VESTIBULITIS~ ***

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DeeTroll wrote: (also see responses at very bottom) Interesting. Dee ================================================== BMJ 2004;328:1214-1215 (22 May), doi:10.1136/bmj.328.7450.1214 Editorial Vulval vestibulitis Is a common and poorly recognised cause of dyspareunia Vulval vestibulitis or vestibulodynia is one of the vulval pain syndromes and is characterised by burning and soreness at the vaginal introitus at attempted penetration.1 It is found predominantly in young, well educated, white women. Although the prevalence is unknown, a recent, as yet unpublished, survey in community settings in west Hertfordshire shows a prevalence of 2.8-9.3%. The diagnosis is based on a triad of findings—penetrative pain, introital tenderness, and patchy erythema localised to the orifices of the vestibular glands in the absence of an infective, inflammatory, or neoplastic cause.1 The burning nature of the pain is typical of dysaesthesia, and many patients go on to develop more persistent and generalised vulval pain that would be compatible with dysaesthetic vulvodynia, a condition classically found in older women. The pain of vulval vestibulitis should be distinguished from vulval pruritus, (itch) which has different causes. The cause of the condition is unknown, attempts to identify an infective cause have been unsuccessful, and no characteristic histological findings are known.2 The subtlety of the physical findings may lead some clinicians to say that "there is nothing wrong" and attribute the symptoms to a psychosomatic disorder. Vulval vestibulitis is poorly recognised by primary care doctors and some gynaecologists, and this may lead to patients repeatedly seeking a diagnosis from a variety of clinicians over a long period of time.3

A common 'misdiagnosis' is recurrent thrush (yeast infection). Such patients will explain that they have tried all the currently available preparations against candidiasis, without relief of symptoms. Once the condition is recognised, the patient is best referred to a specialist vulval clinic. Different local arrangements pertain in the United Kingdom, some clinics being multidisciplinary and some led by dermatologists, gynaecologists, or genitourinary physicians. Since the cause of the condition is poorly understood, management is largely pragmatic and several models of care exist. The evidence base for

treatment is poor. Establishing the diagnosis and offering the patients a sympathetic hearing is an important first step. Patients are reassured by the fact that the condition is not psychosomatic in origin and that anxiety, low mood, and reduced pleasurable sensations with sexual arousal are common byproducts of chronic pain that has become associated with sex. No consistent evidence exists to date to show that women with vulval vestibulitis have an increased background rate of psychological disorders. The chronicity and severity of the symptoms often leads

to secondary effects on psychological wellbeing and self esteem. This may lead to secondary sexual dysfunction in the patient or her partner, which in turn can exacerbate psychological distress, emotional disequilibrium, low self esteem, and reduced sexual and social functioning.4 All of these can become maintaining factors in the condition. Advice about vulval hygiene practices is required, and patients should be advised to avoid soaps, shower gels, and similar products, and to wash with aqueous cream or emulsifying ointment.5 Topical

local anaesthetics such as lignocaine ointment are often helpful.6 Topical steroid ointments and creams, estrogen creams, and topical ketoconazole have been used in some centres,7 and anecdotal data support their use in some patients. A popular treatment in North America is the use of a diet low in oxalates. This was described in a ''single'' case report,8 but, in the absence of better evidence, it may perhaps be

offered to some patients who prefer a non-medicalised approach to treatment.9 Many patients turn to complementary therapies. Glazer et al have proposed that the condition is caused by a dysfunction of the pelvic floor muscles and have published impressive results for a biofeedback technique.10 Many patients do have pelvic floor dysfunction, but in some cases this seems to be secondary to the pain. Low dose amitriptyline is the treatment of choice for dysaesthetic vulvodynia and may be useful in some

patients, particularly when the pain is not restricted to attempted vaginal penetration.11 In North America, vestibulectomy, a procedure that involves excision of all or part of the vestibule, has been a popular treatment. Bergeron et al have reviewed 20 published case series and note that impressive results have been obtained, but the lack of controlled studies or long term follow up throws 'considerable doubt' on the validity of the conclusions.12 In the United Kingdom, this procedure is rarely used. Whatever

therapeutic approach is adopted, the psychological, interpersonal, sexual, and social consequences of the condition need to be assessed. Every clinician managing patients with the condition should have access to a psychologist or psychotherapist with experience of managing sexual dysfunctions in individuals and couples. Many patients find that support from other patients may be helpful. In the United Kingdom, the Vulval Pain Society provides a useful handbook for patients, as does the US National Vulvodynia Association (www.nva.com). Pat Munday, consultant genitourinary physician (pat.munday@... ) Ann Buchan, psychotherapist Watford Sexual Health Centre, Watford General Hospital, Watford, Hertfordshire WD18 0HB source for above: http://bmj.bmjjournals.com/cgi/content/full/328/7450/1214 (At the very bottom you may find the discussion interesting too, DT.) Competing interests: None declared. References Friedrich EG Jr. Vulvar

vestibulitis syndrome. J Reprod Med 1987;32: 110-4.[iSI][Medline] Boardman LA, Peipert JF. Vulvar vestibulitis: Is it a defined and treatable entity? Clin Obstet Gynecol 1999;42: 945-56.[CrossRef][iSI][Medline] Paavonen J. Vulvodynia—a complex syndrome of vulvar pain. Acta Obstet Gynecol Scand 1995;74: 243-7.[iSI][Medline] Van Lankveld JJDM, Philomeen TH, Weijenborg M, Ter Kuile MM. Psychological profiles of and sexual function in women with vulval vestibulitis and their partners. Obstet Gynecol 1996;88: 65-70.[Abstract/Free Full Text] Ridley CM. Vulvodynia; theory and management. Dermatol Clin 1998;16: 775-8.[iSI][Medline] Zolnoun DA, Hartmann KE, Steege JF. Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis. Obstet Gynecol 2003;102:

84-7.[Abstract/Free Full Text] Eva LJ, Reid MN, Maclean AB, on GD. Assessment of response to treatment in vulvar vestibulitis syndrome by means of the vulvar algesiometer. Am J Obstet Gynecol 1999;181: 99-102.[iSI][Medline] Solomons CC, Melmed MH, Heitler SM. Calcium citrate for vulvar vestibulitis. J Reprod Med 1991;36: 879-82.[iSI][Medline] Poole S, Ravenhill G, Munday PE. A pilot study of the use of a low oxalate diet in the treatment of vulval vestibulitis. J Obstet Gynaecol 1999;19: 271-2.[CrossRef] Glazer HI, Rodke G, Swencionis C, Hertz R, Young AW. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med 1995;40: 283-90.[iSI][Medline] Munday PE. Response to treatment in dysaesthetic vulvodynia. J Obstet Gynaecol 2001;21: 610-3.[CrossRef][Medline] Bergeron S, Binik YM, Khalifé S, Pagidas K. Vulvar vestibulitis syndrome: a critical review. Clin J Pain 1997;13: 27-42.[CrossRef][iSI][Medline] Rapid Responses: Read all Rapid Responses A Patient's Voice J. Elpern bmj.com, 21 May 2004 [Full text] Sexual pain disorders and vulval vestibulitis: what is common? Dr. Naseem A.

Qureshi, MD, IMAPA, LMIPS bmj.com, 23 May 2004 [Full text] Vulva vestibulitis-a nociceptive afferent nerve proliferation disease. Willén bmj.com, 17 Jun 2004 [Full text] Vulval Vestibulitis Allan B MacLean bmj.com, 25 Jun 2004 [Full text] See all their comments at http://bmj.bmjjournals.com/cgi/eletters/328/7450/1214