Synopsis
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 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 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.
Key red flags
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.
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.
Investigation priorities
Classify location, provocation, onset, temporal pattern, severity and effect on function and relationships.
Management branches
Vulval pain has persisted or recurred for at least three months without an established explanation.
- Classify pain location, provocation, onset and timing and assess menstrual, menopausal, infection, skin, neurological, bladder, bowel and trauma context.
- Inspect the vulva and map tenderness with consent, using culture, STI testing, biopsy or imaging only when a clinical hypothesis supports each test.
- Name vulvodynia when no specific disorder explains the pain, while documenting and treating any coexisting condition separately.