Vulval pain

Also called Vulvodynia, Vaginismus, Painful sex

Persistent vulval pain, or the muscles tightening involuntarily. Both are real, both are treatable, and both are routinely dismissed as psychological.

What it is

Two related and frequently confused problems.

**Vulvodynia** is persistent vulval pain lasting more than three months without an identifiable cause. It is burning, stinging or rawness, either constant or provoked by touch, sex, tampons, cycling or sitting. It is a nerve sensitisation problem, like other chronic pain conditions, and the tests being normal is part of the diagnosis rather than evidence of nothing being wrong.

**Vaginismus** is involuntary tightening of the pelvic floor muscles when penetration is attempted, making sex, tampon use or examination painful or impossible. It is not deliberate and it cannot be willed away. It often begins after pain from another cause, and then persists after that cause has gone.

The two commonly occur together, each maintaining the other: pain causes guarding, guarding causes pain.

Both are treatable. Pelvic floor physiotherapy, which focuses on relaxing rather than strengthening, is highly effective and dramatically under-referred. So are topical treatments, neuropathic pain medication, dilator therapy and psychosexual therapy.

First, treatable causes must be excluded: lichen sclerosus, thrush, genital herpes, skin conditions, menopausal changes and endometriosis. Somebody should look.

Signs you might notice

Burning, stinging, rawness or aching of the vulva.

Pain on touch, on sex, on inserting a tampon, on sitting or cycling.

Pain that persists after sex, sometimes for days.

Inability to tolerate examination or a smear test.

Muscles visibly or palpably tightening on attempted penetration.

Often normal-looking skin, which is what leads to dismissal.

Needing examination and treatment rather than a pain diagnosis: white or thickened skin, splitting, or scarring, suggesting lichen sclerosus; ulcers or blisters; discharge; bleeding; or a lump or non-healing sore, which needs urgent assessment.

Also: new pain after the menopause, which is often treatable vaginal atrophy and responds well to local oestrogen.

How it can affect day-to-day life

Being disbelieved is the defining experience. Women report years of normal swabs, being told it is stress, and being advised to have a glass of wine and relax. That advice is both useless and harmful.

The relationship impact is severe, and partners are often left with no information and considerable guilt.

Avoiding cervical screening is common and has real consequences; it can be done with adjustments, a smaller speculum, self-insertion, more time, and topical anaesthetic. Asking for those is reasonable.

Sitting is a practical daily problem: work, driving, cycling. A cut-out cushion helps.

Everyday products make it worse: soaps, shower gels, wipes, scented products, tight synthetic clothing and panty liners. Removing them is part of the treatment.

Recovery is usually gradual over months, and improvement is measured in what somebody can tolerate rather than in tests.

Supporting someone well

Ask for an examination. The diagnosis is one of exclusion and something treatable is found in a proportion of cases.

Ask for pelvic floor physiotherapy by name; it is the most effective and least offered treatment.

Stop soap, shower gel, wipes and scented products. Use a soap substitute and a bland emollient.

Ask about topical treatments, neuropathic pain medication and, after the menopause, local oestrogen.

Use dilators as a graded programme with guidance, not as an endurance test.

Ask for psychosexual therapy, for the person and where wanted for the couple; this is not an implication that it is imaginary.

Ask for adjustments for cervical screening rather than avoiding it.

Ask for referral to a specialist vulval clinic or pelvic pain service.

Do not accept relax more as a treatment plan.

Where to get help

A GP practice for examination and referral.

A specialist vulval clinic, gynaecology, or a pelvic pain service.

Pelvic Obstetric and Gynaecological Physiotherapy list specialist pelvic health physiotherapists.

British Association of Dermatologists publish leaflets on vulval skin conditions.