VULVAL PAIN ‘VULVODYNIA’ Melbourne Melbourne Sexual Health Centre

Melbourne
Sexual
Health
Centre
A part of Alfred Health
Melbourne Sexual Health Centre
580 Swanston Street
Carlton Vic 3053
Australia
Tel: (03) 9341 6200
Fax: (03) 9341 6279
Free Call: 1800 032 017
TTY: (03) 9347 8619
Web: www.mshc.org.au
VULVAL PAIN ‘VULVODYNIA’
WHAT IS IT?
Vulvodynia is typically pain when the vaginal opening
is touched or anything is put in the vagina. It occurs
in the absence of an obvious ongoing cause i.e. no
obvious infection or dermatitis, and the skin looks
normal. Pressure is felt as pain, and touching with
a cotton bud may produce a ‘cut glass’, burning or
tearing feeling. Sometimes the clitoral area is involved
as well. Uncommonly, vestibular pain may be felt
before any direct touching happens.
A less common pattern of pain affects the whole
vulva, or changing areas of it, without any direct
pressure or anything being in the vagina. This is pain
that is usually felt as a burning sensation, but can
also be a sensation of prickling, dryness (despite the
tissues being moist) or mild itch, .In this case, when
something is put in the vagina it is usually painfree,
or if there is burning nearby then it is not aggravated
by penetration. Again the skin looks healthy, but
examination and tests need to be performed to
exclude dermatitis and infections.
Both patterns of symptoms are treated as chronic
pain, and may be associated with pain conditions
affecting other parts of the body, eg. Irritable bowel,
irritable bladder, migraine, fibromyalgia and possibly
chronic fatigue syndrome.
ACT SHEET
Importantly, chronic vulval pain and tenderness
usually do not interfere with pregnancy or the method
of childbirth.
WHAT CAUSES IT?
The exact cause of vulvodynia and other chronic pain
is not known. However there is no single cause.
There is altered sensitivity of nerve endings and
associated muscle spasm. Recent research using
brain scans shows that there are also changes in
brain function associated with chronic pain and so the
sensations of pain continue despite the absence of an
obvious cause. The nerves in the area that is painful
can also produce their own pain impulses, so pain
escalates. Treatment aims to reverse these changes.
It is important to remember that the vulva and vagina
are healthy, but that the sensations are altered. Mostly
these improve with treatment and time.
Vulval pain is sometimes triggered by frequent or
severe skin inflammation, most commonly candida
(thrush) or urinary infections. Thrush needs to be
considered especially if there is a worsening of
symptoms near the period, even if itch and discharge
are not present. However it is well known that many
pain conditions are often worse near period time.
Very occasionally genital herpes may be involved. All
infections need prompt and accurate treatment. Wart
virus has little effect, although its treatments often
irritate, and the skin nearby is often dry.
Persistent pain can occur even after years of enjoyable
and painfree sexual activity. Sometimes it is noticed
with the first attempt at putting something into the
vagina, like using a tampon.
SYMPTOMS
Symptoms may range from none unless the area is
touched, e.g. by attempted use of a tampon, or by
having sex, to frequent vulval awareness whilst sitting,
walking or especially bicycling and horseriding. Tight
clothing will aggravate it also. There may be times of
improvement and worsening.
Intercourse may be possible, with discomfort only at
the very initial stage, or may be too uncomfortable
to attempt at all. Often the pelvic floor muscles will
learn to tense as a protective behaviour, and this will
worsen the pain.
Afterburn may occur after intercourse, lasting minutes
- hours - days. This can be from friction or pressure, or
occasionally from irritation from lubricants, condoms
or semen. (as distinct from an allergy). It can be
associated with candidal infections also. However, this
type of burning or tenderness that persists after sex
is typical of chronic pain when there are no irritants
or infections present. Burning or tender discomfort
will similarly happen after medical examination with a
cotton tip or internal exam.
Relief is often gained by a cool compress or saltwater
soak. You can then apply a bland moisturiser
(especially good if refrigerated)..
Urinary symptoms often occur in vulval pain
conditions, even without true bladder infection. This
is because the bladder and urethra and vulva develop
This fact sheet is designed to provide you with information on Vulval Pain ‘Vulvodynia’. It is not intended to replace the need for a consultation with your doctor. All clients are strongly advised to check with their doctor about any specific questions or concerns they may
have. Every effort has been taken to ensure that the information in this pamphlet is correct at the time of printing.
Last Updated August 2012
p. 1 of 4
Melbourne
Sexual
Health
Centre
A part of Alfred Health
Melbourne Sexual Health Centre
580 Swanston Street
Carlton Vic 3053
Australia
Tel: (03) 9341 6200
Fax: (03) 9341 6279
Free Call: 1800 032 017
TTY: (03) 9347 8619
Web: www.mshc.org.au
VULVAL PAIN ‘VULVODYNIA’
from the same type of tissue and share their nerve
supplies. The bladder sometimes feels ‘irritable’.
Bowel irritability is also a common association.
Anxiety and Depression are common consequences
of any chronic painful condition. Pre-existing stressors
(including poor sleep), fear of the anticipated pain,
consequent poor arousal and poor lubrication, may
worsen the experience of pain. Sexual relationships
invariably suffer even when both partners have a
good understanding of the condition and are mutually
supportive. Professional counselling is often very
helpful in sorting through these natural reactions, and
they help to find an effective way of expressing some
of the inevitable frustrations and anger most partners
feel. People often bury their negative feelings out of
consideration for their partner.. We acknowledge this
impact of pain and will offer you counselling services.
HOW IS IT DIAGNOSED?
ACT SHEET
Diagnosis is made by carefully detailing your
symptoms and an examination. Skin disease and
infection are excluded. A swab may be taken
particularly to exclude thrush. A cotton wool bud is
used to map out the area of discomfort. Pelvic floor
muscle function and tenderness are will be assessed
during a gentle examination. In almost all cases the
skin and vulva look normal but sometimes there can
be a degree of redness that is not an infection or skin
problem,
BIOPSY
Biopsy is not recommended routinely, even when the
area looks red. Biopsy findings in women with symptoms have often been similar to women without symptoms.
TREATMENT
Most cases will eventually resolve spontaneously, but
this can take years.
• Local anaesthetic gel — in very mild cases this
may be sufficient. Unless there is irritation, the
usual prescription is 2% lignocaine gel 3-5 times
daily at the vaginal opening only, for up to 3
months. If tolerated, a 5% ointment can be used
for the 2nd and 3rd months.
• Sexual Practices. Lubricants — If condoms are
used, water based lubricant will not weaken the
condom but may produce irritation. Try various
types as they will differ regarding irritation.
Therefore rinse off and moisturise after.
Condom use for less than 5 minutes is usually OK if
vegetable or almond oil is used. Note the availability
of the morning after pill within 48-72 hours. However,
the amount of time that the penis or finger is in the
vagina usually needs to be brief in pain syndromes
and be preceded by enough sensual touch to feel well
aroused. Be confident about this with your partner beforehand and agree BEFOREHAND whether sexual
penetration will occur. (see below “Sex and Pain”)
• A mild cortisone cream or ointment may help if
there is an associated dermatitis.
• There is no strong evidence to support the role of
particular diets.
• A trial of long-term anticandida treatment may
help (minimum of 2 months of topical or oral
medication) if chronic thrush is suspected.
Sometimes the diagnosis of subtle chronic
candida is difficult and tests can be negative.
• PELVIC FLOOR MUSCLE RETRAINING with
biofeedback techniques is the single most
helpful treatment. A referral to a physiotherapist
can be made Women are usually unaware of
chronic tension in their pelvic floor, as well as in
their abdomen and upper legs. Activities such
as dance and pilates will train these muscles
to be strengthened but sometimes their tone
is excessive and can worsen pain. Sufficient
relaxation doesn’t occur. Physiotherapy will help
to “downtrain” these muscles. Exercises for
the trunk, legs and the pelvic floor are taught.
Later, vaginal dilators of graduated sizes are
used as “downtrainers” under the guidance of a
physiotherapist, to improve the tone and action
of the muscles. They are NOT used to stretch
the vagina, as the elasticity of the tissues will be
normal.
• Low dose antidepressants are often very
effective .(usually used with physiotherapy).
The more correct term is nerve modulators, as
the action of these medications is to adjust pain
perception, not to treat depression. The dose
used is NOT an effective antidepressant. (Higher
This fact sheet is designed to provide you with information on Vulval Pain ‘Vestibulitis’. It is not intended to replace the need for a consultation with your doctor. All clients are strongly advised to check with their doctor about any specific questions or concerns they may
have. Every effort has been taken to ensure that the information in this pamphlet is correct at the time of printing.
Last Updated August 2012
p. 2 of 4
Melbourne
Sexual
Health
Centre
A part of Alfred Health
Melbourne Sexual Health Centre
580 Swanston Street
Carlton Vic 3053
Australia
Tel: (03) 9341 6200
Fax: (03) 9341 6279
Free Call: 1800 032 017
TTY: (03) 9347 8619
Web: www.mshc.org.au
VULVAL PAIN ‘VULVODYNIA’
doses actually are less effective in chronic pain).
If significant depression is present, this should be
treated on its merits. However sleep and anxiety
may be improved with the low dose, and this itself
will help pain.
The ‘tricyclic’ antidepressants also have a powerful
antihistamine action, so will reduce itching and often
improve sleep. Daytime sedation often is an initial
side-effect but mostly reduces with time, and the dose
can gradually be increased to 50 - 75 mg. Dry mouth
or eyes, and slight slowness of the urinary stream may
occur. Newer antidepressants have recently been
tried. The usual length of treatment is 6 months at the
dose that has been effective, then gradually weaning.
However, it is common for treatment at some level to
be needed for several years (see the Pain Medication
pamphlet).
THE ROLE OF SURGERY.
ACT SHEET
Very occasionally surgical removal of an isolated
tender area can be very successful. Widespread areas
of pain are not suitable for surgery. Referrals are made
to highly skilled gynaecologists, and a very thin portion
of the tender area is removed and covered over with
a small section of the back vaginal wall. It is often
difficult to visually detect the surgery after healing.
Psychological and sexual counselling are generally
offered at the same time. Physiotherapy will usually
continue as well.
SEX AND PAIN.
The following is kindly reproduced from the Vulval Pain
Society UK (www.vulvalpainsociety.org),
Courtesy from author Dr. Gundi Keimle, Consultant
Clinical Psychologist, Royal Bolton Hospital UK.
Standard psychosexual couple-therapy known as
“sensate focus”, pioneered by Masters & Johnson
(1970) is very useful in the treatment of a range of
sexual problems. In essence, the couple are instructed
to set “protected” time aside on a regular basis during
which they are encouraged to explore and touch
each other in a mutually pleasurable way. Initially, this
starts off with touching only the non-sexual parts of
the body, and as the couple progresses, the sexual
parts are included gradually. Throughout all this time,
there is a “ban” on sexual intercourse, in order to
allow the woman to relax and enjoy “safe” touching
without tensing up (physically and/or emotionally) at
the thought of “what might follow” (i.e. penetrative
intercourse and pain). It is also important for the
couple to alternate between being the “active” and
“passive” partner during each pleasuring session,
and to take it in turns to initiate (who goes first as the
“active” one, i.e. the one to start touching/stroking/
massaging their partner). Gradually, over a number
of weeks, the woman can hopefully move from safe,
physical, non-sexual closeness to sexual/erotic
intimacy and ultimately to sexual intercourse, whilst
experiencing an increase in libido, arousal, vaginal
expansion and lubrication.
For women with vulval pain during penetration,
“sensate focus” psychosexual therapy with her
partner is best combined with pelvic floor exercises,
biofeedback, and the use of graded vaginal dilators
(“downtrainers”) to use during additional solo
practice. Women who experience painful sex are
likely to suffer from impaired libido and arousal, as
described earlier. Therefore, concentrating more
on foreplay and non-penetrative forms of sexual
pleasuring should help to increase enjoyment and
reduce pain. “Sensate focus” is a good way of “reeducating” partners in the art of sensuous pleasuring
without merely perceiving this to be a “means to an
end”! However, where penetrative intercourse does
occur, it is important to use also plenty of additional
vaginal lubrication.
GENERAL ADVICE.
Skin care.
see Genital skin care pamphlet for advice (soap substitutes especially) and the avoidance of irritants as
described.
e.g.
• tight clothing/Gstrings
• pantyhose
• unlubricated sexual activity
• pads without barrier ointments
• prompt testing and treatment of infections if
worsening symptoms
This fact sheet is designed to provide you with information on Vulval Pain ‘Vulvodynia’. It is not intended to replace the need for a consultation with your doctor. All clients are strongly advised to check with their doctor about any specific questions or concerns they may
have. Every effort has been taken to ensure that the information in this pamphlet is correct at the time of printing.
Last Updated August 2012
p. 3 of 4
Melbourne
Sexual
Health
Centre
A part of Alfred Health
Melbourne Sexual Health Centre
580 Swanston Street
Carlton Vic 3053
Australia
Tel: (03) 9341 6200
Fax: (03) 9341 6279
Free Call: 1800 032 017
TTY: (03) 9347 8619
Web: www.mshc.org.au
VULVAL PAIN ‘VULVODYNIA’
Lifestyle and pain: see www.paintoolkit.org
Specific resources for vulvodynia
• www.anzvs.org Australian and New Zealand
Vulvovaginal Society
• www.issvd.org International Society for the Study
of Vulvovaginal Diseases.
• www.vulvalpainsociety.org UK based website.
• www.nva.org National Vulvodynia Association
USA based
• www.noigroup.com Neuroorthopaedic Institute
Adelaide. Their book “Explain Pain” is highly
recommended.
• www.vaginismus.com - “downtrainers” can be
purchased from this site.
Strategies for anxiety management
Consider online resources such as
• www.anxietyonline.org.au (auspiced by Swinburne
University Melbourne).
• www.mindfulnessandsex.com (other mindfulness
lectures and meditations are accessible on
Youtube).
• ABC Health Report
• Suggested treatment for sexual difficulties and
research into asexuality (11/06/2012)
• Mindfullness meditation (20/08/2012)
ACT SHEET
Books
Good Loving, Great Sex (by Dr. Rosie King) is
an excellent resource for desire discrepancy in
relationships, whatever the cause of the discrepancy.
This fact sheet is designed to provide you with information on Vulval Pain ‘Vulvodynia’. It is not intended to replace the need for a consultation with your doctor. All clients are strongly advised to check with their doctor about any specific questions or concerns they may
have. Every effort has been taken to ensure that the information in this pamphlet is correct at the time of printing.
Last Updated August 2012
p. 4 of 4