Vulval vestibulitis

Vulval vestibulitis or vestibulodynia is one of the vulval pain syndromes and is characterised by burning and soreness at the vaginal introitus at attempted penetration.¹ It is found predominantly in young, well educated, white women. Although the prevalence is unknown, a recent, as yet unpublished, survey in community settings in west Hertfordshire shows a prevalence of 2.8-9.3%. The diagnosis is based on a triad of findings—penetrative pain, introital tenderness, and patchy erythema localised to the orifices of the vestibular glands in the absence of an infective, inflammatory, or neoplastic cause.¹ The burning nature of the pain is typical of dysaesthesia, and many patients go on to develop more persistent and generalised vulval pain that would be compatible with dysaesthetic vulvodynia, a condition classically found in older women. The pain of vulval vestibulitis should be distinguished from vulval pruritus, which has different causes.

The cause of the condition is unknown, attempts to identify an infective cause have been unsuccessful, and no characteristic histological findings are known.² The subtlety of the physical findings may lead some clinicians to say that “there is nothing wrong” and attribute the symptoms to a psychosomatic disorder.

Vulval vestibulitis is poorly recognised by primary care doctors and some gynaecologists, and this may lead to patients repeatedly seeking a diagnosis from a variety of clinicians over a long period of time.³ A common misdiagnosis is recurrent thrush. Such patients will explain that they have tried all the currently available preparations against candidiasis, without relief of symptoms. Once the condition is recognised, the patient is best referred to a specialist vulval clinic. Different local arrangements pertain in the United Kingdom, some clinics being multidisciplinary and some led by dermatologists, gynaecologists, or genitourinary physicians. Since the cause of the condition is poorly understood, management is largely pragmatic and several models of care exist. The evidence base for treatment is poor.

Establishing the diagnosis and offering the patients a sympathetic hearing is an important first step. Patients are reassured by the fact that the condition is not psychosomatic in origin and that anxiety, low mood, and reduced pleasurable sensations with sexual arousal are common byproducts of chronic pain that has become associated with sex. No consistent evidence exists to date to show that women with vulval vestibulitis have an increased background rate of psychological disorders. The chronicity and severity of the symptoms often leads to secondary effects on psychological wellbeing and self esteem. This may lead to secondary sexual dysfunction in the patient or her partner, which in turn can exacerbate psychological distress, emotional disequilibrium, low self esteem, and reduced sexual and social functioning.⁴ All of these can become maintaining factors in the condition.

Advice about vulval hygiene practices is required, and patients should be advised to avoid soaps, shower gels, and similar products, and to wash with aqueous cream or emulsifying ointment.⁵ Topical local anaesthetics such as lignocaine ointment are often helpful.⁶ Topical steroid ointments and creams, oestrogen creams, and topical ketoconazole have been used in some centres,⁷ and anecdotal data support their use in some patients. A popular treatment in North America is the use of a diet low in oxalates. This was described in a single case report,⁸ but, in the absence of better evidence, it may perhaps be offered to some patients who prefer a non-medicalised approach to treatment.⁹ Many patients turn to complementary therapies.

Glazer et al have proposed that the condition is caused by a dysfunction of the pelvic floor muscles and have published impressive results for a biofeedback technique.¹⁰ Many patients do have pelvic floor dysfunction, but in some cases this seems to be secondary to the pain. Low dose amitriptyline is the treatment of choice for dysaesthetic vulvodynia and may be useful in some patients, particularly when the pain is not restricted to attempted vaginal penetration.¹¹ In North America, vestibulectomy, a procedure that involves excision of all or part of the vestibule, has been a popular treatment. Bergeron et al have reviewed 20 published case series and note that impressive results have been obtained, but the lack of controlled studies or long term follow up throws considerable doubt on the validity of the conclusions.¹² In the United Kingdom, this procedure is rarely used.

Whatever therapeutic approach is adopted, the psychological, interpersonal, sexual, and social consequences of the condition need to be assessed. Every clinician managing patients with the condition should have access to a psychologist or psychotherapist with experience of managing sexual dysfunctions in individuals and couples. Many patients find that support from other patients may be helpful. In the United Kingdom, the Vulval Pain Society (www.vul-pain.dircon.co.uk) provides a useful handbook for patients, as does the US National Vulvodynia Association (www.nva.com).