Vulvar vestibulitis

Vulvodynia is persistent, unexplained pain in the vulva, which is the skin surrounding the vagina. There is usually no obvious cause, but much can be done to help relieve the pain so that it no longer causes problems.

The pain of vulvodynia is often described as a burning, stinging or raw sensation. Some women describe the feeling of a needle being stuck in their genitals.

Vulvodynia can be:

unprovoked vulvodynia – pain that is in the background constantly or that comes on spontaneously, with no particular trigger
pressure-provoked vulvodynia (also known as vestibulodynia) – pain triggered when the vulva or vestibule (where the vulva meets the vagina) is lightly touched (for example, after inserting a tampon or during sex)

The pain can also be limited to the vulva or part of the vulva (localised). However, it may also be more widespread (generalised), spreading to the urinary tract, the bottom or the inside of the tops of the thighs.

It can be made worse by activities such as cycling or horse riding, which may put prolonged pressure on the vulva.

The following information and advice about vulvodynia covers:

who is affected
what you should do
the possible causes of vulvodynia
how vulvodynia is managed

Who is affected?

Vulvodynia affects women of all ages, from 20 to 60, but often starts in women younger than 25. It can be very distressing, significantly affecting quality of life.

Women with vulvodynia are usually otherwise healthy, with no history of sexually transmitted infections. However, some women with vulvodynia also have vaginismus, when the muscles around their vagina tighten involuntarily whenever penetration is attempted.

What you should do

If you have vulval pain as described above, see your GP or visit your local genitourinary medicine (GUM) clinic.

Your doctor may touch your vulva lightly with the tip of a cotton bud to see if this causes pain. A diagnosis of vulvodynia is made based on your symptoms.

Possible causes

The cause of vulvodynia is not understood. It's possible that it is caused by:

a nerve problem – irritation or damage of the nerves around the vulva, oversensitive nerve endings in the skin of the vulva, or (less likely) a trapped nerve in the spine
previous surgery to the vulva, especially if it resulted in scarring

Vulvodynia is not contagious and has nothing to do with personal hygiene or hygiene products.

Other conditions that may cause vulval pain

Your GP will want to rule out other conditions that can cause vulval pain, such as:

persistent vaginal thrush
sensitivity to something touching the vulva, such as soap, bubble bath or steroid and antifungal creams (known as irritant contact dermatitis)
a drop in the hormone oestrogen, causing dryness of the vulva, especially during the menopause
a recurrent herpes simplex infection
lichen sclerosus or lichen planus (skin conditions that may cause intense irritation and soreness of the vulva)

In rare cases, Behcet's disease (a disease of the blood vessels that can cause genital ulcers) or Sjogren's syndrome (a disorder of the immune system that can cause vaginal dryness) may be a cause. However, these conditions have often been previously diagnosed.

Stress may also be a factor for some people.

Managing vulvodynia

A combination of some of the following treatments can help relieve symptoms of vulvodynia and reduce its impact on your life. Discuss these options with your doctor.

Lifestyle tips

The following lifestyle tips may help to prevent symptoms of vulvodynia:

Wear 100% cotton underwear and loose-fitting skirts or trousers.
Avoid scented hygiene products such as feminine wipes, bubble bath and soap – an emollient is a good substitute for soap, but long-term use of aqueous cream should be avoided.
Use petroleum jelly before swimming to provide protection from chlorine.
Avoid cycling and any other activities that put prolonged pressure on the vulva.
If sexual intercourse is painful, try to find a position that is comfortable (many women find that being on top is the most comfortable position).
Try to reduce stress as high levels of stress can increase the pain of vulvodynia – read some relaxation tips to relieve stress.

Over-the-counter gels and lubricants

Some women with vulvodynia find that applying the anaesthetic gel lidocaine to their vulva 10 minutes before sex may make intercourse possible, although lidocaine can sometimes irritate the area. If you are using a condom, it is important to wipe the lidocaine off before sex, as it can affect how well condoms works.

A tube of 5% lidocaine ointment can be bought over the counter from a pharmacy.

Vaginal lubricants (also available over the counter) may soothe the area and help moisturise the vulva if it is dry.

Speak to your pharmacist about these treatments.

Prescription medication

The tricyclic antidepressants amitriptyline and nortriptyline have been found to relieve the pain of vulvodynia for some women. However, drowsiness, weight gain and dry mouth are possible side effects.

Your doctor will probably recommend that you start on a low dose of amitriptyline or nortriptyline, and gradually increase the dose until your pain subsides. This may take several weeks, and you may need to take the medication for three to six months.

The anti-epilepsy medicines gabapentin and pregabalin can also help control pain. Make sure you talk to your doctor about the side effects, and how you should take the medication.

Physiotherapy

Your GP may refer you to a physiotherapist if you also have vaginismus.

The physiotherapist may teach you some pelvic floor exercises (such as squeezing and releasing your pelvic floor muscles) to help relax the muscles around your vagina.

Another technique to relax the muscles in the vagina involves using a set of vaginal trainers. These are four smooth, penis-shaped cones of gradually increasing size and length, which can be used in the privacy of your own home.

The smallest one is inserted first, using a lubricant if needed. Once you feel comfortable inserting the smallest one, you can move on to the second size, and so on. It is important to go at your own pace, and it does not matter how long it takes, whether it is days or months.

When you can tolerate the larger cones without feeling anxious or any pain, you and your partner may want to try having sexual intercourse.

Read more about physiotherapy and the treatment of vaginismus.

Talking therapy

Cognitive behavioural therapy (CBT) is a type of therapy that aims to help you manage your problems by changing how you think and act. It can often help women cope with the impact that vulvodynia has on their life.

CBT focuses on the problems and difficulties you have now, and looks for practical ways you can improve your state of mind on a daily basis.

Talk to your GP about whether CBT may benefit you, and whether you can be referred to a therapist for this.

More information

Further advice and support can be found by visiting the following websites: