www.vulvalpainsociety.org).Vulval pain has many causes—inflammatory, infectious, and neoplastic. This chapter describes an approach to managing vulvodynia as a cause of vulval pain; however, pain management principles can be applied to other causes of vulval and pelvic pain, and apply to male urogenital pain.
Vulvodynia is described as ‘vulval discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder’ (International Society for the Study of Vulval Diseases).
• provoked: pain occurs on touch
• spontaneous: pain can occur at any time
• mixed: occurs on touch, but can also be spontaneous.
It is then subdivided into:
• local: an isolated area of pain (vestibulodynia)
• generalized: it is more widespread over the vulval area.
Vulvodynia is a clinical diagnosis without identifiable pathology. It is important not to diagnose someone with vulvodynia unless other causes of vulval pain are excluded; otherwise pathology and treatment options may be missed. Descriptions such as vestibulitis and vulval dysaesthesia should be avoided as they can lead to confusion.
It is not uncommon for ♀ to have experienced many years of symptoms before a diagnosis is reached. They have often self-treated for Candida infection or may have attributed their symptoms to other causes, such as the menopause. Recognition and appreciation of a defined clinical entity is important and reassures the patient.
Vulvodynia can be devastating for the ♀—it can affect intimate relationships, and lead to social isolation and depression. Both the physical pain and the psychosocial consequences of the pain need management.
About 50% will have a trigger factor, e.g. childbirth, chronic candida infection. The remaining cases develop gradually, with no identifiable provoking factor. Several aetiological factors have been proposed, including pelvic floor muscle hypertonicity, genetic factors, bacterial inflammatory processes, and altered CNS function. It is likely to be multifactorial. The European Association of Urologists Guidelines on chronic pelvic pain are updated annually and available online. The introduction contains details on aetiology and mechanism of pain.
Neuralgic type vulval discomfort is characterized usually by burning, stinging, irritation, and/or rawness. Symptoms may be described as hyperaesthesia (exaggerated pain response) or allodynia (when sensation differs to that applied, e.g. light touch can cause pain response).
For ♀ with unprovoked pain, symptoms can worsen while sitting and towards the end of the day. Provoked pain typically causes associated intolerance of tampon insertion because of local pain, and pain on touch or attempted vaginal entry (superficial dyspareunia).
Management should be a team approach. Involve the GP, specialist physiotherapist, psychosexual therapist (if relevant), and pain team, in addition to the vulval specialist. The biopsychosocial approach to pain management should be followed.
• Explore the site and extent of pain, psychosexual and relationship issues, and possible features of depression.
• Ask the patient what the pain prevents them from doing.
• Ask the patient to score the pain on a scale from 0 to 10 (where 10 is the worst pain imaginable).
• Check if pain is provoked by sitting and relieved by standing, which can be a sign of pudendal neuralgia (refer to pain team for assessment and pudendal nerve block).
• Is the pain intermittent lasting few days/weeks then resolving completely before next episode, or do exacerbations follow this pattern? Atypical herpes presentation could be considered, and trial of suppressive acyclovir prescribed.
• Do they experience pain elsewhere – bladder pain, bowel pain (irritable bowel syndrome), dysmenorrhoea, trigeminal neuralgia, fibromyalgia.
• Establish who they have seen and are currently under, and what investigations have been performed. Gain consent to communicate with all those involved in care to ensure team approach to pain management.
No visible signs usually, but can be associated with varying degree of erythema. However, a light touch with a cotton bud can produce pain that outweighs any mild erythema present. It can be useful to map out the area of pain experienced, to determine whether it is local or generalized.
• Exclude other causes: full STI screen (including tests for chlamydia, gonorrhoea, trichomonas, and candida, and microscopy.) Blind self-taken swabs should be considered if speculum not tolerated.
• Examine vulval skin for signs of genital dermatological conditions.
• In cases of diagnostic uncertainty, a second opinion may be helpful.
• Pelvic MRI for unprovoked pain is not routinely recommended. Consider imaging if associated back pain, unilateral pain, or history of trauma.
• Biopsy is not helpful unless a genital dermatosis suspected.
• Establish the diagnosis: if it is uncertain diagnose ‘vulval pain of unknown cause’ until clear.
• Provide verbal and written advice on vulvodynia.
• Give details of Vulval Pain Society for further information and telephone advice ( www.vulvalpainsociety.org).
• Avoid skin allergens and advise washing with a soap substitute, such as epaderm ointment.
• Advise those who experience pain on sitting to purchase a doughnut-shaped cushion.
• 5% lidocaine ointment can be applied to site of pain if external for men and women. Takes 10 minutes to start taking effect.
• Always suggest small test area to genitals first, as some may experience burning. Advise the patient to wait for 10 minutes after applying and if the area is still burning, wash off the ointment thoroughly. Burning sensation usually subsides after a couple of minutes.
• Can be used ‘as and when’ (e.g. prior to sex, car journeys, or other provoking factors), or applied regularly qds.
• If using for sex: non-latex condoms need to be used to prevent lidocaine transferring on to partner. Lidocaine can affect the durability of latex condoms.
• Alternatively, place lidocaine on cotton wool pad/ball and apply to area of pain at night, wearing underwear to keep in place. Wash off next morning. If no adverse reaction, continue every night for 3–6 months (some evidence to support lasting analgesic effects.)
• Useful for managing unprovoked pain: evidence for provoked pain less clear, but can be used when topical, physiotherapy, and psychological therapies are not resolving pain
• Start dose low and build up gradually: explain to patient that benefit might not be immediate or occur at low dose. Roughly 1 in 3 ♀ have to switch treatments due to side effects, and 1 in 3 ♀ do not gain relief from the chosen treatment and need to switch. Therefore, unusual to get a ‘quick fix’ and patients should be aware of this.
• Consider simple analgesia if they are providing partial benefit (paracetamol, NSAIDS, codeine phosphate), while awaiting effects from/in addition to other oral treatments listed below. Discontinue if ineffective or if side effects outweigh benefits.
• Once pain controlled, continue drug treatment for a period of stability (months). They should not be stopped suddenly, but withdrawn slowly (build-up in reverse), while assessing effect. If pain returns, continue drug in lowest effective dosage. Can be difficult to discontinue. Support and reassurance vital.
• Things to consider when choosing drug options:
• drug interactions with other medications
• check contraindications in BNF
• previous treatments tried (what dose did they reach, why did they stop); often drugs stopped too soon or used incorrectly, and taken ‘as and when’, rather than daily. Consider retrying. Good practice to include detailed relevant drug history in correspondence
• other symptoms—depression, anxiety, urinary frequency (may be able to choose a drug that treats these symptoms, too)
• drugs such as pregabalin have a ‘street value’.
• First line: nortriptyline, amitriptyline, and/or gabapentin.
• Nortriptyline/amitriptyline: start at 10 mg and increase every 1–2 weeks by 10 mg to maximum of 75 mg. Amitriptyline cheaper than nortriptyline and often used first line, but if not tolerated, a direct switch at the same dose can be made between the two drugs. If unable to exclude arrhythmia/cardiac history, request ECG prior to starting nortriptyline. If dose not tolerated due to side effects consider:
• switching amitriptyline to nortriptyline
• switching nortriptyline to gabapentin.
• If benefiting from sedative effects, but not complete analgesic response, continue nortriptyline/amitriptyline, add gabapentin, and assess monthly for analgesic effect up to 2 months.
• Gabapentin: consider baseline FBC, urea & electrolytes (U&E), LFT (if normal no need for further monitoring, but if continuing long term, consider an annual check). See Table 31.1 for dose increases. If dose tolerated, continue to next step. If pain relief not achieved following 2 weeks of 900 mg tid, then unlikely to improve further. Swap gabapentin to pregabalin if side effects.
• Pregabalin: consider baseline FBC, U&E, LFT (if normal no need for further monitoring, but if continuing long term, consider an annual check). Remember cost of pregabalin is per tablet, not dose, therefore, do not prescribe 75 mg tablets for 300 mg dose as this is ×8 more expensive. This does not apply to gabapentin. If not helping, wean patient off and try something else. Escalation steps—every 3–7 days depending on tolerability (see Table 31.2).
• Duloxetine: this is more expensive so reserve for when other medication is contraindicated or fails to reduce pain. No blood monitoring needed. Suggest taking with food before bedtime. Start 30 mg for 2 weeks and increase to 60 mg from week 3 if needed.
Table 31.1 Gabapentin dose increases
| Week | Dose am | Dose noon | Dose bedtime |
| 1 | 0 | 0 | 300 mg |
| 2 | 300 mg | 0 | 300 mg |
| 3 | 300 mg | 300 mg | 300 mg |
| 4 | 300 mg | 300 mg | 600 mg |
| 5 | 300 mg | 600 mg | 600 mg |
| 6 | 600 mg | 600 mg | 600 mg |
| 7 | 600 mg | 600 mg | 900 mg |
| 8 | 600 mg | 900 mg | 900 mg |
| 9 | 900 mg | 900 mg | 900 mg |
Table 31.2 Pregabalin escalation steps
| Escalation steps | Dose am | Dose bedtime |
| 1 | 0 | 75 mg |
| 2 | 75 mg | 75 mg |
| 3 | 75 mg | 150 mg |
| 4 | 150 mg | 150 mg |
| 5 | 150 mg | 225 mg |
| 6 | 225 mg | 225 mg |
| 7 | 225 mg | 300 mg |
| 8 onwards | 300 mg | 300 mg |
• Pelvic hypertonia and vaginismus can be associated with any chronic cause of vulval pain. Use biofeedback technique to help relax pelvic floor to lessen pain (sensor is placed in vagina and contraction results in light change or computer image).
• Massage, TENS, and vaginal trainers can also be used.
• 70% of women have complete response or notice improvement for provoked pain.
Techniques such as mindfulness and cognitive behavioural therapy can be used to improve quality of life and improve pain-coping mechanisms.
Ideally, with their partner. Can help with 2° complications (e.g. vaginismus, loss of libido, anorgasmia, poor lubrication) and improving non-coital sexual contact.
• Codeine, dihydrocodeine, tramadol (in addition to above drugs): only continue if analgesic, rather than sedative benefit, not recommended long term.
• Strong opioids: discuss with pain team.
• Carbamazepine: discuss with pain team.
• Nerve blocks: discuss with pain team.
• Local excision: for localized provoked pain—combine with psychotherapy and consider only if all other options unsuccessful. Always remember to reconsider the diagnosis if patient is unresponsive to treatment. Modified vestibulectomy works best, with 90% having complete or partial response. Vestibuloplasty and laser vaporization are not recommended.
• Reduce urinary oxalate concentration: low oxalate diet and calcium citrate without vitamin D. Evidence lacking, but some patients find it helpful.
• Apply white soft paraffin over vulva for swimming.
• Antihistamines: if patient has dermographism.
• Acupuncture: some women with unprovoked pain have had benefit.
• Botox® injection into affected areas: to date, use is limited, but looks promising.
At least partial relief of symptoms occurs in 40–50% of cases (regardless of approach). If triggered by an infection, prognosis is better.