Vulvodynia / Vestibulitis

Vulvodynia / Vestibulitis: Overview

Alternative Names: The term is also used to refer to vestibulitis or Vulvar Vestibulitis Syndrome (VVS), which is an inflammation of the vestibule, or opening into the vagina and the tissues immediately around the vaginal opening.  This condition is sometimes also called 'vestibular adenitis'.

Vulvodynia is a medical term that means 'painful vulva'.  The term can cover a wide variety of vulvar pain syndromes including various infections and skin disorders.

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Causes and Development

Some cases of vulvodynia may be due to compression or disease of the pudendal nerve, one of the main nerves that relays sensation to and from the genitals.

Signs and Symptoms

In mild cases, a burning or stinging sensation is noted during intercourse or when tampons are inserted.  Upon touching the area with a cotton swab, pain is felt when the hymen and inner vaginal lips are touched.  There also may be redness and swelling.  In severe cases, the pain can be agonizing and much of the vulvar can be reddened, swollen and very inflamed.  Often the edges of the inner vaginal lips are very sensitive and the pain so severe that it makes walking difficult.  There may be a constant itching or stinging sensation in the grooves between the large and small vaginal lips.  Wearing underwear may be very uncomfortable as the slightest touch to the area may result in excruciating pain.

Other signs include pain or discomfort upon touching the pubic hair, over the vulvar skin or in certain spots.  These sensations may extend to the rectal area or skin of the perineum.  The clitoris can become involved, becoming painful or hypersensitive and there may be shooting pains from the clitoris up the abdomen.  Sexual intercourse and urination may be very painful.

Treatment and Prevention

Some women need to avoid underwear that irritates the area or avoid using underwear altogether.  If you must wear pantyhose or stockings for work, wear brands with a cotton crotch over the all-cotton underwear and slit the pantyhose crotch to relieve binding, or use old fashioned garter belts and stockings.  Additionally, during your menstrual period, if you cannot tolerate a tampon string, you may cut off the string prior to insertion.  If menstrual pads are too painful, you may use rolls of absorbent cotton.

Vulvar pain due to skin conditions such as dermatitis, lichen sclerosis may be relieved with topical corticosteroids.  Compresses made from prophyllin powder may provide soothing relief.

Prognosis

In a few people vulvodynia clears up on its own after 6-12 months.

Signs, symptoms & indicators of Vulvodynia / Vestibulitis:

Symptoms - Reproductive - General

(Severe) vulvar pain

Symptoms of vulvodynia or vestibulitis can range in severity from mild to severe.  Burning, itching and pain are experienced in the skin of the vaginal entryway and sometimes the labia or clitoris.

Conditions that suggest Vulvodynia / Vestibulitis:

Uro-Genital

Urethritis / Urethral Syndrome

Vestibulitis may sometimes be part of bladder and/or urethral inflammation as seen in the interstitial cystitis or urethral syndrome.  The lining of both vagina and bladder arise from the same tissue during fetal development; thus when one becomes inflamed, the inflammation may spread to the adjoined areas.

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Risk factors for Vulvodynia / Vestibulitis:

Immunity

Chronic Fatigue / Fibromyalgia Syndrome

Dr. St.  Amand, MD, specializing in fibromyalgia and author of What Your Doctor May Not Tell You About Fibromyalgia believes that all women with chronic vulvodynia have a form of fibromyalgia.  He discovered that at least 11% of his female patients with fibromyalgia also have vulvodynia (painful genitals).  The guaifenesin therapy for chronic fatigue enhances oxalate crystal excretion which has been shown to be beneficial in vulvodynia also.

Infections

Yeast / Candida Infection

Cyclic vulvovaginitis is probably the most common cause of vulvodynia and is believed to be caused by a hypersensitivity reaction to Candida.  While vaginal smears and cultures are not consistently positive, microbiologic proof should be sought by obtaining candidal or fungal cultures during a symptom-free phase.  The diagnosis of cyclic vulvitis is made based on the patient's report of cyclic symptomatic flare-ups (or, conversely, symptom-free days) and by the patient's report of symptomatic improvement after the administration of long-term topical or systemic anticandidal therapy.  [Autoimmunity as a factor in recurrent vaginal candidiasis and the minor vestibular gland syndrome.  J Reprod Med 1989;34: pp.264-6]

Sexually-Transmitted Diseases

HPV (Human Papilloma Virus)

Whether there is an association between vestibulitis and HPV infection is still being debated.

Herpes Simplex Type II

Some women seem to develop vulvodynia in response to infection with the herpes virus.  [Vulvodynia: A Perplexing Disorder; Questions and Answers With Stanley Marinoff, M.D.  NVA News, Vol. I, Issue 1; Winter, 1995]

Recommendations for Vulvodynia / Vestibulitis:

Diet

Oxalate Avoidance

Reducing the amount of oxalate in your diet may be helpful.  Things to avoid include tea, spinach, beer, berry juices, baked beans in tomato sauce, peanuts, peanut butter creams, pecans, soybean curd, concord grapes.  In addition, do not take more than 250mg of Vitamin C per day as it may contribute to oxalate formation.  Restrict or limit milk or dairy products to reduce the amount of calcium oxalate in the body.  Calcium citrate may prescribed to neutralize high blood or urine levels of oxalate.

Drug

Conventional Drug Use

If intercourse is painful, you can apply xylocaine jelly to numb the sore areas.

Antibiotics

Vulvar pain that is due to infection e.g. ureaplasma, candida or strep will respond to the appropriate treatment.

Environmental

Chemical Avoidance

Carefully avoid all potential irritants in your underwear, such as laundry soaps and bleaches.  You may use a mild non-perfumed soap such as Castile soap and run twice through the rinse cycle.  Perfumed or even plain soaps may aggravate the irritation.  Natural glycerin soap may be helpful as it has no residual drying effects.  A hand-held shower massager is preferable to an overhead nozzle as it makes it much easier to wash away any soap residue that remains after washing.  Washing the vulvar area with distilled water instead of tap water may help avoid irritation from chlorine.  Another way to help painful urination is to pour a cup of water on the area while urinating: this dilutes the urine and helps to wash away any irritating residue.

Hormone

Estrogen Replacement

Topical estrogen creams may provide relief.  Estrogen thickens or toughens the skin and increases blood supply.  It may help you even if you have not reached menopause or do not have estrogen deficiency.  If you find vaginal creams painful (possibly from the additives such as alcohol or parabens), your physician may mix 5-10% solution in a petroleum gel base or mineral oil instead of using the standard base.

Physical Medicine

Hot Applications (Thermotherapy)

Soothing relief may be obtained by applying warm soaked tea bags to the area.  This can be done by placing the tea bags on menstrual pads to hold them in place or you can take a sitz bath in which tea bags have been soaked.

Physical Supports and Devices

To relieve pressure on the vulvar area when sitting you may use a pressure relief cushion.

Psychological

Visualization/Relaxation Techniques

Biofeedback and pelvic muscle exercises involving relaxation and muscle strengthening may be helpful.

Surgery/Invasive

Prolotherapy

The iliolumbar ligament may be weakened and referring pain to the vulvar area.  Prolotherapy can strengthen that ligament.

Surgery

Surgical treatment may include removal of painful areas such as the vulvar (bartholin's) glands, decompression surgery of the pudendal nerve to free the nerve and its branches up (from compressions due to blood vessels and veins, damaged tissue, and ligamental grip), and/or laser therapy to destroy underlying vulvar blood vessels.

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