Botulinum neurotoxin (BoNT) is licensed for the treatment of a number of conditions characterized by striated muscle spasticity. However, in recent years, their unlicensed use in the treatment of lower urinary tract conditions has been described (Smith et al., 2004). Chief among these are conditions characterized by detrusor overactivity. Treatment of vulvodynia and chronic pelvic pain, benign prostate hyperplasia (BPH) and detrusor sphincter dyssynergia (DSD) are other emerging indications with promising positive results. This chapter details the use of BoNT for these conditions, giving a clinical definition of each condition, reviewing pertinent studies and describing the injection technique, percutaneous or endoscopic, using anatomical illustrations, and providing dosing recommendations.

Vulval disorders are not uncommon in obstetric practice. This chapter aims to enhance clinical skills in patient assessment, vulval examination and treatment of common benign vulval skin disease and infections. Basic treatments often benefit the patient (e.g. use of emollients and topical steroids). Some patients have complex disease and can present with more than one condition, so careful assessment and individualised management is essential. Understanding of when to refer onwards to a gynaecologist and even a vulval specialist service is important to optimise clinical outcomes.

Vulvodynia is a persistent, idiopathic, and multifactorial vulval pain. It presents a challenge to healthcare providers, mainly because it is a complex syndrome that requires interdisciplinary skills, especially in the neurobiological and algological fields, to avoid incorrect pathogenetic interpretations, inaccurate diagnosis and inadequate treatment.

From a neurobiological perspective, vulvodynia is a dysfunctional vulval pain caused by abnormal function of the nervous system itself, not related to a specific vulval disorder responsible for inflammatory pain, or a neural lesion responsible for neuropathic pain.

Provoked vestibulodynia is the most prevalent subtype of vulvodynia, followed by spontaneous generalized vulvodynia. The primary diagnostic goal is to determine whether the woman suffers from vulvodynia as dysfunctional pain opposed to inflammatory or neuropathic pain.

Treatment of vulvodynia requires an individually tailored and multimodal therapeutic approach, that includes counselling, psychological therapy, medical treatment, and physiotherapy. Surgery can be proposed only as a last resort in provoked vestibulodynia.

A 33-year-old nulligravid woman presents with a complaint of insertional dyspareunia. She has been partnered with the same man for three years and had no issues with coitus until about one year ago. Since that time, she has experienced increasingly severe pain with any attempt at vaginal insertion. She describes the pain as sharp and tearing, occurring when her partner enters her. Because of the pain, she has also experienced diminished arousal and a lack of sexual desire. She denies any vulvar pain in other situations but has a similar sensation with placement of a tampon or sex toy. A trial of topical estrogen worsened her symptoms. Application of lidocaine jelly to the area resulted in improvement of symptoms temporarily, but intercourse without it was persistently painful. Her gynecologic history is notable only for a history of recurrent candida vaginitis, though she has no symptoms currently. She uses a combined oral contraceptive for birth control. She has no significant medical history and has never had surgery. She is a non-smoker and uses alcohol occasionally.