Provoked vestibulodynia

Specialty: Gynecology and breast.

• Vulvar vestibulitis syndrome
• provoked vestibular pain
• allodynia of the vaginal vestibule

Why it occurs

• Hyperalgesia and sensitization of peripheral nociceptors located in the epithelium of the vulvar vestibule, associated with a proliferation of free nerve endings
• Defensive hypertonic dysfunction of the pelvic floor muscles
• Inflammatory sequelae of recurrent vulvovaginal fungal infections
• Prolonged use of irritating topical treatments

Initial workup

Clinical diagnosis using the "cotton-swab test" which consists of applying very light pressure with a cotton applicator in a clockwise direction around the entire vaginal vestibule (exquisite pain is triggered and characteristically located at the 5 and 7 o'clock positions). Exclusion of candidiasis or other active infections by repeated vaginal smear cultures.

Standard management

• 2% Amitriptyline cream combined with 2% Baclofen for local topical application in the vaginal vestibule twice a day for a minimum of 6-8 weeks
• 5% Lidocaine Cream applied locally before sexual intercourse to block pain signals
• Amitriptyline orally starting with 10 mg at night with progressive increases up to 30-50 mg
• Pelvic floor physiotherapy with biofeedback techniques, perineal massage and dry needling on muscle trigger points (note: treatment requires a multidisciplinary approach that combines physical therapy, sexological psychological support and absolute avoidance of irritating chemicals on the vulva).