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VULVAR VESTIBULITIS AND SEXUAL PAIN

An estimated 15% of American women suffer from sexual pain. For these women intimacy can become both a challenge and a burden. If the act of sexual intercourse is associated with burning pain, it dramatically impacts a woman's sense of sexual competency and gender-role identity. Deep sexual pain is often associated with upper pelvic disorders such as endometriosis, PID (pelvic inflammatory disease), interstitial cystitis, and irritable bowel syndrome. For superficial sexual pain, the most common etiology is vulvar vestibulitis syndrome. Other common names for this syndrome are vestibular adenitis, focal vulvitis, vestibulodynia, or vulvodynia. These syndromes are characterized by pain upon entrance to the vagina, focal erythema (redness), generalized rawness and discomfort of the introitus (opening of the vagina), and a sensation of pain associated with a gentle cotton swab touch to the ostia of the Skenes and vestibular glands.

VULVAR VESTIBULITIS (VVS)
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. Recently several theories as to the etiology of VVS have been proposed.

Witkin et al suggest that many women with VVS are homozygous for allele 2 of the IL-IRA gene (IL-IRN*2), a phenotype that is associated with ulcerative colitis, Crohn's disease, and lupus erythematosis. Persons with this phenotype have more prolonged and more severe proinflammatory immune responses than those with other IL-IRA genotypes.

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.

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 that are free from vulvar symptoms.

PSYCHOSEXUAL SEQUELAE
Chronic VVS associated symptoms can last for months or even years. They can affect a woman over a lifetime and have profound effects on her physical and emotional well-being as well as on intimate relationships.
Research has found that women who experience premorbid incidence of depression, history of sexual abuse, sexual promiscuity, or sexual dysfunction are at no greater risk of developing VVS than women who do not. However, after the onset of symptoms, incidences of depression and sexual dysfunction markedly increase.

Women with VVS report that their partners are hesitant to initiate sexual activity for fear of causing more pain, leaving the initiation of sex on the woman who is experiencing painful symptoms. This leaves the woman with the feeling of being undesirable and eventually leads to a lack of interest in any form of sexual activity. To add to this burden, one third to one half of these women have been told by a health care provider that their symptoms are of a psychological etiology due to a "type A" personality or stressed out lifestyle. Instead of being given hope and medical guidance, women are being told to "just relax", resulting in further feelings of isolation and self-doubt.

DIAGNOSIS
The first step to successfully treat women with VVS is to have an accurate diagnosis. A simple physical examination using a saline-moistened cotton swab should be conducted. 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.

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

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. Some SSRI - type antidepressants may decrease the pain.

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; and 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 decreased the incidence of irritant dermatitis secondary to base additives and are generally best tolerated by vulvar pain patients.
Pilot studies using alternative approaches such as acupuncture, pelvic floor physiotherapy, and submucous infiltrations of 1 to 0.3 mL methylprednisone and lodocaine have also shown a decrease in VVS-associated dyspareunia.

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. Complications from surgeries can include vulvar adhesions, hematoma, poorly approximated incision lines, and stenosis of the Bartholin's duct with cyst formation.

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.

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 of 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 treatment of VVS will likely result from ongoing research being done 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

Source: NAM's The Female Patient Vulvar Vestibulitis and Sexual Pain; New Insights by Susan Kellogg-Spadt, Phd, CRNP; Jennifer Giordano, EDD, NCC




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