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Provoked Vestibulodynia (Vulvar Vestibulitis)
Provoked vestibulodynia (vulvar vestibulitis, localized vulvar dysesthesia) is the most common type of superficial (introital) dyspareunia. Pain results from introital pressure. Treatment includes psychologic therapies used in chronic pain syndromes. Adjunctive therapies include topical lidocaine or cromoglycate, but when they are used alone, their efficacy is unproved.
Provoked vestibulodynia (PVD) develops when the nervous system—from peripheral receptors to the cerebral cortex—is sensitized and remodeled. With sensitization, discomfort due to a stimulus that might otherwise be perceived as mild or trivial (eg, touch) is instead perceived as significant pain (allodynia). This disorder is considered to probably be a chronic pain syndrome (see Chronic Pain). The peripheral sensitization leads to a neurogenic inflammatory response. A small group of women have PVD and vulvovaginal candidiasis, which appears to contribute to PVD.
Diagnosis is based on symptoms and confirmed by the Q-tip test for allodynia. Vaginismus causes similar pain during introital pressure and penile containment and movement. However, vaginismus, unlike vestibulodynia, classically does not cause allodynia or postcoital symptoms. Some women who have allodynia have a history that strongly suggests vaginismus (ie, phobia-like avoidance of vaginal penetration), suggesting that vestibulodynia can develop secondary to vaginismus and that allodynia and vaginismus overlap.
Optimal treatment of provoked vestibulodynia is unclear; many approaches are currently used, and there are probably still undefined subtypes that require different treatment. Because this disorder involves chronic pain, treatments are becoming more comprehensive, including management of stress and therapies to target the thoughts and emotions that accompany the pain.
Small-group therapy that combines mindfulness-based cognitive therapy or cognitive-behavioral therapy (see Treatment) with education about chronic pain, PVD, sexuality, and stress appears to be beneficial. Adjunctive drug therapy (eg, with tricyclic antidepressants or anticonvulsants) is also sometimes used.
Once penetration seems worth trying, topical drugs (eg, 2% cromoglycate or 2% or 5% lidocaine in glaxal base) can be used to interrupt chronic pain circuits. Cromoglycate stabilizes WBC membranes, including those of mast cells, interrupting neurogenic inflammation due to PVD. Cromoglycate or lidocaine must be placed precisely on the area of allodynia using a 1-mL syringe without a needle. Physician supervision and use of a mirror (at least initially) are helpful.
Women with pelvic muscle hypertonicity may benefit from pelvic physical therapy using pelvic floor muscle training, possibly with biofeedback.
Surgery, consisting of excision of the hymen, proximal edge of the lower vagina, and innermost portion of the labia minora, is sometimes offered, usually to women who do not have depression, anxiety, or involvement of the introital rim next to the urethral meatus if they previously had pain-free intercourse and are willing to also participate in psychologic therapy. However, pain may recur as nerves regenerate.
Some women with PVD and vaginal candidiasis benefit from long-term candidal prophylaxis (eg, weekly vaginal boric acid capsules).
Provoked vestibulodynia (a chronic pain syndrome) is local pain that results from nonnoxious introital pressure.
Introital pressure (eg, due to penile or dildo movement or ejaculation) immediately causes pain, which usually lessens when the pressure stops.
Confirm the diagnosis by provocation of pain with a Q-tip.
Use psychologic therapies, sometimes supplemented with drugs and/or pelvic physical therapy.
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