Vulval pain conditions
Vulval pain is a frequently encountered complaint. Patients with a pain problem may present to general gynaecologists who may have no special expertise in the diagnosis and management of chronic pain problems.
It is important to distinguish those patients with vulval pain syndromes from those who have pain secondary to an active dermatological disease process (e.g. fissures or erosions). Vulvodynia has been defined as ‘vulval discomfort, most often described as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder' (32). It is a neuropathic pain syndrome and is analogous to other neuropathic pain syndromes. Patients can be classified by whether pain is unprovoked or provoked. Patients with unprovoked pain may experience spontaneous pain whereas patients with provoked pain usually complain of sexual pain and were formerly diagnosed as having ‘vestibulitis'. This is incorrect as there is no evidence that vulvodynia is an inflammatory condition and patient with provoked pain should now be diagnosed as ‘vestibulodynia. Patients can lose confidence in health professionals and can become isolated in their condition through embarrassment and an unwillingness to discuss problems. This can lead to psychological upset. Some patients may have a combination of vulvodynia with another vulval problem, (e.g. irritant dermatitis or thrush) and both conditions may require treatment.Pain pathophysiology
Acute pain has an important protective function as it limits further harm and encourages healing. This pain is usually inflammatory, is associated with tissue damage or injury, and is self-limiting. If pain persists beyond 6 months, some patients can develop a neuropathic pain cycle as a result of central or peripheral nervous system sensitization. This neuropathic pain is not usually inflammatory and the phenomena of hyperalgesia and allodynia may or may not be present. It is important to note some patients do not always identify the term ‘pain’ with neuropathic pain symptoms but can describe a variety of sensations which include burning, stabbing, shooting, aching, and electric shock sensations.
Uncommonly, these can include genital arousal states (33).Vestibulodynia (provoked pain)
Vestibulodynia is a cause of superficial dyspareunia and is characterized by vestibular tenderness on light touch. This excessive sensitivity can be generalized throughout the vestibule or can be more focal, involving the opening of the ducts of the major vestibular glands or the posterior fourchette (34). Women are usually of reproductive age and complain of superficial dyspareunia, tampon intolerance, and pain during gynaecological examinations (35). There is often a delay between the onset of symptoms and receiving a diagnosis, which varies from months to years. As the condition is frequently chronic, a high level of psychological morbidity is common. Some patients are prone to stress and anxiety, which may play a role in developing symptoms (36). Sexual dysfunction is common and frequently reported (37). The vulval skin looks normal and a cotton-tip applicator gently applied can identify allodynia in the area of the vestibule.
Unprovoked vulvodynia
Unlike women with provoked pain, those with unprovoked vulvodynia have more constant neuropathic-type pain in the vulva. Patients can be of all ages (rarely children) and describe intermittent or constant symptoms. Patients may describe tingling or ‘electric shock’ types symptoms. Superficial dyspareunia is not consistently reported and some experience rectal, perineal, and urethral discomfort. Psychological morbidity is likely to be high as a consequence of chronic pain and there is frequently an impact on function. Clinical examination of the vulva shows no skin changes.