Vulval Vestibulitis

Women with vulval vestibulitis experience pain when the vestibule (area around the vaginal opening) is touched, for example during intercourse, when inserting a tampon or as the result of pressure caused by clothing. Often, when examined, the vestibule will appear red and inflamed, but this inflammation may be very subtle and easily overlooked.

The cause of the pain remains unknown but many women with vulval vestibulitis have previously suffered from bouts of thrush infection, which were treated with anti-fungal creams. How this, and the repeated use of anti-fungal creams, affects long term vulval pain such as vestibulitis is still not clear. Many women will have tried a whole range of prescribed and over-the-counter treatments as their symptoms were mistaken as signs of an infection or skin disorder. These repeated, inappropriate treatments are believed to be detrimental to vulval health in general and may play a role in prolonging the symptoms of vestibulitis and dysaesthetic vulvodynia.

At present there is no standard treatment for vestibulitis. Few controlled trials have been carried out, making treatments difficult to compare. Currently, treatments include:

• Steroid creams prescribed by a doctor. These may cause irritation and local allergic skin reaction.
• Ketoconazole cream/tablets (Nizoral). Although this is an anti-fungal treatment, some women benefit by using it for vestibulitis.
• Zinc oxide cream, to ease inflammation.
• Interferon gel. Interferon is anti-inflammatory and anti-viral and in gel form still a relatively new treatment.
• Pain-killing jellies and creams like those containing lignocaine (Xylocaine) can be used, especially before having sex, in order to make it as pain free as possible. One American doctor recommends using a 4% liquid solution of Xylocaine applied on cotton wool to the vaginal opening 5 to 10 minutes before intercourse. This is said to be preferable to the jelly, which during sex can transfer to the male partner, reducing sensitivity and prolonging penetration which may become painful despite the anaesthetic.
• Anti-oxalate therapy. Oxalate, a salt present in food and excreted in urine, can cause skin irritation. Treatment aims to reduce urinary oxalates to alleviate vulval soreness. It consists of tablets to dilute the oxalates and a low oxalate diet to reduce the amount in the urine. This treatment has not yet been thoroughly tested and it is difficult to assess from the information available how useful it is.

• Attention has recently turned to the pelvic floor muscles of women with vestibulitis. When studying these muscles it appeared that many women with vestibulitis had certain things in common, such as heightened muscle tension and muscles taking longer to recover after a contraction. Women participating in a study did pelvic floor exercises using special portable home biofeedback machines (these aim to give greater awareness and voluntary control over muscles and muscle contractions we are usually not aware of). Results of this study imply that using this technique can help to overcome the difficulties experienced by women with vestibulitis when attempting penetrative sex.
• Very occasionally, surgery is suggested to remove the painful area of the skin within the vestibule. This operation (vestibulectomy) is said to be beneficial in specific circumstances but the success rates of surgery are difficult to check as so many factors are involved which can skew the results. The Vulval Pain Society's website contains useful information about surgery for vulval pain syndromes, see Resources for details.

Other forms of reducing symptoms include:

• Using emollients to clean, hydrate and soothe the skin. A number of these, including Aqueous Cream and E45, are available from chemists without prescription. Avoid over-the-counter creams intended for thrush, such as clomitrazole.
• Using Calendula cream and hypercal cream, which are homeopathic creams to treat irritated skin.
• Bathing the area with ice bags, oatmeal sitz baths (Aveeno sachets are available on prescription or over-the-counter from the chemist, but may need to be ordered), very diluted potassium permanganate have all been suggested to soothe burning sensations. Some women have found relief by applying warm, soaked tea bags directly to the vulva or using sitz baths in which tea bags were soaked.
• If using tampons or regular menstrual pads is too painful, using pads with a cotton cover or making or buying pads containing only cotton may be a solution, see Resources.
• One study has shown that up to 30% of women with vestibulitis get better without any treatment. Getting the correct diagnosis, avoiding anything that can irritate the vulval skin and finding a doctor with an understanding of the condition has helped women to overcome vestibulitis.