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Vulvodynia is chronic pain of the vulva, the external or visible region of the female genitalia, in the absence of vulvar or vaginal infection or skin disease.
As with other types of chronic pain, vulvodynia can have a significant impact on the quality of life. The disease may interfere with daily activities including sitting, walking, physical exercise, and social interactions. Sexual intercourse may be painful or impossible. Vulvodynia can lead to exhaustion and depression. In extreme cases a woman may become bedridden.
Vulvodynia has not been well-defined, in part because it has not been well-studied. The symptoms vary greatly in severity and the causes of the condition are unknown. Thus vulvodynia is classified in different ways.
Most often vulvodynia is subdivided into two types:
- vulvar vestibulitis syndrome (VVS), also called vulval vestibulitis or vulvar dysesthesia, is a localized inflammation of the vestibule—the region immediately surrounding the opening of the vagina and the urethra.
- dysesthetic vulvodynia, also called generalized vulvodynia or generalized vulvar dysesthesia, usually is defined as vulvar burning that has no obvious cause and is not limited to the vestibule.
Some women appear to suffer from both types of vulvodynia simultaneously.
An older classification system is still in use. It distinguishes between vulvar vestibulitis and vulvodynia and subdivides vulvodynia into two major categories:
- organic vulvodynia, in which a cause can be identified
- essential vulvodynia, in which a cause cannot be identified and which usually affects older women, particularly women in their 60s.
Females of any age can develop vulvodynia. A 2003 study suggested that up to 16% of women—or 14 million American women—experience chronic vulvar pain lasting three months or longer at some point in their lives. Approximately one-half of these women seek treatment. There is conflicting evidence concerning the prevalence of vulvodynia among different ethnic and racial groups. The 2003 study found that Hispanic women were much more likely to suffer from the condition. The study also found that women who experienced pain when first using a tampon were seven to eight times more likely to have vulvodynia at some point in their lives. Between 10% and 25% of women with interstitial cystitis—a bladder condition that causes frequent urination with burning—also have symptoms of vulvodynia.
The prevalence of VVS is unknown but some surveys have suggested that about 28% of women have a history of vestibular pain. It has been estimated that about 15% of women seeing private gynecologists and about 1% of women visiting genitourinary medical clinics suffer from VVS. Dysesthetic vulvodynia is more common in postmenopausal women and younger women who have had back injuries.
Causes and symptoms
Suggested causes of vulvodynia include:
- irritation or injury to the vulvar nerves
- hypersensitivity of nerves in the vulvar region
- an abnormal response of vulvar cells to environmental factors, including infection or injury
- irritation from oxalate in the urine
- a localized hypersensitivity to the yeast Candida albicans
- frequent yeast infections (candidiasis)
- genital warts caused by the human papillomavirus (HPV)
- genital rashes
- an allergic reaction to environmental irritants
- an autoimmune response to the body's own chemicals
- frequent use of antibiotics
- laser treatment or surgery on the external genitalia
- irritation or spasms in the pelvic floor muscles that support the bladder, uterus, and rectum.
A 2004 study found that women with vulvodynia were more likely than other women to have group D streptococcus (GDS) bacteria in their vaginas. Preliminary evidence suggested that women with vulvodynia might have distinctive vaginal microflora—the various organisms that normally inhabit the vagina. Another 2004 study found that women with vulvodynia were more sensitive to pain in other parts of their bodies and may process pain differently than other women.
In a small subset of women VVS appears to be associated with chronic yeast infections. Some researchers have found an association between VVS and high levels of oxalate in the urine. It also has been suggested that genetic factors may increase a woman's susceptibility to chronic vestibular inflammation. In contrast, many researchers believe that dysesthetic vulvodynia is caused by nerve irritation or inflammation.
ORGANIC VULVODYNIA. Organic vulvodynia—in which a cause for the condition can be identified—includes contact or allergic dermatitis and chemical irritation commonly caused by:
- scented or deodorant soaps or laundry detergent
- fabric softener
- scented or dyed toilet paper
- scented menstrual pads
- vulvar wipes or deodorants—"feminine hygiene" products
- sexual lubricants
- some medications that are used to treat vulvar problems
- synthetic underwear
- excessive vaginal discharge
- urine or feces.
Other causes of organic vulvodynia include:
- chronic vulvar and vaginal yeast infections
- recurrent infection with herpes simplex virus
- other viral or bacterial infections
- nerve irritation
- injury from childbirth or vaginal/vulvar trauma.
GENERAL SYMPTOMS. Vulvodynia usually begins suddenly and may last for months or years. Although the symptoms and their severity vary widely, a burning sensation within the female genitalia is the most common symptom. The pain may be intermittent or constant and localized or generalized throughout the pelvic region.
In addition to burning, sensations of vulvodynia often are described as:
- sharp, knife-like pain.
VULVAR VESTIBULITIS. VVS symptoms are confined to the vestibule and vary from mild to severe. VVS often begins suddenly, following an infection or trauma. Painful sexual intercourse may be the first symptom. The intense itching and painful burning can turn into chronic pain. Symptoms may occur daily or only with sexual intercourse.
In addition to painful burning, typical VVS symptoms include:
- an extremely tender, dry, or raw vestibule
- stinging or irritation of the vestibule
- a sensation of tight skin in the vestibule
- redness of the vestibule
- pain that is so severe as to preclude intercourse
The majority of women with VVS only have symptoms during or after:
- the vestibule is touched
- sexual intercourse
- tampon insertion
- a gynecological examination
- bicycle or horseback riding
- wearing tight pants.
However in severe cases, sitting, walking, or no movement at all can cause pain.
DYSESTHETIC VULVODYNIA. Women with dysesthetic vulvodynia have constant burning throughout the genitalia or in different areas at different times. Symptoms do not necessarily occur in response to touch or pressure on the vulva, although activities such as sexual intercourse or bicycle riding may increase the discomfort.
Areas commonly affected by dysesthetic vulvodynia include:
- introitus—the membranes surrounding the vaginal opening
- small or minor vestibular glands around the vaginal opening
- vulvovaginal (Batholin's) glands located on each side of the vaginal opening
- paraurethral (Skene's) glands located on each side of the urethral opening
- labia minora or inner labia
- labia majora or outer labia
Some women also experience pain in the clitoris, the perineum, the mons pubis, the anus, the groin, and the inner thighs.
ORGANIC VULVODYNIA. Symptoms of organic vulvodynia caused by chronic yeast infection include vulvar itching and burning, especially just before menstruation. Symptoms caused by recurrent herpes simplex virus are intermittent, often reoccurring with stress and lasting for a few days to a week or more. Symptoms of vulvodynia caused by nerve irritation include pain that radiates from the vulva to the perineum, groin, and thighs, and may include lower back pain.
Vulvodynia is characterized by pain or burning that lasts for more than three months with no apparent skin lesions. Although sometimes the vulvar tissue is inflamed, often it appears completely normal. Other conditions that can cause chronic vulvar pain may coexist with vulvodynia. Many women with vulvodynia are misdiagnosed for years. Women often are told that they have a chronic yeast infection or a psychological disorder. It is not uncommon for women to visit at least five doctors before vulvodynia is diagnosed.
To diagnose vulvodynia a healthcare provider may:
- take a medical history
- inquire about symptoms, sexual activity, diet, feminine hygiene, and medications
- examine the vulva and vaginal secretions for signs of infection or a skin disorder
- perform a pelvic examination
- take a vaginal culture to test for yeast or bacteria
- use a Q-tip to determine the location and severity of the pain
- use a magnifying glass to look for abnormalities
- perform a colposcopy—an examination with a special magnifying lens—to look for inflamed surface blood vessels
- perform a tissue biopsy—the removal of a small piece of tissue for microscopic examination—particularly if skin lesions are present.
Women with VVS are more likely to have yeast infections than the general population. A yeast infection must be treated before VVS can be diagnosed. VVS can be diagnosed by a "touch test" with a cotton-tipped applicator to reveal extreme sensitivity at various points on the vestibule. In about two-thirds of VVS cases these points have tiny red spots. Biopsies for VVS generally show signs of chronic inflammation.
Dysesthetic vulvodynia generally is diagnosed after ruling out other causes of vulvar pain including:
- yeast, bacterial, or viral infection
- contact or allergic dermatitis
- overuse of medications, particularly topical steroids
- vulvar dermatoses caused by one of numerous skin conditions and diseases
- cyclic vulvovaginitis—burning or itching that recurs at a particular stage of a woman's menstrual cycle
- vulvovaginal atrophy due to estrogen deficiency in postmenopausal women.
There is no cure for vulvodynia and, because there appear to be multiple causes for the disorder and because individual women have unique symptoms, no single treatment is appropriate for all women. A treatment may work for some women and not for others and some treatments may cause unacceptable side effects in some women. Women with vulvodynia should stop using all topical medications, soaps, douches, and other products that may cause irritation. Yeast infections may require long-term treatment.
Symptoms of vulvodynia may be treated with:
- topical anesthetics such as viscous or liquid 5% lidocaine ointment (Xylocaine) for temporary relief
- nerve blockers
- cortisone creams
- topical estrogen cream
- antihistamines, such as Atarax or Vistaril, that inhibit the release of histamines that can irritate mucous membranes
- physical and exercise therapy to strengthen and relax the pelvic-floor muscles—called pelvic floor therapy—particularly if lower back problems are present.
VVS often is treated first with a corticosteroid ointment, such as triamcinolone or desoximetasone, twice a week for one month. Corticosteroid treatment requires careful monitoring because it can cause irritation or thinning of the skin. If this treatment fails, VVS may be treated with the antidepressant amitriptyline (Elavil) or the anticonvulsant gabapentin (Neurontin). Initial dosages are low and can be increased steadily until symptoms are relieved or side effects become intolerable, up to a maximum daily dosage of 150 mg of amitriptyline or 3200 mg of gabapentin.
Other treatments for VVS include:
- interferon—an anti-viral drug—injected into the vulva, particularly in women who also have human papillomavirus
- vestibulectomy—surgery to remove the vestibule and hymen, usually as a last resort.
- Laser treatments the freeze the tissue have not proved successful and may worsen VVS.
The most common treatments for dysesthetic vulvodynia are medications that treat nerve irritation and pain throughout the body—tricyclic antidepressants such as amitriptyline, nortriptyline (Pamelor), desipramine (Norpramin), and imipramine (Tofranil), and anticonvulsants such as carbamazepine (Tegretol) or gabapentin.
Alternative treatments for vulvodynia include:
- biofeedback; sensitive detectors are available for use on the vulva
- cognitive behavioral therapy
- aerobic exercise
- cool or lukewarm sitz baths for relieving irritation and burning
- douching with baking soda to relieve inflammation
- a compress of Aveeno—a powdered oatmeal bath treatment, made with two tablespoons of Aveeno to one quart of water—placed over the vulva three to four times per day.
Those who believe that vulvodynia may be caused by acidic, irritating oxalate crystals in the urine, recommend trying a low-carbohydrate, low-oxalate diet for three months to a year. The diet involves:
- eliminating all high-oxalate foods—those with more than 10 mg of oxalate per serving
- limiting moderate oxalate-containing foods (2-10 mg per serving) to three servings per week
- drinking 12-14 cups of water per day
- taking calcium citrate without Vitamin D, such as two Citracal tablets three times per day, approximately 45 minutes before eating.
Calcium citrate supplements decrease calcium oxalate formation in the urine, suppress oxalate secretion, and decrease the acidity of the urine.
Foods that are high in oxalates include:
- all beans
- wheat bran, wheat germ, and grits
- white corn
- all nuts and nut butters
- greens including chard, kale, escarole, collards, and spinach
- parsley and watercress
- green peppers
- tomato and vegetable soups
- sweet potatoes
- summer squash
- purple grapes
- beer, beverage mixes, and tea
Vulvodynia sometimes disappears spontaneously. It often improves over time regardless of treatment. In some women treatment results in partial or complete relief of symptoms, although it may take weeks, months, or even years. Other women are never completely free of symptoms.
It has been reported that about 30% of VVS cases improve with corticosteroid treatment and another 60% improve with amitriptyline or other tricyclic antidepressants. Vestibulectomy has the highest success rate of any VVS treatment.
Numerous suggestions have been made for preventing vulvodynia and for relieving symptoms and preventing further irritation, including:
- using soft, white or unbleached, unscented toilet tissue
- using 100% cotton menstrual pads and tampons
- avoiding shampoo in the vulvar region
- avoiding bubble bath, feminine hygiene products, perfumed creams and soaps, petroleum jelly, and bath oils
- washing the vulva frequently with cool or lukewarm water
- using a bidet
- drying the perineum with a hair dryer on the cool setting
- urinating before the bladder is full
- rinsing the vulva with water from a squeeze bottle after urination
- eating fiber from whole grains, fruits, and vegetables, and psyllium products, such as Metamucil or Konsyl, to prevent constipation
- drinking eight glasses of water daily
- sitting on a foam rubber donut and standing periodically when sitting for long periods
- using relaxation techniques
Suggestions for clothing and laundry include:
- wearing all-white cotton underwear and washing new underwear before use
- wearing loose-fitting skirts and pants
- avoiding pantyhose and jeans
- promptly removing wet bathing suits and exercise clothing
- washing clothes in a dermatologically approved detergent, such as Purex or Clear, or baking soda soap
- double-rinsing underwear and other clothing that contacts the vulva
- avoiding fabric softener and dryer sheets.
Advice on physical activity includes:
- avoiding activities that put direct pressure on the vulva, such as bicycle and horseback riding
- limiting intense exercise that applies friction to the vulva
- applying a frozen gel pack wrapped in a towel after exercising to relieve symptoms
- performing stretching and relaxation exercises such as yoga
- avoiding hot tubs and highly-chlorinated swimming pools.
Suggestions for sexual intercourse include:
- applying a topical anesthetic, such as 5% lidocaine gel, to the vestibule 10-15 minutes before intercourse
- using pure almond oil, vegetable oil, or a water-soluble, glycerin-containing lubricant such as Astroglide, applied at the initiation of sexual activity
- avoiding lubricants containing preservatives or other chemicals
- avoiding contraceptive creams, spermicides, and devices that may irritate the vulva
- applying ice or a frozen blue gel pack after intercourse to prevent burning
- urinating and rinsing the vulva with cool water after intercourse.
Colposcopy — The use of a special microscope—a colposcope—to visualize the genitalia.
Contact dermatitis — Irritant dermatitis; direct skin contact with a substance that causes inflammation in some people.
Dysesthetic vulvodynia — Generalized vulvodynia; generalized vulvar dysesthesia; essential vulvodynia; chronic vulvar pain not limited to the vulva for which there is no apparent cause.
Hymen — A membrane that partially or completely covers the vaginal opening.
Interstitial cystitis — Chronic inflammation of the bladder; sometimes associated with vulvodynia.
Labia majora — Major lips; mounds of tissue forming the lateral boundaries of the vulva.
Labia minora — Minor lips; narrow folds of tissue between the labia major, on either side of the urethral and vaginal openings.
Mons pubis — The fatty tissue over the area where the pubic bones meet.
Organic vulvodynia — Chronic vulvar pain for which a cause can be identified.
Oxalate — A salt of oxalic acid produced by the body's metabolism and excreted in the urine.
Perineum — The area between the external genitalia and the anus.
Tricyclic antidepressants — Medications used to treat mental depression and other conditions including chronic pain.
Vestibule — Vestibule of vulva; vestibule of vagina; the space between the labia minor containing the openings of the vagina and urethra.
Vestibulectomy — Surgical removal of the vestibule and hymen.
Vulva — Pendum; the external female genitalia including the mons pubis, labia majora and minor, clitoris, vestibule, glands, and the vaginal opening.
Vulvar vestibulitis syndrome; VVS — Vulval vestibulitis; vulvar dysesthesia; inflammation of the vestibule.
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Stewart, Elizabeth G., and Paula Spencer. The V Book: A Doctor's Guide to Complete Vulvovaginal Health. New York: Bantam, 2002.
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American College of Obstetricians and Gynecologists. 409 12th St., S.W., PO Box 96920, Washington, D.C. 20090-6920. 202-638-5577. http://www.acog.org.
Center for Vulvar Diseases, Department of Obstetrics and Gynecology, University of Michigan Health System. 1500 E. Medical Center Drive, Taubman Center, Reception E, Box 0384, Ann Arbor, MI 48109-0384. 734-936-4000. 〈http://www.med.umich.edu/obgyn/vulva/index.htm〉.
National Vulvodynia Association. P.O. Box 4491, Silver Spring, MD 20914-4491. 301-299-0775. http://www.nva.org.
Vulvar Pain Foundation. P.O. Drawer 177, Graham, NC, 27253. 336-226-0704. http://www.vulvarpainfoundation.org.
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"Self-Help Tips for Vulvar Skin Care." Patient Services. National Vulvodynia Association. November 4, 2002 [cited March 5, 2005]. http://www.nva.org/patient_services/Self_Help_Tips.html.
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Chronic vulvar discomfort with complaints of burning and superficial irritation.
Chronic vulvar pain.
chronic pain and discomfort in the female external genitals.
vulvodyniaA chronic idiopathic pain syndrome affecting the vulvar region.
Burning, irritation, pain; may be exacerbated by physical contact, including sexual activity, bicycle or horseback riding, sitting, and so on.
Allergies, inflammation, autoimmune disease, eczema, infection (e.g., yeasts, bacterial vaginosis, HPV) and neuropathy.
Cotton underwear, avoiding soap, low oxalate (beets, chocolate, nuts, spinach and tea) diet, non-penetrative sex, oestrogen creams, antidepressants, anxiolytics, biofeedback training, pudendal nerve blocking; in the extreme cases, vestibulectomy.