Chronic vulvar pain is common, affecting 4-8% of women at any given time. The most common cause is vulvodynia, defined as chronic vulvar discomfort or burning pain without an identifiable cause. Localized provoked vestibulodynia, characterized by pain with gentle touch in the vulvar introitus, is the most common presentation of vulvodynia. Management of vulvodynia is multidisciplinary and includes genital skin care, topical desensitization therapies, pelvic floor physiotherapy, pain modifying medications, and psychological support to reduce pain and improve quality of life. Regular review and a supportive patient-clinician relationship are important parts of managing this chronic condition.

1. Chronic vulvar pain
Dr Helen Henzell
Vulval Clinic
Melbourne Sexual Health Centre

2. Chronic vulvar pain is common
Population based surveys indicate that vulvar pain
lasting more than 3 months affects between 4 to
8% of women at any one time and 10 to 20% in
their lifetime Arnold. Am J Obstet Gynecol. 2007
The most common cause is vulvodynia

3. Conditions that can result in chronic vulvar pain:
VULVODYNIA
Infection – chronic candidiasis, BV, Trichomoniasis
Dermatoses –contact dermatitis, eczema, lichen simplex chronicus, psoriasis, lichen sclerosus, lichen
planus, plasma cell vulvitis
Trauma – repeated splitting
Post menopausal vulvo-vaginal atrophy and atrophic vaginitis
Neoplasia – VIN, SCC
Vaginismus
Neurologic – pudendal nerve neuralgia or referred pain from pelvic girdle

4. VULVODYNIA is defined by the International Society for the
Study of Vulvovaginal Disease (ISSVD) as:
“chronic vulvar discomfort, most often described as burning pain,
occurring in the absence of relevant findings or a specific, clinically
identifiable, neurologic disorder”
It is a diagnosis of exclusion where other causes of vulvar pain have
been excluded or where pain persists despite adequate management
of other conditions.
Moyal-Barracco. J Reprod Med. 2004

5. Vulvodynia
Pain is often described as burning or raw, but also sharp, tearing,
stabbing, aching, bruised, itchy
Pain may be generalized to the whole vulva, or localized to a
specific area such as the vestibule (vestibulodynia), or the clitoris
(clitorodynia).
The pain may be provoked (caused by direct touch, inserting a
tampon, or sexual touch), unprovoked (present without touch),
or have a mixed pattern

6. Women presenting with vulvodynia have often had pain for
several years
They are usually young, between 20 and 50 years of age
They have often been examined by many physicians before
diagnosis
They may have been told it is all in their head and
instructed to relax
They have often have been treated repeatedly for
vulvovaginitis candidiasis

7. Vulvodynia is associated with significant distress and confusion
Women often do not understand what is happening to their
body and may fear underlying malignancy or sexually
transmitted infection
Relationships and physical intimacy suffer
Secondary depression and anxiety are common
Women with vulvodynia have a 2-3 fold increased incidence of
co-morbid pain disorders
Reed. Obstet Gynecol. 2012

8. Common chronic pain conditions
Vulvodynia
Painful bladder syndrome (irritable bladder or interstitial
cystitis)
Chronic pelvic pain (endometriosis and dysmenorrhoea)
Irritable bowel syndrome
Fibromyalgia
Migraine and chronic tension headache
Chronic low back pain
Chronic neck pain

9. Chronic pain is characterized by:
CENTRAL SENSITIZATION
(augmented central pain processing)
PERIPHERAL SENSITIZATION
(lowered peripheral sensory threshold for pain)
Siddall. Anesth Analg. 2004

10. Vulvodynia generally falls into two broad groups:
localized provoked vestibulodynia (formerly
vestibulitis or vulvar vestibular syndrome) and
generalized vulvodynia (formerly essential or
dysaesthetic vulvodynia)
Localized provoked vestibulodynia (LPV) is by far
the most common presentation

11. Thanks to Dr Karen Berzins
Generalized vulvodynia Localized vestibulodynia

12. Generalized vulvodynia
Occurs in older women
Onset can be gradual or sudden
A diffuse pattern of unprovoked vulvar discomfort
Discomfort is often aggravated by any pressure on the vulva such as
tight clothing, prolonged sitting or bike riding
Sex can be pain-free
Visual examination is normal
Often respond to low dose oral pain modifying medication

13. Localized provoked vestibulodynia
Occurs in younger women
Typical history of pain or discomfort provoked by tampons, tight clothing,
sexual activity
Pain typically continues after intercourse (after sensation)
Pain may be so severe to preclude sexual activity
Usually pain free at other times (but sometimes there is unprovoked
background discomfort)
Visual examination normal
Characterized by pain with gentle touch in the vulvar introitus

14. Peripheral sensitization
In vestibulodynia there are localised
neuroinflammatory changes in the introital mucosa
including increased concentration of pro-
inflammatory peptides and hyperinnervation with
C-fibres. C-fibres are multimodal and when
stimulated result in prolonged burning. In addition,
there is over-activity of the pelvic floor muscles
resulting in a introital narrowing and muscle pain
Wesselmann. Pain. 2014

15. Typically examination is very normal

17. Lichen sclerosus

18. Erosive lichen planus

19. Plasma cell vulvitis

20. Lichen sclerosus and post menopausal atrophy –
pain resolved with vaginal estrogen

21. VIN – vulvar intraepithelial neoplasia

22. Trauma

23. Pain is a clinical diagnosis where other
conditions have been excluded or managed
Look carefully for splits if history suggestive
Check vaginal flora and culture for yeasts
Do not biopsy unless excluding other
dermatogical conditions

24. Recurrent vulvovaginal candidiasis is often
implicated in the onset of vulvar pain
Pain sensitizing effect of repeated painful sex?
Common inflammatory processes?
Have a high index of suspicion in any women
reported repeated episodes of vaginal yeast
infection and consider suppressive therapy

25. Examination
Explain what you are going to do at each step
Use a moistened cotton tipped swab to map areas of pain or
discomfort
Use a mirror to show the patient where the pain is
? apply of topical anaesthetic to introitus
Gently palpate pelvic floor muscles
Avoid speculum examination unless indicated for other
reasons

26. 2% xylocaine gel applied to introitus

27. Management is multidisciplinary
The goal of treatment is to reduce pain, improve quality
of life and sexual function
There is no strong evidence of benefit for any one
treatment Andrews. JCOM. 2010
What works for one woman may not work for another
Treatment is a process of trial and review
Treatments are often combined

28. Patient – clinician relationship is therapeutic
Education: addressing mechanisms of chronic pain can have a positive
effect on pain and disability Louw. Arch Phy Med Rehabil. 2011
To have a name for the pain and to know it is not cancer or an
infection is an enormous relief. To know that they are not mad.
Emphasize pain does not mean damage
Reassurance: This is a recognized condition with recommended
treatments and most women can expect significant improvement over
time
Regular review and support – patients are extremely grateful for your
care and positive physician-patient relationship is beneficial
Bystad. Psychol Res Behav Manag. 2015

29. Basic principles of treatment
Genital skin care in all
Peripheral desensitization – massage, topical therapies
Pelvic floor downtraining - physiotherapy
Central desensitization – pain modifying medication
Psychological – sleep, mood disorders, improved coping
(mindfulness, relaxation, counseling, hypnotherapy),
sexual counseling

30. Basics of genital skin care
Avoid potential irritants:
– Soap and shower gels
– Genital hygiene wipes
– Pads and panty liners
– Fabric softener
– Preservatives and perfumes
– Urine and faeces
– Medicinal and herbal topical products
Improve moisture:
– Avoid prolonged water contact
– Moisturize after washing

31. Topical medications to address peripheral sensitization
2-5% xylocaine gel or ointment – applied 10-20 minutes before sex,
can apply 2-5x daily
2-5% amitriptyline, compounded in a neutral base, applied 2 x daily
2% baclofen applied 2 x daily
2-6% gabapentin 2 x daily
Or combinations (amitriptyline and baclofen)
Massage (desensitization) with moisturizer

32. Address pelvic floor over-activity
• PHYSIOTHERAPY – specialized in vulvar pain
and downtraining
• Use of trainers

33. Pain modifying medication to address central
sensitization
Standard analgesia relatively ineffective in chronic pain.
There is no role for opioids or benzodiazepines in vulvodynia
Low dose tricyclic antidepressants (nortriptyline/amitriptyline
and desipramine) – start 5-10mg and slowly up-titrate
depending on beneficial effect vs side effects (usually max 50-
70mg). Cease if no effect after 6 weeks of maximum tolerated
dose
Gabapentinoids - gabapentin and pregabalin – start low and
go slow, side effect sedation
Other antidepressants - SNRIs like duloxetine and venlafaxine

34. Psychological therapies
Encourage women to look at self management
strategies to reduce anxiety, especially around
anticipation of pain – relaxation, mindfulness
Counseling can be very helpful to address effect of
pain on intimacy, relationships and self-esteem
Couple counseling and sexual therapy
Hypnotherapy

35. Other therapies
Surgery (vestibuloplasty) for a small number of selected
women who have very localized vestibular pain and have
failed other treatments - good evidence of benefit
Intralesional injections of steroid and local anaesthetic –
limited evidence
Botulin toxin injections – limited evidence
Low oxalate diets - controversial

36. How long to continue treatment?
The aim is to have repeated experience of reduced
pain so that this becomes the norm
If oral pain modifying medication is effective,
probably continue for 6 months, but sometimes
longer
In times of stress, pain can flare or recur – educate
in advance as women may misinterpret a flare of
pain and panic, which will wind up pain

37. Published guidelines on management
and resources for vulvodynia
Haefner et al. The Vulvodynia Guideline. J. Lower Genit
Tract Dis. 2005
Mandel et al. Guidelines for the management of vulvodynia.
Br J Dermatol. 2010
Sadownik L. Etiology, diagnosis and clinical management of
vulvodynia. Int J Womens Health. 2014
The National Vulvodynia Association. www.nva.org

38. Thankyou