Vulvar Pain Syndrome

Vulvar pain syndrome, also called vulvodynia, is vulval pain lasting at least 3 months with no clear cause such as infection, skin disease or neoplasia. It may be generalised or localised, provoked or spontaneous.

• Common patterns are provoked vestibulodynia and generalised unprovoked vulvodynia.
• It involves nerve sensitisation, pelvic floor muscle overactivity and psychological factors.
• Treatment uses several approaches together.

Burning, stinging, rawness, irritation or aching of the vulva, and pain with touch, tampon use, intercourse, cycling or tight clothing.

• The vulva looks normal or mildly red; the cotton-swab test finds painful points.
• Differential diagnosis: candidiasis, herpes genitalis, lichen sclerosus, lichen planus, contact dermatitis, atrophic vaginitis, pudendal neuralgia, pelvic floor myalgia, vulval intraepithelial neoplasia.
• Complications: dyspareunia, avoidance of intercourse, depression, anxiety, relationship strain, chronic pain.

Diagnosis is by exclusion.

• History of onset, location, triggers and treatments; examination with a moistened cotton swab touching the vestibule, labia and perineum, graded 0 to 10.
• Vaginal swab and potassium hydroxide preparation for candidiasis; herpes PCR if lesions; STI tests.
• Biopsy for skin changes; pelvic floor examination for tender muscles.
• Screen for depression and anxiety.

Combine skin care, physiotherapy, psychological therapy and drug treatment, and escalate slowly.

• Supportive: gentle skin care with water or soap substitute; avoid irritants and tight clothing; cold gel packs; cotton underwear; lubricants during intercourse; pelvic floor physiotherapy; sexual and cognitive behavioural therapy; pacing of activities.
• Pharmacological: lignocaine 5 percent ointment 1 to 2 g applied to the vestibule 20 to 30 minutes before intercourse. For generalised pain: amitriptyline 10 mg oral at night, increased by 10 mg every 1 to 2 weeks to 50 mg (maximum 100 mg); or gabapentin 100 mg oral at night, increased by 100 to 300 mg every 3 to 7 days to 300 to 600 mg 8-hourly (maximum 3600 mg in 24 hours); or pregabalin 75 mg oral at night increased to 150 mg 12-hourly (maximum 600 mg in 24 hours). Treat associated candidiasis with clotrimazole 500 mg pessary single dose.
• Procedures: botulinum toxin injection to pelvic floor muscles and nerve blocks (pudendal) in specialist care; vestibulectomy for severe localised provoked pain unresponsive to other treatment.
• Special groups: in pregnancy avoid amitriptyline, gabapentin and pregabalin where possible; use lignocaine ointment and physiotherapy. In elderly women start amitriptyline at 10 mg or avoid it. In renal impairment reduce gabapentin (creatinine clearance 30 to 59 mL/minute: 200 to 700 mg oral 12-hourly; 15 to 29 mL/minute: 200 to 700 mg oral once daily) and pregabalin (creatinine clearance 30 to 60 mL/minute: maximum 300 mg daily in 2 to 3 doses).
• Red flags: suicidal thoughts, new ulcers or white plaques, bleeding, pain with fever, neurological deficit.
• Follow-up: review at 4 to 6 weeks, then every 3 months; titrate drugs slowly; refer to a pain or vulval clinic if no response after 3 months.