Puzzling Over the Hurt Down-Under


Pain! Raw, burning, scratchy, sharp, stabbing—down there! And the suffering has gone on for a few months. The patient may complain of pain with sex (and pain with sex is simply not normal), pain when using tampons, or with wearing certain types of clothing. You examine her vulva and see…nothing unusual. No sign of infection, trauma, hormonal deficiency, neoplasm, or something suggesting a neurologic or inflammatory condition. It is hard to help, unless you can diagnose. However, your patient has given you enough clues to help guide you.

With those symptoms and a vulva that looks completely normal (unlike other causes of vulvar pain, which do not present with a normal appearance), she likely has vulvodynia. Vulvodynia is vulvar pain of at least 3 months duration without another clear identifiable cause. Patients suffering from vulvodynia generally visit four to nine different providers before they get their diagnosis. Until the cause of their pain is diagnosed, they get uncoordinated care, receive a potpourri of treatment recommendations that just do not take care of that pain, and through it all continue to have a poor quality of life.

Noor Dasouki Abu-Alnadi, MD, MS, who specializes in chronic pain syndromes such as vulvodynia, presented a 1-hour master class on the topic at the recent Contraceptive Technology conference.[1] Understanding what causes vulvodynia would be helpful, said Dr. Abu-Alnadi, “but the truth is that we’re not exactly sure what causes vulvodynia. There are some theories.” One comes from a study showing that women who have vulvodynia also have a hyper-innervated vulva—10 times the amount of normal nerve endings along the vestibule.[2] This suggests a potential allergic reaction component, with substantial mast cell activation. “We think that there are…triggers—whether someone gets an HPV infection or they get a candida infection or they are wearing tight clothing—and then it causes this mast cell reaction, itchiness,” she said. “When patients have that, like an allergic component, the vestibule can actually look very red, like a cherry red, and they can even complain of recurring tears along the vestibule. This is something that you would biopsy, and the result would come back as just ‘inflammation,’ which is nothing.”

In some cases, patients can localize where their pain originates, but for others it is tricky. Many do not know their anatomy well enough. Some patients commonly mistake their symptoms for those of a urinary tract infection. Others may think the pain is inside their vagina when it is really along the vestibule. The vestibule is the most common area where localized vulvodynia originates. It incorporates the opening of the vagina, surrounds the urethra superiorly, and then extends around the hymen and follows down along the posterior fourchette. Three nerves mainly innervate the vulva:

  • the ilioinguinal nerve extending up toward the Mons
  • the genitofemoral extending from the Mons into the lateral superior thigh
  • the pudendal extending to the rest of the vulva and the vagina

For patients complaining of vulvar pain but whose vulva looks normal, perform the cotton-swab test, the mainstay for diagnosing vulvodynia. With the cotton-swab int hand, apply the swab tip to each side of the vestibule and ask “Does this feel the same” as the other side? You want to make sure both sides are congruent. Then ask whether the patient feels any pain as you apply the cotton swab tip on the mons, just outside the mons, along the labia majora, along the interlabial sulci, and along the labia minora. The most important part of the test is to make sure that you spread the labia and apply the cotton-swab tip along the inner base of the labia minora at the 12:00 o’clock position, at 3 o’clock, 6:00 o’clock, and 9:00 o’clock. Each time you apply the swab tip, ask “Is this sensation painful, or it is pressure?” Ask whether the sensation reproduces the pain felt daily, or with sex, or when inserting a tampon.

The last thing that Dr. Abu-Alnadi does is to get a sample to culture for candida. Swipe the yeast swab from the Mons all the way down, through the labia, and into the perineum near the anus. Many patients with vulvodynia have symptoms that may overlap with candida, so it is important that the culture is negative.

The tampon test is an alternative test for vulvodynia if you don’t want to perform the cotton-swab test or first want to use a screening test or want to corroborate your impression from the cotton-swab test. The tampon test is simple. The patient uses a tampon with an applicator, inserting it through the vestibule and into the vagina. No lubricant can be used. Then the patient immediately pulls out the tampon.

Ask your patient, “How does it feel when you put in or take out a tampon?” This is not always positive with all patients, because essentially in asking about tampon use, you are assuming that the patient as has localized vulvodynia that’s around the vestibule. The tampon test is useful to monitor whether patient’s symptoms improve. If the patient cannot come in for an exam. have them monitor how their tampon test is improving over time.

Patients with vulvodynia often present as a puzzle, but if you know the classic presentations for the condition, it makes sense and an exam may not even be needed, which is useful to know in the context of telemedicine. Here are three case histories of patients presenting with vulvodynia; these cases in some ways overlap, but they are very different.

  • A 21-year-old nulligravida has insertional dyspareunia (always ask if dyspareunia is with insertion or with deep penetration) since she first started having penetrative sex with her male partner. She was on oral contraceptives between the ages of 14 through 19. She tried Slippery Stuff, a water-based lubricant, and position changes, but she hasn’t really had any improvement in her pain. She has never been able to use tampons.
  • A 30-year-old nulligravida transmale is using his vagina and engaging in penetrative vaginal sex. He has had dyspareunia with his partners for at least the past 5 years. He is on testosterone therapy, but only for the past 3 years. He notes a history of sexual abuse about 5 years ago, but he reports now that he is in a safe relationship.
  • A 40-year-old G2P2 insists that she’s had recurring yeast infections. She is typical of the patients who frequently come in saying, “I’ve had six yeast infections this year.” But their records show no documentation of a positive culture, yet they are insistent that they have another yeast infection that just has not gone away completely, and so they need to get another antifungal. But now she’s got dyspareunia, with pain and a rawness. She gets a burning sensation when she wears tight clothing and during exercise. She says Diflucan helps her symptoms for couple of days, but then her itching always returns.

Next month…treatments for vulvodynia.

[1] Abu-Alnadi ND. Sex shouldn’t hurt: managing vulvodynia and pelvic floor dysfunction. Contraceptive technology conference, Sept. 23, 2020.

[2] Bornstein J, Goldschmid N, Sabo E. Hyperinnervation and mast cell activation may be used as histopathologic diagnostic criteria for vulvar vestibulitis. Gynecol Obstet Investig 2004;58:171-8.