Vestibulodynia: Treatment

Content Written By: Irwin Goldstein, MD and Andrew T Goldstein, MD

Unfortunately, despite vulvodynia or vestibulodynia being relatively common and often associated with high distress, there are minimal evidence-based data to guide health care professionals in the management of women with vulvodynia.

If the cause of the chronic vulvar or vestibular pain is known, medical attention can then be directed to the underlying cause. Some examples of known causes of vulvar pain include: vulvovaginal Candida or yeast infections, endometriosis of the vulva, lichen sclerosis or lichen plannus of the vulva, contact dermatitis of the vulva, atrophy of the vulva from low levels of sex steroid hormones, pudendal nerve entrapment syndrome, referred pain from tender pelvic floor muscles, post-operative painful vulva after perineal surgery, painful vulva following pelvic or perineal radiation therapy for cancer, and other pain syndromes including referred pain misdiagnosed as coming from the vulva. Pain in the perineum can actually come from the urethra such as from urethritis, from the bladder such as from interstitial cystitis or even from the coccyx area. Risk factors for the development of vulvar pain include irritable bowel syndrome, interstitial cystitis, and oral contraceptive pills.

One of the most distressing aspects of vulvodynia or vestibulodynia is that afflicted women frequently experience pain for many months, often years, before being diagnosed. Many women with chronic vulvar pain are told that their symptoms are “all in their head,” implying that their pain is not real. Lack of a diagnosis may further increase the distress caused by the vulvodynia and delay access to more specialized medical care often needed for this condition.

When the cause of chronic vulvar pain is not known or is at best uncertain, treatment interventions vary. Many health care professionals combine treatments including psychotherapy and/or behavioral counseling, pain medication, pelvic floor physical therapy, hormone treatments if indicated, and, as a last treatment option, surgical removal of portions of the affected vestibule. More research is needed to better understand how to manage vulvodynia. Topical anesthetic such as lidocaine and antidepressants such as amitriptyline can be used to numb the tissue of the vulva or vestibule. If the cause is hormonal then treatment with topical estrogen and possibly testosterone is may be considered. If the muscles are tight then pelvic floor physical therapy, muscle relaxants, biofeedback, and Botox injections may be used. If there is an increased number of nerves then topical anesthetics, anti-epileptics, anti-depressants, and capsaicin can be used to numb the nerves.

If appropriate conservative treatments for relief of pain have been tried but are not successful, then vestibulectomy surgery is considered to remove the nerves.

When discussing vestibulectomy surgery, it is critical that the surgery involves contemporary strategies. First, that contemporary vestibulectomy involves removal of ALL of the vestibule tissues and not a focal area of the vestibule such as the floor of the vestibule. Focal surgeries, such as a posterior vestibulectomy do not take into account the current theory of neuronal hyperplasia, either congenitally-based or trauma/ inflammation-based, that extends to all the regions of the vestibule. Second, in addition to removal of all of the vestibular tissue, there needs to be a vaginal advancement flap developed that covers the removed vestibular tissue at the floor. Third, to prevent the vaginal advancement flap from being torn during recovery, there need to be two layers of so-called anchoring sutures that pass from the advancement flap to the surrounding tissues between the vagina and the rectum. Fourth, to prevent narrowing of the vaginal opening, the anchoring sutures need to be passed in a horizontal plane such that when the anchoring suture is tied, the vagina advances and does not narrow. Adhering to these contemporary strategies during vestibulectomy surgery allows for a high success rate with minimal side effects or complications.

Thus, in women with primary provoked vestibulodynia, removal of the congenital neuronal hyperplasia in the vestibule is the key to the first phase of recovery post- vestibulectomy surgery. Similarly in women with secondary provoked vestibulodynia, removal of the mast cell induced neuronal hyperplasia in the vestibule is the key to the first phase of recovery post-vestibulectomy surgery.

The second phase of recovery involves an extensive rehabilitation with a pelvic floor physical therapist specialist who treats high tone pelvic floor dysfunction. Since the biologic basis is removed surgically, then the muscles will eventually relax following pelvic floor therapy and the woman with sexual pain can be effectively and successfully cured. An important principle is that pain in the vestibule, at the opening of the vagina, causes the muscles in the pelvic floor to have high muscle tone and often go into muscle spasm. Pelvic floor physical therapy is a critical part of the overall care and management of women with provoked vestibulodynia. However, the other side of this is that there can be no obvious biologic reason for high tone pelvic floor muscle dysfunction. The relaxation provided by pelvic floor physical therapy will return to high tone if there is a biologic reason for pain and thus muscle contractions.

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