Vulvodynia

Persistent vulval pain with no visible cause and no infection to find. The absence of anything to see does not mean the absence of anything wrong, and there are recognised treatments.

What it is

Pain in the vulva persisting for three months or more, where examination finds no skin condition, no infection, no hormonal cause and no neurological cause to explain it. The pain is typically described as burning, rawness, stinging or a feeling of soreness, and less often as itching.

The current understanding is that the pain arises from changes in how nerves in the area transmit and how the nervous system processes those signals, often alongside increased pelvic floor muscle tone. It is a pain condition rather than an imagined one, and it belongs in the same family as other persistent pain conditions.

Types

Two distinctions matter.

Localised or generalised. Localised vulvodynia is confined to a specific area, most often the vestibule, the ring of tissue immediately around the vaginal opening. Generalised vulvodynia affects a wider area of the vulva.

Provoked or spontaneous. Provoked pain occurs on contact: sex, tampon insertion, an examination, tight clothing, cycling or prolonged sitting. Spontaneous pain is present without any trigger, often as a constant background burning. Many people have a mixture.

Provoked pain at the vestibule is the most common presentation, particularly in younger women.

Contributing factors

No single cause has been established. Factors reported repeatedly include a history of recurrent thrush or other infection, prior use of irritant products, hormonal factors including some contraceptives and low oestrogen states, an overactive pelvic floor, other persistent pain conditions such as irritable bowel syndrome, bladder pain syndrome or fibromyalgia, and previous painful experiences that established a guarding pattern.

Anxiety and low mood are frequently present. They are much better understood as consequences of persistent pain than as its cause, though once present they amplify pain and are worth treating for that reason alone.

Assessment

The diagnosis requires that other causes have been looked for properly. That means an examination of the vulval skin in good light for signs of lichen sclerosus, eczema or other dermatoses; swabs for infection; consideration of low oestrogen where relevant; and assessment of the pelvic floor.

A cotton swab test is often used, in which light pressure is applied at defined points around the vestibule to map exactly where pain is provoked. It is uncomfortable and it is informative, because a consistent map is characteristic.

Treatment

Treatment is combined, and expectations should be set accordingly: the aim is substantial reduction in pain and restoration of function, over months.

Vulval care

Stop everything applied to the area except water and, if needed, an unperfumed emollient. No soap, shower gel, wipes, fragranced washing products or panty liners. Cotton underwear, loose clothing, and avoiding prolonged pressure. This alone reduces pain for a proportion of people, and it costs nothing. See vulval hygiene.

Pelvic floor physiotherapy

Raised pelvic floor tone is present in a large share of cases, and treating it is one of the better supported interventions. Treatment includes manual release of tender points, down training, breathing work and graded desensitisation. See pelvic health physiotherapy and an overactive pelvic floor.

Topical treatments

Local anaesthetic preparations are used, either before sex or, in some regimens, applied regularly. Where low oestrogen contributes, topical hormonal treatment may be part of the plan. Some topical preparations irritate rather than help, so a change of approach after a fair trial is reasonable.

Oral medication

Medicines developed for nerve pain, including some antidepressants used at doses intended for pain rather than for mood, are used in this condition. They take weeks to have an effect, have side effects that need discussion, and are prescribed and monitored by a clinician. Specific medicines and doses are not listed here.

Psychological approaches

Cognitive behavioural therapy for pain, mindfulness based approaches and psychosexual therapy all have supporting evidence. They are not offered on the assumption that the pain is psychological; they are offered because persistent pain responds to how attention and threat are managed, which is true of all persistent pain.

Surgery

For localised provoked pain that has not responded to a full course of other treatments, an operation to remove the painful area of the vestibule is offered in some specialist centres, with reported success in selected cases. It is a last resort, considered after everything else and only in the right patient.

Sex during treatment

Continuing to have painful sex is counterproductive: it reinforces guarding and pain. That does not mean stopping all contact. Working around the painful area, generous lubrication, and reducing the pressure to reach any particular outcome all help. Involving a partner in the explanation prevents the misinterpretation that follows silence. See painful sex.

What to expect

Most people improve. Improvement is measured over months, setbacks are normal, and combinations work better than single treatments used in isolation. Being seen in a specialist vulval clinic, where these exist, tends to shorten the process considerably.

Last reviewed: September 2026