Following numerous yeast infections after using a new oral contraceptive pill 2 years ago, Sandra, a 25-year old primary school teacher, started experiencing an intense burning pain at the entrance of her vagina during sexual intercourse. The pain started with initial penetration, lasted throughout intercourse, and was present for ~ 30 min afterwards. Thinking that it was caused by yet another yeast infection, Sandra purchased her usual treatment from the pharmacy: over-the-counter antifungal vaginal suppositories. However, this only increased her pain to the point that, 6 months later, she had become apprehensive about sexual activity with her long-term partner. She also noticed a "tensing up" of her pelvic floor muscles while engaging in foreplay and a marked decrease in her sexual desire and arousal levels, which further contributed to her pain. Sandra began avoiding all sexual activities, even nonpenetrative ones. She sought treatment from several medical professionals, underwent several painful examinations, and tried various topical creams and lubricants without any improvement in her pain or answers as to what her pain was. She began doubting her love for her partner, thinking that the pain was indicative of relationship problems. Finally, through one of her friends at work, Sandra obtained the phone number of a gynecologist who diagnosed her with vulvar vestibulitis syndrome and recommended physical therapy and pain relief therapy.
Friedrich (6) proposed the following diagnostic criteria for vulvar vestibulitis: (1) severe pain upon vestibular touch or attempted vaginal entry, (2) tenderness to pressure localized within the vulvar vestibule, and (3) physical findings limited to vestibular erythema of various degrees. Although the third criterion has not received much support in terms of its validity and reliability, the first two have (14). Typically, vestibulitis patients present with provoked pain at the entrance of the vagina, their main complaint usually being painful intercourse. The cotton-swab test, a standard gynecological tool for diagnosing vestibulitis, consists of the application of a swab to various areas of the genital region. If the woman reports pain when pressure is applied to the vestibule during this test, then the diagnosis of vestibulitis is made. The cotton-swab test is usually performed in a clockwise manner around the vestibule; however, research has shown that pain ratings increase with each successive palpation. Therefore, we recommend a randomized order of cotton-swab application with adequate pauses after each palpation to avoid sensitization of the vulvar vestibule and unnecessary pain to the patient (16,20).
Although the cotton-swab test for the diagnosis of vulvar vestibulitis syndrome is considered the clinical method of choice since it is fast and easy to perform, it is not necessarily the standard tool for research purposes. First, the amount of pressure applied during the cotton-swab test is not standardized either between or within gynecologists (16,20,21). Indeed, it has been shown that different gynecologists apply different pressures and can elicit significantly different pain ratings in the same women (16,20). Second, the amount of pressure applied using this method are above pain threshold level, that is, the point at which women report the first sign of pain, making the cotton-swab test highly painful and distressing for patients. In order to overcome these problems, Pukall et al. (20) have developed a device called a vulvalgesiometer, which holds much promise in terms of standardized genital pain measurement by allowing for the application of known pressures using a spring-based device. The vulvalgesiometer replicates the quality of pain that women with vulvar vestibulitis report experiencing during intercourse, and is currently being used in numerous studies.
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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.