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Vulvodynia – Pain Down There

Barb Dehn | Speaker | Skin Bones CME
By: Barb Dehn, NP, FAANP, NCMP

A very challenging condition women come to me with is pain around their labia, vagina, and genital region, known as Vulvodynia. The highest incidence is seen in ages 18-25, but can occur at any age. These extremely distressing symptoms can make having sex out of the question, and many women find that even their clothing, no matter how loose, will trigger pain. Also, many times there are no visible signs or symptoms, such as a rash or redness, which can further delay diagnosis and treatment– not to mention making a woman feel crazy.  

2 Classifications of Vulvodynia

There are many different reasons for vulvar and genital pain. The way we providers classify them is whether the pain occurs all the time and is in not-response to something (unprovoked), or it occurs only as a response and therefore, is provoked.

Provoked Vulvodynia 

With provoked Vulvodynia, the pain occurs when something touches the outer area of the genitals surrounding the vaginal opening, including the labia minora, labia majora, clitoral hood, urethra or the vaginal opening itself. 

Possible triggers are:

• sexual intercourse
• inserting a tampon
• a gynecological exam
• prolonged sitting or cycling
• wearing tight pants
• Infections

Unprovoked (generalized) Vulvodynia is not caused by a particular trigger, and some women experience pain all the time. Others have episodes of pain in different spots, with periods of relief. Women report various kinds of pain:

• Burning pain
• Pinpoint pain
• Stinging pain
• Itching pain
• Aching pain

Causes and Diagnosis: The Q-tip Test

Though we don’t always know the cause of Vulvodynia, here’s what we think is happening. The nerves under the skin may have become sensitized by a previous trauma, infection, or irritation. They continue to produce chemical proteins (chemokines and cytokines) that further the cycle of inflammation and irritation by directly activating pain-sensitivity neurons. This heightened sensitivity is called hyperalgesia, where the nerves are overreacting to even a light touch. Nerve-type (neuropathic) pain is difficult to track down to a specific cause and is also hard to treat. 

The Q-tip Test

The way we diagnose Vulvodynia is to use a Q-tip swab to find the areas that are painful. Many providers also use magnifying glasses or a vulvoscopy to further inspect the area. Once the area has been identified, we can start to formulate a plan for treatment. 

A Real Patient Story 

I saw a woman recently, Alexa, (not her real name) who had been to see four different providers for over two years for recurrent vaginal infections and pain around the vaginal opening that just wasn’t getting any better. She had not been able to have penetrative intercourse with her long-term partner without debilitating pain for a year. Even getting aroused from oral and manual stimulation started her pain cycle. 

During her exam, I noted that she had a slight amount of redness at the lower part of the vaginal opening, and a Q-tip touch test revealed two areas that were exquisitely tender. She described them as an 8 out of 10 on the pain scale. Incidentally, she also had bacterial vaginosis (BV) at the time.

We treated the BV, and I provided her a range of “tools” for her treatment box to help reduce her symptoms. We talked about how the research from the National Vulvodynia Association NVA shows that treatment can take between 3-6 months. 

I advised her to choose whichever treatments suited her day-to-day situation. They included:

• Access to a pelvic floor physical therapist to help with any overly contracted muscles of the pelvic floor. 

• Liberal use of ice packs for acute pain, especially at night.

• A compounded cream that she could apply to the area, which included lidocaine, baclofen, and amitriptyline – the idea behind this is that this combination helps quiet the overactive nerves and stops the cycle of inflammation. I cautioned Alexa that this often takes months of daily use to achieve pain relief. 

• Scaling back on exercises that put pressure on the vulva, which meant no more cycling, spin class, running, or horseback riding.

• A shopping opportunity to buy white cotton underwear and avoid thongs that often provide too much pressure on the area that’s irritated – dyes and polyester underwear may trigger inflammation and many women find that just switching to white cotton undies increases comfort.

• Advice to skip the underwear and wear loose skirts and pants while at home.

• Avoiding soap to cleanse as it’s very drying, instead, using a gentle cleanser such as Cetaphil or CeraVe

• Using a hairdryer set to a cool setting to dry off after a bath or shower.

This was Alexa’s specific and unique treatment toolbox; yours might be different. 

After 6 months, Alexa was able to have intercourse, and her pain levels went from an 8 to a 1-2 depending upon the day. She sometimes has flares, and when she does, she only needs 1-2 days of treatment to keep her symptoms quiet.

If you’re experiencing vulvar and vaginal pain, known as Vulvodynia, do look for a women’s health provider who has experience treating Vulvodynia, or refer them to this website: NVA.org for treatment plans. 

Here’s a resource to find a pelvic floor physical therapist:  https://www.womenshealthapta.org/patients/

Here are more resources for help with keeping your pelvic floor healthy: 

• https://www.health.harvard.edu/womens-health/pelvic-physical-therapy-another-potential-treatment-option

• https://www.niddk.nih.gov/health-information/urologic-diseases/kegel-exercises

• www.kegel-exercises.com

• http://pelvicphysiotherapy.com/pelvic-floor-release/

Please let me know if you have any success stories or tips to share.

See Barb Dehn, NP, FAANP, NCMP speak at a 2020 Skin, Bones, Hearts & Private Parts event in Virginia Beach • San Antonio • Orlando • Las Vegas