Vulvar vestibulitis

Last updated

Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis, is vulvodynia localized to the vulvar vestibule. It tends to be associated with a highly localized "burning" or "cutting" type of pain. Until recently, "vulvar vestibulitis" was the term used for localized vulvar pain: the suffix "-itis" would normally imply inflammation, but in fact there is little evidence to support an inflammatory process in the condition. "Vestibulodynia" is the term now recognized by the International Society for the Study of Vulvovaginal Disease. [1]

Contents

Provoked vestibulodynia, pain provoked by contact localized to the vulvar vestibule, is the most common subtype of vulvodynia among premenopausal women. [2] The condition has been cited as affecting about 10% to 15% of women seeking gynecological care. [3]

Symptoms

Vestibulodynia is characterized by severe pain with attempted penetration of the vaginal orifice and reports of tenderness with pressure within the vulval vestibule. Usually there are no reports of pain with pressure to other surrounding areas of the vulva. The feelings of irritation and burning can persist for hours or days following sexual activity. Vestibulodynia also can often cause sex to be painful, known as dyspareunia. [3] [4] [5]

The pain may be provoked by touch or contact with an object, such as the insertion of a tampon, with vaginal intercourse, or with the pressure from sitting on a bicycle seat, (provoked vestibulodynia) [6] or it may be constant and not provoked by a physical stimulus (unprovoked vestibulodynia). Some women have had pain since their first penetration (primary vestibulodynia) while some have had it after a period of time with pain-free penetration (secondary vestibulodynia).

The disease may have social and psychological ramifications. Many people with vulvovaginal pain experience of chronic frustration, disappointment, hopelessness and depression because of the impacts that the disease has on their lives. It can negatively impact a person's quality of life, their romantic and sexual relationships, and their ability to participant in normal activities. [7]

Causes

The mechanisms underlying vestibulodynia are not yet fully understood. There are thought to be several subtypes.

Neuroproliferative vestibulodynia is a disease where in there are an excess of pain receptors (C-afferent nociceptors) and mast cells in the vestibule. There can be around 10 times the normal density of these pain receptors. Some people are born with this condition (congenital neuroproliferative vestibulodynia). Many of those born with congenital neuroproliferative vestibulodynia also experience hypersensitivity in their belly-button because both the vulvar vestibule and the belly-button develop from the same tissue in embryo (primitive urogenital sinus). [8]

Others develop neuroproliferation later in life (acquired neuroproliferative vestibulodynia), perhaps as part of an immune response to infection or allergy. [8] A number of causes may be involved, including subclinical human papillomavirus infection, chronic recurrent candidiasis, or chronic recurrent bacterial vaginosis. [4] [5]

Vestibulodynia can also be mediated by hormonal imbalances (hormonally-mediated vestibulodynia), and sometimes caused by hormonal contraceptives. Estrogen-based birth control has been shown to increase the risk of vestibulodynia by up to 11 times. [9] Labs may show high sex hormone binding globulin or low free testosterone. [10]

Hypertonic pelvic floor dysfunction is present in many people who have vestibulodynia. Tight muscles can even contribute to and cause pain in the posterior area of the vestibule. People with hypertonic pelvic floor dysfunction may experience urinary symptoms like urgency and/or symptoms like constipation, rectal fissures, hip pain, and/or lower back pain. [10]

Pain extending outside of the vulvar vestibule may have other sources. Damage to the pudendal nerve ("pudendal neuralgia" or pudendal nerve entrapment) can cause unilateral or bilateral pain. Persistent genital arousal disorder can also cause pain in the vulvar vestibule. Spinal pathology can also cause vulvar pain. [10]

In recent years, diagnostic algorithms for the diagnosis of the various sub-types of vulvodynia have been developed and refined. [10] The International Society for the Study of Women's Sexual Health (ISSWSH) supports this diagnostic algorithm.

Diagnosis

For many people with vulvodynia, getting diagnosed and treated is very difficult. Getting an accurate diagnosis often takes years. [11] A 2012 survey found that less the 2% of people who sought care for symptoms of vulvar pain were able to get a diagnosis. [12]

Diagnosis is made by the q-tip cotton-swab test, in which pressure is applied in a circular fashion around the vulvar vestibule to assess complaints of pain. Laboratory tests are used to exclude bacterial, viral or yeast infection. Laboratory tests can also be used to check the patient's sex hormones to see if there may be a hormonal component. A careful examination of the vulvovaginal area is conducted to assess whether any atrophy is present.

Treatment

Treatment depends on the subtype of disease.

For congenital neuroproliferative vestibulodynia, the gold-standard treatment is a surgery to remove the vestibule, called vestibulectomy. Acquired neuroproliferative vestibulodynia and inflammatory vestibulodynia may be treated with topicals. When such conservative treatments fail, vestibulectomy may be an option. [10]

Hormonally-mediated vestibulodynia is treated by stopping offending medications (commonly, hormonal birth control) and applying topical estradiol combined with topical testosterone. This allows the vulvar tissue to return to a healthy state. [10]

Pelvic floor dysfunction can be treated with pelvic floor physical therapy.

Treatment typically requires a multidisciplinary team including a gynecologist, a pelvic floor physical therapist, sometimes a surgeon, and sometimes a counsellor to help patients navigate the psychosocial burdens of the condition. [13] [14] [15] [16]

Related Research Articles

<span class="mw-page-title-main">Interstitial cystitis</span> Medical condition

Interstitial cystitis (IC), a type of bladder pain syndrome (BPS), is chronic pain in the bladder and pelvic floor of unknown cause. It is the urologic chronic pelvic pain syndrome of women. Symptoms include feeling the need to urinate right away, needing to urinate often, and pain with sex. IC/BPS is associated with depression and lower quality of life. Many of those affected also have irritable bowel syndrome and fibromyalgia.

Vulvodynia is a chronic pain condition that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least three months.

<span class="mw-page-title-main">Vaginismus</span> Involuntary muscle spasm that interferes with vaginal penetration

Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina. This often results in pain with attempts at sex. Often it begins when vaginal intercourse is first attempted.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term dyspareunia covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. Medically, dyspareunia is a pelvic floor dysfunction and is frequently underdiagnosed. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

Persistent genital arousal disorder (PGAD), originally called persistent sexual arousal syndrome (PSAS), is spontaneous, persistent, unwanted and uncontrollable genital arousal in the absence of sexual stimulation or sexual desire, and is typically not relieved by orgasm. Instead, multiple orgasms over hours or days may be required for relief.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

Pudendal nerve entrapment (PNE), also known as Alcock canal syndrome, is an uncommon source of chronic pain in which the pudendal nerve is entrapped or compressed in Alcock's canal. There are several different types of PNE based on the site of entrapment anatomically. Pain is positional and is worsened by sitting. Other symptoms include genital numbness, fecal incontinence and urinary incontinence.

<span class="mw-page-title-main">Vaginal discharge</span> Medical condition

Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. This mixture is constantly produced by the cells of the vagina and cervix, and it exits the body through the vaginal opening. The composition, amount, and quality of discharge varies between individuals and can vary throughout the menstrual cycle and throughout the stages of sexual and reproductive development. Normal vaginal discharge may have a thin, watery consistency or a thick, sticky consistency, and it may be clear or white in color. Normal vaginal discharge may be large in volume but typically does not have a strong odor, nor is it typically associated with itching or pain. While most discharge is considered physiologic or represents normal functioning of the body, some changes in discharge can reflect infection or other pathological processes. Infections that may cause changes in vaginal discharge include vaginal yeast infections, bacterial vaginosis, and sexually transmitted infections. The characteristics of abnormal vaginal discharge vary depending on the cause, but common features include a change in color, a foul odor, and associated symptoms such as itching, burning, pelvic pain, or pain during sexual intercourse.

Adenomyoma is a tumor (-oma) including components derived from glands (adeno-) and muscle (-my-). It is a type of complex and mixed tumor, and several variants have been described in the medical literature. Uterine adenomyoma, the localized form of uterine adenomyosis, is a tumor composed of endometrial gland tissue and smooth muscle in the myometrium. Adenomyomas containing endometrial glands are also found outside of the uterus, most commonly on the uterine adnexa but can also develop at distant sites outside of the pelvis. Gallbladder adenomyoma, the localized form of adenomyomatosis, is a polypoid tumor in the gallbladder composed of hyperplastic mucosal epithelium and muscularis propria.

<span class="mw-page-title-main">Menstrual disorder</span> Medical condition affecting menstrual cycle

A menstrual disorder is characterized as any abnormal condition with regards to a woman's menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability.

<span class="mw-page-title-main">Pelvic pain</span> Medical condition

Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis.

Yitzchak M. "Irv" Binik is an American-Canadian psychologist whose main research interest is human sexuality, specifically sexual pain.

<span class="mw-page-title-main">Perineoplasty</span>

Perineoplasty denotes the plastic surgery procedures used to correct clinical conditions of the vagina and the anus. Among the vagino-anal conditions resolved by perineoplasty are vaginal looseness, vaginal itching, damaged perineum, fecal incontinence, genital warts, dyspareunia, vaginal stenosis, vaginismus, vulvar vestibulitis, and decreased sexual sensation. Depending upon the vagino-anal condition to be treated, there are two variants of the perineoplasty procedure: the first, to tighten the perineal muscles and the vagina; the second, to loosen the perineal muscles.

<span class="mw-page-title-main">Nerve compression syndrome</span> Human disease

Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by chronic, direct pressure on a peripheral nerve. It is known colloquially as a trapped nerve, though this may also refer to nerve root compression. Its symptoms include pain, tingling, numbness and muscle weakness. The symptoms affect just one particular part of the body, depending on which nerve is affected. The diagnosis is largely clinical and can be confirmed with diagnostic nerve blocks. Occasionally imaging and electrophysiology studies aid in the diagnosis. Timely diagnosis is important as untreated chronic nerve compression may cause permanent damage. A surgical nerve decompression can relieve pressure on the nerve but cannot always reverse the physiological changes that occurred before treatment. Nerve injury by a single episode of physical trauma is in one sense an acute compression neuropathy but is not usually included under this heading, as chronic compression takes a unique pathophysiological course.

<span class="mw-page-title-main">Vulva</span> External genitalia of the female mammal

In mammals, the vulva consists of the external female genitalia. The human vulva includes the mons pubis, labia majora, labia minora, clitoris, vulval vestibule, urinary meatus, the vaginal opening, hymen, and Bartholin's and Skene's vestibular glands. The urinary meatus is also included as it opens into the vulval vestibule. The vulva includes the entrance to the vagina, which leads to the uterus, and provides a double layer of protection for this by the folds of the outer and inner labia. Pelvic floor muscles support the structures of the vulva. Other muscles of the urogenital triangle also give support.

<span class="mw-page-title-main">Atrophic vaginitis</span> Medical condition

Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to not enough estrogen. Symptoms may include pain with sex, vaginal itchiness or dryness, and an urge to urinate or burning with urination. It generally does not resolve without ongoing treatment. Complications may include urinary tract infections.

A vulvar disease is a particular abnormal, pathological condition that affects part or all of the vulva. Several pathologies are defined. Some can be prevented by vulvovaginal health maintenance.

A vestibulectomy is a gynecological surgical procedure that can be used to treat vulvar pain, specifically in cases of provoked vestibulodynia. Vestibulodynia is a chronic pain syndrome that is a subtype of localized vulvodynia where chronic pain and irritation is present in the vulval vestibule, which is near the entrance of the vagina. Vestibulectomy may be partial or complete.

Pelvic floor physical therapy (PFPT) is a specialty area within physical therapy focusing on the rehabilitation of muscles in the pelvic floor after injury or dysfunction. It can be used to address issues such as muscle weakness or tightness post childbirth, dyspareunia, vaginismus, vulvodynia, constipation, fecal or urinary incontinence, pelvic organ prolapse, and sexual dysfunction. Licensed physical therapists with specialized pelvic floor physical therapy training address dysfunction in individuals across the gender and sex spectra, though PFPT is often associated with women's health for its heavy focus on addressing issues of pelvic trauma after childbirth.

References

  1. ↑ "Home". issvd.org.
  2. ↑ Rosen, Natalie O.; Dawson, Samantha J.; Brooks, Melissa; Kellogg-Spadt, Susan (2019). "Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches". Drugs. 79 (5): 483–493. doi:10.1007/s40265-019-01085-1. ISSN   1179-1950. PMID   30847806. S2CID   73485304.
  3. 1 2 Bergeron S, Binik YM, Khalifé S, Meana M, Berkley KJ, Pagidas K (1997). "The treatment of vulvar vestibulitis syndrome: Toward a multimodal approach". Sexual and Relationship Therapy. 12 (4): 305–11. doi:10.1080/02674659708408174.
    Bergeron S, Binik YM, Khalifé S, Pagidas K (1997). "Vulvar vestibulitis syndrome: a critical review". Clin J Pain. 13 (1): 27–42. doi:10.1097/00002508-199703000-00006. PMID   9084950.
  4. 1 2 Marinoff SC, Turner ML (1991). "Vulvar vestibulitis syndrome: an overview". Am J Obstet Gynecol. 165 (4 Pt 2): 1228–33. doi:10.1016/S0002-9378(12)90732-2. PMID   1659198.
  5. 1 2 Peckham BM, Maki DG, Patterson JJ, Hafez GR (April 1986). "Focal vulvitis: a characteristic syndrome and cause of dyspareunia. Features, natural history, and management". Am J Obstet Gynecol. 154 (4): 855–64. doi:10.1016/0002-9378(86)90472-2. PMID   3963075.
  6. ↑ http://www.abc.net.au/radionational/programs/healthreport/treatment-of-sexual-difficulties-and-research-into-asexuality/4058034 Suggested treatment for sexual difficulties and research into asexuality, Dr Lori Brotto, 11 June 2012, ABC Radio National
  7. ↑ Goldstein, Andrew; Pukall, Caroline; Goldstein, Irwin (2021). Female Sexual Pain Disorders: Evaluation and Management (2 ed.). p. 143.
  8. 1 2 Rubin, Rachel; W., Caitlin. "Neuroproliferative Vestibulodynia". www.prosayla.com. Retrieved 29 March 2024.
  9. ↑ Aerts, Leen; Pluchino, Nicola (13 December 2021). "Hormonal contraception and vulvodynia: an update". GREM - Gynecological and Reproductive Endocrinology & Metabolism. 2 (3/2021): 156–161. doi:10.53260/GREM.212034. ISSN   2710-2297 . Retrieved 29 March 2024.
  10. 1 2 3 4 5 6 Goldstein, Andrew; Pukall, Caroline; Goldstein, Irwin (2021). Female Sexual Pain Disorders: Evaluation and Management (2 ed.). pp. 157–162.
  11. ↑ Harlow, Bernard (2014). "Prevalence of Symptoms Consistent with a Diagnosis of Vulvodynia: Population-based estimates from two geographical regions". American Journal Obstetrics and Gynecology. 210 (1): 40.e1–8. doi:10.1016/j.ajog.2013.09.033. PMC   3885163 . PMID   24080300.
  12. ↑ Reed, Barbara Diane; Harlow, Siobán Denise; Sen, Ananda; Legocki, Laurie Jo; Edwards, Rayna Monique; Arato, Nora; Haefner, Hope Katharine (February 2012). "Prevalence and demographic characteristics of vulvodynia in a population-based sample". American Journal of Obstetrics and Gynecology. 206 (2): 170.e1–9. doi:10.1016/j.ajog.2011.08.012. ISSN   1097-6868. PMC   3779055 . PMID   21963307.
  13. ↑ https://www.socialstyrelsen.se/publikationer2018/2018-6-16%5B%5D Socialstyrelsen. Kartläggning av vestibulit: Förekomst och behandling av flickor och kvinnor med vestibulit samt behov av kunskapsstöd Sweden: Socialstyrelsen; 2018
  14. ↑ https://www.sfog.se/natupplaga/ARG_nr%2071_webae1437d4-8cc5-4457-9eac-f5c6550a614b.pdf SFOG. Vulvovaginala sjukdomar Sweden: Elanders AB; 2013. 71
  15. ↑ Faye RB, Piraccini E. Vulvodynia. [Updated 2020 Jan 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430792/
  16. ↑ Goldstein, A. T., Pukall, C. F., Brown, C., Bergeron, S., Stein, A., & Kellogg-Spadt, S. (2016). Vulvodynia: Assessment and Treatment. J Sex Med, 13(4), 572-590. doi: 10.1016/j.jsxm.2016.01.020
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.