Vulvodynia and Clitoral Pain
Vulvodynia is defined by the International Society for the
Study of Vulval Disease as chronic vulvar discomfort, especially characterised
by patientís complaint of burning, stinging, irritation and rawness.
Its exact cause is unknown, but a close association to the following factors may suggest possible causation or contributory effects:
· Present and previous genital warts
infection have been suggested, though recently some doubts have been casted on this theory.
· Chemical irritation
of the vulva with detergents, deodorants and soap may lead to chemical
dermatitis which can develop into neuropathic pain with chronic irritation.
· Vulval skin disease
or rash including lichen sclerosus.
vulvovaginitis following recurrent candida infections in diabetic patients,
those on steroids therapy and those using antibiotics repeatedly.
· Surgery or laser
treatment can lead to neuropathic pain related to the pudendal nerve.
· Pelvic muscle spasm
secondary to other pathologies in the pelvis leading to neuropathic pain is a
possibility. This is especially so as patients with vulvodynia may suffer
from other conditions such as interstitial cystitis, irritable bowel syndrome
· Previous abuse both
physical and sexual has been suggested in the past but recent reports doubted
the significance of this issue.
hypo-oestrogenism in postmenopausal women.
The main distressing
issue for patients who are suffering with this problem is their inability to
have a normal sexual relationship because of the severe pain inflicted during
and after sexual intercourse. This could have a very bad effect on the
partnersí relationship. Genital examination might show no visual abnormality.
However, vaginal discharge, scratch marks and red raw appearance could be
noticeable. Q-tip test might reveal severe tenderness in different areas in
cases of vestibulitis with no sign of acute inflammation or any other pathology
Both bacterial and viral
swabs should be taken and vulval biopsies might be needed to exclude skin
disease and vulval intraepithelial neoplasia. These could be colposcopically
directed to aceto white areas. With early lichen sclerosus the skin would be
pale and atrophic with some areas of purpura. However, in advanced cases
hyperkeratosis would be seen.
Management is usually
difficult and long supportive treatment would be needed in most cases. Anti candida treatment should be used
liberally but antibiotics should be used only when pathogenic organisms are
isolated. Fluconazole 150 mg every week for 4 weeks then on alternate weeks for
further 8 weeks should be used in cases of cyclic vulvovaginitis. Both
oestrogen and corticosteroid creams could be useful as appropriate but
excessive use of steroids could worsen the condition by causing skin atrophy.
Using a potent corticosteroid cream could relieve symptoms caused by lichen
sclerosus. Different protocols could be used for that purpose. Clobetasol
propionate cream [Dermovate] could be used twice daily for 3 months or once
daily for one month, twice weekly for one month with review at 2-3 months.
Maintenance treatment could be affected with weaker perpetrations [Edwards et al, 2002]
It is u.nfortunate that
vulval pain is usually recurrent and needs continued effort by the patient and
her treating physician as mentioned before. Supportive therapy is most
important to prevent vulval irritation. This should include strict attention to
hygiene, avoid chemical exposure and use only water for washing the vulva.
Furthermore, unbleached toilet paper, cotton sanitary products and well-rinsed
cotton underwear should be used.
Other means used to treat
difficult and persistent cases especially vestibulitis include topical local
anaesthetic ointment twice daily. Interferon injections have been reported to
have some favourable effect but more evidence is needed. For severe
non-responsive cases surgery in the form of perineoplasty or vestibular
excision has been described. However, perineoplasty was shown to be more
effective than just excision of the vestibule [Bornstein
et al, 1993 and Kehoe and Luesley, 1999]. On the other, hand laser
treatment has been popular but is not used frequently now as it could cause
more local discomfort.
antidepressants are useful to reduce nerve sensitivity and irritation and could
be used in all cases of vulvar pain. It is needed in only smaller doses in
comparison to those used in the treatment of depression. Releasing muscular
spasm with biofeedback under the supervision of a trained physiotherapist
proved useful and should be tried by all patients with recurrent symptoms.
Clitoral pain is not a common presentation
in the chronic pelvic pain clinic. This may reflect a genuine low incidence or under
reporting by the affected patients. In most cases there is no specific cause
but history of trauma to the clitoris can be a predisposing factor. This includes rough masturbation and laser treatment for HPV lesions. In one case excessive
bruising and tenderness after repeated masturbation episodes over a long period of time was almost mistaken for endometriosis. A
biochemical cause has also been suspected as it has been reported by patients
with uncontrolled diabetes. In few cases it might be caused by neuralgia of the
anterior branch of the pudendal nerve causing severe tenderness of the clitoris
itself. Rarely a neuroma of the clitoris might follow genital mutilation
causing chronic vulvar pain and dyspareunia [Fernández-Aguilar
and Noël, 2003]. Similar injury could cause epidermoid inclusion cysts
in the clitoris which could present with pain and sporadic discharge [Hanly and Ojeda, 1995]. Mild and moderate rest-pain
could be felt but severe pain could follow contact, light touch or pressure on
the clitoris [Gordon AS, 2002]. The main
scenario would be severe pain felt during or after intercourse, while wearing
tight clothing, after sitting for long periods of time and during physical
exercise. All these predisposing factors relate to actual physical touching or
stimulation of the clitoris itself and patients might learn how to avoid them
when possible. This is especially so for the type of clothing used. Patients
could also have symptoms related to other types of pelvic pain including interstitial
cystitis. However, a more elaborate list of associated conditions was published
by [Gordon AS, 2002] including multiple
sclerosis, Guillain Barrie Syndrome, lichen sclerosus, spondylolisthiasis,
urethral sphincter syndrome and vaginismus as well as past history of a
tricyclic antidepressants as well as other medications used for neuropathic
pain. However, desensitising nerve supply by repeated injections of a local
anaesthetic lateral and anterior to the base of the clitoris could have a
quicker and more satisfying effect. Such blocks could be repeated as required.
Furthermore, patients should be advised to avoid any trauma to the area
especially those predisposing factors usually responsible for the pain attacks
in the individual case. In the short term, either cold or warm compresses could
be used to provide some comfort. In most cases good pain relief could be
expected if repeated trauma to the area could be avoided. However, with long
history of the condition it might be more difficult to control the pain attacks
and permanent cure would be less likely.