Vulvar, vaginal, or perineal pain affects over 25% of the female population at least once in their lifetime. It is classified into secondary pain and primary pain. Secondary pain can be due to infectious (such as in the case of candida), neoplastic, inflammatory (e.g., in lichen), neurological (inflammation of the pudendal nerve), or post-surgical reasons. Idiopathic pain, on the other hand, occurs in the absence of a primary condition and is classically divided into true vestibulodynia if the pain is located in the vestibule, and clitorodynia if located near the clitoris.

Women with vulvar pain are often treated as if they are psychologically disturbed because it is sometimes difficult to understand the true nature of the pain, find an appropriate therapy, and empathize with their emotions and the reality of their family and relationship. Identifying the real cause of the pain is crucial for prescribing the correct therapy. In the case of metasurgical pain, resulting from surgery, and pain related to conditions such as lichen, the cause is easily attributable to the entrapment of fine nerve endings of the pudendal nerve and tissue ulceration. Defining the causes of idiopathic pain, often localized in a very well-defined point of the vagina or near the clitoris, is more challenging.

Within the same pathology, different levels of pain can be observed depending on the severity of the condition. For example, in the early stages of lichen, the pain is superficial and presents as itching and burning, with painful episodes appearing sporadically and without an apparent cause. As the disease affects deeper layers, the pain becomes subdermal and presents as continuous tensile pain. In cases of even deeper involvement, the pain is continuous and constrictive due to inflammation and underutilization of the muscles.

The therapeutic approach varies depending on the specialist consulted: gynecologist, pain management/anesthesiologist, dermatologist, neurologist, or psychiatrist. Each approaches the disease with their own expertise and learning history, but it is believed that the best results come from a combination of different approaches.

Pain treatment involves immediate prescription of pain relievers to alleviate suffering, administration of muscle relaxants, and psychological support from a specialist. Local treatment of pain involves different procedures depending on the origin of the pain. In cases of postsurgical nerve fiber entrapment, mapping of the pudendal nerve through PTNF and subjective mapping may be necessary to determine the exact course of the affected nerve fiber. The procedure involves implanting small but selected amounts of adipose-derived cells that, when properly placed near the damaged nerve fibers, can reduce pain and trigger a regenerative process. This method is used in the outcomes of episiotomy, perineoplasty, and sphincterotomy. If the scar appears extremely tense and the tissue is inelastic, the implantation will be done using a special needle that can simultaneously inject adipose tissue and segment the scar into smaller microsegments.

In cases of true vulvodynia and vestibulodynia, once the trigger points are identified, they benefit from the implantation of a very small amount of adipose cell preparation. For superficial pain, as in lichen, the local treatment proposed involves intradermal implantation of PRP or an extremely fine adipose preparation called Nanofat, injectable with thin needles almost like hair. Why does adipose tissue work on pain? It works because a substantial body of literature has demonstrated that once implanted, it has a mechanical effect, spacing the mucosa from nerve fibers like a cushion, reducing scar tension by fragmenting the scar and concurrently releasing trapped nerves. It also has a regenerative effect as its cells have neoangiogenic, differentiating, and growth factor-producing capabilities. Recent studies have also shown that adipose tissue contains cells capable of reducing proinflammatory cytokines (causing pain), increasing the production of IL10 (which reduces pain), reducing the number of M2 macrophages (highly present in painful and inflamed tissue), and increasing immunosuppressive cytokines that regulate neurotransmission factors.

For years, adipose tissue has been used without in-depth specific knowledge, but it has been observed in the field that a breast undergoing quadrantectomy and radiotherapy, with thin and ulcerated skin and tense and painful tissues, presented less tension and less pain after treatment with adipose tissue. The real reasons and motivations for this complex mechanism are only beginning to be understood recently. Adipose tissue is not the only innovative treatment, and new procedures are emerging, such as the use of CO2 laser and the use of botulinum toxin, which acts on fine pain-inducing nerve fibers.

In summary, while scar-induced pain is simpler to understand and find a solution for, idiopathic pain is more complex and requires a multidisciplinary approach.