Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis, is

vulvodynia Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made ...

localized to the vulvar vestibule. It tends to be associated with a highly localized "burning" or "cutting" type of pain. Until recently, "vulvar vestibulitis" was the term used for localized vulvar pain: the suffix "-itis" would normally imply inflammation, but in fact there is little evidence to support an inflammatory process in the condition. "Vestibulodynia" is the term now recognized by the International Society for the Study of Vulvovaginal Disease. Provoked vestibulodynia, pain provoked by contact localized to the vulvar vestibule, is the most common subtype of

among premenopausal women. The syndrome has been cited as affecting about 10% to 15% of women seeking gynecological care.

Symptoms

VVS is characterized by severe pain with attempted penetration of the

vaginal orifice In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hymen ...

and reports of tenderness with pressure within the

vulval vestibule The vulval vestibule (or vulvar vestibule or vestibule of vagina) is a part of the vulva between the labia minora into which the urinary meatus (urethral opening) and the vaginal opening open. Its edge is marked by Hart's line. It represents the ...

. Usually there are no reports of pain with pressure to other surrounding areas of the vulva. The feelings of irritation and burning can persist for hours or days following sexual activity, engendering a sense of hopelessness and depression. VVS also can often cause

dyspareunia Dyspareunia ( ) is painful sexual intercourse due to medical or psychological causes. The term ''dyspareunia'' covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the f ...

.
The pain may be provoked by touch or contact with an object, such as the insertion of a tampon, with vaginal intercourse, or with the pressure from sitting on a bicycle seat, ''provoked vestibulodynia'', or it may be constant, as in the case of unprovoked, generalized vestibulodynia. Some women have had pain since their first penetration (primary vulvar vestibulitis) while some have had it after a period of time with pain-free penetration (secondary vulvar vestibulitis). Relationship problems often occur as the result of chronic frustration, disappointment, and depression associated with the condition.

Causes

Little is known about the cause of vestibulodynia. A number of causes may be involved, including

subclinical In medicine, any disease is classified asymptomatic if a patient tests as carrier for a disease or infection but experiences no symptoms. Whenever a medical condition fails to show noticeable symptoms after a diagnosis it might be considered asym ...

human papillomavirus infection Human papillomavirus infection (HPV infection) is caused by a DNA virus from the ''Papillomaviridae'' family. Many HPV infections cause no symptoms and 90% resolve spontaneously within two years. In some cases, an HPV infection persists and res ...

, chronic recurrent

candidiasis Candidiasis is a fungal infection due to any type of '' Candida'' (a type of yeast). When it affects the mouth, in some countries it is commonly called thrush. Signs and symptoms include white patches on the tongue or other areas of the mouth ...

, or chronic recurrent bacterial

vaginosis Bacterial vaginosis (BV) is a disease of the vagina caused by excessive growth of bacteria. Common symptoms include increased vaginal discharge that often smells like fish. The discharge is usually white or gray in color. Burning with urination ...

. Muscular causes have been implicated as well, since chronic vulvar pain may be the result of chronic hypertonic perivaginal muscles, leading to vaginal tightening and subsequent pain. Some investigators have postulated the existence of neurological causes, such as vestibular neural

hyperplasia Hyperplasia (from ancient Greek ὑπέρ ''huper'' 'over' + πλάσις ''plasis'' 'formation'), or hypergenesis, is an enlargement of an organ or tissue caused by an increase in the amount of organic tissue that results from cell proliferati ...

. In vestibulodynia the nerves of the vulva transmit signals of pain when they normally should indicate touch, pressure, heat, or stretch. Normal sensations are processed by the brain as abnormal, which result in a heightened sensitivity, i.e.

hyperalgesia Hyperalgesia ( or ; 'hyper' from Greek ὑπέρ (huper, “over”), '-algesia' from Greek algos, ἄλγος (pain)) is an abnormally increased sensitivity to pain, which may be caused by damage to nociceptors or peripheral nerves and can ...

. Finally, psychological factors may contribute to or exacerbate the problem, since the anticipation of pain often results in a conditioned spasmodic reflex along with sexual desire and arousal problems.

Diagnosis

Diagnosis is readily made by the cotton-swab test, in which pressure is applied in a circular fashion around the vulvar vestibule to assess complaints of pain. Laboratory tests are used to exclude bacterial, viral or yeast infection, and a careful examination of the vulvovaginal area is conducted to assess whether any atrophy is present.

Treatment

Treatment consists of general advice about hygiene and sexual behaviour, pelvic floor and desensitisation exercises, and psychological treatment by a multidisciplinary team.Goldstein, A. T., Pukall, C. F., Brown, C., Bergeron, S., Stein, A., & Kellogg-Spadt, S. (2016). Vulvodynia: Assessment and Treatment. J Sex Med, 13(4), 572-590. doi: 10.1016/j.jsxm.2016.01.020

References

{{Reflist Gynaecologic disorders Pain