Vulvar pain, also known as vulvodynia, simply means “pain at the vulva”. The area of the vulva is the entire external (outside) part of the female genetalia. Also known as “box”, “down there”, “hoo ha”, “beaver”, etc. This includes: the mons pubis, labia majora, labia minora, clitoris, vestibule, glands, urethra, and the vaginal opening. The vulva is not “the vagina”. The vagina is on the inside of the body - anything outside is considered “the vulva”. By the way, it took me years to unlearn that everything down there wasn’t “the vagina”, so if this is you too, don’t feel bad! 

Vulvodynia definition: vulvar pain of at least 3 months duration without a clear identifiable cause, which may have potential associated factors. 

Let’s talk about what causes vulvar pain - specific disorders and associated factors - and then discuss ideas for assessment and treatment. Some areas of assessment are more specific to medical providers and pelvic floor physical therapists, but I’ll also be covering ideas that can be helpful for all people with vulvar pain. Lastly, I’ll share some tips I’ve learned from others, from my 20+ year clinical experience as a pelvic floor physical therapist, and offer resources.

5 major categories of disorders and associated factors that can contribute to vulvar pain:

✴️Hormonally-mediated: genitourinary syndrome of menopause, breastfeeding, amenorrhea (not getting a period), medication (birth control pills, spironolactone for acne or female hair loss), breast cancer treatments that suppress estrogen (medications like aromatase inhibitors and tamoxifen)

✴️Inflammatory: Lichen Sclerosus, Lichen Planus, contact dermatitis, mast cell activation syndrome, yeast infections, bacterial vaginosis, sexually transmitted infections, etc.

✴️Neuropathic: neuroproliferative vestibulodynia, herpatic neuralgia, nerve compression or irritation of the genitofemoral nerve or pudendal nerve, Tarlov cysts, spinal radiculopathy

✴️Neuromuscular: increased pelvic floor muscle tone, hypermobility/Ehler’s Dhanlos syndrome, hip labral tears or other hip pathology, obstetrical trauma, female genital cutting, other vulvovaginal trauma

✴️Associated Factors: painful bladder syndrome/IC, fibromyalgia, IBS, headaches, TMJ dysfunction, endometriosis, autoimmune conditions, depression, anxiety, fatigue, etc.

These categories are super important to consider because getting to the root-cause can be crucial for getting the most effective treatment. As you can see, some of these categories fall into different buckets:

-medical provider (doctor, physician assistant, nurse practicioner, etc.)

-pelvic floor physical therapist

-mental health provider

Are you starting to see why a multi-diciplinary approach is the best approach for great care? More on this later…

First things first: Getting a good history can provide essential clues. For providers, here’s what we want to know:

Where is the specific location(s) of pain? Have them point it out with their finger or a Q-tip. Is it a small area (localized) or a large area (generalized)? Does the pain follow a specific nerve distribution? Is it on both sides of the body or only one side? 

How do they describe the pain? burning, sharp, shooting, numbness, electrifying, dull, etc.

When does the pain occur? constant, only with certain positions or activities, comes and goes at random

History of onset? Did anything happen when these symptoms started or before these symptoms started? Injury, trauma, vaginal birth, surgery, etc. Have they ever been able to have penetrative sexual activity or insert a tampon without pain?

 What makes things better? Worse? How do symptoms feel at night? With sitting, trunk flexion, hip flexion, hip external rotation, hamstring or piriformis stretching? 

Any past history of treatment or is this the first? - has anything helped or made things worse? Any negative experiences with treatment?

What are their thoughts and beliefs about this condition? What do they think is going on?

Other areas to investigate:

• Past medical history (illness, disease, trauma, surgery, accidents, medications and supplements past and present, other areas of injury or pain)

• Sexual health information

• Bowel and bladder health

• Menses

• Birth history

• Exercise and activity level, recreational activities they currently enjoy or are limited in doing

• Occupation, day-to-day stressors

• Family and social support

• Surveys: chronic pain is mapped in the emotional centers of the brain. Screening for central sensitization is crucial because a sensitized nervous system leads to an over-reactive pain system (as the brain’s way of protecting the body from harm). Screening can guide more specific areas of treatment.

  CSI: Central Sensitivity Index has 2 parts and is associated with psychosocial markers of central sensitization. Only one part needs to be positive for the person to be considered “sensitized”. Part A: the cut-off for the presence of central pain mechanisms is >40.

  3PSQ: Pelvic Pain Psychological Screening Questionnaire has 2 parts and helps explore a referral to a sexual health therapist/psychologist

All of this information can provide the clues for a more specific and targeted approach to examination, treatment, referrals, and education.

Examination

Visual:

Medical doctors may use what is called a vulvoscope, a microscope with a light, to magnify the vulvar area to get a better visual assessment. Pelvic floor physical therapists don’t use a vulvoscope and we don’t make medical diagnoses. What we can do is visualize the appearance of the vulva: is it scarred or white, red and inflamed, is there re-absorption of the labia minora, are there any differences in the appearance of the introitus, labia, or clitoris?

Palpation (aka, touching):

• Using a Q-tip we can do a neurosensory exam that tests dermatomes and different nerve distributions (upper thigh, vulva, perianal area, mons pubis, and lower abdomen), find a specific location of pain with light pressure (labia, vestibule, urethra, glands, clitoral region, etc.), and assess clitoral hood mobility. Check out my video showing a vestibule assessment with a Q-tip (on a digital image).

• We can use a gloved finger palpation assessment to check pelvic floor muscle tenderness and tension at the bulbocavernosus, ischiocavernosus, transverse perineal, perineum, levator ani muscles, coccygeus, obturator internus (deep hip rotator), the pudendal nerve near the ischial spine (Tinel’s sign), ischiorectal fossa, and external coccyx region. 

• Consider a pelvic floor muscle assessment using an internal rectal approach, especially if a transvaginal approach would not be tolerated or may create an unintended threat, fear, anxiety, etc.

• Orthopedic assessment of overall joint hypermobility and a hip and spine screen for strength, range of motion, and pain provocation tests

Treatment options for “what causes vulvar pain”: Medical options

Hormonally-mediated: the vestibule has estrogen and androgen (testosterone) receptors. 

• stop taking the offending medication

• Topical combination of Estradiol (estrogen) + testosterone (compounded cream) OR

• Vaginal DHEA suppositories (Intrarosa): DHEA converts to estrogen and androgens in the vagina which will affect and help the vestibule

Inflammatory: biopsy for specificity

• Topical steroids

• Topical immunomodulators

• Antibiotics

• Antifungals

• Antivirals

• Anti-histamines

• Mast cell stabilizers

Neuropathic: 

1) Neuroproliferative vestibulodynia:

• Topical lidocaine

• Topical gabapentin

• Topical capsaicin

• Vulvar vestibulectomy

2) Neuralgias (depending on where along the nerve path the problem is):

• Nerve blocks

• Hydrodissection

• Oral medication (amitriptyline, nortriptyline, gabapentin, pregabalin, duloxetine, etc.)

• Nerve ablation

• Spinal surgery (Tarlov Cysts, annular tears, etc.)

Neuromuscular: 

• Suppositories: Relaxors such as Valium (Diazepam) and Bacflofen or combination

• Pelvic floor muscle botox injections: relax the pelvic floor muscles which can make them more functional and retrainable - can be a good adjunct to pelvic floor physical therapy

Treatment options that can help all people with vulvar pain

Pelvic Floor Physical Therapy: offer choices and work with patients (facilitator, not “fixer”)

• Manual therapy: internal and external pelvic myofascial work, paraurethral desensitization techniques

• Education and exercise: pelvic floor muscle relaxation training, sexual education, including use of good quality lubricant, avoiding wipes, avoiding irritating products on the vulva, use of dilators or pelvic wand, bowel and bladder re-education

• Possible rehab adjuncts to recommend: dilators, wands, TTNS (transcutaneous tibial nerve stimulation), TENS (transcutaneous electrical nerve stimulation), lidocaine or numbing compounds, self-massage tools, cold/hot packs, SI belts, cushions, vibrators

Strategies to guide the down-regulation of a sensitized nervous system:

• Pain neuroscience education

• Stress management, meditation, mindfulness, breathing

• Sleep hygiene

• Exercise/activity that is enjoyable and doesn’t worsen symptoms, stretching, yoga

• Diet

• HRV - heart rate variability to objectively assess stress level (Garmin and Oura have products that can track this)

• Acupuncture

Referrals: a multidisciplinary team = biopsychosocial management

• Specialist in sexual medicine provider - International Society for the Study of Women’s Sexual Health directory

• Functional Medicine provider for optimizing gut health: food sensitivities, increased nutritional support, supplements

• Mental health therapy:  cognitive behavioral therapy (CBT), specialist in chronic pain or sexual dysfunction (American Association of Sexuality Educators, Counselors, and Therapists directory).

Tips for Providers:

💥Be cautious with naming/labeling/diagnosis: many syndromes overlap (IC/PBS, pudendal neuralgia, vulvodynia, endometriosis, etc.) and the label: may be incorrect, cause a patient to go down rabbit holes on Google, increase fear, catastrophization, hopelessness, etc.

💥Work to be a facilitator, not a fixer: collaborate with the assessment and treatment options, listen to their needs, and try to avoid harmful language (entrapment, out of alignment, unstable, etc.)

💥Listen to their story and validate their experiences but also review what they want to accomplish during their first visit and their overall goals. What do they expect from their first visit with you?

💥One size does not fit all for any evaluation: consider their goals, sensitivity, fear/beliefs, etc. Offer options - not everything needs or should be done during the first visit.

💥Consider when to assess and treat the pelvic floor muscles vaginally, rectally or both. Don’t assume you know how the patient feels - explain the process, give them the “why”, and ask.

💥Discuss flare management and communicate mitigation strategies.

💥Less is more - for example, don’t tell them to buy a dilator set, cushion, cupping set, do 20 stretches and breathing exercises, refer to 4 other practitioners, etc. It’s overwhelming. Start small and build up.

💥Offer a realistic timeline for change based on the length of symptoms, severity, number of psychosocial factors, etc.  

💥Brush up on your pain neuroscience education (don’t we all need to work on this?).

💥There is no one magical provider (MD, PT, etc.) - it takes a village and oftentimes, multiple tries. Different people have different skill sets and there isn’t one PT or MD who knows it all and is the expert in everything. As a provider, don’t be afraid to tell your patient you don’t know something or aren’t trained to do something (like a rectal pelvic floor muscle assessment or a vestibule assessment) but guide them to someone who can. It shows respect and they will appreciate your honesty.

Are you looking for an experienced pelvic floor physical therapist for your vulvar issues? If you live in the greater Minneapolis, Minnesota area, my clinic is in Edina, MN. Let’s work together - contact me to learn more!

Bornstein J et al. 2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. J Sex Med. 2016 Apr;13(4):607-12. doi: 10.1016/j.jsxm.2016.02.167. Epub 2016 Mar 25. PMID: 27045260.

Goldstein I et al. ISSWSH Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of PGAD/GPD. J Sex Med 2021 Apr;18(4):665-697. Doi: 10.1016/j.jsxm.2021.01.172. Epub 2021 Feb 19.

Prendergast SA. Pelvic Floor Physical Therapy for Vulvodynia: A Clinician’s Guide. Obstet Gynecol Clin North Am. 2017 Sep;44(3):509-522. Doi: 10.1016/j.ogc.2017.05.006. PMID: 28778646

Book: When Sex Hurts - Understanding and Healing Pelvic Pain by Andrew Goldstein, MD, Caroline Pukall, MD, Irwin Goldstein, MD, and Jill Krapf, MD

Book: Hello, Down There A Guide to Healing Chronic Pelvic and Sexual Pain by Alex Milspaw

Guided mediation with Shelly Prosko, PT, C-IAYT, PCAYT

Did you like this blog? Here’s what’s next on your reading list:

• What the heck is PGAD?

• Cliteracy: meaning and sexual health

Disclaimer: These self-care suggestions are for general use only and are not intended to be used as medical advice, diagnosis, or treatment. Refer to your medical provider for all questions and concerns regarding your individual care.

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