Vulvodynia: A Complex Pain Syndrome
By Keri Marin Vrbanac, Pelvic PT
The vulva is the external part of the female genitals, and it is made up of the labia, the clitoris, the vaginal opening, and the urethral opening. Many people refer to the vulva as the vagina…not so! The vagina is a muscular tube that extends from the cervix to the vulva where you will find its entrance. The vulva has a number of functions including protecting the internal female reproductive organs, playing a role in sexual stimulation, providing lubrication by way of the Bartholin’s glands and assisting in directing the flow of urine.
The vulva has a very rich nerve supply. It is innervated by the anterior labial branches of the ilioinguinal nerve, genitofemoral nerve, and branches of the pudendal nerves. Pain in the vulva may be neuropathic which means that abnormal signals from the nerve fibers may be responsible. These nerve endings are extremely hypersensitive and may result in pain that is continuous or pain that is intermittent. This is one explanation for vulvodynia.
When I say, “one possible explanation,” the truth is the exact cause of vulvar pain or vulvodynia is unknown and the symptoms can range from mild to quite severe. Vulvodynia is often persistent pain, and the diagnosis often details that the pain has been present for more than 3 months. It is a complex pain syndrome and is often a diagnosis of exclusion when all other plausible causes have been ruled out. Vulvodynia typically impacts people with a vagina between the ages of their mid-20’s to their 60’s.
The most common symptoms for vulvodynia include:
- Burning or stinging pain in the vulva
- Raw or “sunburn-type” pain
- Aching or throbbing pain
- Pain is sometimes made worse by sex, inserting tampons, voiding, sitting for prolonged periods, riding a bicycle, or wearing tight-fitting clothing
- Difficulties with urinating or defecation because of tight pelvic floor muscles
There are two main types of vulvodynia:
- Generalized vulvodynia: Pain may occur all over the vulva and it may occur at various times. The pain may be constant, or it may be intermittent
- Localized vulvodynia: Pain will occur in a very specific part of the vulva and often elicits a burning sensation
*Some people may experience a combination of both types, which is called mixed vulvodynia.
Vulvodynia may be “provoked” which means that the pain is caused by pressure or touch in the vulva, or it may be “unprovoked” (or spontaneous) which means that pain can occur in the absence of pressure or touch. Testing will include the use of the “Q tip test” where your healthcare provider will use a Q tip to apply touch to various parts of the vulva.
As mentioned, the cause of vulvodynia remains unknown; however there are a number of theories that researchers continue to explore. These include nerve involvement, infection or tissue trauma, genetic chronic inflammation, muscle spasms, irritation to chemicals, hormonal changes, a history of trauma or abuse, frequent antibiotic use and potential food sensitivities.
Treatment for vulvodynia aims to reduce pain and improve quality of life. Often, there is a team of healthcare providers involved which may include a pelvic physiotherapist, a gynaecologist, a family doctor, and a therapist as there is typically an extensive emotional component. This team is very patient-specific depending on the support needed and treatment may include medications, counselling, surgical discussions, and education.
Pelvic Physiotherapists have an important role to play in the management of vulvodynia. The pelvic floor muscles are often overactive and hypertonic (tight) in response to the pain and the stress associated with this condition. Pelvic physiotherapists have the skillset necessary to assist with relaxation of the pelvic floor muscles to decrease the persistent tone and teach patients how to manage the stress that exacerbates this increased tightness. Relaxation training, biofeedback, manual therapy techniques, pain physiology education, neuromuscular re-education and CNS desensitization, and the development of a home exercise program are all useful tools in managing the pain associated with vulvodynia. There is often a significant amount of stress placed on the body because of anxiety, depression, difficulties sleeping, sexual and relationship issues, and negative body image and Pelvic Physiotherapists have the knowledge and the education to provide help to a body that is under immense stress. Treatment plans are individualized and multi-modal.
If you are experiencing vulvar pain, it is important to discuss this with your healthcare provider, as not all pain in the vulva is vulvodynia and there may be an easy solution. If you are diagnosed with vulvodynia, do involve a Pelvic Physiotherapist in your healthcare village…you will be glad you did!
Keri Martin is a Pelvic Floor Physiotherapist and owner of A Body in Motion Rehabilitation. She discovered her passion for Pelvic Physiotherapy in 2013 and has continued to further her education in the areas of sexual pain, incontinence, special topics in women’s health including endometriosis, infertility and post hysterectomy treatment, gastrointestinal disorders, and oncology. Keri enjoys her work with children with paediatric incontinence, her pre-natal and post-natal clientele as well as men and women suffering with pelvic pain as a result of bladder or bowel difficulties, interstitial cystitis and prostatitis.