Vulvodynia: Defining and treating chronic vulvar pain

By Tiffaney Marlow, Reg. PT

There have been more and more articles in popular culture describing women’s struggle with vulvar and vaginal pain. In an era where women’s health seems to be making its way to the forefront, it is uplifting to see articles detailing what was once a taboo topic that women often hid or ignored. Statistics show upwards of 16% of women will experience vulvodynia in their life (1). Knowledge is power and we want to make sure that women struggling with vulvar pain get the right information so they can make the best-informed decisions about their care.

So, what is vulvodynia?

To understand vulvodynia we have to first understand what the vulva is. The vulva is actually the external female genitalia. It includes the mons pubis (pubic mound), the labia majora and minora, the clitoris and the clitoral hood, as well as the vaginal vestibule or entrance of the vaginal opening.  This is not the same as the vagina which is the muscular internal canal which connects the external opening to the uterus.

Vulvodynia is an umbrella term defined as vulvar pain at least three months with no identifiable cause (2). This pain cannot be traced back to a specific cause such as an infection, inflammatory skin disease, neural irritation, trauma, surgery or hormonal changes (2). Vulvodynia is typically a diagnosis of exclusion, meaning all other causes of vulvar pain have been ruled out before a patient is diagnosed (1). The pain experience can vary greatly from one woman to another, with women often describing their symptoms as itching, burning, stinging or raw (1).

Despite the variation in symptoms, we attempt to classify vulvodynia with a few key descriptors. The pain can be described as:

• Localized (ie. Affecting only the clitoris or vaginal opening), Generalized (affecting the entire vulva) or Mixed (2)

• Provoked (requiring some form of contact), Spontaneous (pain without a provoking factor) or Mixed (2)

• Intermittent, Constant or having a Delayed onset after provocation (2)

Although there may be no specific cause of this vulvar pain there are some factors which have been associated with vulvadynia (2), these may include:

• Other genitourinary pain syndromes (ie. painful bladder syndrome, urinary frequency and urgency or pain with urination)

• Genetics

• Hormonal factors (ie. caused by some medications)

• Inflammation

• Musculoskeletal (ie. tight and overactive pelvic floor muscles)

• Neurological (ie. a sensitized nervous system)

• Psycho-social factors (ie. mood or sexual function)

• Changes in the structure of the vulva

With no clear cause of vulvodynia and such a diverse presentation, it is clear why many women see multiple health care specialists before a diagnosis is made (1). This is not only a burden to our healthcare system but more importantly to the women affected (4). The impect of vulvodynia is widespread and can be damaging when women don’t receive proper care.

So, how do we treat vulvodynia?

There are no specific guidelines for treating vulvodynia as each presentation is so unique, however, a multi-modal approach is considered best practice (1). Psychological support is strongly recommended as women dealing with chronic vulvar pain are susceptible to anxiety, stress and depression (1,6). There are also options for medical management such as hormonal therapies and anticonvulsants, although the research and evidence for these treatments is not conclusive (6).

Pelvic physiotherapy plays a significant role in helping women suffering from chronic vulvar pain (1,5,6). Women with vulvodynia may experience shortening or tightening of the pelvic floor musculature, weakness and poor control of the pelvic floor as well as reflexive spasms of these muscles in response to pain (1,2). With soft tissue release, exercise and education a pelvic floor physiotherapist can help to improve body awareness and posture, release tension in the pelvic floor and improve control (both contraction and relaxation) of the pelvic floor musculature (1).

Pelvic physiotherapists can also play a role in treating a sensitized nervous system. Long term exposure to pain can modify the nervous system, changing the way peripheral nerves and the brain respond to a stimulus. A typically non-painful stimulus, such as light touch, may be perceived as painful. Physiotherapists, through graded exposure, improved body awareness and pain education can help to desensitize the sensitized nervous system.

For many women, validation that their pain is real, is the first step in the treatment of vulvodynia. If you have been diagnosed with vulvodynia, book an appointment with a pelvic physiotherapist today!

References:

Photograph by @alexsiapriolo, vulvar ornament by Feltmelons.

1) Sadownik L. Etiology, diagnosis and clinical managment of vulvodynia. Int J Women’s Health. 2014; 6:437-440

2) Bornstein J, Goldstein A and Coady D. 2015 Consensus terminology and classification of persistent vulvar pain. International Society for the study of vulvovaginal disease, International Society for the Study of Women’s Sexual Health and the International Pelvic Pain Society

3) Brotto L, Yong P, Smoth KB and Sadownik L. Impact of the multidisciplinary vulvodynia program on sexual functioning and Dyspareunia. J Sex Med. 2015 12 (1):238-247

4) Xie Y, Shi L, Xiong X, Wu E, Veasley C, Dade C. Economic burden and quality of life of vulvodynia in the United States. Curr Med Res Opin. 2012;28:601-608.

5) http://www.vulvalpainsociety.org/vps/index.php/treatments

6) Goldstein A, Pukall C, Brown C, Bergeron S, Stein A, Kellogg-Spadt S. Vulvodynia: Assessment and Treatment. The Journal of Sexual Medicine. 2016 13(4): 572-590