Painful Intercourse Due to Vulvar Vestibulitis
Frederick R. Jelovsek MD
Painful intercourse can be divided into two major categories:
- pain right at the entrance to the vagina -- see superficial dyspareunia
- pain deep in the pelvis -- see deep dyspareunia
Of the diagnoses associated with painful intercourse at the entrance to the vagina, one of the most difficult to diagnose is vulvar vestibulitis. Vestibulitis stands for inflammation of the vestibule of the vagina which is the moist pink skin area just in front of the hymen and goes to where the dry skin starts. It is usually less than an inch (2 cm.) wide and extends from about 3 o'clock to 9 o'clock around the vaginal opening. In vulvar vestibulitis, this area gets so sensitive that even touching it with a Q-tip (cotton-tipped applicator stick) elicits moderate to severe pain.
The diagnosis is often missed because aside from some redness of the skin and the pain, there are no signs of infection, bleeding, discharge or any lesions that can be seen or felt. If a vestibule biopsy is performed it only shows inflammatory cells and slightly increased blood vessel supply under the microscope.
In a recent article, Westrom LV and Willen R: Vestibular nerve proliferation in vulvar vestibulitis syndrome. Obstet Gynecol 1998;91:572-6, these authors did special nerve stains on the biopsy tissue of vestibule skin. They found increased numbers of nerve fibers present. These are similar findings to what investigators have found in Crohn disease (an inflammatory condition of the bowel) and interstitial cystitis (a chronic inflammatory condition of the bladder which produces pain and frequent urination without a bacterial infection present). The increased number of nerve endings may explain the increased pain that is present.
The significance of this report is that physicians may have a new way of confirming their clinical impression of vulvar vestibulitis by asking their pathologist to do a nerve stain (S-100 immunostain was the one used in this study) on the biopsy specimen in addition to the regular microscopic exam. If there appears to be increased nerve proliferation on the biopsy specimen, that would add certainty to the diagnosis. Keep in mind that the doctor can make the diagnosis on just clinical findings.