Vestibulodynia

What is vestibulodynia?

Vestibulodynia, previously known as vulvar vestibulitis, is a type of vulvodynia or ‘vulvar dysaesthesia’ that is characterised by painful tender areas at the entrance to the vagina, the vestibule. The International Society for the Study of Vulvovaginal Diseases (ISSVD) in 2001 reclassified the symptom as ‘provoked vulvar dysesthesia localized to the vestibule’.

The vulva appears entirely normal in most affected women but tender areas can be detected in the vestibule when gently pressed with a cotton bud.

What are the symptoms?

Symptoms of vestibulodynia include:

• Pain that occurs when the vestibule is touched, either during sexual penetration, insertion of a tampon, or sometimes during other physical activity such as bike riding
• Pain that is not present all the time
• Pain that is confined to the vestibule
• In some patients, pain on urination

The pain may persist for several hours and can prevent penetrative intercourse altogether. The fear of being hurt can provoke secondary involuntary muscular pain and spasm in the vagina, known as vaginismus.

What causes it?

Vestibulodynia appears to be due to hypersensitive nerve endings relating to spasm in the pubococcygeus muscle, but the precise cause is not known. It is thought that the following may have a role to play in triggering or exacerbating it:

• Chronic yeast infections (thrush)
• Injury, including sexual abuse, childbirth and laser treatment or surgery
• Skin diseases especially irritant contact dermatitis to detergents, douches, panty liners
• Emotional factors

The tender spots in the vestibular mucosa are trigger points linked to hypersensitive muscle spindles within the pelvic floor muscles. These muscles have high resting tone, i.e. they are contracting even at apparent times of rest. There may also be an increased number of hypersensitive nerve endings in affected areas.

In some women, small red spots may be noted within the vestibule due to inflammation of minor lubricating glands. These are no longer considered related to vulvodynia; they are often present in women with no symptoms.

Who gets vestibulodynia?

It usually affects sexually active women aged 20 to 40, but younger and older women may also be affected. It affects pale skinned races and Asians, but is rare in women of African descent.

Delay in diagnosis is common. One reason is the appearance of the vulva may seem normal when the doctor does an examination. Usually swabs will be taken to culture bacteria, yeasts and viruses in case an infection accounts for the symptoms. Treatment for these infections is often recommended, and the lack of response to this makes vestibulitis, or localised provoked vulvodynia, a possible cause of a painful vulva.

Management

Women who suffer from vestibulodynia may have done so for months or years. Treatment is difficult and dedication by the patient and doctor is required in order to overcome the physical and psychological impact the disorder has on daily life.

No medical treatment is guaranteed to cure vestibulodynia. In some patients symptoms settle by themselves, although it may take months or sometimes years to do so. Ask your doctor to explain the treatment that has been recommended for you. The most successful measures appear to be:

• Referral to a physiotherapist specialising in urological and gynaecological problems for pelvic floor exercises, biofeedback, electrical stimulation and muscle relaxation training.
• The tricyclic medicines amitriptyline, nortriptyline or desipramine, usually thought of as anti-depressants, taken in small doses at night. The dose should be increased 5 to 10 mg at first to 75 to 100 mg, depending on effect. They have a membrane stabilising effect on nerve endings.
• If these are unsuccessful, anticonvulsant medications, particularly gabapentin, may be successful.

Experimentally, botulinum toxin injections into the affected areas have been reported to be effective. In severe cases, the affected area may be excised (cut out). Surgery may be very successful, but it sometimes makes symptoms worse.

Corticosteroid creams and other topical agents are not effective. Local anaesthetic creams may provide temporary relief e.g. to allow intercourse.

Support for and education of the condition are essential components of treatment. Both the patient and their partner need to understand and learn how to cope with the stresses that the condition can place on relationships.

• Discuss your problem openly with your partner; bring him to the appointment with your doctor.
• Avoid all contact with the affected area for several weeks.
• Make sure you are ready for intercourse physically and emotionally before it occurs - learn how the body responds to sexual stimuli. Foreplay is very important to provide adequate lubrication and to relax and enlarge the vagina.
• Lubricate with K-Y jelly, Sylke or a similar product before intercourse or inserting a tampon.
• Have a warm relaxing bath when the pain occurs - don't apply soap.
• Sex without penetration: ask your doctor to refer you and your partner to a sex therapist for advice - lovemaking can still be satisfying for both of you.