Laëtitia, 26 years old. Pain during sexual intercourse.

Reviewed by Dr. Alexandre, dermatologist

Dr. Marina Alexandre In collaboration with 4 other professionals

What clinical diagnosis factor(s) should you look out for?

Dyspareunia (pain during intercourse) is a telltale symptom.
The vulvar pain felt by Laetitia: burning, warmth, irritation, searing pain throughout the vulvar region.
Pain that may become chronic even in the absence of sexual intercourse, but which worsens or recurs after each act of sexual intercourse with vaginal penetration/attempted.
A recent change in contraception to a non-oestrogenic choice, which may increase associated vaginal dryness.

Following the clinical diagnosis, the diagnosis of inflammatory vestibulitis caused by vaginal dryness of hormonal origin (a type of vulvodynia) was confirmed.

Reminders about inflammatory vestibulitis (type of vulvodynia):

Vulvar vestibulitis manifests itself as a burning sensation in the vestibule, the area extending from the labia minora to the vaginal introitus.
Vestibulitis is a cause of dyspareunia, i.e. pain felt during sexual intercourse.
Often, it is caused by a lack of lubrication, leading to a sensation of warmth and burning.

Moisturise mucous membranes well:

Use lubricant during sexual intercourse.
Apply local oestrogen.
Apply a moisturising lotion.

Pain management:

Apply a local anaesthetic beforehand to reduce pain.
Analgesics can be supplemented with certain types of antidepressants for pain relief.

Pelvic floor therapy sessions:

Aim to relax the perineal and pelvic muscles, as pain leads to contraction, which then increases the pain. Such therapy sessions can also include TENS (gentle electrostimulation for pain relief; devices may be recommended for self-treatment in severe forms or cases that have been chronic for more than 3 months).

Innovative therapies:

Innovative therapies such as radiofrequency or biophotomodulation can also be used to improve dryness (action on the Skene and Bartholin glands and the vaginal mucosa).

Additional therapies:

Other additional therapies can complement the treatment, particularly for pain management: acupuncture, homeopathic remedies, yoga, etc.
A mindfulness approach (relaxation, hypnosis, meditation, etc.) or cognitivebehavioural psychotherapy may be offered.
In some cases, the patient may be referred to a sex therapist.

How to carry out a self-massage?

Piriformis stretching: pain reduction

By stretching your piriformis muscle, you’ll reduce literally all pain, especially sciatica and lower-back pain. It also helps to reduce stiffness in the back of the legs, buttocks, hamstrings, and potentially the calf muscles.

The butterfly:

Butterfly stretching helps to open up the hips and thigh, and improves flexibility. This stretch targets the groin, relaxing and lengthening the thigh muscles (adductor). The adductors are often neglected during training sessions, but they play an essential role in your stability and balance.

Self-massage during application of moisturizing/soothing creams:

Two fingers, making small circles with as little pressure as possible around the vulva.

Gentle pressure from the edge of the vulva outwards in a star shape from 3 o’clock to 9 o’clock.

Cold water bath :

To reduce over-stimulation of the sympathetic nervous system linked to stress and pain, and reactivate the parasympathetic nervous system:

Apply a glove filled with cold water and a few ice cubes to the perineal area for a few seconds.
Repeat for 20 minutes a day, 3 times a week (if the patient adheres to the treatment).

Intimate hygiene and advice on vulvodynia:

Vulvodynia cannot be prevented because its cause is unknown, but it is sometimes possible to prevent the associated pain.

External cleansing should be carried out with special soaps that maintain pH and do not dry out the skin, rather than with a conventional soap.
Be careful not to clean excessively.
The patient should be advised to wear cotton underwear and loosefitting clothing to limit the rubbing that triggers pain.
Reduce self-medication, especially in cases of suspected mycosis, particularly if the mycosis seems to recur: in that case, a vaginal swab is indicated as mycosis is often treated when the cased is actually vaginosis (and vice versa). This can even make the situation worse…
Do not remove all hair.

Popular beliefs:

A patient with vulvodynia does not systematically have a history of experiencing sexual violence.
Psychological disorders (depression or others) are generally the consequence of vulvodynia rather than its cause.
Vaginismus must be clearly distinguished (= involuntary contraction of the pelvic floor muscles during an attempt at penetration).
There is not always a history of infection, but mistaken selfmedication for a suspected infection is common.
Not all vaginal pathologies are caused by fungal infection…

Dr Samuel Sarfati

General practitioner , France

Antifungal medications should not be prescribed repeatedly, particularly in the event of a recurrence.

Non-medicinal treatment guidelines are of crucial importance regardless of the care given based on aetiology: external cleansing with intimate cleanser, no excessive cleansing (in particular, no intra-vaginal cleansing), no complete hair.

Nicolas Dutriaux

Midwife

Clinical diagnosis using the cotton swab test.

Make treatment for vaginal dryness a priority.

Pain should be taken into account and analgesics (local and/or systemic) and additional treatment adapted as soon as possible; after 3 months, the pain will become chronic and its management even longer and more complicated.

Dr Christelle Besnard-Charvet

Gynaecologist , France

Not every unpleasant sensation in the vulva is a fungal infection.

When symptoms recur, an examination is essential.

Beware of prescribing antifungal suppositories or of self-medication without a diagnosis.

The vaginal flora must be preserved.

Annabel Maruani-Raphael

Pediatric dermatologist , France

Not all vulvodynia is caused by fungal!

Create easily your professional account

Get access to exclusive dermatological services to increase your professionnal knowledge: +500 pathology visuals, clinical cases, expert videos
Benefit from valuable features: audio listening, materials to be shared with your patients
Stay informed about the upcoming events and webinars, latest scientific publications and product innovations

Laëtitia, 26 years old. Pain during sexual intercourse.

What test(s) should be offered as a first step? (many possible response)

What diagnosis(es) do you suggest? (many possible response)

You suspect inflammatory vestibulitis due to vaginal dryness of hormonal origin. What do you do? (many possible response)

Differential diagnosis

What clinical diagnosis factor(s) should you look out for?

Reminders about inflammatory vestibulitis (type of vulvodynia):

Moisturise mucous membranes well:

Pain management:

Pelvic floor therapy sessions:

Innovative therapies:

Additional therapies:

How to carry out a self-massage?

Cold water bath :

Intimate hygiene and advice on vulvodynia:

Popular beliefs:

Laëtitia, 26 years old. Pain during sexual intercourse.

Clinical presentation

Quiz

Key points to remember

Treatment

Your Colleagues’ Advice