British Journal of Obstetrics and Gynaecology

May 2001, Vol. 108, pp. 451±455

Vaginal microbiological ¯ora, and behavioural and clinical

®ndings in women with vulvar pain
Krasimira Tchoudomirova a, Per-Anders MaÊrdh b, Dan Hellberg c,*
Objective To study genital symptoms and signs in women with vulvar pain, and the association with potential
risk factors such as microbiological agents, sexual behaviour and genital hygiene.
Design Prospective cohort study of apparently healthy women attending for contraceptive advice.
Setting Two family planning clinics and one youth clinic in Sweden.
Population Out of 996 women recruited, 79 women (7.9%) had, on request, complaints of current burning and
smarting vulvar pain and/or super®cial dyspareunia (our de®nition of vulvar pain) while 917 women without
such symptoms served as controls.
Results Complaints of dysmenorrhoea, vaginal discharge, genito-anal pruritus, dysuria, and abdominal pain
were more frequent in the study group, than in the control group. In the women with vulvar pain, erythemas,
super®cial ulcerations, and ®ssures were found signi®cantly more frequently. Vaginal candidosis was the only
current genital infection that occurred more often in the study group, than among the controls. There were no
differences in the history of gonorrhoea, genital chlamydial infection, genital herpes, genital warts, and
candidosis between the two groups. The sexual debut of the women with vulvar pain occurred later in life,
compared with the control group. Control subjects were more likely to use tampons for menstrual sanitation,
than the women with vulvar pain.
Conclusions Neither infectious conditions caused by current known agents, with the exception of candidosis in
some cases, nor behavioural factors, such as sexual behaviour and genital hygiene habits could in this study
explain vulvar pain.

INTRODUCTION toses (e.g. lichen planus, bullous dermatoses, infectious

`Extensive sensitivity' or `hyperesthesia' of the vulva
was described by Skene in 1889 1. The medical literature
did not mention vulvar pain until the early 1980s 2. The
burning vulva syndrome is de®ned as chronic vulvar
discomfort, characterised by the patient's complaint of
burning, stinging, irritation or rawness 3. Vulvodynia is
characterised by unexplained vulvar pain, sexual
dysfunction, and psychological disability 4. Several
subsets of vulvodynia have been recognised 5 (i.e. vulvar
vestibulitis syndrome, cyclic vulvovaginitis, dysesthetic
vulvodynia, and vulvar papillomatosis). Vulvodynia can
also be a combination of several of these subtypes. As
there are many de®nitions we chose only to use the term
vulvar pain in this study.
Other causes, such as cytolytic vaginitis 6, lactobacil-
losis 7, and desquamative in¯ammatory vaginitis 8 can
mimic the symptoms of vulvodynia. Many vulvar derma-
a
Department of Venerology, University Hospital, Bulgaria
b
Institute of Clinical Bacteriology, University Hospital,
Sweden
c
Department of Obstetrics and Gynaecology, Falun
Hospital, Sweden
* Corresponding: Dr D. Hellberg, Department of Obstetrics and Gynae-
cology, Falun Hospital, S-791 82 Falun, Sweden.
q RCOG 2001 British Journal of Obstetrics and Gynaecology
PII: S 0306-545 6(00)00114-5
dermatoses, allergic dermatoses, autoimmune derma-
toses, and vulvar intraepithelial neoplasia) can cause
acute or chronic vulvar itching and pain. These diseases
can cause complex differential diagnostic problems 9.
The aim of the present study was to register genital
symptoms and signs among apparantly healthy women
with current vulvar pain (i.e. burning and smarting pain
and/or super®cial dyspareunia) and to study the preva-
lence of bacterial and viral genital infections and vaginal
¯ora changes. Finally, we tried to identify any possible
association between symptoms of vulvar pain and sexual
behaviour and genital hygiene habits.
METHODS
The women were recruited at the family planning
clinics at Eskilstuna Hospital, Eskilstuna and at Danderyd
Hospital, Stockholm, as well at the youth clinic in Eskil-
stuna, Sweden. Of the 1077 women, all attending for
contraceptive advice, who were asked, 1011 (93.9%)
agreed to participate in the study. Due to incomplete
records, 15 women (1.5%) were excluded from the
analyses. Seventy-nine (7.9%) of the remaining 996
women had burning and smarting pain and/or super®cial
dyspareunia, the majority of them for more than six
months, and, on the basis of personal, structured inter-
views, were de®ned as suffering from vulvar pain. The
www.bjog-elsevier.com
452 K. TCHOUDOMIROVA ET AL.
comparison group consisted of the remaining 917 women
without such symptoms.
A structured in-depth interview included a history of
any sexually transmitted disease, other genital infections,
and current genital symptoms. Complaints of vaginal
discharge, dysuria, dysmenorrhoea, hypermenorrhoea,
intermenstrual bleeding, and abdominal pain, including
low-sited abdominal pain, were noted. A thorough gyne-
cologic examination was performed where ®ndings of
erythema, ®ssures, super®cial vulvovaginal ulcerations,
ectopies, and the character of the vaginal discharge, were
noted.
Urethral and endocervical specimens were collected,
transported, and analysed for Chlamydia trachomatis and
Neisseria gonorrhoeae, while vaginal specimens were
tested for Candida albicans, Mycoplasma hominis, lacto-
bacilli, and obligate and facultative anaerobic bacteria, as
described in detail previously 10.
Wet smears of material collected from the vaginal
mucosa and from the posterior vaginal fornix were used
for detection of yeast blastospores and pseudohyphae,
trichomonades, bacteria of mobiluncus morphotype,
and of clue cells. Vaginal secretion was also collected
for performing amine tests and pH-measurement. Genital
candidosis was de®ned as a positive candida culture from
the vagina and/or ®ndings of blastospores and pseudohy-
phae at wet smear microscopy as previously described 11.
Bacterial vaginosis was diagnosed in cases ful®lling at
least three out of the following four criteria: a grey homo-
geneous vaginal discharge, clue cells (i.e. epithelial cells
covered by bacteria of Gardnerella vaginalis morpho-
type), a vaginal pH of $ 4.7, and a positive amine test.
For detection and typing of human papillomavirus,
samples were collected from the ecto- and endocervix
by means of a brush device (Cytobrush, Medscand,
MalmoÈ, Sweden) and analysed by Southern blot as
described in detail elsewhere 10.
The material was computerised and analysed with the
JMP statistical programme (SAS Institute Inc. JMP statis-
tics for the Apple Macintosh, Cary, North Carolina USA,
1994). Differences were studied by using x 2 (Pearson and
likelihood ratio) for nominal variables and t test for
Table 1. Sexually transmitted diseases (STD), allied conditions, and urine cultures in women with (n ˆ 79) and without vulvar pain (n ˆ 917). Values are given
as n (%).
Genital chlamydial infection
Human papillomavirus infection
Genital warts
Vaginal candidosis
Bacterial vaginosis
Bacterial urine culture$ 10 5CFU/ml (colony forming units)
continuous variables. Logistic regression was used for
multifactorial analyses (e.g. adjustment for age).
RESULTS
The mean age of the 79 women with vulvar pain and of
the 917 controls differed signi®cantly: 23.5 and 26.1
years, respectively [P ˆ 0.002; range 15-44 years].
Therefore all comparisons were adjusted for age.
With exception of candidosis, there was no signi®cant
differences in the prevalence of any current sexually
transmitted disease or related conditions in the women
with vulvodynia, as compared with the controls (Table
1). Nor were there any difference in a history of pelvic
in¯ammatory disease or any sexually transmitted
diseases, including gonorrhoea, genital chlamydial infec-
tion, genital herpes, genital warts, and vaginal candidosis.
Other vaginal ¯ora ®ndings, such as betahaemolytic
streptococci group B, Escherichia coli, Staphylococcus
saprophyticus, G. vaginalis, lactobacilli species, Myco-
plasma hominis, Ureaplasma urealyticum, and obligate
and facultative Gram-positive and Gram-negative cocci
and rods did not differ between the two groups of women.
Differences were noted between the study and the
comparison group concerning symptoms of dysmenor-
rhoea, vaginal discharge, genital and perianal pruritus,
general abdominal pain, and lower abdominal pain
(Table 2).
Among the women with vulvar pain, erythema, super-
®cial ulcerations, and ®ssures were signi®cantly more
often observed at the examination as compared with
the controls. Erythema was also associated with candi-
dosis in the study groupin that 11 of the 18 women
(38.9%) with candidosis had erythema, compared with
8 of 61 (13.1%) without candidosis (P ˆ 0.02). The
corresponding ®gures for super®cial ulcerations were 5
of 13 (27.8%) and 3 of 66 (4.5%) (P ˆ 0.01), respec-
tively. There was no signi®cant association between
®ssures and candidosis: 5.6% versus 6.6% (P ˆ 0.88).
The women with vulvar pain less often used tampons
only for menstrual hygiene than the controls (11.4%
Vulvar pain
With (n ˆ 79) Without (n ˆ 917) P
n (%) n (%)
9 (11.4) 76 (8.3) 0.55
6 (7.6) 60 (6.6) 0.86
3 (3.8) 36 (3.9) 0.97
18 (22.8) 112 (12.4) 0.01
7 (7.8) 124 (14.1) 0.33
4 (5.1) 65 (7.1) 0.48
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 POSSIBLE CAUSES OF VULVAR PAIN 453

Table 2. Gynaecological symptoms and signs in women with and without DISCUSSION
vulvar pain. Values are given as n (%).

Symptoms Vulvar pain One of the most interesting ®ndings in this study was
what we did not ®nd. Despite comprehensive cultures and
With (n ˆ 79) Without (n ˆ 917) P other diagnostic methods to detect all possible microor-
n (%) n (%)
ganisms that we could expect to ®nd, combined with a
Dysmenorrhoea 43 (54.4) 334 (36.4) 0.004 detailed history of previous genital infections, we only
Vaginal discharge 38 (48.1) 184 (20.1) 0.0001 found an increase of vulvovaginal candidosis among the
Genital pruritus 25 (31.7) 60 (6.5) 0.0001 women with vulvar pain compared with the control
Perianal pruritus 6 (7.6) 28 (3.1) 0.02 group. These cases of candidosis could only explain a
Dysuria 13 (16.5) 52 (5.7) 0.0003
General abdominal pain 38 (48.1) 277 (30.2) 0.0007
small minority of the cases of vulvar pain.
Lower abdominal pain 20 (27.0) 155 (17.7) 0.05 Although vulvodynia was described one hundred years
Signs ago, the aetiology remains obscure. Women may present
Abnormal discharge 21 (26.6) 217 (23.7) 0.37 with a variety of symptoms, but with few objective signs
Erythema 15 (19.0) 55 (6.0) 0.0001 of disease. A psychosomatic aetiology of this multisymp-
Super®cial ulcerations 8 (10.1) 12 (1.3) 0.0001
Fissures 5 (6.3) 19 (2.1) 0.03
tomatic condition has been assumed 12 along with various
Ectopy 34 (43.0) 399 (43.6) 0.53 infectious causes, such as candidosis 2,13±15, human papil-
lomavirus 16±18 and herpes virus infections 19. Also chronic
recurrent bacterial vaginosis 20, chronic alteration of the
versus 23.2%, P ˆ 0.02). No other signi®cant differ- vaginal pH 20 and the use of intimate hygiene products,
ences concerning genital hygiene such as other methods such as creams, soap, douches, and sprays, have all been
of menstrual sanitation, use of different kinds of washing considered as potential aetiological factors 21. Hormones
solutions, frequency of washing, vaginal douching and have also been regarded as possible causes for this condi-
the habit of taking hot baths, were observed between the tion 22,23. Furthermore, autoimmunity has been suggested
two groups of women studied. as an aetiological factor, because of the concordance of
No differences were observed between the study group the two in¯ammatory syndromes (interstitial cystitis and
and the controls concerning contraceptive use (i.e. for focal vulvitis) involving the bladder, the urethra and the
oral contraceptives, intrauterine device, condom, and vestibulum, all organs derived from the embryonic
for no contraceptive use at all). Sexual behaviour of the urogenital sinus 24.
women with vulvar pain, compared with the controls, The incidence and prevalence of vulvar pain is not
differed only for age at ®rst intercourse (which occurred known. However, vulvar pain is likely to be an under-
later among the women with vulvar pain), but not for diagnosed clinical syndrome. In one study 25 in a general
number of lifetime partners, more than one partner during gynaecological practice, the prevalence of vulvodynia
the last 6 months, the practise of casual sex, regular oral was 15% when it was actively looked for. In our study
or experience of anal sex, intercourse during menstrua- the prevalence of vulvodynia was 7.9% in a group of
tion and masturbation (Table 3). women who considered themselves gynaecologically
No age-adjusted differences were observed in having healthy.
had an induced or miscarriage. The controls had had The reported mean age of women with this condition
more pregnancies (1.0 versus 0.40) than the cases. has varied, with a range from 25 to 60 years of age 26. In
After adjustment for age and childbirths (0.65 versus this study the women with vulvar pain were younger than
0.30), the difference disappeared (P ˆ 0.25). the control group, with a mean age of 23.5 years.

Table 3. Sexual behaviour in women with and without vulvar pain. Values are given as n (%).

Variable Vulvar pain

With (n ˆ 79) Without (n ˆ 917) P

n (%) n (%)

Age of ®rst intercourse 16.7 16.1 0.0005

Number of lifetime partners 9.2 11.4 0.56
.1 partner last six months 17 (21.5) 188 (20.5) 0.55
Casual sex, ever 54 (68.4) 659 (72.3) 0.76
Masturbation .once/month 21 (26.6) 255 (24.5) 0.96
Oral sex .once /month 14 (17.7) 95 (10.4) 0.07
Anal sex, ever 19 (24.1) 199 (21.7) 0.30
Intercourse during menstruation 17 (21.5) 144 (15.7) 0.10

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454 K. TCHOUDOMIROVA ET AL.
The perception of one and the same pathological
changes differ from woman to woman. In contrast to the
vivid ¯ora of symptoms reported by the women studied
(e.g. discharge, genital and anal pruritus, dysmenorrhoea,
and abdominal pain) only erythema and super®cial ulcera-
tions and ®ssures could be found at gynaecological exam-
ination and these were mainly observed in those having
candidosis. In 27% of the vulvodynia cases, an increased
discharge was observed on examination. This might give
chronic irritation to the vulva.
Recent case±control studies have provided little support
for the hypothesis of a viral or bacterial infection being the
cause of vulvodynia 22. Studies have failed to identify
herpes simplex, N. gonorrhoeae, Staphylococcus aureus,
group B streptococci, C. trachomatis, Mycoplasma homi-
nis, C. albicans, Trichomonas vaginalis, and human papil-
lomavirus as causes of vulvodynia 22,27±29. In one study a
history of recurrent candidosis, previous condyloma
acuminata, or earlier oral contraceptive use was noted
more often in patients with vulvodynia than in controls 28.
Our study, like others 22,26, did not ®nd any such associa-
tions.
Extensive washing with intimate hygiene products
might cause symptoms from the genital tract. However,
we could not ®nd any correlation between the genital
washing habits of the women with vulvodynia concern-
ing low pH solutions, soap, water, taking hot baths or
practising vaginal douching. The choice of menstrual
sanitation method was related to vulvodynia, as these
women less often used tampons than the controls. This
may be due to pain at insertion of the tampon.
Sexual partner factors, such as the number of lifetime
sexual partners, recent partner change, history of casual
sex, and practise of anal and oral sex did not differ from
the comparison group. Age at ®rst intercourse differed
signi®cantly between the two groups of women studied,
but only by 0.6 years, due to a later sexual debut in the
women with vulvar pain, and would not seem likely to
have any causal association to vulvodynia. However, oral
sex was practised by the women with vulvodynia almost
twice as often as the controls: in 18% versus 10%
(P ˆ 0.07). This might be explained by dyspareunia.
Bazin et al. 22 found no association of the occurrence of
the vestibulitis syndrome and the number of sexual part-
ners, but reported that early age at ®rst intercourse was
related to the development of vulvar vestibulitis. Bazin et
al. also found a greater parity rate was related to a
decrease in the relative risk of vulvodynia. This was
also the case in our study but after adjustment for age
the difference was not signi®cant between the study
group and the control group.
Vulvar pain continues to be a mystery as to its patho-
genesis. It is a complex multifactorial, multidisciplinary,
and underdiagnosed clinical syndrome. The interrelation-
ship of factors in¯uencing vulvar pain is confusing. The
occurence of chronic infections with human papilloma-
virus/or candida species may suggest an immune-
mediated aetiology with sensitiisation to antigens causing
erythema and pain. Remission and exacerbation of symp-
toms may occur when treatment for one condition affects
the development of another. For example, prompt treat-
ment for vulvovaginal candidosis or condylomata may
prevent chronic in¯ammation contributing to vestibulitis.
Fear of cancer or infection may lead to overcleaning and
the use of potential allergens or irritants, which may
obscure an underlying dermatosis or vestibulitis. Long
term topical application of corticosteroids may itself
induce vulvodynia as well as potentiating candidosis.
It is important to investigate all potential aetiological
factors in every patient with vulvodynia. The recognition
of the multifactorial nature of vulvodynia is important for
appropriate diagnostic evaluation and management.
Patients who have experienced chronic pain are a manage-
ment challenge, as they remain hypersensitive and fearful,
even after `successful' therapy. Vulvar pain usually
improves in time, but resolution is typically slow. Patients
must be followed up regularly and encouraged as small
increments of progress are made. One consequence of
vulvar pain is that it may severely disturb relations with
partners. One of the major ®ndings of this study was that,
despite extensive diagnostic procedures, we did not ®nd
evidence of an infectious aetiology of vulvodynia, with the
exception of some cases of candidosis. The pathogenicity
of vulvodynia remains a scienti®c challenge.
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Accepted 21 November 2000