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Sexual Health & Intimacy

Vulvar Vestibulitis and Sexual Pain: New Insights

Susan Kellogg-Spadt, PhD, CRNP; Jennifer Giordano, EdD, NCC

For the estimated 15% of American women who suffer with sexual pain, physical intimacy can become a challenge and a burden.¹ When the act of sexual intercourse becomes associated with burning pain, it dramatically impacts a woman's sense of sexual competency and gender-role identity.² Although deep sexual pain is often associated with upper pelvic disorders, ie, endometriosis, pelvic inflammatory disease, interstitial cystitis, and irritable bowel syndrome, the most common etiology of superficial sexual pain is vulvar vestibulitis syndrome.³

VULAR VESTIBULITIS
Vulvar vestibulitis syndrome (VVS), also referred to as vestibular adenitis, focal vulvitis, vestibulodynia, or vulvodynia, is characterized by entry dyspareunia, focal erythema, generalized rawness and discomfort of the introitus, and a sensation of pain associated with a gentle cotton swab touch to the ostia of the Skenes and vestibular glands.⁴

The exact etiology of VVS is unknown. Sentinel events for the development of symptoms include yeast or urinary tract infections, viral exposure, prolonged antibiotic use, or a history of chemical, mechanical, or allergic trauma to sensitive mucosal tissue.⁵ Although VVS remains a poorly understood entity, several theories regarding its etiology have recently been proposed. Witkin et al suggest that many women with VVS are homozygous for allele 2 of the IL-1RA gene (IL1RN*2), a phenotype that is associated with ulcerative colitis, Crohn's disease, and lupus erythematosus. Persons with this phenotype have more prolonged and more severe proinflammatory immune responses than those with other IL-1RA genotypes.⁶

Ekgren proposes that neurogenic inflammation of the vulvar vestibule "end-organ" occurs in response to noxious environmental stimuli, which result in parasympathetic efferent and visceral nocioceptive afferent hyperactivity with release of antidronic substance P and calcitonin gene-related peptide and nitric oxide processing around the glandular ostia.⁷

Bohm-Starke et al and Westrom and Willen document the presence of VVS-associated vestibular neural hyperplasia revealed by PGP 9.5 immunohistochemistry. The increases in intraepithelial innervation and nerve bundle density are significant for women with VVS when compared to controls who are free from vulvar symptoms.^8,9

PSYCHOSEXUAL SEQUELAE
Chronic VVS-associated symptoms can last for months or even years. They can affect women across the life span and have profound affects on women's sense of physical and/or emotional well-being and on intimate relationships.¹⁰

Research suggests that women with sexual pain do not differ from controls in terms of premorbid incidence of depression, sexual abuse history, sexual promiscuity, or sexual dysfunction. After the onset of symptoms, however, they show markedly increased rates of depression and sexual dysfunction.^11,12

The sequencing and scripting of sexual interactions are altered after the onset of VVS. Women with VVS report that their partners often become hesitant to introduce sexual activity, and fear that they will cause more pain. This places responsibility for the initiation of sex with the women who are experiencing painful symptoms. With altered partner expressions of interest in intimacy, many women report feeling undesired. Lack of interest in all forms of sexual activity often follows.¹³

To add to the burden of chronic pain and altered sexual relationships, research suggests that one third to one half of women diagnosed with VVS report being told by a health care provider that the symptoms were of psychological etiology due to a "type A" personality or stressed out lifestyle.¹³ Rather than being given hope and medical guidance, women are often given empty advice and told to "just relax." This results in feelings of isolation and self-doubt.

DIAGNOSIS
Competent care of women with VVS begins with accurate and timely diagnosis. A simple physical examination can be conducted using a saline-moistened cotton swab. The "touch test," is performed by firmly touching a cotton swab to the labia majora, interlabial sulci, and lateral labia minora, and comparing the woman's response to these maneuvers with a similar firm touch to the ostia of the Skene's glands and the major and minor vestibular glands. In VVS, little or no tenderness is reported when lateral genital structures are touched, but heightened painful sensitivity is usually associated with touch of the gland openings. If diagnosis is in doubt, the touch test can be repeated after 5% lidocaine gel is placed on the vestibule. When a previously positive swab sites within the vestibule become nonpainful to touch after lidocaine has been applied, a diagnosis of vulvar vestibulitis is plausible.¹

After physical examination, women with VVS should be assured that the condition is real, that she has a physical manifestation. It is empowering for the patient to hold a mirror, and view the vestibule while the condition and the location of the glands are explained to her by the clinician.³

TREATMENT OPTIONS
Although no one treatment is considered curative for vestibulitis, reduction in dyspareunia has been reported with traditional treatment options such as low-dose tricyclic antidepressant medications, treatment of coexisting fungal infections, pelvic muscle biofeedback, intradermal interferon injections, and application of mild topical cortisone or estrogen preparations.¹⁴

Newer treatment options that have been compared with placebo and shown favorable results in limited study populations include topical application of 4% cromolyn cream applied daily; 0.2% nitroglycerin cream applied prior to sexual relations, topical 0.2% atropine cream applied daily, and topical 0.025% capsaicin cream applied for 20 minutes daily. Compounded creams and ointments using hypoallergenic bases such as acid mantle or aquaphor decrease the incidence of irritant dermatitis secondary to base additives and are generally best tolerated by vulvar pain patients.^7,15-17

Pilot studies using alternative approaches such as acupuncture, pelvic floor physiotherapy, and submucous infiltrations of 1 to 0.3 mL methylprednisone and lidocaine have also shown a decrease in VVS-associated dyspareunuia.^18-20 Laser or excisional treatment should be reserved for use in cases of VVS for which all forms of medical treatment have failed. In severe or recalcitrant cases, surgical intervention for superficial dyspareunia can be a viable option and can result in high rates of patient satisfaction.²¹ Complications from surgeries can include vulvar adhesions, hematoma, poorly approximated incision lines, and stenosis of the Bartholin's duct with cyst formation.²²

HOW CAN YOU HELP THESE PATIENTS?
OB/GYNs can play an integral role by making the diagnosis as early as possible, educating women about the disorder, and starting a management plan. A patient should be assured that symptoms are not "in her head" and are not associated with a life-threatening illness. Setting expectations that treatment may take months or years and confirming that targeted VVS research is being conducted at local and national levels may help a woman stay committed to a treatment program and maintain an optimistic yet realistic outlook.

REFERRALS
Some OB/GYNs enjoy the challenge of managing chronic sexual pain issues. Others find that due to the chronic nature and protracted treatment course of VVS, the condition is best managed by referring patients to a clinician who specializes in sexual pain.

To assist in dealing with changing interpersonal dynamics, couples may benefit from a referral to a relationship therapist. Research suggests that outcomes are more favorable when combined medical-psychosexual treatment approaches are employed.¹⁹

Women with VVS may benefit from the support and education offered by the National Vulvodynia Association (www.nva.org).

LOOKING AHEAD
Vulvar vestibulitis presents unique challenges to women in the 21st century. Bombarded by cultural and media messages that they should be free to enjoy sex, women are conflicted by symptoms that prohibit such freedom.

New advances in the treatment of VVS will likely result from ongoing research in the United States and worldwide. Until a cure is identified, supportive care provision and knowledgeable referrals will assist women as they face the dilemma of managing sexual pain.

REFERENCES

1. Goetsch MF. Vulvar vestibulitis: prevalence and historic features in a general gynecologic practice population. Am J Obstet Gynecol. 1991;164:1609-1616.
2. White G, Jantos M. Sexual behavior changes with vulvar vestibulitis syndrome. J Reprod Med. 1998;43(9):783-789.
3. Steege JF, Metzger DA, Levy BS. Chronic Pelvic Pain: An Integrated Approach. New York, NY: W.B. Saunders Company;1998.
4. McKay M. Vulvitis and vulvovaginitis: cutaneous considerations. Am J Obstet Gynecol. 1991;165:1176-1182.
5. Paavonen J. Diagnosis and treatment of vulvodynia. Ann Med. 1995;27:175-181.
6. Witkin SS, Gerber S, Ledger WJ. Influence of interleukin-1 receptor antagonist gene polymorphism on disease. Clin Infect Dis. 2002; 34(2):204-209.
7. Ekgren JS. Vulvovaginitis treated with anticholinergics. Gastroenterology Intl. 2000;13(2):72.
8. Bohm-Starke N, Hilliges M, Falconer C, Rylander E. Increased intraepithelial innervation in women with vulvar vestibulitis syndrome. Gynecol Obstet Invest. 1998;46(4): 256-260.
9. Westrom LV, Willen R. Vestibular nerve fiber proliferation in vulvar vestibulitis syndrome. Obstet Gynecol. 1998;(4): 572-576.
10. Sackett S, Gates E, Heckman-Stone C, Kobus AM, Galask R. Psychosexual aspects of vulvar vestibulitis. J Repro Med. 2001; 46(6):593-598.
11. Danilsson I, Sjoberg I, Wikman M. Vulvar vestibulitis: medical, psychosexual and psychosocial aspects, a case-control study. Acta Obstet Gynecol Scand. 2000;79(10):872-878.
12. Meana M, Binik YM, Kalife S, Cohen D. Dyspareunia: sexual dysfunction or pain syndrome? Obstet Gynecol. 1997;185(9):561-589.
13. Kellogg-Spadt S. Listening to the Voices of Women Diagnosed with Vulvodynia. Philadelphia, Pa: University of Pennsylvania Press;2002.
14. Metts J. Vulvodynia and vulvar vestibulitis: Challenges in diagnosis and management. Am Fam Physician. 1999; 15:1547-1561.
15. Nyirjesy P, Sobel JD, Weitz MV, Leaman DJ, Small MJ, Gelon SP. Cromolyn cream for recalcitrant idiopathic vulvar vestibulitis: results of a placebo controlled study. Sex Transm Infect. 2001; 77(1):53-57.
16. Miles M, Niezen P, Berman L, Berman J. Relief of vaginal and labial pain and burning with 0.2% nitroglycerin cream in women with vulvodynia. Proceedings from the Female Sexual Function Forum, Boston, Mass. 2001;104.
17. Zyczynski HM, Culbertson S, Gruss J, DeGroat WC. Topical capsaicin in the treatment of vulvar vestibulitis. J Society Gynecol Invest. 1997;4(1):107a.
18. Danielsson I, Sjoberg I, Ostman C. Acupuncture for the treatment of vulvar vestibulitis: a pilot study. Acta Obstet Gynecol Scand. 2001;80 (5):437-441.
19. Sarig J, Har-Toov J, Chen J, Melitscher I, Abramov L. Biofeedback combined with medical and sex therapy for VVS: results of a preliminary study. Proceedings from the Female Sexual Function Forum, Boston, Mass. 2001;157.
20. Murina F, Tassan P, Roberti P, Bianco V. Treatment of vulvar vestibulitis with submucous infiltrations of methylprednisone and lidociane. J Repro Med. 2001;46(8):713-716.
21. Schneider D, Yaron M, Bukovsky I Soffer Y Halperin R. Outcome of surgical treatment for superficial dyspareunia from vulvar vestibulitis. J Repro Med. 2001;46(3):227-231.
22. Marinoff SC, Turner ML. Vulvar vestibulitis syndrome: an overview. Am J Obstet Gynecol. 1991;165:1228-1233.

Susan Kellogg-Spadt, CRNP, PhD, is an OB/GYN nurse practitioner and director of sexual medicine, The Pelvic Floor Institute, Graduate Hospital, Philadelphia, Pa. Jennifer L. Giordano, EdD, NCC, is a sexologist and intimacy management specialist, The Pelvic Floor Institute, Graduate Hospital, Philadelphia, Pa.

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