VULVODYNIA

    Definition and Prevalence

    The term vulvodynia literally means pain, or an unpleasant, altered sensation in the region of the vulva. Vulvodynia is defined as chronic vulvar discomfort or pain that is often characterized by burning, stinging, irritation or rawness of the female genitalia. Theses symptoms occur in the absence of infectious or other skin diseases conditions of the vulva or vagina; sometimes only a small area of redness may be the only sign of the condition. Of the aforementioned symptoms, burning appears to be the most common symptom however the type and severity of symptoms are highly individualized. The pain can be of a constant or intermittent nature, and can be localized or diffuse. The symptoms can be mildly irritating or completely disabling to the woman. The prevalence of vulvodynia in one study is suggested to affect 1of every 6 women and symptoms were found equally distributed in white and non-white women.1 In a larger study, 4,915 women aged 18 to 64 from 5 different ethnic background were interviewed regarding symptoms of vulvodynia; 16% of those surveyed reported a history of chronic burning pain and 7% were experiencing such symptoms at the time of the survey.2 This same study found that white and African American women had similar lifetime prevalence of vulvodynia symptoms while Hispanic women were 80% more likely to experience symptoms of vulvodynia than white or African American women.

    In women that have become pregnant since being diagnosed with vulvodynia, one survey reported that 30% of women experienced an improvement in symptoms while 40% experienced no change in symptoms during or after pregnancy; overall pregnancy was not associated with worsening of pain in most of the women surveyed.3

    Unfortunately, because of the lack of definite signs as well as physician education, oftentimes doctors mistakenly suggest that this is a psychological condition resulting in the patient seeing multiple doctors before the correct diagnosis and treatment can be made.

    The symptoms of vulvodynia can have a profound negative impact on the woman’s quality of life; affecting her ability to engage in normal everyday activities such as sitting at a desk, exercising, engaging in social activities as well as intercourse. Additionally, these limitations also negatively affect self image and can lead to symptoms of depression as well.

    Classification:

    vulvodynia can be classified into distinct subtypes:4

    1. Dysesthetic Vulvodynia (generalized vulvar dysesthesia): These symptoms are often varied, and appear in different locations at different times. The painful sensation may be present in the labia majora, labia minora, and the vestibule area. Additionally, pain may be felt in the clitoris, mons pubis, perineum, and the inner thighs as well. Symptoms are not necessarily caused by touch or pressure to the vulvar area (as with intercourse or sports activities) but these factors can aggravate the symptoms as well.

    2. Vulvar Vestibulitis Syndrome (vulvar dysesthesia localized in the vestibule): These pain symptoms occur only in the vestibule and only following touch or pressure in the area. The most common pain sensation is burning and may be experienced during intercourse, tampon insertion, gynecologic examinations, tight underwear/pants and bicycle riding.

    3. Other conditions that cause chronic vulvar pain and may exacerbate vulvodynia:

    • Cyclic Vulvovaginitis: Women with this condition often have recurrent burning and itching symptoms that occur at the same stage of the menstrual cycle; many are also affected by similarly occurring yeast infections.
    • Vulvar Dermatoses: There are several dermatologic conditions that can lead to chronic pain in the vulva; the most common are allergic or contact dermatitis, lichen planus, lichen simplex chronicus, or lichen sclersosis. All of these cause itching and burning symptoms that are worsened by the woman scratching the itch or overusing topical medications that can lead to inflammed tissue.

    Causes:

    The exact cause of vulvodynia is unknown at this time; however it is more than likely due to a variety of factors such as:

    • Injury or irritation of the nerves serving the vulva
    • Allergy to environmental irritants
    • Hypersensitivity to candida (yeast)
    • Excess oxalate crystals in the urine
    • Spasms in the muscles supporting the pelvic organs

    Despite the fact that infection is often indicated as a causative factor, the evidence for this or other inflammatory processes is minimal at this time. Immunohistochemical studies have revealed altered nerve ending densities and that of estrogen receptors as well. Vulvodynia is not caused by sexually transmitted infections or other infectious processes, despite many patients pointing to infectious processes as worsening their symptoms of vulvar pain.

    In a survey study of women who frequented vulvodynia-based Internet discussion panels, the large majority felt that among the most probable causes of their symptoms were yeast infections, stress, antibiotic use, other vaginal infections, and various chemicals as playing a contributing role.5 Other factors that were often present with vulvodynia in this survey were irritable bowel syndrome, fibromyalgia and interstitial cystitis, hinting at the possibility that vulvodynia relates to broader conditions in the body that are not only localized to one area.

    Diagnosis and Treatment

    Vulvodynia, in many cases, is termed a diagnosis of exclusion. This means that once all other possible causes of pain and irritation are ruled out, the patient is diagnosed with vulvodynia. Conditions to be ruled out include chronic or active yeast infections, herpes, skin conditions such as eczema, psoriasis or other dermatitis, and bacterial infections. Examination can reveal mildly inflammed or swollen tissue or completely normal looking tissues; most of the time the tissue appears healthy.

    Standard treatments for vulvodynia are primarily directed at symptom relief using pharmaceuticals such as anticonvulsants, tricyclic antidepressants, and local anesthetics in order to alter nerve conduction, and other methods such as interferon treatment and nerve blocks whereby local nerves are numbed or destroyed in order to alleviate the pain signaling pathway to the brain. Other treatments directed at the cause of the symptoms utilize biofeedback (a method of teaching a person to control body functions that are not normally controllable), pelvic muscle training, dietary modification, and counseling. Finally, surgical intervention is offered as a last resort when standard treatments do not provide adequate relief.


    1Smart OC, MacLean AB. Vulvodynia. Curr Opin Obstet Gynecol. 2003 Dec;15(6):497-500.

    2Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003 Spring;58(2):82-8.

    33 Reed BD, Haefner HK, Cantor L. Vulvar dysesthesia (vulvodynia). A follow-up study. J Reprod Med. 2003 Jun;48(6):409-16.

    4Edwards L. New concepts in vulvodynia. Am J Obstet Gynecol. 2003 Sep;189(3 Suppl):S24-30.

    5 Gordon AS, Panahian-Jand M, Mccomb F, Melegari C, Sharp S. Characteristics of women with vulvar pain disorders: responses to a Web-based survey. J Sex Marital Ther. 2003;29 Suppl 1:45-58.