Vulvar Vestibulitis Syndrome

Vulvar vestibulitis syndrome is believed to be the most common form of painful intercourse in premenopausal women (10), affecting an estimated 12% in the general population (8). Women with vulvar vestibulitis typically experience a severe sharp, burning pain localized at the entrance of the vagina (i.e., the vulvar vestibule) (14). This pain occurs upon contact, through both sexual and nonsexual stimulation (10,14). Approximately half of the women with vulvar vestibulitis syndrome have "primary" vestibulitis, that is, they have experienced the pain from their first intercourse attempt, whereas the other half of the sufferers develop the pain after a period of pain-free intercourse, termed "secondary" vestibulitis (29,30).

Characteristics of the Vulvar Vestibule in Affected and Non-affected Women

To answer the question of what causes vulvar vestibulitis, it is necessary to start with where the vulvar vestibule is located and its normal tissue characteristics. The vulvar vestibule (Fig. 10.1) is a part of the external genitalia (i.e., the vulva). It extends from the inner aspects of the labia minora to the hymen, is bordered anteriorly by the clitoral frenulum and posteriorly by the fourchette, and includes the vaginal and urethral openings (31). The vestibule is innervated by the pudendal nerve (32) and contains free nerve endings, the majority of which are believed to be C-fibers, otherwise known as pain fibers (33). Although the vulvar vestibule is composed of visceral tissue, it has a nonvisceral innervation

Vulvar Vestibulitis Treatment

Figure 10.1 The vulva. Parts of the vulva are shown, including the vulvar vestibule (indicated by dotted lines), clitoris, urethral and vaginal openings, and the labia majora and minora. The vulvar vestibule extends laterally from the base of the labia minora, and is bordered anteriorly by the clitoral frenulum and posteriorly by the fourchette. [Image courtesy of Katherine Muldoon.]

Figure 10.1 The vulva. Parts of the vulva are shown, including the vulvar vestibule (indicated by dotted lines), clitoris, urethral and vaginal openings, and the labia majora and minora. The vulvar vestibule extends laterally from the base of the labia minora, and is bordered anteriorly by the clitoral frenulum and posteriorly by the fourchette. [Image courtesy of Katherine Muldoon.]

(34). Therefore, sensations of touch, temperature, and pain are similar to those evoked in the skin.

The suffix "-itis" refers to conditions of inflammatory origin and, in the case of vulvar vestibulitis, implies that the pain is due to an inflammation of vestibular tissue. However, studies examining indices of inflammation in this tissue suggest that inflammatory infiltrates are common in the vestibule, and thus, not necessarily related to the pain (35,36). Other controlled investigations of vestibular tissue suggest that altered pain processing plays a role in the development and/or maintenance of vulvar vestibulitis. Evidence for this includes the following: a heightened innervation of intraepithelial nerve fibers (33,37), an increase in blood flow and erythema (38), nociceptor sensitization (39), the presence of calcitonin gene-related peptide (i.e., a peptide that exists in pain nerves) (40), and lower pain thresholds (41). These tissue properties would lead to an increase in sensation in response to vestibular pressure, consistent with the clinical picture of provoked pain in women with vestibulitis. Taking a cotton-swab, for example, and touching different areas of the vestibule in a non-affected woman is perceivable but not painful, but this same stimulation in the vestibule of a vestibulitis sufferer is perceived as excruciatingly painful.

Etiological Theories: Physical Explanations for the Pain

Yeast infections: Many etiological theories exist regarding what initiates the increase in sensitivity of the vulvar vestibule in sufferers (42,43). One of the most consistently reported findings associated with the onset of vulvar vestibuli-tis is a history of repeated yeast infections (44). However, it is not clear whether the culprit is the yeast itself or treatments undertaken which can sensitize the vestibular tissue or an underlying sensitivity already present in the tissue (29,45,46). Many women, like Sandra, when they feel the irritation during intercourse do not go to the doctor's office to have a culture taken before they treat what they think is a yeast infection with over-the-counter remedies from the local drugstore. At the same time, some gynecologists may not perform the culture themselves, and on the basis of symptomatic description alone, suggest to the woman that she has a yeast infection (47). It is vital that both the woman and her health care professional ensure that treatment is not being undertaken without reason, as this can aggravate the problem.

Hormonal factors: Hormonal factors have also been found to be associated with vestibulitis in controlled studies. Bazin et al. (30) and Bouchard et al. (48) found that women who used oral contraceptives had an increased risk of developing vestibulitis later in life, with those starting before the age of 16 being especially at risk. Early menarche (i.e., before the age of 11) and painful menstruation were also associated with an increased risk of vestibulitis (8,30). These findings suggest that hormonal factors may play a role in the increase in sensitivity of the vulvar vestibule, but the question of how hormones are involved remains to be elucidated.

Genetic factors: In one controlled study, Jeremias et al. (49) found that affected women have a high incidence of a genetic allele that is involved in the regulation of inflammation and is associated with chronic inflammatory conditions (e.g., ulcerative colitis, inflammatory bowel disease) (50,51). It is possible that women with this allele are genetically susceptible to the development of vestibulitis, but may only develop it after some injury to the vulvar vestibule, whether through repeated infections, local treatments, hormonal factors, early age at first intercourse, early age at first tampon use, and/or difficulty with or pain during first tampon use (8,9,30). Although these findings need to be replicated, they lead to several possible explanations for the development of vulvar vestibulitis. For example, women with this particular gene profile may have an abnormality in the regulation of inflammation, which has recently been shown in vestibulitis sufferers (52-54). This would allow vulvar vestibulitis to be one of many expressions of this gene; others would include colitis and inflammatory bowel disease. In addition, it would imply that women with vulvar vestibulitis might have associated pain problems and/or sensory abnormalities. Although just beginning to be examined, controlled studies support this implication. Women with vulvar vestibulitis have a higher sensitivity to vestibular touch (41), a higher sensitivity to nonvestibular touch, painful pressure, and heat pain (41,55), in addition to more somatic pain-related complaints (41,56) when compared with non-affected women.

Other factors: Many other physically based etiological theories of vulvar vestibulitis exist; however, they are based on uncontrolled studies and should be interpreted with caution. These include human papillomavirus infection (57), faulty immune system functioning/allergies (6,58), urethral conditions (e.g., interstitial cystitis) (59), vaginismus (46), sexual abuse (44,60), and psychological factors (e.g., somatization disorder) (46). It is important to note that controlled studies of sexual abuse (10,12) show no difference between affected and non-affected women, although a history of depression and physical abuse has been linked to vulvar vestibulitis (8). Furthermore, an increase in pelvic floor muscle tension (61,62) has also been associated with vulvar vestibulitis. Although the tensing of pelvic floor musculature may represent a protective reaction against, or a conditioned response to vulvar pain, this increase in tension is likely to only exacerbate the pain.

Etiological Theories: Psychosocial Explanations for the Pain

Psychological and cognitive factors: In accordance with current chronic pain models, there is much more to the experience of dyspareunia than the pain and its possible physiological underpinnings. This point is illustrated by a recent functional magnetic resonance imaging study of women with vulvar vestibulitis (63), demonstrating that both sensory and affective brain areas are activated in response to painful genital stimulation. These findings are consistent with results from other pain imaging studies (64-67) and support the multidimensional conceptualization of dyspareunia proposed in this chapter.

Factors such as psychological distress, anxiety, depression, low sexual self-esteem, harm avoidance, somatization, shyness, and pain catastrophization (41,55,56,60,68,69) have been found in women with vulvar vestibulitis. Whether they precede or develop subsequent to the pain remains to be elucidated; however, it is crucial to investigate the role of these factors in the maintenance of dyspareunia as negative affect has been shown to modulate pain intensity (70). Negative affect is also associated with an increase in attention towards pain stimuli, otherwise known as hypervigilance (71), which in turn can increase perceived pain intensity (72). In a recent study (73), hypervigilance for pain stimuli was examined in women with vestibulitis and matched control women. Results indicated that women with vulvar vestibulitis syndrome reported hypervigilance to coital pain and exhibited a selective attentional bias towards pain stimuli, an effect mediated by anxiety and fear of pain. These results suggest that anxiety and fear-mediated hypervigilance represent important factors for pain perception in vulvar vestibulitis. Furthermore, hypervigilance to pain stimuli could exacerbate sexual impairment in women suffering from dyspareunia by distracting attentional resources away from erotic cues, a cognitive bias that has been associated with impaired sexual arousal (74-76). The role of sexual arousal in vulvar sensation has not yet been established; however, many theoretical models posit arousal as a key factor in preparing the female reproductive system for the "trauma" of coitus. Therefore, hypervigilance to pain stimuli in women with VVS may result in both a heightened awareness of pain and a distraction away from sexual stimuli, resulting in impaired sexual arousal which may further aggravate the pain experience.

Relationship factors: The examination of relationship factors has been quite limited despite the tremendous impact dyspareunia has on intimate relationships. Seventy-four percent of vestibulitis sufferers report that the pain impacts their relationships (77), although they do not typically report significant levels of dyadic distress. In addition, high dyadic adjustment is related to decreased pain severity in women with dyspareunia (78), whereas psychosocial attributions for the pain are associated with dyadic distress, suggesting an interaction between pain coping style and relationship adjustment (79). Further research is currently underway to clarify the complex relationship among pain severity, relationship adjustment, and coping styles in this population of women.

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