Generality
Vulvar vestibulitis is an inflammation of the tissues that surround access to the vagina (vestibule).
At the origin of vulvar vestibulitis there is often a hyperactivity of some cells of the immune system, called mast cells, which induce a prolonged inflammatory state. The disorder can also contribute to the reflex contraction of the pelvic muscles and the hyperstimulation of the nerve endings appointed to the perception of pain. Among the factors that aggravate or maintain the manifestations also include chronic or recurrent infections, microtraumas associated with vaginal dryness and the use of inappropriate hygiene products.
Vulvar vestibulitis typically manifests itself with reddening of the mucosa of the vulvar vestibule, pain during sexual intercourse ( dyspareunia ) and strong localized burning . This involves a series of more or less limiting annoyances; if it is not managed promptly, this problem may persist for years and, in general, the manifestations tend to extend also to the perianal region or to other genital areas not initially involved.
The treatment allows to alleviate the manifestations connected to vulvar vestibulitis and can include medical, rehabilitative and psychosexual measures.
What is the vulvar vestibule?
The vulvar vestibule is the area of the female external genitalia between the labia minora, bounded anteriorly by the clitoris, to which inferiorly follow the meatus of the urethra and the orifice of the vagina.
At the lower level, this vulvar region is bounded by the posterior labial commissure (or navicular fossa). In the following image (taken from wikipedia.org), the vulvar vestibule is delimited by a dotted line.
Causes
The vestibulitis is an inflammation that can involve the mucosa of the vestibule of the vagina and of the vulvar region located inside the labia minora and around the outer edge of the hymen.
The disorder can be determined by many causes, which often interact with each other or contribute to worsen the symptoms. Etiology may involve different systems (immune, muscle, vascular and nervous, including fibers and pain centers).
Mast cell hyperactivity
Vulvar vestibulitis can be induced by the hyperactivation of some cells responsible for immune defense ( mast cells ); this reaction is caused by prolonged and / or elevated exposure to an infectious or irritative factor, responsible for an excessive local immune response .
The mast cells do not only produce the inflammatory substances responsible for erythema and irritation, but they are also responsible for the activation of the nerve growth factor (NGF, a nerve growth factor), which promotes the proliferation of the terminations responsible for the perception of pain.
Mast cell overactivation can be favored by:
- Repeated inflammation from infectious agents, such as Candida, Gardnerella or Escherichia coli (from the intestine);
- Microtrauma of the mucosa of the vaginal vestibule due to sexual intercourse in conditions of poor or no lubrication. In turn, dryness may depend on poor desire or reduced excitement, estrogen deficiency or pain during penetration;
- Inappropriate lifestyles, such as the use of aggressive soaps in intimate areas and the habit of wearing tight-fitting clothes made with synthetic fabrics, which can amplify local inflammation.
Hypertonus of the pelvic floor
The vulvar vestibulitis can be favored by a defensive reaction of the vaginal area, which causes a permanent muscular spasm .
The reflex narrowing of the vagina can be prior to the vestibulitis (as happens in cases of vaginismus ) or can be determined by dyspareunia related to the disorder. This contraction can itself become a cause for pain.
Hyperstimulation of the pain system
The excessive sensitivity to pain stimuli related to vulvar vestibulitis recognizes peripheral causes (due to the proliferation of nerve endings) or central causes (secondary to the lowering of the pain threshold). This results in hyperalgesia (amplified and / or exaggeratedly prolonged pain response to a modest pain stimulus) and / or allodynia (ie the evocation of pain by a commonly non-painful or even non-existent stimulus).
Other triggers
Vulvar vestibulitis can be aggravated by the simultaneous presence of urinary and gynecological disorders, especially of an inflammatory nature (eg recurrent cystitis), which can be accompanied by muscular hypertonia. Immune disorders (allergies, lichen sclerosus, eczema, etc.), neuropathies and psychosexual or relational factors may also contribute to the onset of the disorder.
How it manifests itself
There are three main symptoms of vulvar vestibulitis:
- Redness : the erythema can be of variable degree, but it is always localized in very specific vestibular points. Upon observation with a mirror, it is possible to notice a more intense redness at the level of the tissues in the region of the vulva that goes from the base of the clitoris to the medial border of the lips, up to the entrance of the vagina.
- Burning : imagining the vaginal vestibule as a clock face, the burning sensation is located above all in the "hourly" zone placed between five and seven.
- Pain during sexual intercourse: in the vulvar vestibulitis, the introital pressure, the penetration of the vaginal orifice and the containment of the penis during coitus generally causes an immediate dysmorea ; in general, the pain is interrupted when the penile movement of the sexual partner stops and resumes with the continuation of coitus.
Vulvar vestibulitis can also cause vulvar burning after sexual intercourse and dysuria (in the absence of laboratory signs related to a urinary infection). Clinical manifestations can be exacerbated by all those situations that exert pressure on the vulvar area, such as riding a bicycle or inserting a vaginal swab.
If it is not diagnosed in time and treated appropriately, the disorder tends to become chronic : when the spontaneous or provoked vulvar pain becomes persistent and is maintained even after the resolution of the inflammatory picture, we speak of vulvodynia . In this case, the problem persists regardless of sexual intercourse or other triggers, and can become debilitating at the level of daily life.
Diagnosis
Vulvar vestibulitis is diagnosed based on the symptoms that emerged during the collection of anamnestic data and gynecological examination. At the inspection of the vulva there is no evidence of any abnormality attributable to other diseases, local or systemic: the physical examination shows localized redness, which may indicate the presence of inflammation, but other physical findings are normal.
The gynecological examination must exclude the anomalies that cause pain, such as those responsible for dyspareunia, including atrophic vaginitis, lichen sclerosus, vulvar dystrophies, congenital malformations, genital herpes and post-surgical introital narrowing.
Vaginismus causes similar pain with the introital pressure and movement of the penis of the sexual partner. However, unlike vulvar vestibulitis, there is no allodynia. Furthermore, the pain due to vaginismus continues even after the interruption of the penile movement, but may progressively decrease during sexual intercourse.
The diagnosis of vulvar vestibulitis is confirmed by the increased sensitivity to pressure on the vulva and the positivity for the Q-tip test for allodynia . The latter involves the contact of a cotton bud on the vestibular area and allows the delineation of areas in which unpleasant sensations are more intense or violently painful.
Treatment
The treatment of vulvar vestibulitis can include different approaches, which make painful sensations less frequent and debilitating.
The most effective therapeutic combination is always personalized by the doctor based on the predisposing factors, the severity and duration of the symptoms.
To alleviate the manifestations of vulvar vestibulitis, first of all, it is recommended to avoid irritating substances (eg aggressive soaps for intimate hygiene) and to change inappropriate lifestyles.
Pain modulation is possible by applying topical medications, such as lidocaine (local anesthetic) or sodium cromoglycate (stabilizing white blood cell membranes, including those of mast cells, interrupting neurogenic inflammation at the basis of the problem). At the beginning of treatment, the supervision of a doctor and the use of a mirror can be very useful.
Drug therapy may also include the use of specific analgesics, such as amiptriptyline or gabapentin. Sometimes, to interrupt the circuits of chronic pain, the intake of systemic drugs is indicated (eg tricyclic antidepressants, anticonvulsants, etc.)
Some women with vulvar vestibulitis can also benefit from psychological interventions, including cognitive-behavioral psychotherapy and sex therapy, to rediscover the pleasure of intimacy. Currently, the measures used also include stress management and emotional reactions to problems associated with the problem, such as in the management of chronic pain syndromes.
Women with hypertonia of the vaginal muscles can benefit from physiotherapy (pelvic floor training) and electromyographic biofeedback of pelvic musculature (a self-relaxation technique that teaches how to better control muscle contractions and the pain they cause).
In some cases, surgical procedures are indicated to remove the proliferated nerve endings, such as the excision of the hymen, the proximal margin of the lower vagina and the innermost part of the small lips. However, the pain can recur when the nerves regenerate.
An experimental treatment involves the local injection of botulinum toxin type A for the analgesic block of hyperactive nerve endings and the simultaneous inhibition of local muscle contraction, bringing a beneficial relaxation for up to six months.
Besides the therapeutic approaches directed to the management of vulvar vestibulitis it is also appropriate:
- Prevent infections by observing proper personal hygiene;
- Use products with a delicate pH;
- Take care of food by promoting low-sugar foods and drinking plenty of water;
- Refrain from sexual intercourse during periods when vestibular inflammation is present.
