Vulvar Vestibulitis (Provoked Vestibulodynia)

What the vestibule is

The vestibule is the area of skin around the opening of the vagina, inside the inner lips (labia minora), containing the openings of the urethra and small glands. It is densely supplied with nerves. In vestibulodynia, these nerves become hypersensitive: touch that should feel normal is felt as pain (allodynia).

Vestibulodynia is a form of vulvodynia, which describes chronic vulvar pain without a clear cause. "Provoked" means pain occurs with touch, as opposed to spontaneous, constant pain.

Symptoms

• sharp, burning, stinging or raw pain at the vaginal entrance
• pain with penetration: tampons, sex, speculum exams (dyspareunia)
• pain with tight clothing, cycling or prolonged sitting
• burning for hours or days after sex
• sometimes slight redness of the vestibule
• urinary urgency or burning without infection in some women

Over time, anticipation of pain can cause the pelvic floor muscles to tighten, making penetration more difficult and painful (vaginismus).

Causes and contributing factors

The cause is likely a combination of factors:

• increased nerve fibers and sensitivity in the vestibule
• pelvic floor muscle overactivity
• hormonal factors: some combined oral contraceptives may reduce hormones that keep vestibular tissue healthy; low estrogen during breastfeeding or menopause
• recurrent vaginal yeast infections or repeated topical treatments causing irritation
• inflammation and genetic factors affecting pain processing
• central sensitization, sometimes with other pain conditions such as interstitial cystitis, IBS or fibromyalgia
• psychological factors such as anxiety, which can amplify pain, though they are not the root cause

Diagnosis

• history: when pain started, triggers, sexual history, contraception, infections and other pain conditions
• examination: looking for skin conditions such as lichen sclerosus, atrophy or infection
• cotton swab test: gentle touch at points around the vestibule reproduces the pain
• pelvic floor muscle assessment
• tests for yeast, bacterial vaginosis, trichomoniasis and herpes when appropriate
• hormone assessment in some cases

Treatment

Most women improve with a combination of treatments over months.

Self-care

• cotton underwear, loose clothing
• gentle, fragrance-free washing with water only; no douches or scented products
• water- or silicone-based lubricants for sex
• cool gel packs after intercourse
• avoiding activities that put pressure on the vulva during flares

Physical and psychological therapies

• pelvic floor physical therapy: relaxation, manual therapy, biofeedback and dilators; one of the most effective treatments
• cognitive behavioral therapy and sex therapy: reduce pain-related fear and improve sexual function

Medicines

• topical lidocaine before sex
• topical estrogen or estrogen-testosterone creams, especially with hormonal causes or after stopping certain pills
• switching contraception if a pill appears to contribute
• nerve pain medicines: tricyclic antidepressants, gabapentin or pregabalin
• treating recurrent yeast infections with suppressive antifungals if confirmed

Surgery

Vestibulectomy, removal of the painful vestibular tissue, has high success rates for provoked vestibulodynia that does not respond to other treatments.

Outlook

Vestibulodynia is a real and treatable condition. Most women improve significantly with multimodal treatment, and many return to pain-free sex. Recovery often takes months and benefits from a specialist in vulvar pain.

Frequently asked questions

What is vulvar vestibulitis?

Vulvar vestibulitis, now called provoked vestibulodynia, is chronic pain at the entrance to the vagina triggered by touch or pressure, such as from tampons or sex. The area often looks normal. It is not an infection and is not sexually transmitted.

What causes vestibulodynia?

It is likely caused by a combination of hypersensitive nerves in the vestibule, tight pelvic floor muscles, hormonal factors, recurrent yeast infections or irritation, and changes in how the nervous system processes pain.

How is vestibulodynia treated?

Treatment usually combines pelvic floor physical therapy, gentle vulvar care, topical lidocaine or hormone creams, nerve pain medicines, and counseling or sex therapy. Surgery (vestibulectomy) helps women whose pain does not respond.

Is vestibulodynia the same as vulvodynia?

Vestibulodynia is a type of vulvodynia. Vulvodynia is chronic vulvar pain without a clear cause; vestibulodynia is when the pain is localized to the vestibule and usually provoked by touch.