitting cotton underwear, avoiding potential irritants (soaps, detergents, feminine products), using lubricants during intercourse, applying cool compresses, and practicing good vulvar hygiene without excessive washing.

Topical Medications

Applied directly to the vulvar area, these may include lidocaine ointment for temporary pain relief, estrogen cream for postmenopausal women, topical gabapentin or amitriptyline compounded in special bases, or corticosteroid creams for certain inflammatory conditions.

Oral Medications

Various medications taken by mouth may help manage vulvodynia, including tricyclic antidepressants (like amitriptyline), anticonvulsants (like gabapentin or pregabalin), SNRIs (like duloxetine), or pain relievers as appropriate.

Pelvic Floor Physical Therapy

Specialized therapy focusing on relaxing and strengthening pelvic floor muscles, releasing trigger points, improving blood flow, and reducing pain through various techniques including manual therapy, biofeedback, electrical stimulation, and at-home exercises.

Nerve Blocks and Injections

Procedures to temporarily block pain signals or reduce inflammation, including pudendal nerve blocks, trigger point injections with local anesthetics or steroids, or botulinum toxin (Botox) injections for muscle spasm.

Psychological Approaches

While not implying vulvodynia is psychological in origin, cognitive behavioral therapy, mindfulness, and other approaches can help manage chronic pain, reduce anxiety, and address sexual difficulties that may arise from vulvodynia.

Complementary Therapies

Some women find relief with acupuncture, low-level laser therapy, hypnotherapy, or biofeedback training, though scientific evidence varies for these approaches.

Home Remedies

Gentle Vulvar Care

Wash only with water or a gentle, fragrance-free cleanser specifically for sensitive skin. Pat dry gently rather than rubbing. Avoid douches, feminine sprays, scented pads or tampons, and colored or scented toilet paper.

Cold or Warm Compresses

Apply a cold pack wrapped in a soft cloth to the vulva for 5-10 minutes to reduce pain and inflammation. Some women find warm compresses more soothing. Experiment to see which works better for you.

Clothing Choices

Wear loose-fitting cotton underwear and avoid tight pants, pantyhose, or synthetic fabrics that trap moisture and heat. Remove wet swimsuits or exercise clothes promptly. Consider going underwear-free at night to allow airflow.

Sitz Baths

Sit in a few inches of lukewarm (not hot) water for 5-10 minutes several times a day. Adding baking soda (1/4 cup) to the bath may provide additional relief. Gently pat dry afterward.

Lubricants and Moisturizers

Use preservative-free, water-based lubricants during sexual activity. For daily comfort, consider a vulvar moisturizer designed for sensitive skin. Avoid products with potential irritants like glycerin, propylene glycol, or parabens.

Stress Reduction

Practice stress-management techniques such as deep breathing, meditation, yoga, or progressive muscle relaxation. While stress doesn't cause vulvodynia, it can exacerbate pain perception.

Pelvic Floor Relaxation

Learn and practice pelvic floor relaxation exercises daily. One simple technique is to imagine your pelvic floor muscles softening and releasing downward, like an elevator gently descending. Hold this relaxed state for 30 seconds, then release.

Sleep Position

Sleep on your side with a pillow between your knees to reduce pressure on the pelvis. Use breathable cotton sheets and avoid tight pajama bottoms that might cause friction.

Prevention Tips

Follow a gentle vulvar care routine consistently, even when symptoms improve.

Avoid potential irritants identified through your experience with the condition.

Maintain regular, open communication with your healthcare providers about your symptoms.

Continue prescribed treatments, even after initial improvement, until advised otherwise.

Practice pelvic floor relaxation techniques regularly, not just during flare-ups.

Manage other health conditions that might impact vulvodynia, such as diabetes or hormonal issues.

Use appropriate lubricants and practice gentle techniques during sexual activity.

Consider pelvic floor physical therapy maintenance sessions if recommended.

Be mindful of activities that might trigger symptoms and plan accordingly.

Stay hydrated and maintain bowel regularity to reduce pressure on the pelvic floor.

Consider keeping a symptom journal to identify patterns or triggers.

Maintain a support network and consider counseling if vulvodynia affects your emotional well-being.

If using topical medications, follow application instructions carefully and consistently.

Attend all scheduled follow-up appointments to monitor progress and adjust treatment as needed.

Surgical Solutions

Advanced surgical procedures performed by our expert specialists

Vestibulectomy

A surgical procedure that removes painful tissue from the vestibule (the area around the entrance to the vagina). This is typically only considered for cases of localized provoked vestibulodynia that haven't responded to conservative treatments. The procedure involves removing the affected vestibular tissue and advancing the vaginal mucosa to cover the excised area. While success rates can be high for carefully selected patients, it carries risks including scarring, altered sensation, and potential complications with healing.

Perineoplasty

A surgical procedure that may be performed alongside vestibulectomy to address pain in the posterior vestibule and perineum. It involves removing and reconstructing tissue in this area. This approach may be considered when pain extends beyond the vestibule or when there are specific anatomical issues contributing to pain.

Neurectomy Procedures

Surgical interventions that target specific nerves contributing to vulvar pain, such as pudendal nerve decompression or vestibular neurectomy. These procedures aim to release entrapped nerves or interrupt pain signals. They are typically considered only in very specific cases where nerve involvement has been clearly identified and other approaches have failed.

Neuromodulation Implants

While not traditional surgery, the implantation of neuromodulation devices like sacral nerve stimulators involves a surgical procedure. These devices deliver mild electrical impulses to interrupt pain signals. This approach is typically considered only for severe, refractory cases of vulvodynia where the pain is thought to have a strong neuropathic component.

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