Clinical overview
Vestibulodynia — historically called "vulvar vestibulitis syndrome" until the ISSVD 2015 terminology revision removed the "-itis" because the disorder is not primarily inflammatory — is one of the commonest causes of dyspareunia in young women and a frequent reason for new gynaecology referrals. The clinical hallmark is well-localised pain at the vulval vestibule provoked by touch, intercourse, tampon insertion, or even tight clothing. The pain is severe, the impact on intimate relationships and quality of life is profound, and the natural history without intervention is often years of unrecognised suffering.
ISSVD (International Society for the Study of Vulvovaginal Disease) classifies vulvar pain into:
- Vulvodynia — vulval pain of at least 3 months' duration without a clear identifiable cause.
- Vulval pain caused by a specific disorder — infectious, inflammatory, neoplastic, neurologic, trauma, hormonal, iatrogenic.
Vulvodynia is further subdivided by:
- Location: localised (vestibulodynia, clitorodynia) or generalised.
- Provocation: provoked, spontaneous (unprovoked), or mixed.
- Onset: primary (since first attempt at vaginal entry) or secondary (developing after a period of pain-free intercourse).
- Temporal pattern: intermittent, persistent, constant, immediate, delayed.
This chapter focuses on vestibulodynia (the localised, often provoked form) and on the broader clinical entity of "vestibulitis"/vulval vestibular pain syndromes, including inflammatory and infectious causes.
Core knowledge
Anatomy and innervation
Vestibular pain localises to the mucosa at the introitus, especially the posterior vestibule with dense pudendal sensory endings.
The vulval vestibule is the area medial to Hart's line on the inner labia minora, extending around the vaginal introitus. It contains the urethral meatus, Skene's ducts, Bartholin's gland openings, and the hymeneal remnants. The vestibule is embryologically derived from the urogenital sinus (endodermal origin, unlike the ectodermal labial skin), with sparse keratinisation and high density of free nerve endings.
Innervation: pudendal nerve (S2–S4) — perineal branch supplying labia minora and posterior vestibule; ilioinguinal nerve anteriorly.
Causes ("vestibulitis" differential)
Vestibular pain is a syndrome: exclude infection, dermatoses, hypoestrogenism, neural pain, trauma and neoplasia before calling it idiopathic vestibulodynia.
Infections:
- Candidiasis: chronic or recurrent vulvovaginal candidiasis with hyperaesthesia. See Candidiasis.
- Herpes simplex virus: primary herpes presents with vesicles, ulcers, dysuria, lymphadenopathy; HSV-2 most common.
- Trichomoniasis: frothy discharge, intense itch, "strawberry cervix."
- Bacterial vaginosis with vestibular involvement.
- Streptococcal vulvitis (group A or B) — bright erythema, intense pain.
- HPV — condylomata with associated discomfort.
- Bartholin's gland infection (see Acute pelvic infection).