Provoked Vestibulodynia

Provoked vestibulodynia is pain at the vulval vestibule that occurs only on contact, such as intercourse, tampon insertion or touch, and is absent at rest.

• It is a common form of vestibulodynia and a frequent cause of dyspareunia.
• Primary type starts at first attempt at penetration; secondary type follows a pain-free period.
• It responds best to combined physiotherapy, psychological therapy and topical or oral drugs.

Burning or tearing pain at the vaginal entrance on penetration, lasting for hours afterwards in some women.

• Cotton-swab test reproduces the pain, usually at the 4, 6 and 8 o'clock positions; vestibular erythema may be present.
• Tender, tight pelvic floor muscles.
• Differential diagnosis: vulvovaginal candidiasis, genital herpes, lichen sclerosus, atrophic vaginitis, vaginismus, Bartholin gland disease, contact dermatitis, pudendal neuralgia, hormonal contraceptive effect.
• Complications: avoidance of intercourse, secondary vaginismus, anxiety, depression, relationship strain and infertility from non-consummation.

Diagnosis is clinical, with the cotton-swab test and exclusion of infection and skin disease.

• History: onset, primary or secondary, triggers, hormonal contraception, infection and sexual function.
• Cotton-swab test and pelvic floor palpation; speculum or finger examination only when tolerated.
• Swab and potassium hydroxide preparation for candidiasis; herpes PCR for lesions; STI tests.
• Biopsy for skin changes.
• Screen for depression and anxiety.

Combine physiotherapy, psychological therapy and topical or oral drugs, and escalate slowly.

• Supportive: avoid irritants; lubricant during intercourse; slow, graded vaginal dilator use; pelvic floor physiotherapy; cognitive behavioural therapy and sex therapy; cold gel packs after intercourse; counselling for the partner.
• Pharmacological: lignocaine 5 percent ointment 1 to 2 g to the vestibule 20 to 30 minutes before intercourse, or nightly for 6 to 8 weeks. If pain persists: amitriptyline 10 mg oral at night, increased by 10 mg every 1 to 2 weeks to 50 mg (maximum 100 mg). Alternative: gabapentin 100 mg oral at night, increased to 300 mg 8-hourly (maximum 3600 mg in 24 hours). If hormonal contraception began before pain, change to a non-hormonal or progestogen-only method. Treat candidiasis with clotrimazole 500 mg pessary single dose.
• Procedures: botulinum toxin injection to pelvic floor muscles in specialist care; vestibulectomy (excision of the painful vestibule with vaginal advancement) for severe pain unresponsive to 6 months of other treatment.
• Special groups: in pregnancy avoid amitriptyline and gabapentin and use lignocaine ointment with physiotherapy. In elderly women start amitriptyline at 10 mg or avoid it. In renal impairment reduce gabapentin (creatinine clearance 30 to 59 mL/minute: 200 to 700 mg oral 12-hourly; 15 to 29 mL/minute: 200 to 700 mg oral once daily).
• Red flags: new ulcers or white plaque, bleeding, severe depression or suicidal thoughts, sudden onset with fever.
• Follow-up: review at 4 to 6 weeks and 3 months; refer to a pain or vulval clinic if no response; after vestibulectomy review at 2 and 6 weeks.