Vestibulodynia

What is vestibulodynia?

Vestibulodynia, previously known as vulvar vestibulitis, is a descriptive term used for recurrent pain arising at the entrance to the vagina, the vestibule. By definition, there is no known cause for the pain and the affected tissue appears normal. Vestibulodynia, like 'itch' or 'headache', is not a disease.

Vestibulodynia is a common reason for entry dyspareunia (pain on attempting penetration during sexual intercourse). Vestibulodynia may be accompanied by vaginismus, an involuntary pelvic muscle contraction that prevents sexual intercourse. Vaginismus may also cause pain.

Vestibulodynia is also sometimes described as localised provoked vulvodynia following the classification of The International Society for the Study of Vulvovaginal Diseases (ISSVD) in 2003. This was updated in 2015.

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 and lower vagina
• In some patients, pain on urination.

The pain may persist for several hours and can prevent penetrative intercourse altogether.

What causes vestibulodynia?

The cause of vestibulodynia is unknown. It is thought that vestibulodynia may reflect hypersensitive nerve endings in the affected mucosa. Vestibulodynia may be triggered or exacerbated by previous inflammation, for example:

• Chronic yeast infection (thrush) resulting in vulval and vaginal soreness
• Injury, including sexual abuse, childbirth, and laser treatment or surgery
• Skin disease 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 pubococcygeus or pelvic floor muscles. These muscles have high resting tone, ie, they are contracting even at apparent times of rest and may completely close the vagina.

Small red spots may be noted within the vestibule due to inflammation of minor lubricating glands. These are no longer considered related to vulvodynia and are are often present in women with no symptoms.

Who gets vestibulodynia?

Vestibulodynia 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 reported to be rare in women of African descent. Several conditions are associated with vestibulodynia.

• Fibromyalgia
• Painful bladder
• Pain in temporomandibular joint
• Musculoskeletal conditions
• Mood and anxiety disorders

How is vestibulodynia diagnosed?

Vestibulodynia is diagnosed when a woman describes pain in the entrance to the vagina when the affected area appears normal and treatment of infection has failed. Vaginismus is diagnosed when tight pelvic muscles are found on internal examination.

Thorough skin and gynaecological examination, lower vaginal swabs for bacteria and yeasts, and skin biopsy may be performed but are generally unhelpful. There are several reports of increased numbers of nerve fibres within the affected epithelium.

It may be important that examination is carried out when symptoms are present, as signs of an active skin disorder may be subtle, especially recurrent fissuring of the posterior fourchette.

Management of vestibulodynia

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

In some patients symptoms settle by themselves, although it may take months or sometimes years to do so. Treatments reported to help some women with localised vestibulodynia are listed.

• Cool gel packs, or local anaesthetic cream, gel or ointment containing lignocaine/lidocaine, may provide temporary relief to allow intercourse or sleep.
• Topical 2% amitriptyline cream is applied to affected area (off label); when assessed after 3 months use, 56% of 150 women reeported improvement in symptoms. [1]
• Pelvic floor exercises, biofeedback, electrical stimulation and muscle relaxation training is offered by physiotherapists specialising in urological and gynaecological problems.
• Intralesional corticosteroid injections into a focal trigger point, repeated at 4 weeks, has helped some patients.
• Pudenal, genitofemoral and ilioinguinal nerve blocks are usually undertaken by pain specialists with anaesthetic training.
• The tricyclic medicines amitriptyline, nortriptyline, doxepin, desipramine, usually thought of as anti-depressants, are taken in small doses at night and have a membrane stabilising effect on nerve endings. The dose should be commenced at 5 to 10 mg, 2 hours before bedtime, then increased slowly to 75 to 100 mg as tolerated, depending on effect. It make take several weeks to experience benefit. These medications have multiple drug interactions and potential adverse effects.
• SSNRIs venlafaxine and duloxetine are also used. These drugs may cause nausea, dry mouth, drowsiness, constipation, weight gain and sexual side effects.
• If antidepressants are unsuccessful, anticonvulsant medications may be tried, particularly gabapentin 300 to 1800 mg daily or pregabalin 25 to 300 mg daily. Topiramate and lamotrigine are also prescribed. Side effects from anticonvulsants are common.
• Botulinum toxin injections into the affected areas have been reported to be effective, particularly with vaginismus, but response is inconsistent. In severe cases, the affected area may be excised (cut out).
• Surgery may be very successful, but it can make symptoms worse and is rarely performed.

Support for and education of the condition are essential components of treatment. Pyschosocial therapies such as couples counselling, sexual education and psychological treatments such as cognitive behavioural therapy are important. Both the patient and their partner need to understand and learn how to cope with the stresses that the condition can place on relationships. And to understand that a poor relationship can lead to vulvodynia.

• Avoid contact with the affected area for several weeks.
• Be prepared 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 before intercourse or inserting a tampon.
• Have a warm relaxing bath when the pain occurs – don't apply soap or wet wipes (which mostly include preservatives that can irritate, or cause contact allergic dermatitis).
• Enjoy sex without penetration.