Vulvodynia - how to treat pain in intimate areas?

What is vulvodynia?

It is an uncomfortable sensation in the vulvar area, often described by the patient as a vaginal burning/stinging sensation occurring without any apparent infection or a specific neurological disorder. Its symptoms include itching, stinging, burning, stinging, or a tearing sensation in the vulvar area. This condition affects approximately 3-14% of the population and is associated with other pain conditions such as cystitis, irritable bowel syndrome, and fibromyalgia.

Chronic vulvar pain associated with vulvodynia negatively impacts relationships and can contribute to fertility problems and increase the rate of cesarean sections. It often occurs alongside chronic stress and an increased fear of pain, which can lead to exaggerated sensations of pain in the intimate area. Due to the fact that current medicine cannot clearly identify the cause of this perineal dysfunction, diagnosis and treatment are difficult, and the results are often unsatisfactory for the patient (difficult intercourse).

Is all sexual discomfort or pain in the intimate areas vulvodynia?

When suffering from any ailment, we tend to simplify diagnosis, and any persistent intimate pain (vulvar pain) would be classified as vulvodynia – this is a mistake. The most recent classification of the causes of this condition dates back to 2015, but it is quite possible that this will change in the coming years. Currently, vulvodynia refers to pain lasting at least three months without a specific cause. Therefore, we must exclude a whole group of causes of vulvar pain – in which case it is NOT vulvodynia. The causes of vulvodynia are not yet known (many of them are not entirely certain assumptions).

Vulvar pain resulting from a clear cause (not considered vulvodynia)

Other conditions that can cause pain in the intimate areas include:

• fungal and bacterial infections
• inflammations, e.g., lichenoids and dermatological lesions
• cancers
• neurological conditions, e.g., neuroma, pudendal nerve compression, neuralgia
• iatrogenic conditions after radiotherapy/chemotherap,
• hormonal conditions, e.g., hypoestrogenism during lactation, postmenopausal syndrome

Vulvodynia - pain affecting the vulva without a clearly identifiable cause

Vulvar pain that lasts continuously for 3 months without a identifiable cause is considered vulvodynia according to the 2015 consensus.

Types of vulvodynia:

• Localized, e.g., pain around the clitoris (clitrodynia), pain at the vaginal introitus (vestibulodynia), generalized, and mixed.
• Provoked - symptoms occur during intercourse or a gynecological examination, spontaneous or mixed.
• Primary (if always present) or secondary (if occurring at some point in a woman's life).
• Intermittent or constant, delayed, depending on the onset and duration.
  
  

What are the possible causes of vulvodynia?

The causes of vulvodynia postulated by researchers include:

• Genetic causes - recurrent vaginal infections, which can cause pain but also complicate resolution of the inflammatory response, even if the infection has been treated.
• Women with a tendency to allergies and hypersensitivity are more likely to suffer from vulvodynia. Androgens affect receptors around the vulva, and dysregulation of vulvar estrogen receptors has been observed in vulvodynia
• Improper pelvic floor muscle tone - primarily increased and hyperactive pelvic floor muscles. Combined hormonal contraception negatively impacts the function of these muscles, negatively impacting pain not only through vaginal dryness. Until recently, the term "vulvodynia" was used to describe a pain syndrome caused by pelvic floor muscle dysfunction. This term is no longer used to diagnose the condition.
• Nervous system - as a result of its effects, healthy women perceive ordinary touch, while women who are in pain do.
• Depression - Living with pain worsens mood and increases the risk of depression. It can also be a comorbid condition, independent of the pain itself. Women with diagnosed depression, anxiety disorders, and severe past traumas are more susceptible to vulvodynia.

What are the symptoms of vulvodynia?

Symptoms of vulvodynia can vary from case to case, but generally include:

• Vulvar pain: This can be felt as a burning, stinging, dryness, discomfort, or sharp pain. This is the main symptom of vulvodynia.
• Pain and discomfort with touch: Many women experience pain with light touch, such as when wearing tight clothing, having intercourse, standing, sitting, or even with gentle touch.
• Chronic nature of pain: The pain can persist for a long time, often for months or years.
• Pain occurring without visible skin lesions: Unlike other conditions, vulvodynia is not associated with visible skin lesions such as rashes or redness.
• Variable pain intensity: The intensity of the pain can fluctuate and change throughout the day; the pain has a neuropathic origin.
• Discomfort with daily activities: The pain can affect the ability to perform daily activities, such as walking, sitting, or playing sports.
• Sexual difficulties: Vulvodynia can cause pain during intercourse, which can impact your sex life and relationships.
• Discomfort when using the toilet: Urination may cause discomfort or pain.

Diagnosing Vulvodynia

To determine whether a patient suffers from vulvodynia, it is necessary to complete a complete diagnostic process, which the doctor then uses to make a diagnosis.

• Patient interview – duration of pain, observed associations with factors that exacerbate or alleviate pain, comorbidities
• Gynecological examinations called the "cotton swab test" or "Q-tip test." These involve touching sensitive areas. During the test, the doctor gently touches various areas of the patient's vulva with a cotton swab (similar to a small tampon). This process helps pinpoint the exact areas of tenderness or pain. The purpose of the test is to identify areas of pain and determine whether the pain is superficial (affecting the skin) or deeper. The test can also help differentiate vulvodynia from other causes of pain in the vulvar area.
• Rule out a current infection
• Hormonal tests – hyperthyroidism can alter nerve conduction, and diabetes can contribute to the development of neuropathy.
• Pelvic muscle tone assessment – ​​most often to rule out vaginismus or vaginal pain of other origins. Most often performed by a urogynecological physiotherapist. Ultrasound and EMG biofeedback may be helpful in the assessment to demonstrate the resting tone of the pelvic floor muscles, with the goal of muscle relaxation.
• Vulvoscopy – sometimes a local biopsy of the patient's vulva is indicated to rule out lichen planus or cancer.
• Neurological examination – to rule out compression of the pudendal nerve, lesions within the spinal cord, and the CNS.

How to treat vulvodynia?

How to treat a condition with unknown causes? A number of studies have been conducted demonstrating the effectiveness of various techniques, but not all have been recognized in the 2015 consensus of international and American organizations. However, it should be emphasized that research is ongoing, and medications and interventions that are not recognized in the aforementioned consensus are often used. Therefore, we have decided to divide vulvodynia treatment into three parts:

• Recognized by consensus, by the ISSVD, ISSWSH, and IPPS.
• Unrecognized by consensus, whose results are scientifically inconsistent and prevent their official recognition (which does not mean they do not improve the patient's quality of life).
• Urogynecological physiotherapy – recognized by consensus as effective, but sometimes using methods not specified in the consensus.

Recognized vulvodynia treatment methods according to the 2015 consensus:

• Changing women's habits – wearing breathable underwear, sleeping naked at night, using cosmetics that do not cause allergies in the intimate areas, avoiding sanitary pads, and vaginal douching with water.
• The occurrence of vulvodynia is directly related to neuropsychological mechanisms that contribute to the exacerbation of symptoms, therefore, psychotherapy is recommended in treatment. Vulvodynia can also be directly related to stress. Behavioral techniques, such as working with dilators, are used to reduce tension and stress, which in turn can reduce symptoms.
• Physiotherapy - described in the paragraph below.
• Contraception - changing the form of contraception can alleviate pain.
• Antidepressants (psychoactive medications) - discontinuing some medications can trigger the problem.
• Pharmacotherapy - no evidence of effectiveness; the only recommended treatment option is estrogen therapy for women during menopause or with other estrogen deficiency.
• Surgery - if pudendal nerve compression is detected or in the case of vestibulectomy (for a local cause and when other treatments have failed). Once pudendal nerve compression is detected, the condition is no longer classified as vulvodynia.

Other forms of therapy for intimate pain

The search for effective therapies to effectively treat this condition is ongoing. Below is a list of therapies that have sometimes been shown to be beneficial:

• acupuncture
• ESWT shockwave therapy
• perineal electrical stimulation (TENS)
• methods used in aesthetic gynecology, such as laser therapy

Vulvodynia – physiotherapy

A visit to a urogynecological physiotherapist can be very helpful. A physiotherapist can suggest:

• in many cases, in-depth ultrasound diagnostics and pelvic floor muscle tone assessment using EMG
• pelvic floor muscle training and relaxation training (reducing tension, which can increase pain sensations)
  
• behavioral therapy using standard dilators or magnetic dilators. This can also be helpful before sexual intercourse
• pelvic pain reduction techniques.