In the medical care system, it is not uncommon to encounter a woman complaining of vulval pain, and these patients might see several different medical professionals such as gynaecologists, dermatologists, midwives, paediatricians, urologists, GPs, genitourinary physicians, and psychiatrists before the diagnosis is clear. They usually complain of vulval pain, soreness, and burning, and associations with comorbid pain syndromes, psychosocial, neurological as well as musculoskeletal factors have been described. Women of all ages are affected with lifetime prevalence rates of around 16% [1, 2], but there is a lack of global studies, especially in low‐income nations [3].

Vulvodynia is now classified as a spontaneous and/or provoked vulval pain occurring for more than 3 months without any apparent cause and is associated with several factors according to the 2015 consensus terminology (see below) [4].

History

The early reports of this condition occurred in the nineteenth century. The British‐American gynaecologist Alexander Johnson Chalmers Skene, who also described the Skene´s glands, wrote in 1888 of ‘hyperaesthesia’ of the vulva: [5].

Pruritus is absent, and on examination of the parts affected no redness or other external manifestation of the disease is visible. When, however, the examining finger comes in contact with the hyperaesthetic part, the patient complains of pain, which is sometimes so great as to cause her to cry out. Indeed, the sensitiveness is occasionally so exaggerated as to keep the patient from consulting her physician until it becomes absolutely unbearable. Sexual intercourse is equally painful, and becomes in aggravated cases impossible. This affection must not be confounded with vaginismus, or with other conditions of increased sensitiveness of the vulva due to inflammatory conditions.

The American gynaecologist Theodore Gaillard Thomas together with his fellow countryman Paul F Mundé also used the term ‘hyperaesthesia’, writing in 1891 [6].

The disease … constitutes, on account of its excessive obstinacy, and the great influence which it obtains over the mind of the patient, a malady of a great deal of importance. It consists in an excessive sensibility of the nerves supplying the mucous membrane of some portion of the vulva; sometimes the area of tenderness is confined to the vestibule, at other times to one labium minus, at others to the meatus urinarius; and again a number of these parts may be affected … So commonly is it met with at least that it becomes a matter of surprise that it has not been more generally and fully described … No inflammatory action affects the tender surface, no pruritus attends the condition, and physical examination reveals nothing except occasional spots of erythematous redness scattered here and there … The slightest friction excites intolerable pain and nervousness; even a cold and unexpected current of air produces discomfort; and any degree of pressure is absolutely intolerable. For this reason, sexual intercourse becomes a source of great discomfort, even when the ostium vaginae is large and free from disease … it will be observed that her mind is disproportionately disturbed and depressed by this. In some cases, it seems to absorb all the thoughts and to produce a state bordering upon monomania.

Howard Atwood Kelly also observed the superficial tenderness as opposed to vaginismus alone, noting: ‘Exquisitely sensitive deep‐red spots in the mucosa of the hymeneal ring are a fruitful source of dyspareunia – tender enough at times to make a vaginal examination impossible’ [7]. Mundé discerned that tissue removal was futile: ‘My observation of the results of caustics and the knife is not such as to inspire me with confidence in them’.

The idea of surgical treatment was later attempted by Kelly, who found that excision of the painful area in the same way as a caruncle was not as successful: ‘… the hope is greater when the cause lies more obviously in the caruncles’.

It took almost a century before an international society, International Society for the Study of Vulvovaginal Disease (ISSVD), set a focus on the problem [8]. Ever since there has been an evolving classification of vulval pain syndromes. Initially ‘the burning vulva syndrome’ described the presence of burning, soreness, or pain without any other visible cause. In the 1970s, patients were diagnosed with ‘psychosomatic vulvovaginitis’ [9]. Progressively the combined Latin‐Greek term ‘vulvodynia’ became more prevalent.

E. G. Friedrich defined the vulval vestibulitis syndrome for localised pain in the area around the vaginal opening causing severe pain at any attempt of vaginal entry or touch, and erythema of various degrees may also be present [10]. Patients who complained of unprovoked persistent pain in the vulva without visible cause were diagnosed with essential vulvodynia, a term that was later changed to dysaesthetic vulvodynia.

Initially, research tried to establish a relation between the human papillomavirus (HPV) and the finding of vestibular papillomatosis, but the latter is now considered a normal variant and HPV is not associated with vulvodynia [11].

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