In 1988 an American gynaecologist called Edward Freidrich described a group of women who experienced severe pain and discomfort of the vestibule area of the vagina. The vestibule is where the vulva (area of the skin on the outside) meets with the vagina. It is an extremely sensitive part of your body and contains the Bartholin’s gland (which produces vaginal lubrication), the urethra (where you pass urine) and a number of the small minor vestibule glands which also produce vaginal discharge.

 

Symptoms of Vestibulodynia

The pain experienced by women with vestibulodynia is very individual. The main problem for women with this diagnosis relates to hyper-sensitivity on light touch to the vestibule, such as during intercourse and the insertion of tampons. The degree of pain is variable. Some women have pain but are able to tolerate penetrative sex. For others any pressure to the vestibule area causes symptoms of soreness and tenderness including tight clothes and even light touch to the area. Itc hing is not usually a feature of the condition. Vestibulitis was the former term for vestibulodynia. This term is out of date now. It is slightly misleading as it implies that the vestibule is inflamed – hence the term vestibulitis. It is not believed that an inflammatory process in the skin is to blame for symptoms. An excessive sensitivity of the nerve fibres and even, on occasions, overgrowth of the nerve fibres in the area is believed to be responsible for symptoms. Although the pain on light touch is the main symptom it is wrong to think that this is a skin condition. When sex has been painful for some time there are inevitable effects on your sex-life. Tension in the lower pelvic floor muscles during attempted sex can lead to increased pain and subsequent avoidance. If communication breaks down between a couple then this can lead to further disharmony. In some couples where the symptoms have been present for many months/years, provoked vulvodynia can alter sexual function and a referral to a psychosexual counsellor is necessary.

What is there to see on examination?

Vestibulodynia is a very real physical disease. Often on examination of the vestibule there is tenderness to light touch. There can be red areas at the site of tenderness, but frequently the findings are normal. Just because your doctor cannot see anything does not mean that there is nothing present.

What tests should be done?

Vestibulodynia should be diagnosed by a doctor who should rule out infections and vulval skin conditions which may cause similar symptoms. Many doctors, however, are unaware that the condition exists and often regard the condition as ‘thrush’. Your doctor should listen to your symptoms, examine the vulval area and refer you to a specialist necessary. This specialist would be either a gynaecologist, dermatologist or a genito-urinary (GUM) physician. If thrush is suspected by your doctor then it should be confirmed by performing a vaginal swab. Repeated vaginal anti-thrush treatments make the condition worse so insist on oral treatment instead, with Diflucan or Sporanox, for instance.

How is it treated?

As there is no obvious cause for symptoms, it is difficult for many women (and some doctors) to understand the condition. The treatments available for this condition are very variable. Different doctors treat the condition in different ways but below are a selection of suggested treatments. Not all doctors will use these methods, but you can discuss the different options with him/her. Some treatments will help some women and not others. Treatments range from local anaesthetic cream/gels, vaginal dilators, pelvic floor muscle physiotherapy, psychosexual counselling and rarely surgery.

 

What causes it?

It is likely that a number of factors cause vestibulodynia, but often no identifiable cause can be found. Some women have a sudden onset of symptoms following a specific event and this is commonly recognised a severe attack of thrush followed by anti-thrush treatment. Once the attack of thrush settles following treatment, soreness and burning may persist as vestibulodynia. Some women complain of vestibulodynia following childbirth, or the use of certain bubble-baths and soaps or with the use of antiseptic in the bath eg Dettol. Where symptoms have gradually occurred over some time, even years, then it’s difficult to identify a cause. Some women with interstitial cystitis also suffer from the condition. The reasons why the two conditions are connected remain unknown.

Treatments available from your doctor

Local anaesthetic gel is a waterbased gel which contains a weak amount of a local anaesthetic such as Lignocaine. The anaesthetic can ‘numb’ the nerves in the skin temporarily and may be used safely on a regular basis. Many women have gained considerable benefit using the treatment particularly with vestibulodynia when used half-an-hour prior to sexual intercourse. They find it helpful to rub the gel into the tender areas – this helps numb the skin and also can help overcome tension in the pelvic floor muscles. The gel can now be bought over the counter. Make sure that you use a test dose first on a small area of the vulva as around 10 per cent of women can have a skin reaction to it. Vaginal dilators can be inserted to relax the muscles around the entrance to the vagina and to gently stretch the area. These can be helpful to overcome the tension in the pelvic floor muscles that can occur in vestibulodynia.

Medical

Conventional analgesics and narcotics are not helpful in vulvodynia. Instead, medications used in other neuropathic disorders have been borrowed, including:

• Tricyclic antidepressants (TCAs) – frequently used as first-line therapy. Side-effects are common.
• Gabapentin – shown to be efficacious in the treatment of unprovoked generalised vulvodynia.
• Paroxetine and venlafaxine have been used in patients who could not tolerate TCAs.¹⁴

 

Topical therapies include:

• Soothing agents such as aqueous cream. Patients should also be advised to avoid irritants such as soap, bubble baths, shower gels, shampoo, special vaginal wipes or douches, etc. in this area. Use a soap substitute and Vaseline® to protect the area when swimming.
• Lidocaine gel or cream (5%) can be used to control symptoms during sexual intercourse (use 10 minutes prior to intercourse and wipe off fully if using a condom) or as a regular adjunct to other treatment.

 

Surgical

Approaches include perineoplasty and vestibulectomy:

• The aim is to remove hypersensitive tissue and replace with the advancement of normal vaginal mucosa.
• It is only appropriate for localised disease and tends to be reserved for patients who have had limited success with other therapies.
• Failure rates are higher if pain was present from first intercourse or was constant. ²²

Physiotherapy

• Pain in the vulva can cause spasm of the adductor muscles of the thigh and other muscles in that region and physiotherapy can be beneficial.
• Biofeedback training has also been used to improve strength and relaxation of the pelvic floor musculature.
• Devices to make sitting more comfortable may also be helpful.

Psychological therapies

• Cognitive and behavioural therapies have been used successfully to improve reported vulval pain with intercourse (as with many other chronic pain syndromes).
• Additional support may be required – including reassurance of the partner.
• Sexual, individual or relationship counselling may also be appropriate.

Botox For Treatment of Vestibulodynia.

We feel this article will help put into perspective the possibility of Botox being used for the treatment of Vestibulodynia or Vulvodynia in general. Botx does not have lincense for this use, but there is a chance that as research in this area progresses, the use of Botox for this purpose may become geneally acceptable for of treating Vestibulodynia and perhaps all Vulvodynia conditions in general.

Provok ed vestibulodynia (PV) previously k nown as vulval vestibulitis, is the most common clinical form of vulvodynia. It is defined by pain in the vulval vestibule triggered by a stimulus such as wearing clothes, using tampons or of course, sexual activity. The British Society for the Study of Vulval Diseases has produced treatment guidelines for the condition and common therapies include tricyclic antidepressants, local anaesthetic agents, physiotherapy or even vestibulectomy. The exact aetiology of the condition is still being debated but one hypothesis is that sufferers of the condition have increased muscular hypertonia in the superficial area of the perineum, which becomes painful.

Botulinum toxin A or botox could therefore be effective in the treatment of PV by reducing muscle tone and block ing the release of neuropeptides and neurotransmitters involved in the perception of chronic pain. This open pilot study recruited 20 patients who attended a specialist service for vulval pathology. The patients were aged between 18 and 60 years old with a mean age of 26. All complained of introital dyspareunia. Pain could be reproduced using light touch with a cotton bud on all or part of the vestibule. All the women had undergone more conventional therapy including psychosexual therapy, for at least 3 months without response. All had a history of vulvovaginal candidiasis but all were given an infectio.n screen prior to treatment. All examinations were conducted by the same doctor using EMG guidance to track the muscles. The eligible women received 1ml of Botox injected into the right and left bulbospongiosus muscles. The total dose given was 100U of botulinum toxin A. Perceived vulval pain was then measured using a visual analogue scale before the injections and at 3 and 6 months after. The ability to have sexual intercourse was also evaluated at these time points. The subjects evaluated their sexual function using the Female Sexual Function Index and general wellbeing with the Dermatology Life Quality Index. 16 out of the 20 patients (80%) reported an improvement in the pain at 3 months which was still present at 6 months. Before injections 18 of the patients were unable to have sexual intercourse, after 3 months 13 (72%) had been able to have sex again; 8 had no pain at all during sex, 5 had some residual pain. The results were the same at 6 months. Patients who responded to the injections reported improvements in sexual function and quality of life scores too. There were no side effects reported.

This was a small pilot study but the results do look promising. We are all aware of the psychosocial factors that can impact on vulvodynia and this study wasn’t designed to look at these factors or tak e them into account. Evidence is increasingly pointing to a mixed aetiology to many sexual dysfunctions including both physical and psychological factors. Botox may offer an additional tool in our armour to bring symptomatic relief to women with this condition while we also address any psychological processes exacerbating the condition. (Pelletier F, Parratte B, Penz S et al. Efficacy of high doses of botulinum toxin A for treating provoked vestibulodynia. B J of Dermatology 2011; 164 : 617 -622).

What is vulvitis?

Vulvitis is an inflammation of the vulva (the visible external genitalia). Vulvitis is not a condition or disease; it is a symptom that results from a number of different causes including allergies, infections, injuries, and other external irritants. Other vaginal infections such as vaginitis or genital herpes often accompany vulvitis. Women who experience excessive stress, whose nutrition is poor, or who have poor hygiene may be more susceptible to vulvitis. Pruritus Vulvae is whe n vulvitis is accompanied by vulval itching.

What causes vulvitis and vulval itching?

Several factors may contribute to the development of vulvitis:

• Oral sex.
• Scented or colored toilet tissue.
• Bacterial or fungal infection.
• Hot tubs and swimming pools.
• Horseback riding.
• Sexually transmitted infections
• Leaving a wet swimming suit on for a long period.
• Bicycle riding.
• Allergic reactions to products such as: soaps, shampoos, bubble baths, powders, deodorants, sanitary napkins, non-cotton underwear, pantyhose, vaginal douches, topical medications.

Risk Factors / Associations for Vulvitis?

• Diabetic women face increased risk of developing vulvitis because the high sugar content of their cells increases susceptibility to infections. As oestrogen levels drop during perimenopause, vulvar tissues become thinner, drier, and less elastic increasing a woman’s chance of developing vulvitis, or other infections such as vaginitis. Young girls who have not yet reached puberty are also at possible risk due to the fact that adequate hormone levels have not yet been reached. Any woman who is allergy-prone, has sensitive skin, or who has other infections or diseases can develop vulvitis.
• Other associations or risk factors include immune deficiency states, Urinary incontinence. Faecal incontinence, Any cause of generalised pruritus, e.g. liver disease, lymphoma, Psychological problems.

Symptoms of vulvitis?

While each woman may experience vulvitis symptoms differently, some of the most common symptoms are:

• Redness. Swelling. Fluid-filled, clear blisters that break open, and form a crust (sometimes mistaken for herpes). Irritation. Burning sensation.
• Scaly appearance. Thickened or whitish patches. Possible vaginal discharge.

It’s important for women with these symptoms to remember not to scratch as this can lead to further irritation and/or infection. Although it may seem like a good idea to wash repeatedly over the day, the fact is that over washing the affected area can lead to further irritation. It’s best to wash just once a day with warm water only when symptoms of vulvitis are present.

How is vulvitis diagnosed?

Several diagnostic tools such as blood tests, urinalysis, testing for sexually transmitted diseases (STDs), and Pap smears help your doctor diagnose vulvitis. A personal or family history of skin

disease (e.g. atopy, psoriasis, eczema) or autoimmune disease (associated with lichen sclerosus) may be significant.

Investigations to aid diagnosis may include the following:

• Blood tests – which may include fasting glucose, FBC, serum ferritin and TFTs..
• If an infection is suspected, appropriate swabs or cultures should be taken to look for conditions such as candida or bacterial vaginosis.
• If a sexually transmitted disease is suspected, appropriate swabs and/or blood tests should be arranged.
• Skin biopsy may be required in cases of diagnostic difficulty (as a rule of thumb, any skin lesion not responding to a six-week course of treatment).

 

What is the treatment for vulvitis?

The treatment for vulvitis varies according to cause. Your clinician will consider several factors before determining which treatment is the right one. Some factors your clinician will consider include:

• Your age, general health, and medical history.
• The cause of your symptoms.
• The specific symptoms you are experiencing.
• The severity of your symptoms.
• How well you tolerate certain medications, procedures, or therapies.

Once these factors are considered, several methods of treatment are available including both self-help measures, and prescribed medications. Low-dose hydrocortisone creams may be prescribed

for short periods. Anti-fungal creams are sometimes helpful for treatment of vulvitis. Post menopausal women may find topical oestrogen relieves their symptoms. Self-help treatments include:

• Baths containing soothing compounds such as Aveeno baths or comfrey tea baths.
• Stopping the use of any products that may be a contributing factor.
• The vulva should be kept clean, dry, and cool. Do remember to wipe from front to back.
• Hot boric acid compresses.
• Cold compresses filled with plain yogurt or cottage cheese help ease itching and irritation.
• Calamine lotion.
• Using sterile, non-irritating personal lubricants such as K-Y Jelly, or Sylk during sexual activity.
• Learning to reduce stress.
• Eating an adequate and nutritious diet.
• Making sure you get enough sleep at night.

 

Pruritus vulvae of unknown cause

In the absence of a specific diagnosis, or whilst waiting for results, the following treatments can be tried. Most are based on the empirical experience of experts, as there is little published evidence:

• Emollients can be used as an adjunct to other treatments and are suitable for easing itching in almost all types of vulval disease; they can be used in addition to most other therapies. They can also be used as a soap substitute or moisturiser. There is wide patient variability and lack of comparative evidence, so the choice of preparation can be left to individual preference. If topical steroids are used as well, the emollient should be used first and the steroid 10-20 minutes later. This ensures the skin is moisturised and avoids spread of the steroid to normal skin.

• Sedating oral antihistamines appear to work by promoting sedation rather than blocking the action of histamine. Sedative antidepressants have been used with similar benefit
• Low-potency topical corticosteroids, e.g. hydrocortisone 1% ointment, can be considered as a short trial (1-2 weeks). Potent steroids should be avoided as they can affect surface features and confuse the diagnosis should subsequent specialist referral be required. Specialist referral is indicated if there is no response to steroids.

Specific management (known cause)

This will depend on the underlying condition and the results of investigations. Potent steroids should only be used if the prescriber is confident in the diagnosis. This is usually after confirmation by a specialist, often on the basis of biopsy results.

Infection – Vulval and vaginal infections should be treated with the appropriate antibiotic, antifungal,

antiviral or other antimicrobial agent. Consider investigating and treating the partners of women with recurrent Group A beta-haemolytic streptococcal (GAS) infection. Such men have been found to have a high incidence of GAS in the bowel which is passed on via contamination of bedding. Treating both partners sometimes results in resolution of the condition.

Dermatological conditions

• Contact dermatitis – this is mainly centred on irritant avoidance, with topical corticosteroid treatment as a secondary measure to relieve itching.

• Seborrhoeic dermatitis and psoriasis – these are usually treated with judicious use of topical corticosteroids (sometimes combined with an antibacterial or anticandidal agent). Ketoconazole shampoo can be used as body wash for seborrhoeic dermatitis.
• Lichen simplex can be treated with topical betamethasone for 1-2 weeks to break the itch-scratch cycle.
• Lichen sclerosus and lichen planus may respond to short-term regular potent or superpotent topical corticosteroids followed by maintenance application. Women with lichen sclerosus have a small risk (2-5%) of developing carcinoma, so long-term follow-up is recommended. Regular use of a simple moisturiser may lessen attacks and reduce the requirement for steroids.

• Zoon’s vulvitis – This normally responds to high-potency topical steroids.

Other Vulval Conditions

• Vulvar vestibular syndrome – this is also known as vestibulitis, vestibular pain syndrome, vestibulodynia and localised vulval dysaesthesia. Altered pain perception is the major feature of this syndrome. Management is often difficult. A number of treatments have been tried, including Xylocaine® gel, pelvic floor retraining with biofeedback, low-dose tricyclic antidepressants,  newer   agents  for  neuropathic  pain,  and   cognitive  behavioural  therapy. Rarely, vestibulectomy is offered as a last resort.

• Dysaesthetic vulvodynia – this is also known as essential vulvodynia and generalised vulval dysaesthesia. The predominant symptom is chronic, poorly localised vulval burning or pain. The exact aetiology is unclear, but the condition shares some features with neuropathic pain syndromes. Low-dose tricyclic antidepressants are the standard treatment for dysaesthetic vulvodynia. Gabapentin, imipramine and venlafaxine have also been reported to be beneficial.

• Lichen sclerosus – The main symptom of lichen sclerosus is severe itching. Scratching can result in broken skin, burning or stinging, pain during sex and/or urination. Lichen sclerosus is thought to be an autoimmune disorder. It affects women of all ages but is primarily found in post-menopausal women. Lichen sclerosus can be misdiagnosed as thrush however, on inspection, the skin is dry, shiny, finely wrinkled and may have white patches. If left untreated lichen sclerosus can cause severe scarring of the vulva (including the shrinking of the labia and narrowing of the vaginal entrance). It is also associated with a small increased risk of vulval cancer. Treatment involves the use of a topical steroid and is often life-long. Once a woman is diagnosed with lichen sclerosus she should undergo regular reviews, even if asymptomatic, to ensure the condition is under control and no cancerous changes have occurred.
• Lichen planus This skin condition affects a number of areas of the body including the vagina and vulva. As with lichen sclerosus the exact cause is unknown, but an overactive immune system or genetic predisposition may play a role. Symptoms can include small lesions, a red – purplish colour to the skin, soreness and burning associated with raw areas of skin as well as bleeding and/or painful sex. Vaginal discharge may be heavier, sticky and/or yellow. If left untreated lichen planus can cause scarring of the vagina and vulva. Treatment involves topical or oral steroids and pain relief gels, oral pain relief and antidepressants (used for pain relief). Lichen planus may be associated with a small increased risk of vulval cancer
• Psoriasis – Women with psoriasis of the vulva often have the skin condition elsewhere on their body. Psoriasis is an immune system disorder. Symptoms include scaly, red plaques (although on the vulva these are generally less well defined than on other areas of the body). Other signs which may point to psoriasis include nail pitting, scalp scaling and a family history of the condition. Treatment includes the use of topical steroids and a low dose coal tar cream.

Dermatitis is the most common cause of chronic vulval symptoms. In some cases, vulval dermatitis can be caused by a genetic predisposition to allergies and hypersensitivity. These women will have conditions like asthma, hay fever or dermatitis in other areas of the body. Vulval dermatitis can also be caused by contact with an irritant or allergen such as:

• laundry detergents, toilet paper, deodorants, dusting powders/talc
• lubricants and spermicides
• sanitary pads and panty liners
• bath products, soap and shower gels
• depilatory products
• underwear (lace, G-strings)
• latex in condoms or a diaphragm
• over-the-counter medication (thrush treatments)

 

The main initial symptom of dermatitis is itching. Scratching the area can result in broken skin, burning or stinging, and pain during sex. Treatment for dermatitis usually involves the use of a topical corticosteroid cream. Cool compresses and antihistamines may be used to bring relief from symptoms. If the dermatitis is thought to be due to an allergy or irritant, it is important that attempts are made to identify and avoid the substance. It can take some time for symptoms to resolve as the skin of the vulva generall y takes longer to heal than in other areas of the body. If a woman’s symptoms persist she should return to her doctor as women with vulval dermatitis may develop secondary infections such as thrush. Some general tips for vulval care are:

• Switch to hypoallergenic versions of products like toilet paper and laundry detergent as these products have no or limited perfume and colourings known to cause irritation.
• Avoid soap or use a soap substitute.
• Take showers instead of baths and do not use douches or talc.
• Wear cotton underwear and avoid tight-fitting trousers, pantyhose and G-strings.
• When showering avoid getting shampoo or conditioner residue on the vulval area. Alternatively, wash hair in the basin.
• Use tampons rather than sanitary pads where possible—they are less irritating to the vulva. If pads are preferred, consider using washable cloth sanitary pads. Avoid the use of panty -liners between periods. Avoid repeated use of over the counter anti-fungal preparations for thrush. If symptoms of thrush continue after an initial treatment women should consult their doctor as these preparations are a common cause of irritation.