Vulvodynia or Pudendal Neuralgia By Lori Montgomery, MD, CCFP and Magali Robert, MD, FRCSC
Introduction Vulvodynia (say: vul-vo-DYNE-ee-uh) is a word used to describe pain that involves the vulva. The vulva is the area around the vagina. This pain can come from many different sources. The symptoms can range from quite mild to very severe. We do not really know how often it occurs, because women often do not seek medical treatment for it. It often involves a great deal of emotional and psychological distress, perhaps because it affects relationships so much and because it is hard for women to talk about this problem.
Signs and symptoms •burning or stinging pain in the area around the vagina •pain often starts slowly, with no apparent cause and can go away all of a sudden •pain is sometimes made worse by sex, inserting tampons, voiding, sitting for prolonged periods, riding a bicycle, or wearing tight-fitting clothing •itching •raw, sunburned feeling •problems voiding or constipation (when pelvic floor muscles get tense as a result of pain)
Causes While many people think that vulvodynia is a kind of neuropathic pain, the exact cause of vulvodynia is not known. There are certain things that make you more likely to develop it. They include:
•use of soaps, feminine hygiene products, or scented bath products •diabetes •previous surgery, biopsy, or other procedures in the area •pain or abnormal functioning of the pelvic floor muscles Sometimes, an irritation of the pudendal nerve can cause vulvodynia. If this is the case, it is called pudendal neuralgia.
Diagnostic tests Your doctor will do a physical exam to see if there is a rash or other problems that explain your symptoms. A pap test and pelvic exam, and swabs for yeast and bacterial infections will be needed as well. Sometimes more intensive testing is needed if any of these tests are not normal. With vulvodynia, the exam will be normal.
Treatment approaches Treatment will depend on whether a cause for the pain is found.
Pills or cream for yeast or bacterial infection If a yeast or bacterial infection is the cause, this will need to be treated with pills or creams.
Surgeries and other treatments for pudendal neuralgia If pudendal neuralgia is the cause, it may be possible to alter the pudendal nerve. Surgeries and other treatments to cut the nerve, burn it, or stimulate it with electric current have been tested. This involves the potential for serious side effects. There are no good studies yet proving that they are helpful.
Avoid scented products, wash thoroughly Avoid scented products like soaps, bath gels, bubble baths, or feminine hygiene products. Wash only with clear water, and rinse the area with a spray or squeeze bottle of water after voiding. Do not wear tight-fitting clothing, especially synthetic fabrics.
Avoid certain foods Some foods irritate the vulva, and you should consider a trial period of avoiding these foods to see if they are an irritant for you. They include:
•citrus fruits •coffee or tea •simple carbohydrates (especially foods high in refined sugar) •spices such as ginger, pepper, and cinnamon •soy products •peanuts
Lidocaine gel The usual first medicine to try is lidocaine gel, taken regularly over the vulva. Estrogen cream can also be used in perimenopausal and menopausal women.
Medicines for nerve pain There are a number of medicines that are used to control nerve pain. Some patients with vulvodynia may benefit from:
•tricyclic antidepressants (such as amitriptyline or nortriptyline) •gabapentin or pregabalin •serotonin-norepinephrine reuptake inhibitors (such as venlafaxine or duloxetine) Non-drug therapies Physiotherapy with a therapist trained to work with the muscles of the pelvic floor can be useful. Sometimes, the pain around the vulva causes the muscles of the pelvic floor to become tense and sore. This causes pain itself. It makes vulvodynia worse. It makes sex more difficult. There is a list of pelvic physiotherapists elsewhere on this site.
Acupuncture and TENS
Some patients find things like acupuncture or transcutaneous electrical nerve stimulation (TENS) helpful as well.
Non-drug therapies Studies have shown that non-drug therapies can help to reduce pain levels and enhance pain coping. These include:
•relaxation •meditation •activity pacing •cognitive behavioural therapy These self-management strategies can help you to improve your function so you can do more and enjoy life more.
For more information •Neuropathic Pain •Pain Medications •Physical Therapies Web sites International Association for the Study of Pain www.iasp-pain.org
National Vulvodynia Association www.nva.org
American Pain Foundation www.painfoundation.org
TRIP Database (Resources for Evidence Based Medicine) www.tripdatabase.com
References Vulvodynia and Vulvar Vestibulitis: Challenges in Diagnosis and Management, JF Metts, American Family Physician March 15, 1999
MayoClinic.com. Vulvodynia. http://www.mayoclinic.com/health/vulvodynia/DS00159>. Last accessed March 2, 2009.
Harris G; Horowitz B; Borgida A. Evaluation of Gabapentin in the Treatment of Generalized Vulvodynia, Unprovoked. Journal of Lower Genital Tract Disease. January 2008;12(1):65.
Masheb RM, Kerns RD, Lozano C, Minkin MJ, Richman S. A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy. ,Pain. 2009; 141(1-2):31-40.