Re: Assessment and management of vulval pain
We read with great interest your recent comprehensive paper on the assessment and management of vulval pain (1). As outlined by the authors, accurate data on the prevalence of vulval pain are scarce and it suggest that it is more common than suspected (2). The most recent ISSVD classification of vulval pain is related to its aetiology, which is very helpful as a diagnostic tool (3). We recently conducted an audit of vulval (genital) pain in patients presenting to an open-access genito-urinary medicine (GUM) clinic and in reply to the article we would like to share our results.
We audited 244 case notes of female patients who attended between the first and twelfth of September 2011. A bit more than a quarter of these women, 27% (65) had symptoms of vulval pain. The mean age of this population was 29.6 years old (range 17-47). Of these patients the majority, 85% (56) presented with acute pain and 14% (9) with chronic pain (present for more than three months). The symptoms described by the patients included; pain (39), dysuria (28), superficial dyspareunia (28), soreness (26) and burning (19). Additional symptoms described were itching and discharge, reported by 41 patients. An underlying infectious cause was identified in more than three quarters, 78.5% (51) of the cohort, thrush being the most common diagnosis, present in 41.5% (27).
The standard set for this audit was that "all female patients, presenting with vulval pain should have a diagnosis to explain the vulval pain or an appropriate management plan in place on the day". We found that in four fifths, 81.5% (53) of the patients this standard was achieved. A diagnosis that was unlikely to explain the pain was ascribed to three patients. Thus, nine patients remained for whom no diagnosis was established. Of these, only 22% (2) had a follow-up plan documented on the day.
These data show that in our GUM clinic infections causing vulval pain are well recognized and managed. However when the diagnosis remains unclear at presentation we are not putting an appropriate follow-up plan in place. In less typical pain presentations physicians seem to lack the confidence to plan further management.
In conclusion, many female patients, over a quarter, presenting to GUM clinics will have vulval pain. As well as managing infections GU physicians need to have knowledge of the non infectious causes as well as the less common causes of vulval pain in order to make appropriate care plans.
(1) Nunns D., Murphy R., Assessment and management of vulval pain, BMJ 2012, 344: e1723
(2) Harlow BL, Stewart EG, A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am med Womens Assoc 2003;58:82-8
(3) Moyal-Barracco M. Lynch PJ. 2003 ISSVD terminology and classification of vulvodynia: a historical perspective. Journal of Reproductive Medicine. 2004;49 (10):772-7
Competing interests: No competing interests