Normal anatomic variant Variable history of human papillomavirus infection Many are asymptomatic. Papillomatous appearance of mucosal surfaces Biopsy to rule out koilocytosis or human papillomavirus infection if symptomatic or questionable. No treatment required Treat for human papillomavirus infection only if biopsy is positive. Information derived from reference 6. Vulvar vestibulitis syndrome is also known as adenitis or focal vulvitis.
It is characterized by entry dyspareunia, discomfort at the opening of the vagina, a positive swab test, tenderness localized within the vulvar vestibulum, and focal or diffuse vestibular erythema 6 , 8 Figures 1 and 2. Vulvar area in a year-old patient with chronic vulvar irritation and no history of sexual activity. Her symptoms preceded surgery for imperforate hymen, which was performed 18 months before this photograph was taken. Vulvar vestibulitis associated with condyloma acuminata in a year-old patient.
Biopsy of the posterior fourchette showed severe koilocytotic changes that were related to human papillomavirus infection. Chronic vestibulitis lasts for months to years, and patients may experience entry dyspareunia and pain when attempting to insert a tampon. Some cases seem to be provoked by yeast vaginitis.
Other suspected causes include recent use of chemical irritants, a history of destructive therapy such as carbon dioxide laser or cryotherapy, or allergic drug reactions. Histologic examination of symptomatic vestibular tissue has confirmed the presence of mixed chronic inflammatory infiltrates in the superficial stroma, but inflammatory cells have not been found to invade the vestibular glands or gland lumens, vessels or nerves.
Cyclic vulvovaginitis is probably the most common cause of vulvodynia and is believed to be caused by a hypersensitivity reaction to Candida.
Pain is typically worse just before or during menstrual bleeding. It also may be exacerbated after intercourse, especially on the following day. The diagnosis of cyclic vulvitis is made retrospectively based on the patient's report of cyclic symptomatic flare-ups or, conversely, symptom-free days. The diagnosis is suggested prospectively by the patient's report of symptomatic improvement after the administration of long-term topical or systemic anticandidal therapy.
Dysesthetic vulvodynia essential vulvodynia typically occurs in women who are peri- or postmenopausal. Patients with dysesthetic vulvodynia have less dyspareunia or point tenderness than patients with vulvar vestibulitis syndrome. Patients describe burning pain similar to that occurring in cases of postherpetic neuralgia or glossodynia burning tongue syndrome.
Vulvar dermatoses may be manifested by itching and, in some cases, pain Figures 3 through 5. Vulvar dermatoses include papulosquamous thick and scaly lesions. Erosions or ulcers may result from excessive scratching. If the patient has blisters or ulcers and denies scratching, the cause may be a vesiculobullous disease. Differential diagnoses of papulosquamous lesions and vesiculobullous lesions are included in Table 2.
A recent study showed the most common cause of symptomatic vulvar disease itching or burning to be dermatitis or another dermatosis. The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.
Bullous dermatoses with potential involvement of the vulva. Systemic diseases with potential involvement of the vulva.
Information from reference 6. Vestibular papillomatosis is the term describing the presence of multiple small 1-to 3-mm papillae over the entire inner labia Figure 7. These papillae are probably congenital in origin and are a normal anatomic variant.
The significance of papillomatosis identified in the vulvar vestibule with acetowhitening is uncertain.
The evaluation of patients with vulvar vestibulitis or vulvodynia should include a thorough history, pelvic examination, fungal and bacterial cultures, and KOH microscopic examination. In patients with vulvar vestibulitis, erythema may commonly be visualized at the 5 and 7 o'clock positions or on a horseshoe-shaped area of the lower vestibulum.
It extends from the frenulum of the clitoris anteriorly to the fourchette of the vaginal introitus posteriorly. This area includes the Bartholin's glands, Skene's glands and numerous minor vestibular glands Figure 8. Some treatments are specific to the subtype of vulvodynia that can be most closely associated with the patient. Vulvodynia is multifactorial in cause, and each subset probably has a different etiology.
Cyclic vulvovaginitis is believed to be a reaction to yeast, which may be detected at times and not detected at other times with KOH preparation or fungal cultures. Some physicians may use a test for anticandidal antibodies in directing treatment.
Because of the link with Candida, treatment for cyclic vulvovaginitis may include anticandidal medication even if cultures are not positive. One regimen is fluconazole Diflucan , mg orally once weekly for two months and then once every other week for two months. Other anticandidal agents that may be used include long-term therapy with topical nystatin Micostatin Cream, Mytrex Cream , miconazole nitrate Monistat-Derm Cream and clotrimazole Lotrimin. Vulvar vestibulitis syndrome has been treated successfully in some cases with topical estrogen cream about a pea-sized amount , applied two times a day for four to eight weeks, or longer.
Intralesional injections of interferon in 13 women with vulvar vestibulitis resulted in significant improvement of dyspareunia in 50 percent. Tricyclic agents amitriptyline [Elavil], imipramine [Tofranil] or desipra mine [Norpramin] have been successful in the treatment of dysesthetic vulvodynia. A recommended regimen begins with 10 mg daily, gradually increasing to 40 to 60 mg daily. Patients should continue taking the highest tolerable dosage that gives symptom relief for four to six months and then gradually decrease the dosage to the minimum amount required to control symptoms.
Since some patients do not wish to take a psychiatric drug, it is important to explain that the medication is being used for its effect on cutaneous nerves. In one study, the average time required for effective treatment with amitriptyline was seven months, after which therapy was either discontinued or tapered. One theory is that oxalate may irritate the vestibulum and may be a contributing cause to vulvodynia pain over a long period. Therapy with potent topical corticosteroids should be limited to brief or short-term use.
Long-term use may induce telangiectasias, skin friability, striae formation and easy bruising. Potent steroids can also cause periorificial dermatitis, a rebound inflammatory reaction with erythema and a burning sensation that occurs as the steroid is withdrawn. A cycle of vulvar dermatitis may become worse as the patient treats the erythema and discomfort with the same potent topical steroids that started the problem.
Since vaginal muscle spasm aggravates the pain and discomfort of vulvodynia, physical therapy using biofeedback and gynecologic instruments has been successful in many patients with vaginismus spasm of the vaginal muscle and instability of the pelvic floor. Biofeedback training helps patients learn exercises to strengthen weakened pelvic floor muscles and to relax these same muscles, with a resultant reduction in pain. Laser or surgical treatment should be reserved for use in cases in which all forms of medical treatment have failed.
Many cases of vulvar vestibulitis that are refractive to medical therapy respond to vulvar vestibulectomy or treatment with excited dye laser. According to Marinoff and Turner, 26 surgery should be reserved for use in patients with pain of at least six months' duration, pain that partly or completely prevents sexual intercourse and patients who have undergone failed treatment for a specific subset of vulvodynia or in whom no cause can be established.
Surgical excision of vulvar tissue containing vestibular glands has been reported to alleviate symptoms in up to two thirds of patients. Flashlamp-excited dye laser therapy for the treatment of idiopathic vulvodynia has been used with some success and may reduce the need for resective surgery in many cases. Vulvodynia may cause drastic alterations in lifestyles. It may decrease the patient's ability to walk, exercise, sit for long periods or participate in sexual activities.
All of these normal activities may exacerbate the vulvar pain. Many patients with vulvodynia worry that they will never recover. The prevalence of physical and sexual abuse in patients with vulvodynia does not appear to be increased. Patients should be supported with the acknowledgement that vulvodynia does not appear to be a psychosomatic condition and that it has no predisposition toward cancer or other life-threatening conditions.
It should be explained that improvement will occur with appropriate treatment, but that successful treatment may take months or years, and patients may have intermittent exacerbations and remissions. Research indicates that vulvodynia and vulvar vestibulitis are being identified by physicians with increasing frequency. Failure to consider vulvodynia as the cause of vulvar pain is the most common reason for misdiagnosis. Vulvodynia is a multifactorial problem with subsets that may overlap.
Proper management is based on identification of the subsets of vulvodynia and identification of any concurrent infections that may be appropriately treated. Family physicians working together with gynecologists who are experienced in treating patients with vulvodynia can properly diagnose vulvodynia, identify subsets and institute the management plan that can best benefit the patient.
Family physicians are in an ideal position to help and support the patient psychologically with validation, education and referral to support groups.
Appropriate medical treatment should be instituted and, when indicated, physical therapy with biofeedback training should be considered. More research is needed to further identify patients with subsets of vulvodynia and to evaluate various treatment modalities. Already a member or subscriber?
Log in. It's not a large area but the great pain more than makes up for it. Vulvodynia not vv is general pain that can include the area right above the clitoris in the pubic hair all the way to the anus and the labia's minora and majora. You can have vulvar vestibulitis with your vulvodynia lucky me!
Then it would be vulvodynia :- Blessings, Shirley. Share this post Link to post Share on other sites. Join the conversation You are posting as a guest. Reply to this topic Sign in to follow this Followers 0. Go To Topic Listing. Vulvodynia: It is the same, we use to call it vestibulitis now vulvodynia; provoked, non provoked, mixed. Get help now: Ask doctors free Personalized answers. Pamela Pappas answered. Chronic pain: Your doctor may use low doses of certain antidepressants such as amitriptylene because they can help with chronic pain.
A Verified Doctor answered. A US doctor answered Learn more. Vulvar pain: The new terminology for vulvar vestibulitis is localized provoked vulvodynia. It is characterized by severe pain incited by focal touch or pressure of Dennis Higginbotham answered.
Patience: There are treatment options, but success rates vary widely. Your doctor is your best reference for treatment. Often the condition will resolve on it It depends: It depends on the cause. You can convert to all cotton panties only, loose clothing, unscented dove soap, unscented white toilet paper, Dreft baby det View 1 more answer.
Victor Bonuel answered. The response depends: On your body-may take days- weeks. Try otc Motrin , prescription muscle relaxers.
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