Categories of vulvodynia
I still get confused about vulvodynia versus vulvar vestibulitis. What is the difference?
Vulvodynia refers not to a specific disease, but rather to a symptom - vulvar pain. In this case the pain is chronic and either recurrent or almost constant.
Vulvodynia can be primary, i.e., starting from the first episode of intercourse, or secondary, starting after a specific event.
There are 4 main categories of vulvodynia:
- vulvar dermatoses
- cyclic vulvovaginitis
- vulvar vestibulitis syndrome
- dysesthetic vulvodynia
Again, these four categories are not diseases themselves but rather clusters of different diseases or descriptive syndromes whose etiology is unknown.
Vulvar dermatoses often require a biopsy for diagnosis. Examples might include psoriasis, seborrheic dermatitis, tinea cruris, contact dermatitis, lichen simplex chronicus, lichen planus, lichen sclerosis, pemphigus, and erythema multiforme.
Sometimes a dermatologist is the person to see for this rather than a gynecologist especially if the vulva seems to have a chronic redness or scaliness.
Cyclic vulvovaginitis is frequently due to a recurrent yeast infection but it can also be bacterial in origin commonly from E.Coli and Group D or B streptococcus. In this instance, secretions from the vagina are the skin irritants and if use of a tampon eases the burning, it is very likely that cyclic vulvovaginitis is the major factor.
The remaining two subcategories, vulvar vestibulitis and dysesthetic vulvodynia are totally unknown as to their etiology.
Vulvar vestibulitis shows inflammation of the vestibular glands on biopsy but what causes the inflammation is unknown. It does not respond to antibiotics. HPV virus was postulated as a possible cause but current concepts are that HPV is not the cause.
Dysethetic vulvodynia tends to be found in postmenopausal women and is postulated to be an inflammation of the nerves similar to a herpetic vulvitis. There are no histological changes on biopsy so it is really just the existence of vulvar pain in the absence of inflammation on biopsy.
Primary vulvodynia may also fall under this category. In this case it is young women who have the problem and vaginismus, involuntary contraction of the pelvic floor muscles plays a big role. Pelvic floor therapy with microelectrical stimulation may be helpful for this.
All categories of vulvodynia may be associated with a secondary vaginismus. If a woman fears pain with vaginal intercourse, there is almost always an involuntary muscle contraction that narrows the vaginal opening and continues to cause vulvar pain because of direct friction.
Thus the primary cause can be cured (the dermatosis, the vaginitis, the vestibulitis, the atrophic vulvitis) but the pain continues because of fear of pain and involuntary muscle spasms.