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Author: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand + Vanessa Ngan, Staff Writer 1999. Latest update, 2017.
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.
Symptoms of vestibulodynia include:
The pain may persist for several hours and can prevent penetrative intercourse altogether.
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:
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.
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.
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.
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.
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.
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Vulvovaginal Disorders: an algorithm for basic adult diagnosis and treatment — ISSVD
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