Vulvodynia: Symptoms, Causes and Treatment

Vulvodynia is vulvar pain that has lasted at least three months and has no identifiable cause: no infection, no skin condition, no nerve injury that accounts for it1. It is a diagnosis reached after other causes have been excluded, not a label applied because nobody could find anything.

The pain is usually described as burning, stinging, rawness, throbbing or aching. For some people it only appears when something touches the area: a tampon, sex, an examination, a bike seat, tight jeans. For others it is there most of the time with no trigger at all.

On examination the vulva normally looks unremarkable. That is expected rather than reassuring, and it is one of the main reasons the condition is missed: there is nothing to see.

Vulvodynia is not one condition, and which pattern you have shapes what will help. Clinicians describe it along four axes: where the pain is, what sets it off, whether it has been there since the first attempt at contact, and its pattern over time1.

Two further descriptors come up at your appointment. Primary means the pain has been there since the very first attempt at penetration or tampon use; secondary means there was a pain-free period first. The temporal pattern is recorded too, whether intermittent, constant, immediate on contact or delayed afterwards, because it helps separate vulvodynia from other causes of vulvar pain1.

These are the categories ACOG lists before vulvodynia can be diagnosed1. Most are settled by a careful history, a look at the vulva and a swab or two. Worth knowing what is not usually needed: fungal sensitivity testing and HPV testing are generally unnecessary, vulvoscopy is rarely required, and acetic acid soaks are not recommended1.

There is no blood test and no scan for vulvodynia. The diagnosis comes from the history and a careful examination, and both are worth knowing about in advance.

A moistened cotton swab is pressed gently at points around the vestibule and across the vulva. You rate each point, and the clinician maps where it hurts and how badly, grading each point mild, moderate or severe. That is what separates localized pain from generalized pain1. A pain diagram is often kept so that change can be measured later rather than guessed at.

Referred pain and pelvic floor muscle problems frequently contribute, so ACOG recommends a musculoskeletal assessment as part of the work-up1. The muscles around the vaginal opening are often tight and tender, and that is treatable in its own right, which is why it matters that somebody actually checks.

Most of what is prescribed for vulvodynia rests on clinical experience rather than trials. A few options have been tested properly, and they are worth knowing apart from the rest.

The practical reading of that table: start with a pelvic floor physiotherapist. It is the one option with a large multicentre trial behind it, it carries no risk worth speaking of, and the dilator work that people often attempt alone is far more effective when it is part of a plan somebody set for them.

Surgery sits at the other end. It is reserved for localized vestibular pain that has not responded to anything else, muscle spasm should be treated first, and people whose pain began after a pain-free period do better than those who have had it from the start1.

These come up constantly, and several are probably in your bathroom cabinet already. None of them is worthless; all of them are weaker on their own than their popularity suggests.

None of this treats vulvodynia on its own, and anyone who tells you otherwise is selling something. What it does is remove the things that keep irritating sensitised tissue, which makes the actual treatment easier to tolerate1.

In one population study, 48% of the women who had symptoms consistent with vulvodynia and went looking for help came away without a diagnosis2. Walking in with specifics makes that less likely.

These are the tools a pelvic floor physiotherapist most often sends people home with. None of them diagnoses vulvodynia and none replaces an assessment. They are what you use between appointments.