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Provoked Vestibulodynia (Vulvar Vestibulitis)

by Rosemary Basson, MD

Provoked vestibulodynia (vulvar vestibulitis) is increased sensitivity to pain at the opening of the vagina (vestibule), making even gentle touch or stimulation painful.

Provoked vestibulodynia is the most common cause of superficial pain that is felt when sexual intercourse is attempted or is occurring (dyspareunia—see Dyspareunia). It occurs when the penis (or a dildo) enters the vagina or moves. The pain starts immediately, lessens when the penis stops moving, and resumes when the penis moves again.

Doctors are not sure why it happens, but the nerve pathways that conduct pain signals from the vulva and the parts of the brain that process those signals are physically changed (remodeled) and become more sensitive. As a result, touch that normally would seem mild is perceived as very painful. Muscles in the pelvis may also be tight, increasing pain. After intercourse, women may have a burning sensation in the genital area or during urination.

Having a genital yeast (candidal) infection that recurs may make provoked vestibulodynia more likely to develop or worsen.

Provoked vestibulodynia is considered a chronic pain syndrome. That is, the pain tends to remain, often for years unless treatment relieves it. It occurs whenever pressure is put on the area around the vagina's opening. Women who have this disorder often have other types of chronic pain, such as jaw pain or pain due to irritable bowel syndrome.

Diagnosis

Doctors suspect the diagnosis based on the woman's description of the pain, including when and where it occurs. To confirm the diagnosis, they use a cotton swab to check for areas that are painful. They first lightly touch the swab to areas that are not expected to be painful. They then use the swab to touch the area around the vagina's opening. If pain results, the diagnosis is confirmed.

Treatment

Because this disorder is considered a chronic pain syndrome, many types of treatments are used. They include techniques to manage stress, psychologic therapies that help women deal with the thoughts and emotions accompanying the pain, and specific treatments for the pain.

Women may benefit from a type of psychologic therapy called mindfulness-based cognitive therapy (MBCT—see Treatment). Mindfulness involves focusing on what is happening in the moment. MBCT is usually done in small groups and is combined with information about chronic pain, sexuality, stress, and provoked vestibulodynia.

When women are ready to attempt sex, anti-inflammatory or anesthetic creams (such as those containing lidocaine) may be applied to the area. They are used twice a day. Doctors teach women how to apply these creams precisely on the sensitive area, where they are most effective. Using a mirror, at least at first, may help. Anti-inflammatory or anesthetic creams may help interrupt the altered nerve pathways that are increasing sensitivity to pain.

Avoiding possible irritants, such as soap, bubble bath, panty liners, and tight jeans, may help prevent irritation that could make symptoms worse. Pelvic muscle relaxation exercises, yoga, and general relaxation exercises can help relax pelvic (and other) muscles.

If women with provoked vestibulodynia have recurring yeast infections, they may be given long-term treatment to prevent the infections. One such treatment is boric acid capsules, placed in the vagina once a week.

Surgery to remove part of the area around the vaginal opening is sometimes suggested. This procedure removes the hypersensitive nerve endings, but the nerves can regrow, and pain can recur.

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