and Filippo Murina2
(1)
Center of Gynecology and Medical Sexology, San Raffaele Resnati Hospital, Milan, Italy
(2)
Lower Genital Tract Disease Unit V. Buzzi Hospital, University of Milan, Milan, Italy
Vulvar pain is challenging for patients and healthcare providers. It can be acute, recurrent, chronic, and neuropathic with or without premenstrual flares. Patients may present with a variety of symptoms such as pain, burning, itching, irritation, soreness, and patterns continuous or intermittent, localized or generalized. Some critically differential aspects are summarized in Box 10.1.
Box 10.1. Differential Diagnostic Criteria in Different Types of Vulvar Pain
Duration of vulvar pain: shorter than 3 months when acute, between 3 and 6 or more for chronic, more than 6 months neuropathic.
Etiology: usually objective, clear, and precise in the acute and chronic types, it becomes progressively difficult to be objectified when the neuropathic pain is in play.
Type of inflammation associated:
In acute vulvar pain, it is:
Finalized to restore the normal tissue cytoarchitecture and function (“resolving”)
Of short duration (less than three months)
Of severity proportional to the intensity of the tissue damage
Limited in intensity
In neuropathic vulvar pain, it is:
Non finalized, “non-resolving”
Of duration lasting more than 6 months
Of growing intensity, disproportionate to the type/extension of the visible lesion
Graziottin A., Presented at the 18th World Congress of Childhood and Adolescents Gynecology, Florence June 25–28, 2016
Vulvar pain often has a burning quality, while other patients describe their problem as “irritation,” “stinging,” “raw feelings,” “crawling,” or just “vulvar awareness.” Sometimes discomfort has also been referred to as “the pain down there” or as “feminine pain.”
Furthermore, vulvar pain can be provoked, when it occurs in response to stimulation, or unprovoked, if it occurs independently of stimulation. Some experience allodynia, which is defined as pain resulting from stimuli which would not normally cause pain, such as touch or pressure. Some suffer from hyperalgesia, or severe pain experienced from mild pain stimuli.
Virtually every condition of the vulva can be sore, raw, irritating, or burning at times. Even common problems such as vulvar dermatitis, which is usually only itchy, can become painful if scratching or splitting leads to open areas and ulcerations.
A simple general concept about the relationship between intensity of pain and meaning of it (useful to be explained to women and partners) is represented in Fig. 10.1.
Fig. 10.1
Relationship between pain and inflammation
The golden rules for an accurate diagnosis of vulvar pain include:
Report carefully in the clinical record the woman’s wording about her symptoms; do it “verbatim” that means reporting exactly the woman’s words. Virtually every condition of the vulva can be sore, raw, irritating, or burning at times. Even common problems such as vulvar dermatitis, which is usually only itchy, can become painful if scratching or splitting leads to open areas, ulcerations, and infections.
Record the precise narrative timing of the pain picture. The symptom of vulvar pain must be fully evaluated. As pain is subjective, the patient’s history provides the main evaluation. Useful questions include the following: When did pain start? Was there a specific damaging agent: a trauma, intentional (abuse) or unintentional, an infection, surgery (episiotomy, colporrhaphy), or the onset of pain that was not triggered by any specific event? Examination and investigations provide further understanding of the pain syndrome and exclude other conditions.
Quantify the intensity of vulvar pain. Vulvar pain can only be measured subjectively. The most reliable and well-understood method is a numerical rating scale, from 0 (no pain) to 10 (extreme pain), with half-points marked. This is superior to the widely used visual analogue scale (VAS), which is a 10 cm line with “no pain” marked at one end and “extreme pain” at the other. Alternatively, a simple verbal rating scale can be used, e.g., “none,” “mild,” “moderate,” and “severe.” Both numerical and verbal scales can be used by patients without the need for paper and pen, unlike the VAS.
Record pain distress, and interference of pain with activities of daily life, besides pain intensity. Because pain is multidimensional, a single rating scale combines these dimensions in unknown quantities. Depending on the clinical question, treatment, patient, and setting, it can be helpful to assess separately pain intensity, pain distress, and interference of pain with activities of daily life. It can also be helpful to ask about average pain, worst pain (as even if this only occurs rarely, it can still reveal what patients should avoid), and pain on, for example, bladder voiding. Pain reduction or relief is measured directly using a percentage, from 0 % = no relief up to 100 % = total relief.
Classically, pain can be considered to have three dimensions: sensory discriminative, motivational affective, and cognitive evaluative. The most used and validated multidimensional tools for the measuring pain are the long and short forms of the McGill Pain Questionnaire (Melzack 1987) (Fig. 10.2).
The questionnaire consists primarily of three major classes of word descriptors – sensory, affective, and evaluative – that are used by patients to specify subjective pain experience. It also contains an intensity scale and other items to determine the properties of the pain experience. The questionnaire was designed to provide quantitative measures of clinical pain that can be treated statistically. Vulvar pain analysis and quantification are optimal for a comprehensive understanding of the patient’s experience and for effective treatment planning, and pre- and posttreatment quantification of vulvar sensitivity can lead to advances in the optimization of treatment success.
The audiovisual recording of the vulvar lesions either intentional or unintentional with the immediate description of the causative events in the child/adolescent/women should be accurately recorded at the first examination in the emergency department (Box 10.2).
Box 10.2. Vulvar Pain from Intentional Trauma/Sexual Abuse: Recording Is Mandatory
At the very first visit in emergency units, every physician, especially those working in emergency departments, should immediately do an audiovisual recording of any vulvar/genital lesion and of the child/adolescent/woman wording. A mobile phone that everybody possesses today is sufficient if more sophisticated instruments are not available. This is mandatory when the type of lesions and/or the child/adolescent/woman’s wording suggests sexual abuse.
The goal of the immediate accurate audiovisual recording at first visit is twofold:
Avoid repeated questioning and examining, especially for legal purposes, as repeated investigations and examinations may trigger negative memories and exacerbate the emotional and physical suffering.
Record an impeccable “fresh” documentation for legal reasons, if the author of the intentional lesions is to be suited.
10.1 The Sexual Correlate of Vulvar Pain: Introital Dyspareunia
Dyspareunia is a component of vulvar pain related to the “provocation” of sexual intercourse, and it may be the only symptom, especially in provoked vestibulodynia (Box 10.3). Dyspareunia is a genital pain experienced just before, during, or after sexual intercourse; patients with dyspareunia may complain of a well-defined and localized pain or express a general disinterest in and dissatisfaction with intercourse that stems from the associated discomfort.
Patients with dyspareunia are more likely than the general population to report pain with insertion of a tampon or finger, or during a gynecologic examination. Dyspareunia is an important component of vulvodynia, and it can occur as an isolated symptom.
If a woman reports difficulties with intercourse, it is important to determine whether pain on intercourse is superficial, at the point of penetration, which is likely to be related to a vulvar problem, or deep inside (deep dyspareunia), which is not caused by vulvar disease, but may be a component of a comorbid condition.
Box 10.3. Marinoff Dyspareunia Scale
0 | No dyspareunia |
1 | Causes discomfort but does not interfere with frequency of intercourse |
2 | Sometimes prevents intercourse |
3 | Completely prevents intercourse (Marinoff and Turner 1992) |
The Female Sexual Function Index (FSFI) is a 19-item multidimensional, self-report measure of sexual function. The measure has received empirical support for its reliability in several patient samples and for its ability to discriminate between samples of women with sexual dysfunction and healthy samples (Rosen et al. 2000).
The FSFI includes both frequency items (“Over the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?”) and intensity items (“Over the past 4 weeks, how would you rate your level [degree] of discomfort or pain during or following vaginal penetration?”). Higher scores reflect better functioning.
10.2 How Should Patients with Vulvar Pain Be Evaluated?
10.2.1 Medical History
Obtaining a history is of paramount importance for a diagnosis, but the process may be hampered by the woman’s embarrassment when discussing the topic. The manner of questioning requires a nonjudgmental approach, with a mixture of directed and open-ended questions (Box 10.4).
Personal habit is a fundamental aspect to consider: eliminating all possible irritants is an important step. If patients are using topical creams with an irritating base, as is often the case, they have to inform the clinician. The daily use of a potentially irritating mini-pad or panty liner is not healthy for any woman, and many lubricants also contain irritants as preservatives. It is also important to recognize certain aspects of a patient’s medical history such as bladder and bowel function. It has been estimated that more than half of vulvodynia patients have symptoms of excessive urgency and frequency of urination and suprapubic pain. This condition is defined painful bladder syndrome/interstitial cystitis (PBS/IC). PBS/IC is a chronic, severely debilitating disease of the urinary bladder with a course that is usually marked by flare-ups and remissions. Dyspareunia is not uncommon in women with PBS/IC and may be related to the mechanical effects of intercourse on the inflamed bladder.
Box 10.4. History of Vulvar Pain
Demographics | Age, occupation (sitting, standing), and leisure activities (bicycle riding, running) |
Duration | Weeks, months, years |
Timeline of pain | Start, factors at onset, what happened then and now, course |
Site | Localized to one area or all over the vulva |
Description | Burning, rawness, and irritation Spontaneous or provoked Intermittent or constant |
Severity | 0–10 scale (0 no pain, 10 most severe pain) |
Factors that worsen or relieve pain | Cycling, sitting, pain with tampon insertion |
All treatments | Over the counter and prescribed |
Current sexual activity | Frequency, use of lubricants and devices |
Contraception | Method, age of onset, duration |
Pain with sexual intercourse | Pain on arousal, foreplay, touch, penetration, afterward, when the last time normal painless intercourse, if any, took place |
OB/GYN history | Abortions, pregnancy termination, pregnancy, mode of delivery, complications, lactation, postpartum depression |
Menstrual history | Last menstrual period, onset, duration, regularity, menstrual symptoms, menstrual worsening of vulvar pain, pads/tampons, douching |
Trauma history | Vulvar, pelvic (including obstetric) or back trauma, sexual and/or physical abuse, motor vehicle, bicycle or equestrian accident |
Family history | Vulvovaginal disease, skin diseases, atopy, autoimmune diseases, gastrointestinal diseases |
Comorbid conditions | Migraines, endometriosis, irritable bowel syndrome, chronic constipation, interstitial cystitis, temporomandibular joint disease, fibromyalgia, chronic low back pain, anxiety, depression, stress |
10.2.2 Physical Examination
The first important aspect of physical examination is the visual inspection of vulvar region. A systemic approach should be utilized, to make sure that all vulvar parts are included in the examination: this requires a meticulous and methodical examination of the vulva, including the perineum and perianal region. You should pay attention to skin texture, color, and the presence of lesions, ulcers, cysts, excoriations, and anything else that attracts your attention as “different.”
It is extremely important to allow the patient to control over the situation, which means that the patient must feel free to stop the examination at any time.
There are some common normal variants which may be mistaken for pathology:
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Enlarged sebaceous glands, called Fordyce spots, present as multiple small yellow sebaceous glands along the inner aspects of the labia minora (Fig. 10.3). They can coalesce into cobblestone appearance, but have no clinical significance.
Fig. 10.3
Fordyce spots on labia minora
A common normal variant is vulvar papillomatosis, which is found in 8–48 % of women in the reproductive age group. These are filiform soft projections often found in the vestibule. They can be mistaken for condylomas (Table 10.1). Vulvar micropapillomatosis should be left untreated: laser removal, for example, frequently results in an “iatrogenic” trigger for the development of a vestibulodynia (Fig. 10.4) (Cohen Sacher 2015).
Table 10.1
Differentiating vulvar micropapillomatosis from vulvar condylomas
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