VVS is characterized by pain confined to the vulvar vestibule that occurs upon vestibular touch or attempted introital entry (e.g., intercourse, tampon insertion),
Reprinted from Farage MA, Galask RP. Vulvar vestibulitis syndrome: a review. European Journal of Obstetric & Gynecology and Reproductive Biology 2005; 123(1):9—16, with permission from Elsevier.
with minimal associated clinical findings. In 1987, Friedrich proposed three diagnostic criteria that define VVS (1):
1. Severe pain with vestibular touch or attempted vaginal entry
2. Tenderness in response to pressure on the vulvar vestibule
3. Physical findings limited to varying degrees of vestibular erythema
Because spontaneous remissions have been reported (1-3), the persistence of symptoms for more than six consecutive months is another often-used criterion.
Introital dyspareunia, the intensity of which may inhibit or prevent intercourse, is often the presenting symptom. Pain can occur in other situations that exert pressure upon the vestibule, such as tampon insertion and removal, bicycle and horseback riding, tight clothing, and prolonged periods of sitting.
Clinicians can assess the vestibular tenderness by applying a cotton-tipped swab to the vulvar vestibule in a clock-face pattern (1). Gentle touch provokes either hyperesthesia, a heightened intensity relative to the degree of applied pressure, or allodynia, the perception of a different sensation to that applied (i.e., pain rather than gentle touch). Thresholds to pain provoked by pressure are markedly lower in VVS patients (4). Reportedly, the areas most often affected are the mucosa around the openings of the Bartholin's gland ducts (4 o'clock and 8 o'clock positions) and the posterior aspect of the vestibule. However, studies using a randomized order of palpation challenge this as an artifact of increasing subjective pain with each successive clockwise or counterclockwise palpation (4).
Newer techniques have been proposed to standardize the measurement of induced vestibular pain. An assessment of various forms of thermal, tactile, and pressure stimuli demonstrated that a simple spring-pressure device (a manually operated 10 mL syringe with a spring inserted between the piston and the syringe cavity) was highly accurate in differentiating the VVS cases from controls and in distinguishing the most severe cases (5). A variation on this technique employs a vulvalgesiometer, which consists of a series of cylindrical syringe-like devices attached to a standard cotton-swab tip and springs of different compression rates for incremental pressure application (4). Though not available commercially, such tools may help refine diagnostic criteria by standardizing elicitation of the pain response.
Vestibular erythema is the most subjective and least specific of Friedrich's criteria: erythema is also present in normal subjects and determining its presence and severity depends upon clinical judgment. A recent evaluation of Friedrich's diagnostic criteria found that tenderness to vestibular pressure most reliably distinguished patients with and without VVS who had a history of dyspareunia; erythema was not a reliable criterion (6).
Some investigators distinguish between primary and secondary VVS. Primary VVS is distinguished by a history of introital dyspareunia from the first episode of sexual intercourse. Secondary VVS is preceded by symptomfree intercourse. It is unclear whether these are different entities or represent different onsets of the same disease process. Characteristically, women with primary VVS are younger, more likely to be nulliparous, and less likely to have involvement of the whole vestibule; but they do not differ in other demographic, social, or medical variables (7,8). An elevated systemic pain response to the thermal stimulus of the forearm has been associated with primary VVS (9), yet patients with primary or secondary VVS report similar symptoms and perceived symptom severity (8).
Some patients experience pain confined to the posterior vestibule (including the fourchette and the Bartholin's glands) and others have pain in the posterior and in the anterior vestibule (10). The latter type is thought to be more recalcitrant to treatment. As noted earlier, however, localized distinctions in pain have been challenged as an artifact of the order of palpation.
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