Generalised vulvodynia

What is generalised vulvodynia?

Generalised vulvodynia is one of the most common types of vulvodynia or vulval pain of unknown cause. In men, a similar disorder is known as male genital dysaesthesia. It was previously known as dysaesthetic vulvodynia and is a form of cutaneous dysaesthesia.

Vulvodynia is defined by the International Society for the Study of Vulvovaginal Diseases (ISSVD) as vulvar pain of at least 3 months duration, without a clearly identifiable cause.

Generalised vulvodynia describes widespread pain throughout the vulvar region where there is no physical explanation for it. Pain may be present in the labia, clitoris, vestibule, perineum, mon pubis, and inner thighs. Pain may be constant or unprovoked by touch or pressure to the vulva. Activities such as intercourse, bicycle riding, and horse riding may make symptoms worse.

What are the symptoms of generalised vulvodynia?

Patients with generalised vulvodynia may describe intermittent or continuous symptoms, including:

• Widespread, generalised vulvar discomfort and pain, not altered by position or activity (vulvar burning only when sitting suggests pudendal nerve entrapment)
• Burning, raw feeling, irritation, throbbing, stinging sensation in the vulva
• Poking, as if needle stuck in the vulva, vagina and/or anus
• Pain may be initiated by light touch or pressure (this is called allodynia), but it often occurs spontaneously
• Pain and discomfort sometimes experienced in the urethra or rectum
• Sexual intercourse may be unpleasant, difficult or impossible due to discomfort
• Associated stress-related and chronic pain conditions such as headaches, face, tongue and mouth pain (burning mouth syndrome), fibromyalgia, irritable bowel syndrome, painful bladder syndrome, bloating, fatigue, sleep problems and eating disorders.

What causes generalised vulvodynia?

By definition, the cause of generalised vulvodynia is unknown. Current theories consider generalised vulvodynia is a chronic pain syndrome related to hypersensitive nerves. One or more of the following may have a role to play in the development of this condition.

• Stretched, inflamed nerves in the vulvar area (pudendal nerve entrapment or pudendal neuralgia), spine or related structures
• Trigger points where there are proliferating or sensitised nerve endings in the skin itself
• Previous vulvar skin condition, surgery or childbirth resulting in scarring or another injury
• Hormonal changes causing vulvar dryness, especially during menopause
• Previous inflammatory disorders such as herpes simplex or herpes zoster/shingles infection
• Emotional stress

Management of generalised vulvodynia

Women who suffer from generalised vulvodynia require a range of treatments to help overcome their cycle of endless pain. A combination of therapies should be used and may include:

• Regular sleep, daily exercise and resolution of stressful issues.
• Physical therapy and pelvic floor exercises to relieve muscle spasms and generalised vulvar pain. These may also help associated urethral and bowel problems.
• Small doses of a tricyclic antidepressant such as amitriptyline (5 to 30 mg), desipramine or nortriptyline. They are prescribed for at least several weeks to months and if successful may need to be continued long term. Side effects such as drowsiness, weight gain, and dry mouth occur in up to 50% of patients, especially when they first start on the medication.
• Anticonvulsants such as carbamazepine, gabapentin or pregabalin may control chronic pain. Referral to a pain specialist may be helpful.
• Support and education: both the patient and their partner and families need to understand and learn how to cope with the stresses that the condition can place on relationships.