C. Paul Perry, MD, FACOG
Pelvic Pain Center
Brookwood Women’s Medical Center
Clitoral pain is a specific subset of vulvodynia produced by neuralgia of the anterior division of the pudendal nerve. It is manifested by pain localized to the clitoris with or without associated pain such as vulvar vestibulitis and pelvic floor myalgia. Unlike classical pudendal neuralgia (i.e., dysesthetic vulvodynia) the pain is very localized and may have more of an aching quality than the more commonly reported burning sensation of classical pudendal neuralgia.
The etiology may be metabolic, traumatic, or idiopathic (i.e., unknown). The determinative factor is that the signaling mechanism of clitoral sensation becomes abnormal. Trauma from violent stimulation, tight clothing, or straddle injuries may produce these neuropathic changes. Vulvar laser vaporization or chemical ablation for human papilloma viral lesions (veneral warts) may produce this chronic pain. Diabetes can be a metabolic cause for clitoral pain. The majority of patients will have no discernible cause.
The diagnosis is made with careful history taking and physical examination. The key to a diagnostic history is the localization of the pain to the clitoral and peri-clitoral area. Patients may have a difficult time describing the location of their pain, but usually report pain with intercourse, tight clothing, and exercise. Stress usually is noted to aggravate the pain. Sometimes sitting increases the pain. Therefore, these women may suffer increased pain after riding in a car for extended periods. A constant “aching” and “soreness” are most commonly used adjectives. Occasionally, patients describe this pain as shooting or burning.
Sexual stimulation is painful because clitoral engorgement aggravates the pain. Intercourse may be impossible. Patients will often suffer without seeking medical care because of embarrassment. Marriages are threatened because of spousal misunderstanding or lack of communication.
On physical exam, the absence of diffuse involvement of the entire vulvar and perineal area distinguishes it from the more common dysesthetic neuralgia. The tissues appear healthy with no evidence of inflammation or distortion. The Q-tip test of the minor vestibular glands, which is so characteristically positive in vulvar vestibulitis, is negative in pure neuropathic clitoral pain. However, light touch of the clitoris will reproduce the pain.
The treatment for clitoral neuralgia includes both medications known to benefit neuropathic pain and therapeutic desensitizing blocks of the dorsal nerve to the clitoris with local anesthetics. Drugs that may be beneficial include: amitriptyline, gabapentin, diphenylhydantoin, divalproex sodium, trazodone, doxepin hydrochloride, and lamotrigine. In cases of severe unresponsive pain, chronic time contingent opioid therapy may be necessary. Anti-depressants should be used frequently since most patients with this chronic pain will have some degree of serotonin deficiency from this stressful condition. Psychosocial counseling may be necessary for many marriages.
The dorsal nerve to the clitoris is a division of the pudendal nerve. It divides from the posterior branch after leaving Alcock’s canal and travels anteriorly in the labia-crural fold toward the pubis. At the mons, it takes an almost 180 degree turn to innervate the clitoral corpus. The nerve can be easily blocked on each side by injecting 5mls of 0.5% bupivacaine about 2cm lateral and 1cm anterior to the root of the clitoral corpus. The frequency of these blocks depends on the patient’s response and can vary from weekly to once every few months.
Patients with chronic pelvic pain from clitoral neuralgia have found that loose clothing, nontraumatic exercises, and either cold or warm compresses will decrease the pain. Some patients have noted improvement after modifying their diet (avoiding spicy foods, increasing fiber and water intake to prevent constipation). Stress reduction, meditation, prayer, and compassionate counseling help these patients to cope with their pain and changing lifestyle. Increasing social contacts and distraction with career and recreational activities are beneficial.
With proper diagnosis and treatment this condition can be helped. As with any neuropathic pain, the longer the pain is present and the more intense the discomfort, the less likely treatment outcomes will be good.
1 Perry CP. Vulvodynia. In: Pelvic Pain: Diagnosis and Management. Edited by, Howard FM, Perry, CP, Carter JE, El-Minawi AM. Lippincott Williams & Wilkins 2000 Philadelphia 204-210.