Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Chronic vulval pain and vulvodynia
Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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New severe pain still needs acute assessment
Rapid onset with fever, necrosis, urinary retention, ulceration, pregnancy-related pain, neurological deficit or an acute safeguarding concern is not explained by chronic vulvodynia.
Action: Assess observations, examine for infection, trauma and neurological disease with consent, obtain pregnancy or lesion tests where relevant, and use same-day acute gynaecology, urology or emergency referral before chronic-pain labelling.
Overview
Diagnose persistent vulval pain only after excluding specific disease, classify the pain phenotype, and build a realistic multidisciplinary plan addressing nerves, pelvic floor and psychosexual impact.
Vulvodynia describes persistent vulval pain for at least three months without a specific disorder that fully explains it. The pain is real even when tissue appears normal, and the diagnosis does not imply a purely psychological cause. Ask the patient to describe quality, location, onset, daily pattern and triggers in their own words. Clarify pain with touch, clothing, sitting, cycling, tampon use, examination, sex, urination or defaecation and whether symptoms occur spontaneously. Record sleep, work, movement, relationships and emotional impact.
Use the consensus descriptors because they guide treatment. Pain may be localised to the vestibule or clitoris, generalised across the vulva, or mixed. It may be provoked, unprovoked or both, and primary from first attempted penetration or secondary after a pain-free period. Provoked vestibulodynia often presents with entry dyspareunia and tampon intolerance; unprovoked vulvodynia can be a persistent burning syndrome associated with bladder pain, irritable bowel or fibromyalgia. These phenotypes overlap and can change over time.
Aetiology
01
Multifactorial susceptibility
No single cause explains vulvodynia; genetic, inflammatory, hormonal, neural, pelvic-floor and psychosocial factors can combine differently between patients.
02
Prior noxious input
Infection, trauma, surgery or repeated painful penetration may initiate sensitisation even after the original tissue insult has resolved.
03
Coexisting pain conditions
Bladder pain, irritable bowel, fibromyalgia, migraine and other persistent pain syndromes occur more often and can share amplification mechanisms.
Pathophysiology
1
Peripheral sensitisation
Vulval nociceptors develop lower activation thresholds after inflammatory or neural input, converting light touch into burning or sharp pain.
2
Central amplification
Spinal and brain pain networks sustain heightened responses after tissue healing, producing allodynia, hyperalgesia and pain beyond an initial trigger.
3
Protective muscle guarding
Anticipated pain causes pelvic-floor contraction, which adds myofascial tenderness and makes penetration or examination progressively more difficult.
4
Threat and avoidance loop
Repeated painful experiences increase vigilance and avoidance, reducing normal movement and intimacy while reinforcing nervous-system predictions of danger.
Clinical features and red flags
Provoked vestibulodynia
Reproducible entry pain with light touch, tampon use or penetration and focal vestibular cotton-bud tenderness is the common localised provoked phenotype.
Unprovoked vulvodynia
Longstanding spontaneous burning, shooting or raw vulval pain with normal inspection can be generalised and associated with other chronic pain syndromes.
Pelvic-floor overactivity
High resting tone, tenderness, guarding and difficulty releasing the muscles can amplify entry pain and requires relaxation-focused specialist physiotherapy.
Coexisting specific disorder
Visible dermatosis, oestrogen-deficient tissue, proven Candida or neural injury may explain part of the pain while central sensitisation persists concurrently.
Atypical focal lesion
Induration, ulceration, pigmentation change, bleeding or architectural loss is not a normal vulvodynia finding and requires targeted biopsy assessment.
Red flags requiring action
A new ulcer, lump, pigmentation change, bleeding, induration, architectural change or non-healing lesion requires biopsy-oriented vulval assessment.
Fever, rapidly spreading erythema, necrosis, severe swelling, urinary retention or systemic illness suggests infection or another acute disorder.
New saddle sensory loss, leg weakness, bladder or bowel dysfunction or progressive neurological pain requires urgent neurological or spinal assessment.
Investigations
01Structured pain and impact assessmentFirst step
Why
Classify location, provocation, onset, temporal pattern, severity and effect on function and relationships.
Interpretation and limitations
A consistent phenotype guides care and supplies baseline outcomes; symptom complexity or psychological distress does not invalidate the pain.
02Consent-based vulval inspection and cotton-bud mapping
Why
Identify visible specific disease and map light-touch allodynia across vestibular and vulval sites.
Interpretation and limitations
Focal provoked tenderness with otherwise normal tissue supports vestibulodynia; visible lesions redirect testing or biopsy and cotton-bud pain is not a credibility test.
03Microscopy, fungal culture and selected infection tests
Why
Exclude symptomatic Candida or another infection when discharge, inflammation, lesions or exposure support it.
Interpretation and limitations
Candida culture without compatible inflammation may represent colonisation; repeated negative tests argue against serial empirical antifungal treatment.
04Vulval biopsy
Why
Diagnose a dermatosis, intraepithelial neoplasia or malignancy when examination shows a focal tissue abnormality.
Interpretation and limitations
Biopsy the abnormal area through an experienced pathway; normal-looking painful skin does not require biopsy merely to establish vulvodynia.
Differential diagnosis
01
Vulval dermatosis
Lichen sclerosus, lichen planus, eczema and psoriasis cause visible colour, texture, erosion or architectural changes that guide biopsy and treatment.
02
Infection or dysbiosis
Candida, herpes, trichomonas and other infections cause characteristic inflammation, discharge or lesions and require microbiological correlation.
03
Oestrogen-deficient tissue
Genitourinary syndrome of menopause produces dryness, fragility, burning, dyspareunia and urinary symptoms with pale thin tissue and higher vaginal pH.
04
Neurological pain
Pudendal neuralgia, radiculopathy, post-surgical nerve injury and spinal disease produce distributional symptoms, positional triggers or neurological deficits.
05
Vulval neoplasia
Persistent focal ulceration, induration, bleeding, pigmentation or a mass requires biopsy and cannot be explained by normal-appearing vulvodynia.
Management
01DiagnosisExclude specific disease proportionatelyFirst stepVulval pain has persisted or recurred for at least three months without an established explanation.+
1Classify pain location, provocation, onset and timing and assess menstrual, menopausal, infection, skin, neurological, bladder, bowel and trauma context.
2Inspect the vulva and map tenderness with consent, using culture, STI testing, biopsy or imaging only when a clinical hypothesis supports each test.
3Name vulvodynia when no specific disorder explains the pain, while documenting and treating any coexisting condition separately.
02Initial careReduce irritation and protective guardingA vulvodynia formulation has been shared and immediate red flags have been excluded.+
1Validate the pain, explain sensitisation in neutral language and agree functional goals meaningful to the patient.
Complications
01
Sexual and relationship difficulty
Pain, fear and involuntary guarding can make penetration impossible, reduce desire and strain intimacy without reducing the need for consent.
02
Functional restriction
Sitting, exercise, clothing, work, sleep, menstruation products and clinical examination may become difficult or intolerable daily.
03
Psychological morbidity
Invalidation, diagnostic delay and persistent pain increase distress, depression, anxiety and occasionally suicidality, requiring active compassionate assessment.
04
Iatrogenic injury
Repeated antimicrobials, irritant topicals, painful examinations and unnecessary procedures can worsen tissue sensitivity, fear and treatment burden.
Monitoring and follow-up
Track patient-chosen functional outcomes such as sleep, sitting, clothing tolerance, tampon or examination tolerance, sexual comfort and return to valued activity.
Map pain less often than symptoms and function require, avoiding repeated provocative examination that adds distress without changing treatment.
Review topical lidocaine for irritation and meaningful benefit, stopping it when numbing, burning or inconvenience outweighs improvement.
During amitriptyline titration, review daytime sedation, dry mouth, constipation, urinary difficulty, mood, cardiac risk and total daily dose.
Reinspect when the phenotype changes or bleeding, discharge, ulceration, colour change, mass or systemic symptoms appear, even after a longstanding pain diagnosis.
Coordinate physiotherapy, psychosexual and medical plans at defined intervals so lack of progress triggers reformulation rather than an endless sequence of isolated treatments.
Special situations
Normal appearance does not negate pain
Vulvodynia reflects altered pain processing and can be severe without visible injury; validation is a clinical intervention, not mere reassurance.
Specific disease can coexist
Treating lichen sclerosus, Candida or oestrogen deficiency does not guarantee that sensitisation and pelvic-floor guarding will disappear simultaneously.
Pelvic floors may be overactive
Pain commonly drives sustained contraction and poor relaxation, so unsupervised strengthening exercises can reinforce the problem.
Psychological therapy is not dismissal
CBT and psychosexual work target threat, avoidance, distress and intimacy while recognising that the sensory pain is biologically real.
Medication benefit is uncertain
Guidelines permit selected trials, but modest evidence and adverse effects require shared goals, slow titration and planned discontinuation when ineffective.
Common pitfalls
01
Repeating antifungal treatment for every flare despite negative microscopy or culture and absence of inflammatory Candida features.
02
Calling the pain psychogenic because inspection is normal or because anxiety and relationship strain have developed.
03
Skipping inspection and biopsy of a changing focal lesion after a previous diagnosis of vulvodynia.
04
Prescribing generic pelvic-floor strengthening when examination shows overactivity and inability to relax.
05
Starting several medicines and therapies simultaneously, making benefit, harm and adherence impossible to interpret.
06
Promising cure from amitriptyline, lidocaine or surgery despite limited evidence and heterogeneous pain mechanisms.
07
Pursuing repeated invasive tests after an adequate negative evaluation instead of explaining and treating a chronic-pain syndrome.
Practice
Two practice questions
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Question 1 of 2
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Obstetrics and gynaecologyOriginal SBA
Recognising vulvodynia
A 30-year-old has six months of burning vestibular pain triggered by tampon insertion and penetration. Examination shows no lesion, infection tests are negative, and gentle cotton-bud touch reproduces focal pain. Which diagnosis best fits?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Diagnosis requires a careful search for treatable causes without endless investigations. Ask about discharge, itch, ulcers, urinary and bowel symptoms, skin disease, menopause, childbirth or surgery, nerve injury, recurrent antimicrobial use and medicines. Inspect the whole vulva, perineum and perianal skin for erythema, fissures, depigmentation, fusion, erosions, mass or ulcer. Perform light cotton-bud mapping of vestibular sites after explaining the purpose. Pelvic-floor examination is optional and consented; assess resting tone, tenderness and ability to relax rather than assuming weakness.
Test according to findings. Microscopy or fungal culture is useful when Candida is plausible, especially after a recurrent-thrush label; STI or HSV testing follows exposure and lesions. Biopsy visible architectural, pigmentary, erosive, indurated or non-healing abnormalities, but do not biopsy normal skin solely to prove vulvodynia. Consider urinalysis, bladder evaluation, pelvic imaging or neurological assessment only when symptoms point beyond the vulva. Once specific disease is excluded, repeated swabs and scans reinforce uncertainty without improving care.
Explain a multifactorial pain model involving peripheral sensitivity, central amplification, protective pelvic-floor contraction and learned threat responses. This validates biology without blaming the patient. Agree practical skin care: avoid fragranced products, douching and irritating topical treatments, use a bland emollient as a soap substitute and select comfortable clothing. Specialist pelvic-health physiotherapy can teach pelvic-floor relaxation, manual techniques, breathing, desensitisation and graded vaginal trainers when desired. Psychosexual therapy and CBT address fear, avoidance, relationship strain and pain coping rather than claiming the pain is psychological.
Medication is a trial with explicit goals, not a guaranteed cure. Topical 5% lidocaine ointment may be applied daily or 15 to 20 minutes before a trigger and washed off before sexual contact; local irritation and limited effectiveness are important. For unprovoked pain, amitriptyline can begin at 10 mg nightly and increase in small steps toward a maximum 100 mg daily according to response and adverse effects, although trial evidence is uncertain. Review anticholinergic effects, sedation, cardiac risk, overdose toxicity and pregnancy before prescribing. Gabapentinoids and duloxetine require specialist consideration because evidence and harms differ.
Set functional outcomes such as sitting duration, sleep, examination tolerance, enjoyable non-penetrative intimacy or return to activity rather than pursuing zero pain before life resumes. Review one intervention at a time while maintaining a coordinated plan. Treat coexisting lichen sclerosus, menopause-related atrophy or candidiasis on its own evidence while recognising that vulvodynia may remain. Refer persistent disabling pain to a multidisciplinary vulval service; surgery is an exceptional option for carefully mapped localised provoked vestibulodynia after conservative treatment, not for generalised or unexplained pain.
Key points
Vulvodynia is vulval pain lasting at least three months without a clear identifiable cause; it is a positive chronic-pain formulation reached after proportionate exclusion of specific disease.
Classify location as localised, generalised or mixed; stimulus as provoked, spontaneous or mixed; and record whether onset was primary or followed a pain-free period.
Burning, stinging, rawness, stabbing pain, allodynia and hyperalgesia can occur while the vulva looks normal; normal appearance does not mean the pain is imagined.
Use gentle cotton-bud mapping to record the distribution and intensity of evoked tenderness, but only after consent and never as a test of credibility.
Exclude candidiasis and other infection, lichen sclerosus or planus, dermatitis, genitourinary syndrome of menopause, neoplasia, trauma and neurological pain according to history and findings.
Assess pelvic-floor overactivity and inability to relax; physiotherapy should be specialist and may prioritise down-training, breathing and graded exposure rather than generic strengthening exercises.
Treatment is individualised and multimodal: explanation, vulval skin care, pelvic physiotherapy, psychosexual or cognitive behavioural therapy and selected local or systemic pain modifiers.
Medication evidence is limited: topical lidocaine can irritate and does not help everyone, while low-dose
Postmenopausal bleeding, unexplained weight loss, groin nodes or persistent focal night pain should not be attributed to vulvodynia without cancer exclusion.
Severe depression, suicidal thinking, trauma disclosure, coercion or intolerable functional decline requires prompt mental-health and safeguarding support.
1Reconfirm the phenotype and revisit visible skin, menopause, infection, pelvic-floor, bladder, bowel, neurological and safeguarding contributors.
2Refer to a specialist vulval service with pelvic physiotherapy, pain medicine and psychosexual expertise, reducing fragmented and contradictory prescribing.
3Consider vestibulectomy only for carefully selected localised provoked vestibulodynia after conservative options, never as routine treatment for generalised pain.
Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
Provides a reversible local-anaesthetic trial for selected provoked or unprovoked vulval pain within broader multidisciplinary care.
Lidocaine topical ointment
Apply 5% ointment thinly to the painful area daily or 15 to 20 minutes before a predictable trigger, then wash off before sexual contact.
Local irritation is common and efficacy is inconsistent; avoid oral contact, prevent partner numbness and check product compatibility with barrier contraception.
Offers an off-label systemic pain-modifying trial mainly for unprovoked vulvodynia when non-drug measures alone are insufficient.
Amitriptyline
Start 10 mg orally at night and titrate in small increments according to benefit and tolerability, up to 100 mg daily under review.
Evidence is limited; review sedation, anticholinergic effects, cardiac disease, interactions, pregnancy and overdose risk, and taper rather than stopping abruptly after prolonged use.
amitriptyline
is off-label and requires slow titration and adverse-effect review.
Avoid repeated empirical antifungals after negative investigations and reserve vestibulectomy for exceptionally selected, localised refractory provoked disease in a specialist service.