What investigations should be considered for a patient with chronic vulval pain before initiating treatment?

Before initiating treatment for a patient with chronic vulval pain, a thorough assessment including targeted investigations should be considered to identify underlying causes and exclude secondary pain sources. This includes:

• Clinical history and focused examination to identify symptoms such as vaginal discharge, bleeding, painful intercourse, urinary or bowel symptoms, and neurological signs that may indicate specific causes or mesh-related complications if relevant ²,³.
• Vaginal and vulval examination to assess for atrophy, mesh exposure, or other local pathology ²,³.
• Urine analysis and culture to exclude urinary tract infection ³.
• Neurological assessment if pain distribution suggests nerve involvement or sensory changes ².
• Pelvic floor and rectal examination if indicated by symptoms, to exclude prolapse, fistula, or bowel involvement ²,³.
• Imaging investigations such as MRI or ultrasound may be considered if mesh-related complications or deep tissue pathology are suspected, to map anatomy and guide management ².
• Other investigations to exclude systemic causes such as diabetes, inflammatory conditions, or malignancy based on clinical suspicion ³.

These investigations help differentiate chronic primary vulval pain from secondary causes and guide appropriate management ¹,²,³.