Vulvodynia (vulval pain)

Vulvodynia is pain in the vulva lasting at least three months for which no visible cause can be found: no infection, no inflammation, no skin disease, no injury. It is a diagnosis in its own right, not a polite way of saying "we found nothing". The pain is real, it disrupts sleep, work, relationships and mood, and its mechanism is understood: the nerve endings of the vulva become over-sensitive and send a pain signal to the brain in response to ordinary touch, or with no trigger at all. Other kinds of nerve pain work in exactly the same way, with skin that looks completely healthy. Vulvodynia is a good deal more common than people assume, and it can be treated, though not quickly.

What the pain is like

Most often it is described as burning, as though the skin were scalded or chafed. Less often it is soreness, tingling, throbbing, tightness or a stabbing feeling, "like a splinter of glass". The vulva usually looks unremarkable, sometimes with slight redness at the vaginal opening.

• The pain may come only on contact: putting in a tampon, an examination, sex, the seam of underwear, cycling. This is the commonest pattern, and the tender area is often confined to the vestibule at the vaginal entrance.
• It may be constant, with no trigger at all, smouldering all day and sometimes worse by evening.
• It may involve the whole vulva or just one spot, and it can be one-sided.
• It may spread to the inner thighs, the area around the anus, the pubic bone or the urethra.
• It is sometimes accompanied by frequent urges to pass urine, stinging at the end of passing it, and pain on opening the bowels.
• It often goes together with tension in the pelvic floor muscles: they clench reflexively in response to pain, and that makes the pain worse still.

The course is usually one of waves: weeks of relative quiet alternate with flare-ups, sometimes for no clear reason, sometimes after stress, an infection, a course of antibiotics, or sex that was "got through".

"Everything is fine" does not mean "there is nothing there"

This is the single most important point on the page. The absence of visible change in vulvodynia is part of the diagnosis, not proof that the problem does not exist. The doctor examines the vulva precisely in order to establish that the skin is intact, that there is no inflammation and no infection. That is not a negative result; it is the necessary step after which the diagnosis is made.

Women with this pain often hear that "the tests are fine, so you are fine", that "it is nerves", that they should "just relax", or that "it will pass after childbirth". On average it takes several years and several doctors to reach the right diagnosis, and in that time many women conclude that they invented the illness. They did not. Pain without visible damage is ordinary in medicine: migraine, fibromyalgia and trigeminal neuralgia all work that way. Nobody doubts a migraine on the grounds that the head looks normal from the outside.

The practical conclusion is simple: if you are told that because nothing can be seen there is nothing to discuss, it is worth finding someone else — a gynaecologist who works with chronic pelvic pain, or a pain specialist. And put the complaint in concrete terms: not "I am uncomfortable" but "burning at the vaginal entrance on touch, for more than six months, which makes sex impossible and sitting difficult".

What gets ruled out first

Vulvodynia is diagnosed once other causes of pain have not been confirmed, so the first appointment is mostly a search for whatever can be treated straight away. The usual checklist runs as follows.

• Infections. Thrush, particularly recurrent thrush, bacterial vaginosis, trichomoniasis and herpes, including its subtle forms in which there are no blisters, only burning.
• Lichen sclerosus and lichen planus. Skin conditions of the vulva causing itching, burning, splitting and tightness. They are visible on examination and have treatments of their own.
• Eczema and contact reaction. A very common story: perfumed soaps, intimate washes, wet wipes, panty liners, laundry detergent, latex — and sometimes the very antifungal creams a woman has been using for months.
• Atrophy after the menopause. Falling oestrogen leaves the tissue thin, dry and easily damaged. The same happens during breastfeeding and with some medicines. Local oestrogen preparations help here.
• Endometriosis and other causes of chronic pelvic pain, including bladder pain syndrome and painful pelvic floor spasm.
• Vaginismus, the involuntary tightening of the muscles at the vaginal entrance. It can be a problem in itself or the consequence of long-standing pain.
• Nerve damage or entrapment after childbirth, surgery or a coccyx injury, and also a past episode of shingles.

Some of this is settled by examination and swabs in a single visit; some takes time. What matters is that the search does not become endless: if three or four courses of thrush treatment in a row have changed nothing, thrush is not the problem.

What happens at the appointment

The doctor will ask in detail where exactly it hurts, what the sensation is like, when it started, what brings it on and what eases it, how things are with passing urine, opening the bowels and sex, and what you have already tried. It helps to arrive with a record covering a week or two: when the pain got worse and after what.

The examination begins with simply looking at the skin. A cotton bud test usually follows: different points on the vulva are touched lightly and you are asked to say where it hurts and how much. That maps out the tender area, which is sometimes only a few millimetres across. Swabs are taken to rule out infection. An internal examination is done gently and not necessarily on the first occasion; if the pain is severe it can wait. You are entitled to ask for a female doctor, to ask for someone else to be in the room, and to stop the examination at any moment — saying so out loud is a reasonable request, not a fuss.

How it is treated

The aim is to reduce the sensitivity of the nerve endings and to break the loop of pain, muscle tension and more pain. There is no single universal remedy: several approaches are usually combined, and finding the right mix takes months. It is worth knowing that from the outset, so that nothing gets abandoned after a fortnight.

• Topical treatments. A gel or ointment with a local anaesthetic, applied before a situation that provokes pain or at night; emollients instead of soap; local oestrogen where there is atrophy. Specially prepared ointments containing nerve pain medicines also exist.
• Medicines for nerve pain. Usually tricyclic antidepressants and gabapentinoids. They are prescribed not because the pain is "in the nerves" in a figurative sense, but because they lower the excitability of nerve fibres. The dose is built up gradually and the effect appears after some weeks.
• Pelvic floor physiotherapy. One of the most effective options. The physiotherapist teaches you to relax these muscles rather than train them, works manually on tender points, and adds breathing techniques.
• Gradual desensitisation. Careful work with touch, starting with a finger or a small soft dilator and moving up. It is done slowly, through discomfort but not through pain.
• Psychological therapy. Cognitive behavioural and psychosexual therapy do not "treat something imaginary": they address the real consequences of chronic pain — fear, avoidance, tension and conflict within a couple.
• Nerve blocks and, rarely, surgery. Removing the painful part of the vestibule is considered only when the painful area is sharply defined and everything else has been tried.

What helps day to day

These measures do not replace treatment, but they lower the background level noticeably and stop you provoking the pain afresh every day.

• Wash with warm water only, or a mild soap-free cleanser, once a day and with your hand. Do not put anything inside and do not douche.
• Get rid of anything perfumed: intimate washes, bubble bath, wipes, deodorising sprays. Wash underwear without fabric conditioner.
• Give up panty liners: they hold in heat and moisture and often keep the irritation going by themselves.
• Wear loose cotton underwear and sleep without it. Avoid tight jeans, synthetic fabrics and sitting for a long time in a wet swimming costume.
• Use lubricant for any contact. Products with glycerine, fragrance or a warming effect often sting; plain water-based ones without additives and silicone ones are better tolerated. Oil-based lubricants are not compatible with latex condoms.
• Cold helps in a flare: a cool gel pack wrapped in cloth for ten to fifteen minutes. Hot baths, by contrast, tend to intensify the burning.
• Do not stay in one position for long, use a cushion with a central cut-out, take breaks. Keep the bowels regular: constipation and straining increase pelvic floor tension.

Pain during sex is a reason to seek help, not to put up with it

Sex should not hurt, and enduring pain "so as not to upset a partner" is a poor strategy for a purely physiological reason: every painful episode reinforces the nervous system's response and the reflex clenching of muscles, so next time it will hurt more. The loop is only broken by stopping.

What helps in practice: an honest conversation with your partner about what hurts and what does not; a temporary break from penetrative sex while keeping other intimacy; plenty of lubricant; a position in which you control depth and pace; the freedom to stop at any moment without explaining. Many couples find it useful to attend an appointment together. And it is worth understanding that loss of desire alongside chronic pain is a normal bodily response rather than a "problem with feelings": desire returns as the pain recedes.

Online consultation

A remote appointment suits this condition unusually well, because the diagnosis is built above all on a detailed history, and a face-to-face slot almost never allows time for one. The doctor can go through the character of the pain, its circumstances and its history, look at previous test results, and say what is genuinely worth checking and what you have already checked quite enough. It is also easier online to raise the things that feel awkward to say in a consulting room.

Treatment is easy to run in the same format: choosing and adjusting medicines, understanding when to expect an effect, sorting out day-to-day care and the choice of lubricant, getting a referral to pelvic floor physiotherapy or to psychological therapy, talking through a flare-up and not abandoning the plan halfway.

The limits are clear: examination and swabs cannot be done remotely, and those are exactly what rule out infection and skin disease, so a face-to-face visit will still be needed. And separately: if pain comes on acutely with fever, purulent discharge, ulcers, bleeding, inability to pass urine or rapidly increasing swelling, that is not vulvodynia and needs to be seen the same day.

This material is for information only and does not replace medical advice.