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Vulval Pain and Discomfort Many women experience vulval pain or itching at some time in their lives. Some women have to deal with vulval pain for many months or years because of mis-diagnosis and incorrect treatments. There are many different causes for pain, itching and inflammation of a woman's genital area. These webpages give an overview of the different types of vulval pain and discomfort and also looks at two forms of vulval pain for which no specific cause has been found: vulval vestibulitis and dysaesthetic vulvodynia. What does the term 'vulva' mean? The term 'vulva' refers to a woman's external genitals and includes:
All organisations supporting women with vulval problems suggest you check your vulva whenever you feel a problem occurring, such as thickening of the skin, itchiness, soreness and pain on penetration. They also suggest you check your vulva at regular intervals, even when there are no problems. To do this, prop yourself up on a bed or a couch. Holding a mirror in one hand, use the other hand to gently open the vulval lips and look at the areas indicated in the diagram of the vulval area. Once you are familiar with the appearance of your own vulval skin, you can check for any colour changes (such as whitening or reddening). You should also check for any areas of thickening skin, small hard lumps such as warts and patches of sore or cracked skin, especially those that won't heal. Consult your doctor or attend a Genito-Urinary Medicine (GUM) clinic if you experience any of these changes. What can cause vulval pain and itching? Pain, itching, burning and irritation of the vulval area can be the result of an infection such as thrush or bacterial vaginosis, or the result of a non-infectious skin problem such as dermatitis, eczema or lichen sclerosis. There are also forms of vulval problems where the exact cause of the pain is unknown. In addition, women suffering from interstitial cystitis, a form of cystitis that appears to have no infection as its cause, also have vulval pain and tenderness as part of their symptoms. Causes of vulval pain and discomfort — vaginal infections Vaginal infections often affect not only the vagina but also the vaginal opening and the skin around it causing itching and pain. Getting a prompt diagnosis and treatment will alleviate symptoms and may reduce the amount of treatment you need. It is important to remember that not all women get all the symptoms associated with an infection. Also, symptoms may vary between different bouts of the same infection. The most common infections with symptoms of vulval discomfort are thrush, bacterial vaginosis, trichomonas vaginalis and herpes simplex. Thrush This is usually caused by a fungal organism called candida albicans which lives in our bodies but can grow out of control in our genital area causing symptoms of thrush. These include a white, thick, yeasty smelling vaginal discharge, and a very itchy, sore and red vulval area. Sometimes the anal opening can become itchy and sore, too. Thrush is treated with a range of antifungal drugs available as vaginal creams, vaginal pessaries and tablets to be swallowed. The creams and pessaries, which you put inside your vagina, may sometimes cause burning and skin irritation similar to the thrush infection itself. This may make it hard to tell the difference between the side effects of the treatment and the symptoms of the infection. You can also get cream to put on the vulval skin to ease the soreness and itching. Many women prefer to take tablets by mouth either as a single dose or two doses on the same day. These may cause more side effects compared to vaginal creams or pessaries and should not be taken if you are pregnant, breastfeeding or taking certain other medicines. Treatment for thrush can be bought over the counter or prescribed by your doctor. Because you can buy these medications over the counter, it is possible to mis-use the treatment for itching and soreness that is not actually thrush. If the treatment you are using is not working, if you have any doubts about the cause of your symptoms, or if you are pregnant, see your doctor or attend a clinic to get an accurate diagnosis. Inappropriate use of thrush treatments may lead to long-standing vulval problems or make other infections worse. Thrush is not a sexually transmitted infection, but if women suffer repeated attacks, especially after penetrative sex, it is possible they are being re-infected by their partners. Michele Goldsmith, author of the book Painful Sex, suggests using condoms for a few months to see if the attacks stop. If they do, it may be a good idea for your partner to be examined or tested, and if necessary, treated for thrush before you stop using condoms. Thrush infection does not always cause symptoms in men and may present as balanitis or a non-specific urethritis (NSU). For more information on thrush, including information on prevention and self-help remedies, see our online leaflet on thrush. Bacterial Vaginosis This vaginal infection, like thrush, causes soreness, burning and itching of the vulva but little or no redness or swelling. Symptoms also include a grey or white vaginal discharge with a strong, fishy smell. Bacterial Vaginosis (BV) occurs when the 'good' bacteria normally living in the vagina are wiped out and replaced by 'bad' bacteria. Because of the similarity of symptoms, it is easy to think you have thrush when you may have BV. For an accurate diagnosis visit your doctor or a clinic where an examination and tests can be carried out to determine what infection is causing your symptoms. BV, unlike thrush, can lead to a more serious internal infection called pelvic inflammatory disease (PID) [Women's Health have an online leaflet on PID]. This can happen under certain circumstances, such as gynaecological surgery. BV may also cause complications during pregnancy. Treatment for BV consists of a course of antibiotics taken by mouth or an antibiotic cream to be used inside the vagina. BV is not a sexually transmitted infection, and there is no reason to treat your sexual partner. However, if you are having sex with a man, you may want to consider using condoms, as ejaculate may upset the balance between the good and bad bacteria in your vagina. Trichomonas Vaginalis Also known as Trichomoniasis or Trich, this vaginal infection can cause the vulva to become sore, red and inflamed. The most notable symptom is a foamy, yellow greenish vaginal discharge. In some women it also hurts to urinate. The organism that causes these symptoms is a parasite in the vaginal mucus. It spreads through penetrative vaginal sex and the exchange of vaginal fluid, for example, through sharing sex toys. Treatment is usually antibiotics taken by mouth. To prevent re-infection, your sexual partner(s) should also be treated. Infection in men often does not cause any symptoms, so testing, treatment and the use of condoms is advised. Avoid sharing sex toys during treatment and always clean them thoroughly. Herpes Simplex Usually known as just herpes, this infection is caused by a virus. Women with herpes have often been made to feel guilty or bad about it. This means they have to deal with the psychological effects of the infection as well as with the physical symptoms. The virus exists in two types. Herpes simplex type 1 is usually the cause of recurring cold sores around the mouth, and herpes simplex type 2 is usually the cause of symptoms in the genital area. However, type 1 can cause genital infection and type 2 can cause infection around the mouth. This crossover is usually the result of the virus being passed on during oral sex. During the first outbreak of the infection, painful sores appear on the vulva and vagina and sometimes also on the top of the thighs and buttocks. It may hurt to urinate as urine is acidic and stings when it touches the sores. The sores, also called blisters or lesions, usually heal after seven to twelve days but in some women healing can take up to six weeks. Other symptoms include a tingly and itchy vagina (this is the first sign of the start of an attack in 50% of women with herpes), swollen glands in the groin and general flu-like symptoms. Subsequent outbreaks of the infection are usually milder and shorter than the first outbreak, and the sores tend to heal more quickly. The time between outbreaks can vary from weeks to years and some people only ever get one attack. Swollen glands or flu-like symptoms only happen during the first attack. Herpes is spread through direct skin contact between the sores and the mouth or genital skin of another person. You risk passing the virus on from the first sign of infection until the sores have healed and the current advice is not to have intercourse or oral sex during this time. A doctor may be able make a diagnosis by looking at the affected skin but a swab is sometimes taken to be absolutely sure. Treatment consists of antiviral drugs aimed at reducing the severity and length of the attack and should be taken as soon as the first signs of an outbreak are felt. Painkilling creams can help to ease the vulval symptoms. As with many viral infections, there is no permanent cure for herpes and its recurrence can be very upsetting. More information on genital herpes is available from the Herpes Viruses Association, see Resources.
Causes of vulval pain and discomfort — non-infectious vulval skin problems A woman's vulva can also be affected by skin problems that are not infectious and cannot be passed on to sexual partners. Soap, disinfectants and detergents used for washing underwear can easily irritate vulval skin. It is also possible to have an allergic skin reaction to the preservatives and other ingredients in vulval creams. Vulval skin problems can be difficult to diagnose and you may want to ask to be referred to a dermatologist or specialist vulval clinic. Treatment often includes using a corticosteroid cream and emollients. Emollients are bland creams and ointments that should be free of skin irritants. They can be used to soothe and hydrate sore and cracked skin and as a soap substitute to clean the vulva. They are available as creams, lotions and bath additives, and are available from chemists without a prescription. Examples are Aqueous Cream, E45 and Epaderm ointment. There are also a number of things you can do yourself to alleviate symptoms. See the vulval care section under Other issues. Lichen sclerosis Lichen sclerosis (LS) is a non-infectious inflammatory skin disorder which affects the vulval and perianal skin (around the anal opening). It tends to affect women in their middle years (around 50) but young women, children and men can also get it. If it affects other parts of the body it is known as 'extra genital LS'. Symptoms include itchy, sore and inflamed vulval skin which cracks, causing additional pain and stinging. The skin becomes pale and parts of the vulva (lips, clitoris) can shrink and fuse together. Not everyone affected with LS will experience all these symptoms. Because a GP may not be familiar with this condition, it can be misdiagnosed as thrush or believed to be related to the menopause or hormonal problems. Referral to a dermatologist, gynaecologist or vulval clinic is advisable. Once diagnosed (usually after taking a small piece of skin under local anaesthetic) LS is treated with a strong steroid cream, usually greatly improving symptoms, although unfortunately it can flare up again at a later date. Women with LS should avoid anything that could irritate the vulval skin. Lichen planus Lichen planus is an itchy skin disease that can affect any part of the body but if it affects the moist skin of the mouth and genital area, it causes raw and painful patches. Treatment is in the form of steroid cream or even steroid tablets and treatment should be supervised by a specialist dermatologist. The advice on vulval care under Other issues applies. In a small percentage of cases, women with lichen sclerosis or lichen planus may develop vulval cancer so the area should be checked at regular intervals for any changes in the skin. Vulval pain and discomfort — vulval pain syndromes When doctors and the medical profession talk about vulval pain, they may not be talking about the symptoms of vaginal infections or vulval skin problems. What they may be talking about are two other conditions: vulval vestibulitis and dysaesthetic vulvodynia, collectively known as vulval pain syndromes. Women with vulval vestibulitis or dysaesthetic vulvodynia have vulval pain for which there is no easy explanation. No infection or skin problem can be found to explain their symptoms and a diagnosis is made as a result of excluding all other possible causes of vulval pain or discomfort. The degree of pain, rawness and stinging experienced is very individual but for many affected women it causes considerable problems in their daily lives and can make sex difficult or impossible. Vulval Vestibulitis Women with vulval vestibulitis experience pain when the vestibule (area around the vaginal opening) is touched, for example during intercourse, when inserting a tampon or as the result of pressure caused by clothing. Often, when examined, the vestibule will appear red and inflamed, but this inflammation may be very subtle and easily overlooked. The cause of the pain remains unknown but many women with vulval vestibulitis have previously suffered from bouts of thrush infection, which were treated with anti-fungal creams. How this, and the repeated use of anti-fungal creams, affects long term vulval pain such as vestibulitis is still not clear. Many women will have tried a whole range of prescribed and over-the-counter treatments as their symptoms were mistaken as signs of an infection or skin disorder. These repeated, inappropriate treatments are believed to be detrimental to vulval health in general and may play a role in prolonging the symptoms of vestibulitis and dysaesthetic vulvodynia. At present there is no standard treatment for vestibulitis. Few controlled trials have been carried out, making treatments difficult to compare. Currently, treatments include:
Other forms of reducing symptoms include:
Dysaesthetic Vulvodynia Dysaesthetic Vulvodynia (previously called essential vulvodynia) has much in common with vestibulitis but the pain and burning, instead of provoked by touch or pressure, is constant. The pain sensation is often described as a nerve-type or neuralgic pain. Although the skin looks normal, the nerve fibres in the vulval skin may be damaged or irritated and on 'high alert', causing pain, burning and aching regardless of touch or pressure. The pain can affect more than just the vulva, such as the inside of the thighs and the anal area, and some women experience pain when emptying their bowels. The term vulvodynia can be very confusing. It was used, and sometimes still is, as a general term for vulval pain including those types with known causes such as infection and skin problems. In 1991, the International Society for the Study of Vulval Diseases redefined the term to describe women with unexplained chronic vulval discomfort characterised by burning, stinging, irritation and rawness, i.e. vulval vestibulitis and dysaesthetic vulvodynia. Additional confusion arises when the terms vulvodynia and dysaesthetic vulvodynia are used interchangeably. Like vestibulitis, dysaesthetic vulvodynia (DV) is diagnosed after all other causes of similar symptoms are ruled out. Treatment can include the same anaesthetic jellies and soothing emollients as for vestibulitis. As the pain seems to involve the nerve fibres, treatment with drugs that affect the nervous system can be helpful. The anti-depressant Amitriptyline is often prescribed for this reason and treatment can last up to six months. Side effects, such as a dry mouth and tiredness, are common and constipation may occur as well. Self-help remedies to soothe the painful areas as described for vestibulitis (ice bags, Aveeno sitz baths etc.) can also be used for DV.
Vulval pain and discomfort — other issues to consider Taking care of your vulval skin Regardless of whether you have any vulval problems, the main advice is to avoid using soap, bubble bath, antiseptic, scented shower gels and other perfumed products on the delicate vulval skin. Avoid scrubbing with flannels, just gently clean with water only. Women with vulval skin problems like lichen sclerosis and with vulval pain syndromes are advised to clean and soothe the area with Aqueous cream or other emollients. If drying the vulva with a towel is too painful, try using a hairdryer on a cool setting. This is also recommended for women with active genital herpes. To avoid shampoo coming into contact with the vulva, washing hair separately above a hand basin is recommended. If you have, or are prone to, vulval problems, avoid wearing tights or tight fitting trousers. Avoid synthetic underwear and try cotton knickers that are not too tight. As detergents and fabric softeners can be an irritant to vulval skin, switch to non-biological washing powder or try washing underwear in baking soda only. Always rinse underwear well. If urinating causes stinging and pain because the urine touches the sore vulval skin, try pouring luke warm water over the vulva while you are on the toilet. Other methods include urinating while in the bath or shower. It may also help to lean slightly forward when you are on the toilet as this directs the stream of urine straight down and minimises the amount that touches the skin. Vulval discomfort and sex Any form of vulval discomfort can affect intimate personal relationships. In particular, long standing vulval pain or lichen sclerosis can make many forms of sexual contact difficult. If you have intercourse, ensure there is sufficient lubrication, using a lubricant, such as KY Jelly, if necessary. Don't use oil or petroleum based lubricants, like Vaseline, when using a condom or diaphragm, as they will damage the latex. Women with vulval vestibulitis or dysaesthetic vulvodynia may find they begin to avoid sexual intimacy for fear of pain during intercourse. This may lead to reduced sexual arousal, loss of sexual desire and relationship problems. Help with the sexual and emotional problems of vulval pain can be obtained from a psychosexual therapist or clinical psychologist. Where to go for help with vulval problems Getting the right diagnosis and treatment for vulval problems can prove to be difficult for some women. Initially, your GP should examine you and treat or advise you appropriately. If your symptoms persist you can ask to be referred to a specialist. This referral can be to a dermatologist, gynaecologist or genito-urinary specialist. Some hospitals have special vulval clinics that you can be referred to. There are also clinics you can attend without a referral. Many hospitals have a sexual health clinic at their GUM (Genito-Urinary Medicine) department. They hold frequent clinics and you can either make an appointment or attend at a time when no appointment is needed. They often have patient or sexual health advisors you can speak to over the phone first. A check-up at a sexual health clinic involves an examination of your vagina and vulva and swabs are taken to test for thrush, BV, trichomonas, gonorrhoea and chlamydia, as well as genital herpes and warts. A blood sample is taken to screen for syphilis and hepatitis B. Doctors at these clinics will refer you to other specialists if necessary. Other clinics for which you need no referral are well-woman and contraceptive clinics. See Resources for details of how to find local clinics. Vulval pain and discomfort: resources and links UK-based organisations Women’s Health British Society for the Study of Vulval Diseases (BSSVD) Herpes Viruses Association National Lichen Sclerosis Support Group Vulval Health Awareness Campaign Vulval Pain Society USA Organisations National Vulvodynia Association Vulvar Pain Foundation Books Painful Sex by Michele Goldsmith (Thorsons 1995) How to find a clinic GUM clinics are also called sexual health clinics. Visit the www.playingsafely.co.uk website to find your nearest clinic. Contraception/well woman clinics: Call the fpa helpline on 0845 310 1334 (mon-Fri 9am-6pm) or visit their website: www.fpa.org.uk. Brook Advisory clinics: ring 0800 0185 023 or visit their website at www.brook.org.uk.
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Written by Ingrid Smit and published in printed format (2001) by Women's Health
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It is difficult for a woman to see her own vulva, therefore many women may not know what their vulvas look like, or what is normal for them. This in turn makes it more difficult to be alert to any changes in appearance of the vulval skin that may be a sign of a problem. As with all parts of your body, the more familiar you are with your vulva, the easier it is to know when something seems not quite right.
Attention has recently turned to the pelvic floor muscles of women with vestibulitis. When studying these muscles it appeared that many women with vestibulitis had certain things in common, such as heightened muscle tension and muscles taking longer to recover after a contraction. Women participating in a study did pelvic floor exercises using special portable home biofeedback machines (these aim to give greater awareness and voluntary control over muscles and muscle contractions we are usually not aware of). Results of this study imply that using this technique can help to overcome the difficulties experienced by women with vestibulitis when attempting penetrative sex.