Clinical Review

Assessment and management of vulval pain

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1723 (Published 28 March 2012) Cite this as: BMJ 2012;344:e1723
  1. David Nunns, consultant gynaecological oncologist,
  2. Ruth Murphy, consultant dermatologist
  1. 1Nottingham University Hospitals, Nottingham NG5 1PB, UK
  1. Correspondence to: D Nunns david.nunns{at}nuh.nhs.uk

Summary points

  • Vulvodynia is a diagnosis of exclusion; it may be generalised or localised, unprovoked or provoked, and it often presents as chronic superficial pain in the genital region

  • Patients with generalised skin conditions may have painful involvement of the vulval area

  • Cultures from vulval swabs (or findings on a wet preparation) may identify a treatable infective cause

  • A punch biopsy may be a useful diagnostic tool if abnormal lesions are seen on examination

  • Refer patients with vulvodynia or difficult to treat disease to specialist care—ideally to a multidisciplinary service

  • Treat unprovoked vulvodynia according to principles of chronic pain management (for example, tricyclic antidepressants or gabapentin); women with provoked vulvodynia may respond to physical and psychosexual therapy aimed at desensitisation

The vulva refers to the female external genitalia comprising the mons pubis, clitoris, labia majora, labia minora, and perineum (figure). Vulval pain can be divided into two categories: pain secondary to a specific, identifiable, underlying disorder and idiopathic pain with no recognisable underlying disease. Women use the term pain to include a variety of unpleasant symptoms including burning, soreness, and throbbing, and some women insist that they do not have pain but describe the sensation with one of these words, which can be misleading for clinicians.

Fig 1 Normal vulval anatomy

Sources and selection criteria

We searched for papers that had been published up to August 2011 using appropriate index terms (vulval pain, vulvodynia, vestibulodynia, lichen planus, and lichen sclerosus) from the National Library computerised search service (Medline, PubMed). Most studies were observational but a few randomised controlled trials were available.

The exact prevalence of vulval pain in adult women is not known, but a recent population based survey from the United States found that 16% of women had at some time experienced chronic burning, knife-like pain, or pain on contact with the vulva that …

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