Vestibulodynia

Vestibulodynia is chronic pain localised to the vulval vestibule, the area around the vaginal opening. It may be provoked by touch, spontaneous, or both.

• It is a common cause of dyspareunia in premenopausal women.
• It can start at first intercourse (primary) or after a pain-free period (secondary).
• Causes include recurrent infection, hormonal contraception, pelvic floor overactivity, nerve proliferation and inflammation.

Sharp, burning or raw pain at the vaginal entrance with intercourse, tampon insertion, speculum examination, tight clothing or cycling, and sometimes unprovoked pain.

• Cotton-swab test: pain at the 4, 6 and 8 o'clock vestibular positions, with red, tender vestibule in some women.
• Differential diagnosis: candidiasis, herpes genitalis, lichen sclerosus, lichen planus, atrophic vaginitis, vaginismus, Bartholin gland disease, contact dermatitis, pudendal neuralgia.
• Complications: avoidance of intercourse, vaginismus, depression, relationship difficulty and chronic pain.

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

• Detailed history of onset, triggers, treatments, hormonal contraceptive use and sexual function.
• Cotton-swab test with graded pain scores; pelvic floor muscle tenderness examination.
• Vaginal swab and potassium hydroxide preparation; herpes PCR if lesions; STI tests.
• Biopsy for skin changes.
• Screen for anxiety and depression.

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

• Supportive: avoid irritants and tight clothing; lubricant at intercourse; pelvic floor physiotherapy with biofeedback and vaginal dilators; cognitive behavioural and sex therapy; cold gel packs; counselling for 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. Amitriptyline 10 mg oral at night, increased by 10 mg every 1 to 2 weeks to 50 mg (maximum 100 mg). Gabapentin 100 mg oral at night increased to 300 mg 8-hourly (maximum 3600 mg in 24 hours). Treat associated candidiasis with clotrimazole 500 mg pessary single dose. In women on combined hormonal contraception consider changing to a progestogen-only or non-hormonal method.
• Procedures: botulinum toxin injection to pelvic floor muscles in specialist care; vestibulectomy for severe provoked vestibulodynia that has failed 6 months of other treatment.
• Special groups: in pregnancy avoid amitriptyline and gabapentin; use lignocaine ointment and physiotherapy. 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). In breastfeeding women with low oestrogen add oestriol 0.1 percent cream 0.5 g intravaginal nightly.
• Red flags: new ulcers or white plaques, bleeding, suicidal thoughts, fever.
• Follow-up: review at 4 to 6 weeks; refer to a pain or vulval clinic if no response after 3 months.