Diseases That Cause Vulvar Pain Vulvar Vestibulitis

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Vulvar pain was documented as early as 1888, by Dr. Alexander J.C. Skene in his textbook Treatise on the Disease of Women, in which he identified "hyperesthesia of the vulva" (21). Vulvar vestibulitis syndrome (VVS) was first described by Woodruff and Parmley in 1983 (22). The criteria for the diagnosis were described by Eduard Friedrich in 1987. His three subjective and objective criteria are (23):

1. Severe pain on vestibular touch or attempted vaginal entry

2. Tenderness to pressure localized within the vulvar vestibule

3. Physical findings confined to vestibule erythema of various degrees.

Women with VVS experience substantial pain with tampon insertion, insertion of a speculum, or with sexual activity. When the insertional pain is associated with sexual activity, women usually experience relationship difficulties with their partners. When this occurs, lowered self-esteem is common and some women can experience substantial depression (1,24,25). In the more severe cases, women can experience pain and burning on a day-to-day basis when walking, sitting, wearing clothing that comes in contact with the vulva, after exercise, and wiping after urination. If the inflammatory process includes the periurethral ducts of the vestibule, women may complain of urgency and frequency in the absence of a urinary tract infection. Symptoms can also be totally unpredictable and unprovoked.

Vestibulitis is often undiagnosed and these patients may see multiple physicians prior to receiving an accurate diagnosis. It is imperative to identify the Bartholin's duct ostia on every examination and to evaluate for inflammation of the lesser vestibular glands (Figs. 15-17). Erythema is limited to the vulvar vestibule and there is a disproportionate pain-to-touch ratio when a cotton-tipped swab is pressed into the erythematous area.

Treatment strategies include applying a low-to-moderate-potency topical steroid ointment to decrease the inflammatory response. In addition, following strict vulvar skin care hygiene practices and using lukewarm water soaks of either baking soda or colloidal oatmeal help decrease inflammation and provide symptom relief. For some patients, the addition of oral calcium citrate daily in conjunction with a low-oxalate diet has proven helpful (26). Other non-steroidal options to help decrease the inflammatory response and T-cell function include an immune suppressor such as tacrolimus ointment, but the efficacy has not been documented. Numerous other topical medications have been used, such as estrogen cream and lidocaine gel, and other treatment modalities such as surgery and laser ablation have been employed for treatment as well (27). It is the authors' experience that vulvar vestibulitis disease is self-limiting and, thus, conservative management best serves the patient.

Vulvar Vestibule Healthy
Figure 16 Vestibulitis: localized erythema in the right vestibule. (See color insert p. 5.)
Vulvar Vestibulitis
Figure 17 Vestibulitis: localized erythema in the right periurethral area. (See color insert p. 5.)

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