Vulvar vestibulitis is a chronic disorder that is manifested by pain, burning and itching that occur when touching, pressing or rubbing the vestibule of the vagina. To diagnose the disease, an examination on a gynecological chair, a test with a cotton applicator, vulvoscopy, laboratory methods are used. The treatment regimen is determined by the causes that caused vulvovestibulitis, may include hormonal, antibacterial, painkillers, anesthetics, anti-inflammatory, sedatives, anticonvulsants and antidepressants. In severe cases, a vestibulectomy is performed.
Vulvar vestibulitis (vulvovestibulitis, induced or acquired vestibulodynia, local dysesthesia of the vulva) is one of the variants of vulvodynia. According to some data, up to 15% of women aged 18-65 years experienced pain in the area of the entrance to the vagina at least once in their lives during sexual intercourse, and in some of them the duration of such an episode exceeded 3 months. At the same time, more than half of the respondents did not seek medical help. Usually, the disorder affects women of childbearing age (from 25 to 35 years). In recent years, vestibulodynia has been increasingly diagnosed in mature patients who suffer from dishormonal atrophic processes in the vulvar ring area, but retain sexual activity. Sometimes vulvovestibulitis is combined with other conditions accompanied by chronic pain — irritable bowel syndrome, etc.
The etiology of the disorder has not been definitively established. Like other types of vulvodynia, the disorder occurs when several causes are combined. The most likely factors provoking contact soreness of the vestibule of the vagina are:
- The infectious process. Pathology is more often detected in patients with vaginitis and cervicitis. The main pathogens are trichomonas, gonococci, candida, Gardnerella, genital herpes viruses and human papilloma.
- Sterile colpitis. Non-infectious inflammation of the vagina is observed when irritated with lubricants, spermicides, latex in condoms, vaginal candles. Sterile atrophic vestibulitis also occurs with hypoestrogenemia and desquamative inflammatory vaginitis (DIV).
- Dermatoses and vulvar dystrophy. Vestibulitis is diagnosed with scleroatrophic lichen, mucosal pemphigoid, plasmocellular vulvitis, leukoplakia and kraurosis.
- Systemic diseases. Provoked vestibulodynia may be part of the clinical picture of Behcet’s disease, systemic lupus erythematosus, Crohn’s disease and other disorders associated with a violation of the immune system.
- Allergic reactions. The sensitivity of the entrance to the vagina increases under the influence of intimate hygiene products, materials used in the manufacture of tampons, pads, toilet paper. Allergies can also be caused by laundry detergents, laundry conditioners, even male sperm.
- Drug therapy. A decrease in the level of estrogens against the background of taking combined oral contraceptives and drugs that inhibit the synthesis of estrogens may be accompanied by vulvovestibulitis.
- Hyperproliferation of sensitive neurons. An increase in the density of nerve endings is primary (congenital) and secondary, provoked by the action of various stimuli (often antifungal vaginal ointments).
- Vaginismus. Irritation and soreness of the vestibule of the vagina are secondary, arise due to additional mechanical loads on tightly compressed, painful pelvic floor muscles.
In some cases, vulvar vestibulitis becomes a consequence of injuries. The patient receives similar injuries during rough interventions during childbirth and gynecological manipulations, accidents, accidents and sexual violence.
According to many specialists in the field of gynecology, the key link in the development of local dysesthesia of the vulva is the altered sensitivity of the nerve endings of the genital nerve and increased reactivity of the corresponding areas of the cerebral cortex. The number of receptors increases or remains unchanged, but under the influence of irritating factors, the threshold of their sensitivity decreases or distorts. As a result, weak and, moreover, ordinary touches are perceived as extremely painful (allodynia). In addition, changes at the level of neurons lead to the development of neurogenic inflammation with redness and burning of the mucous membrane.
When determining the form of induced vestibulodynia, the time of occurrence of sexual disorder is taken into account. To date , the following types of diseases are distinguished:
- Primary vestibulitis is a persistent disorder that has been observed since the first sexual intercourse, usually has a congenital character and is extremely rarely diagnosed.
- Secondary vestibulitis is a pathological condition provoked by external causes (chemical or infectious agents, trauma, etc.). It is the main form of the disorder.
The main clinical manifestation of the disease is superficial dyspareunia. Pain in the vestibule of the vagina occurs when touching the vulvar ring area, pressing, inserting a penis, a dildo, a finger, a tampon and other objects into the vagina. Painful sensations increase, and sometimes become unbearable, sharp, burning during sexual frictions and ejaculation of the partner. Vestibulodynia can be accompanied by post-genital vulvodynia and dysuric disorders. In some women, the pain spreads to the external genitalia (clitoris, labia majora and labia minora), radiates into the perineum, rectum, anus, urethra and inner thighs. Sometimes the equivalent of pain is burning or itching, which occur during intimate contacts, manifest themselves during physical exertion, prolonged walking, rubbing of underwear and even at rest.
Although vulvar vestibulitis does not pose a threat to a woman’s life, it can significantly worsen the quality of her life, especially sexual. Gradually, the fear of sexual contact develops, various types of emotional and behavioral disorders arise, from isolation, depression, tearfulness, short temper and irritability to clinical manifestations of depression. In some cases, sleep worsens and performance decreases. In 90% of patients with local dysesthesia of the vulva, the disease is complicated by vaginismus.
The main purpose of the examination in vestibulodynia is to confirm the diagnosis and identify the causes that provoked the disease. If vulvovestibulitis is suspected, the main diagnostic methods are:
- Examination on a chair. The vulvar area looks reddened, edematous. Small red spots may be visible on it. Vaginal discharge, serous or purulent plaque are less often detected. With atrophy, dryness and pallor of the mucous membranes are observed.
- Test with a cotton swab. When touching the applicator with a cotton tip to the soft tissues of the vestibule, areas with increased pain sensitivity are revealed.
- Vulvoscopy. Examination under a special microscope allows you to detect areas of inflammation, atrophy, thickened epithelium, neoplasia.
- Microbiological analyses. To exclude the infectious nature of vestibulitis, a vaginal smear is examined, its sowing on candida and other flora.
- PCR diagnostics. The method makes it possible to identify the causative agents of chlamydia, genital herpes, papillomatous infection and other STDs.
- Hormonal studies. When vulvar vestibulitis is associated with a reduced level of estrogens, the corresponding changes in the level of estradiol and follicle-stimulating hormone are determined.
To exclude other diseases, the patient is prescribed ultrasound of the pelvic organs, extended colposcopy, consultation of an endocrinologist, neurologist, psychiatrist, psychotherapist. Differential diagnosis is carried out with atrophic and inflammatory diseases of the genitals, dermatoses, vaginosis, neuroses and mental illnesses.
Since in most cases vestibulodynia occurs against the background of other pathological processes, appropriate therapy is prescribed when identifying the causes of the disease. The treatment regimen usually includes:
- Antibacterial drugs. If contact dysesthesia of the vulva is associated with the action of infectious agents, antibiotics, antifungal and antiviral agents are recommended, selected taking into account the sensitivity of the pathogen.
- Hormonal drugs. Hormonal background correction is indicated for atrophic processes that have arisen against the background of hypoestrogenemia. Medications are used orally and applied locally to painful areas.
To reduce pain, burning and itching, antipruritic, antihistamines and anti-inflammatory drugs are applied topically, as well as ointments, creams, gels, sprays with anesthetics and pain blockers. In parallel, mild sedatives are prescribed, usually of plant origin. It is recommended to supplement medical treatment with physiotherapy techniques (percutaneous stimulation of the genital nerve, ultrasound, manual techniques), reflexology with acupuncture, exercise therapy complexes and Kegel exercises to strengthen pelvic muscles. Effective correction of the diet with the exception of products that contain calcium oxalate (celery, chocolate, etc.).
To influence the brain links of the pathological process, patients are prescribed psychotherapeutic sessions in small groups, cognitive and cognitive behavioral psychotherapy. With severe pain syndrome and a combination of vestibulodynia with emotional disorders, novocaine blockades, injections of steroids and anesthetics into trigger points, antidepressants, anticonvulsants are indicated. In particularly severe cases of vulvar vestibulitis, a vestibulectomy operation is recommended, during which a section of tissue in the vestibule of the vagina is removed.
Prognosis and prevention
Vulvovestibulitis is a chronic disease and is resistant to therapy. Without treatment, the pain syndrome can persist for many years. The correct selection of medicinal and non-medicinal methods of therapy allows you to eliminate or significantly reduce painful manifestations. The effectiveness of surgical treatment of persistent cases of vestibulodynia is about 70%. The basis of prevention is regular observation by a gynecologist for the timely detection and treatment of pathological processes. Taking into account possible provoking factors, it is recommended that the justified appointment of oral contraceptives, the rejection of strong hygiene products, compliance with the rules for the use of sanitary tampons, wearing underwear made of natural fabrics.