Vulvar Vestibulitis (Provoked Vulvodynia)

Introduction

• Description: Vulvar vestibulitis (provoked vulvodynia) is an uncommon syndrome of intense sensitivity of the skin of the posterior vaginal introitus and vulvar vestibule, with progressive worsening, leading to loss of function. Provoked pain in other areas of the vulva is possible, but much less common. Vestibulitis is one possible cause of the broader syndrome of chronic vulvar pain, vulvodynia. Unlike undifferentiated vulvodynia, vestibulitis causes pain mainly when touched (intercourse, examination, tampon insertion) and is better localized to the posterior vulva.

• Prevalence: Some estimates place it at 15% of all women, but significant, disabling symptoms are much less common.

• Predominant Age: 19–81 years (median age, 36 years).

• Genetics: No genetic pattern, although some studies suggest these women are more likely to carry immune-related gene polymorphisms.

Etiology and Pathogenesis

• Causes: Unknown. High degree of association with human papillomavirus (HPV) but no causal link established. Despite the implication of the term, true inflammation is not a characteristic of this process.

• Risk Factors: None known. It has been postulated that the use of oral contraceptives increases the risk or severity of vulvar vestibulitis and that users who experience symptoms should switch to other methods of contraception. Strong evidence for either causation or significant improvement is lacking.

Signs and Symptoms

• Intense pain and tenderness at the posterior introitus and vestibule, most often present for 2–5 years (some authors suggest that symptoms should be present for more than 6 months before the diagnosis is made)

• Unable to use tampons (33%) or have intercourse (entry dyspareunia, 100%)

• Focal inflammation, punctation, and ulceration of the perineal and vaginal epithelium. Erythema is not required for the diagnosis.

• Punctate areas (1–10) of inflammation 3–10 mm in size may be seen between the Bartholin glands (75%), hymenal ring, and middle perineum

Diagnostic Approach