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Vestibulodynia (Vulvar Vestibulitis, Provoked Localized Vulvodynia) – Q&A Summary
In the medical journal Sexual Medicine, a special column called Patient Highlights was published at the end of 2012 on the topic of vestibulodynia, one of the subjects patients were most curious about. The summary was done by two OB/GYN doctors at the University of California, and it is fairly well organized. Although there are parts that strongly reflect the authors’ subjective opinions, it seems to contain the most up-to-date insights among recent columns, so I’d like to introduce it on the blog.
What is the Vulvar Vestibule?
The vulvar vestibule refers to the mucosa between the labia minora and the hymen that contains glands that secrete lubricating fluid during intercourse. This mucosa is said to respond sensitively to sex hormones like estrogen and androgens.
What is Vestibulodynia?
Vestibulodynia refers to a situation where painful sensations are felt near the vestibule. In a localized sense, it refers to pain felt at the entrance of the vagina. It is the most common reason for pain during sexual intercourse or genital touch, and about 1 in 8 women are said to experience this at some point in their lives. When vestibulodynia occurs, it can cause chronic irritation, daily pain, and dyspareunia (pain during intercourse). In the past, it was called vulvar vestibulitis, provoked localized vulvodynia, localized vulvar dysesthesia, etc., but to avoid confusion with infection or inflammatory responses, the term vestibulodynia was standardized. The most widely accepted diagnostic definitions are: (i) severe pain when the vestibule is touched or when attempting vaginal entry; (ii) tenderness when pressure is applied to the vestibule with a cotton swab.
What Causes a Woman to Have Vestibulodynia?
There are various theories and hypotheses, but the exact cause is still unknown. However, several contributing factors are thought to exist. To diagnose vestibulodynia, bacterial or viral infections and skin diseases must first be ruled out. Representative causes include chronic fungal infections, allergies, inflammatory reactions caused by irritating substances such as detergents, lubricants, or vaginal suppositories, hormonal changes due to oral contraceptives, menopause, medications for endometriosis or breast cancer, and overly tense pelvic floor muscles (hypertonic pelvic floor dysfunction). There are also reports of women who have had vestibulodynia since birth.
Are There Causes Other than Inflammation?
Interestingly, some women have a very high density of nerve fibers in the vestibular area. This can make them overly sensitive to stimulation, and what should be pleasant sensations may be perceived as discomfort. Additionally, some people have a genetic predisposition to strong inflammatory reactions in the tissue when exposed to infections or chemical substances. Embryologically, the vulvar vestibule is different from the vagina or uterus and is actually derived from the same origin as the urethra and bladder. Therefore, it is often found together with chronic bladder-related diseases such as interstitial cystitis or bladder pain syndrome.
What are the Symptoms of Vestibulodynia?
The most important symptom is pain observed near the vestibular area. Pain triggered by stimulation such as sexual intercourse, tampon use, tight underwear, or fingers is called the provoked type, and pain that occurs even when at rest without stimulation is the unprovoked type. Some patients may experience both types simultaneously. Previously, “erythema” (redness) was considered a very important objective indicator, but many normal cases also have redness without pain.
How is Vestibulodynia Diagnosed?
The examination should be performed by a skilled physician and involves a thorough evaluation of the vulva and vaginal entrance, similar to a gynecological pelvic exam. First, a visual inspection is conducted to carefully evaluate the skin of the vulva and the mucosa at the vaginal entrance. If abnormal lesions are found, a biopsy may be sent to a pathologist. A cotton swab (Q-tip) is then used to accurately assess the location and nature of the pain. A speculum must be used to evaluate vaginal discharge or perform bacterial tests. Finally, a gynecological pelvic exam is performed to evaluate the condition of the pelvic floor muscles.