Vulvar vestibulitis subjects undergoing surgical intervention: a descriptive analysis and histopathological correlates

The association between vulvodynia and interstitial cystitis/bladder pain syndrome: A systematic review

BACKGROUND

Vulvodynia (VVD) is a debilitating chronic vulvar pain significantly affecting patients' quality of life. Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic and complex illness characterized by an unpleasant sensation related to the filling of the bladder and it strongly impacts patients' lives. The exact mechanisms of the two syndromes remain unknown, but there is an overlap between suspected pathophysiologies.

OBJECTIVE

To present an overview of the current research on the association between VVD and IC/BPS.

SEARCH STRATEGY

A systematic search of three electronic databases was conducted. Studies examining the correlation between VVD and IC/BPS with male and female patients aged over 18 years were included.

SELECTION CRITERIA

Studies assessing the coexistence of VVD and IC/BPS were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers screened the studies for eligibility. Eligible studies were screened for quality.

MAIN RESULTS

A total of 13 studies were included in the final review. Among them, 11 presented a positive association between the two syndromes. The studies highlighted that VVD and IC/BPS share common comorbidities and possibly etiopathogenic pathways.

CONCLUSION

VVD and IC/BPS are both complex and multifactorial syndromes. This review highlights an association between them, but additional studies on the topic should be conducted for a more precise conclusion.

Surgical Treatment for Provoked Vulvodynia: A Systematic Review

OBJECTIVE

Provoked vulvodynia (PV), characterized by vulvar pain upon touch or pressure, is the leading cause of pain during sexual intercourse. It causes a significant decline in overall quality of life, including sexual dysfunction and mental distress. Surgical interventions, such as perineoplasty and vestibulectomy, are considered a last resort for PV cases unresponsive to less invasive therapies. This systematic review evaluates the efficacy of surgery for PV and suggests areas for future research.

MATERIALS AND METHODS

The literature search encompassed PubMed, Scopus, Web of Science, and Cochrane Library, identifying relevant peer-reviewed studies up to August 21, 2023.

RESULTS

Out of 1102 records retrieved, 29 met the eligibility criteria. Surgery was typically considered after failed conservative treatments. In 15 of the 29 studies defining surgical success as a significant reduction in dyspareunia, success rates ranged from 52% to 93%. Six studies using validated scales for pain assessment noted a significant reduction in vulvar pain following surgery (p < .001). Two studies reported enhancements in sexual function ranging from 57% to 87%, while 3 studies found 89%-97% of women regained the ability to engage in sexual intercourse after surgery. Patient satisfaction rates ranged from 79% to 93%. Bartholin cysts occurred in up to 9% of cases, the most common complication reported.

CONCLUSION

Surgery seems to be an effective and safe PV treatment option with success rates ranging from 52% to 97%, depending on the variation of outcome measures. Randomized clinical trials with established outcome measures are needed to determine the best surgical approach with minimal operative risk and optimal long-term outcomes.

Immunohistochemical staining with CD117 and PGP9.5 of excised vestibular tissue from patients with neuroproliferative vestibulodynia

BACKGROUND

Neuroproliferative vestibulodynia (NPV), a provoked genital pain characterized by severe allodynia and hyperalgesia, is confirmed in excised vestibular tissue by immunohistochemical staining (>8 CD117-positive immunostained cells/100× microscopic field) rather than by hematoxylin and eosin staining.

AIM

In this study we sought to assess immunostaining of tissue samples obtained during vestibulectomy surgery and to correlate results with patient outcomes.

METHODS

Patients (n = 65) meeting criteria for NPV who underwent vestibulectomy during the period from June 2019 through December 2022 formed the study cohort. We performed assessment of pathology of vestibular tissues by use of immunohistochemical staining, including quantitation of mast cells by CD117 (mast cell marker) and nerve fibers by protein gene product (PGP) 9.5 (neuronal marker). We analyzed 725 photomicrographs of immunostained tissue sections (100× and 200×) by manual counting and computer-assisted histometry and correlated these data to clinical assessments.

OUTCOMES

Outcomes included density of CD117 and PGP9.5 immunostaining in the 1:00-11:00 o'clock and 12:00 o'clock vestibular regions, and patient-reported outcomes assessing sexual function, pain, distress, and symptom improvement.

RESULTS

All 65 NPV patients (median age 26 years), 45 with lifelong and 20 with acquired NPV, had severe pain documented by PROs and vulvoscopy and had >8 CD117-immunopositive cells/100× microscopic field. Median cell count values were similar in the 1:00-11:00 o'clock and 12:00 vestibular regions (28.5 and 29.5/100× field, respectively). Likewise, the marker) and nerve fibers by protein gene product (PGP) 9.5 (neuronal marker). We analyzed 725 photomicrographs of immunostained tissue sections (100× and 200×) by manual counting and computer-assisted histometry and correlated these data to clinical assessments.

OUTCOMES

Outcomes included density of CD117 and PGP9.5 immunostaining in the 1:00-11:00 o'clock and 12:00 o'clock vestibular regions, and patient-reported outcomes assessing sexual function, pain, distress, and symptom improvement.

RESULTS

All 65 NPV patients (median age 26 years), 45 with lifelong and 20 with acquired NPV, had severe pain documented by PROs and vulvoscopy and had >8 CD117-immunopositive cells/100× microscopic field. Median cell count values were similar in the 1:00-11:00 o'clock and 12:00 vestibular regions (28.5 and 29.5/100× field, respectively). Likewise, the median area of CD117 immunostaining was similar in both regions (0.69% and 0.73%). The median area of PGP9.5 immunostaining was 0.47% and 0.31% in these same regions. Pain scores determined with cotton-tipped swab testing were nominally higher in lifelong vs acquired NPV patients, reaching statistical significance in the 1:00-11:00 o'clock region (P < .001). The median score for the McGill Pain Questionnaire affective subscale dimension was also significantly higher in lifelong vs acquired NPV patients (P = .011). No correlations were observed between hematoxylin and eosin results and density of mast cells or neuronal markers. Of note, 63% of the patient cohort reported having additional conditions associated with aberrant mast cell activity.

CLINICAL IMPLICATIONS

The pathology of NPV is primarily localized to the vestibular epithelial basement membrane and subepithelial stroma with no visible vulvoscopic findings, making clinical diagnosis challenging.

STRENGTHS AND LIMITATIONS

Strengths of this study include the large number of tissues examined with what is to our knowledge the first-ever assessment of the 12:00 vestibule. Major limitations are specimens from a single timepoint within the disease state and lack of control tissues.

CONCLUSIONS

Performing immunohistochemical staining of excised vestibular tissue with CD117 and PGP9.5 led to histometric confirmation of NPV, indications that NPV is a field disease involving all vestibular regions, validation for patients whose pain had been ignored and who had experienced negative psychosocial impact, and appreciation that such staining can advance knowledge.

Inflammatory Renin-Angiotensin System Disruption Attenuates Sensory Hyperinnervation and Mechanical Hypersensitivity in a Rat Model of Provoked Vestibulodynia

Vestibulodynia is characterized by perivaginal mechanical hypersensitivity, hyperinnervation, and abundant inflammatory cells expressing renin-angiotensin system proteins. We developed a tractable rat model of vestibulodynia to further assess the contributions of the renin-angiotensin system. Complete Freund's adjuvant injected into the posterior vestibule induced marked vestibular hypersensitivity throughout a 7-day test period. Numbers of axons immunoreactive for PGP9.5, calcitonin gene-related peptide, and GFRα2 were increased. Numbers of macrophages and T cells were also increased whereas B cells were not. Renin-angiotensin-associated proteins were abundant, with T cells as well as macrophages contributing to increased renin and angiotensinogen. Media conditioned with inflamed vestibular tissue promoted neurite sprouting by rat dorsal root ganglion neurons in vitro, and this was blocked by the angiotensin II receptor type 2 receptor antagonist PD123319 or by an angiotensin II function blocking antibody. Sensory axon sprouting induced by inflamed tissue was dependent on activity of angiotensin-converting enzyme or chymase, but not cathepsin G. Thus, vestibular Complete Freund's adjuvant injection substantially recapitulates changes seen in patients with provoked vestibulodynia, and shows that manipulation of the local inflammatory renin-angiotensin system may be a useful therapeutic strategy.

PERSPECTIVE

This study provides evidence that inflammation of the rat vestibule induces a phenotype recapitulating behavioral and cytological features of human vestibulodynia. The model confirms a crucial role of the local inflammatory renin-angiotensin system in hypersensitivity and hyperinnervation. Targeting this system holds promise for developing new nonopioid analgesic treatment strategies.

A Local Inflammatory Renin-Angiotensin System Drives Sensory Axon Sprouting in Provoked Vestibulodynia

Vestibulodynia is a form of provoked vulvodynia characterized by profound tenderness, hyperinnervation, and frequently inflammation within well-defined areas of the human vestibule. Previous experiments in animal models show that inflammatory hypersensitivity and hyperinnervation occur in concert with establishment of a local renin-angiotensin system (RAS). Moreover, mechanical hypersensitivity and sensory axon sprouting are prevented by blocking effects of angiotensin II on angiotensin II receptor type 2 (AT2) receptors. This case-control study assessed whether a RAS contributes to hyperinnervation observed in human vestibulodynia. Vestibular biopsies from asymptomatic controls or patients' nontender areas showed moderate innervation and small numbers of inflammatory cells. In women with vestibulodynia, tender areas contained increased numbers of mechanoreceptive nociceptor axons, T-cells, macrophages, and B-cells, whereas mast cells were unchanged. RAS proteins were increased because of greater numbers of T cells and B cells expressing angiotensinogen, and increased renin-expressing T cells and macrophages. Chymase, which converts angiotensin I to angiotensin II, was present in constant numbers of mast cells. To determine if tender vestibular tissue generates angiotensin II that promotes axon sprouting, we conditioned culture medium with vestibular tissue. Rat sensory neurons cultured in control-conditioned medium showed normal axon outgrowth, whereas those in tender tissue-conditioned medium showed enhanced sprouting that was prevented by adding an AT2 antagonist or angiotensin II neutralizing antibody. Hypersensitivity in provoked vestibulodynia is therefore characterized by abnormal mechanonociceptor axon proliferation, which is attributable to inflammatory cell-derived angiotensin II (or a closely related peptide) acting on neuronal AT2 receptors. Accordingly, reducing inflammation or blocking AT2 represent rational strategies to mitigate this common pain syndrome.

PERSPECTIVE

This study provides evidence that local inflammation leads to angiotensin II formation, which acts on the AT2 to induce nociceptor axon sprouting in vulvodynia. Preventing inflammation and blocking AT2 therefore present potential pharmacological strategies for reducing vestibular pain.

Recent advances in understanding provoked vestibulodynia

Vulvodynia refers to pain in the vulva of at least 3 months’ duration in the absence of a recognized underlying cause. Provoked, localized vestibulodynia is the term used to describe superficial pain confined to the vulvar vestibule, provoked by touch. This review will focus on provoked vestibulodynia with regard to its suggested causative factors and will discuss the role of inflammation, vulvovaginal infections, mucosal nerve fiber proliferation, hormonal associations, central pain mechanisms, pelvic floor muscle dysfunction, and genetic factors.

Clinical observations, epidemiological studies, and data from basic research emphasize the heterogeneity of vulvar pain syndromes. There is a critical need to perform prospective, longitudinal studies that will allow better diagnostic criteria and subgrouping of patients that would lead to improvements in our understanding of provoked vestibulodynia and its treatment.

Vestibular Mast Cell Density in Vulvodynia: A Case-Controlled Study

OBJECTIVES

To identify whether mast cell densities in vulvar biopsies from the vestibule are associated with vulvodynia.

METHODS

We enrolled 100 women aged 19 to 59 years with confirmed vulvodynia cases, 100 racially matched controls, and 100 black control women. All had vulvar biopsies performed at the 7 o'clock position of the vestibule, which were then immunostained to detect c-KIT protein. The numbers of c-KIT positive mast cells per ×400 magnification field were manually counted, and t tests and logistic regression were used to assess the association with case-control status.

RESULTS

Of the biopsies, 235 were adequate samples for c-KIT testing for mast cells. The mast cell density was substantially lower in black control women (13.9 ± 10.9) in comparison to white control women (22.5 ± 13.2 p < 0.001): hence the analysis was confined to white cases and racially matched control women. Compared with racially matched controls, cases were younger, more likely to be married, and reported a higher household income. The average number of mast cells per ×400 magnification field overall was 19.1 ± 13.2 (range, 0-62). There was no difference in the mast cell count between racially matched cases (22.4 ± 13.9 per ×400 field) and controls (22.5 ± 13.2) in either the univariate or multivariable analyses. Within the group of cases, there was no difference in mast cell density based on the presence or absence of a variety of urogenital symptoms.

CONCLUSIONS

No difference in mast cell density in biopsies of the vestibule was found between white cases and racially matched controls. Black control women have a lower mast cell density compared with white control women.

A review of the available clinical therapies for vulvodynia management and new data implicating proinflammatory mediators in pain elicitation

Localised provoked vulvodynia (LPV) is a common, chronic, and disabling condition: patients experience profound pain and a diminished quality of life. The aetiologic origins of vulvodynia are poorly understood, yet recent evidence suggests a link to site-specific inflammatory responses. Fibroblasts isolated from the vestibule of LPV patients are sensitive to proinflammatory stimuli and copiously produce pain-associated proinflammatory mediators (IL-6 and PGE₂ ). Although LPV is a multifactorial disorder, understanding vulvar inflammation and targeting the inflammatory response should lead to treatment advances, especially for patients exhibiting signs of inflammation. NFκB (already targeted clinically) or other inflammatory components may be suitable therapeutic targets.

TWEETABLE ABSTRACT

Vulvodynia is a poorly understood, prevalent, and serious women's health issue requiring better understanding to improve therapy.

Similarities between interstitial cystitis/bladder pain syndrome and vulvodynia: implications for patient management

Interstitial cystitis/bladder pain syndrome (IC/BPS) and vulvodynia are chronic pain syndromes that appear to be intertwined from the perspectives of embryology, pathology and epidemiology. These associations may account for similar responses to various therapies.

Activation of vestibule-associated lymphoid tissue in localized provoked vulvodynia

OBJECTIVE

Localized provoked vulvodynia (LPV) may have inflammatory etiology. We wanted to find out whether the cell-mediated immune system becomes activated in the vestibular mucosa in LPV.

STUDY DESIGN

This was a controlled cross-sectional study. Vestibular mucosal specimens were obtained from 27 patients with severe LPV and 15 controls. Detailed clinical history of the patients was obtained. For immunohistochemistry, antibodies against CD3 (T cells), CD20 (B cells), IgA (mucosal plasma cells), CD163 (dendritic cells [DCs]), CD68 (macrophages), and CD117 (mast cells) were employed. Mann-Whitney U test and χ(2) test were used for statistical analyses.

RESULTS

More B lymphocytes and mature mucosal IgA-plasma cells were found in patients than in controls (P < .001 and P < .001, respectively). In LPV samples, B and T cells were arranged into germinal centers representing local immune activation. Germinal centers were not seen in controls. Antigen-presenting DCs and macrophages were found both in patients and controls with similar densities. DCs were found to extend their dendrites into the luminal space through an intact epithelium. Similar amounts of mast cells were found evenly scattered throughout the stroma of vestibular mucosa of both patients and controls.

CONCLUSION

We demonstrate here local organized vestibule-associated lymphoid tissue analogous to mucosa-associated lymphoid tissue. Vestibule-associated lymphoid tissue may emerge as a response to local infection or inflammation in LPV.

Decreased concentration of protease inhibitors: possible contributors to allodynia and hyperalgesia in women with vestibulodynia

OBJECTIVE

Women with vestibulodynia exhibit increased pain sensitivity to contact with the vaginal vestibule as well as with vaginal penetration. The mechanism(s) responsible for this effect remains incompletely defined. Based on reports of a possible role for proteases in induction of pain, we compared levels of proteases and protease inhibitors in vaginal secretions from women with vestibulodynia and controls.

STUDY DESIGN

Vaginal secretions from 76 women with vestibulodynia and from 41 control women were assayed by an enzyme-linked immunosorbent assay for the protease inhibitors, secretory leukocyte protease inhibitor (SLPI) and human epididymis protein-4 (HE-4), and the proteases, kallikrein-5 and cathepsins B and S. Concentrations between subjects and controls were compared and levels related to clinical and demographic variables.

RESULTS

Concentrations of HE-4 and SLPI were markedly reduced in vaginal samples from women with vestibulodynia compared with controls (P ≤ .006). All other compounds were similar in both groups. HE-4 (P = .0195) and SLPI (P = .0033) were lower in women with secondary, but not primary, vestibulodynia than in controls. Subjects who had constant vulvar pain had lower levels of HE-4 and SLPI than did healthy control women (P ≤ .006) or women who experienced vulvar pain only during sexual intercourse (P ≤ .0191). There were no associations between HE-4 or SLPI levels and event associated with symptom onset, duration of symptoms, age, number of lifetime sexual partners, or age at sex initiation.

CONCLUSION

Insufficient vaginal protease inhibitor production may contribute to increased pain sensitivity in an undefined subset of women with secondary vestibulodynia who experience constant vulvar pain.

The recurrent pain and sexual sequelae of provoked vestibulodynia: a perpetuating cycle

INTRODUCTION

Optimal management of provoked vestibulodynia (PVD), thought to be the most common form of chronic dyspareunia, is unclear.

AIM

To integrate recent brain data on chronic pain circuitry with stress-induced neuroendocrine mechanisms in the skin and the stress burden (allostatic load) of women with PVD; to also clarify the typical chronicity and negative sexual sequelae associated with PVD; and then review modulation of pain circuitry by cognitive therapy and mindfulness practice and apply to PVD management. Methods.  Review of scientific publications in the areas of sexual medicine, pain, brain imaging, gynecology, stress response, mindfulness, and cognitive behavioral therapy (CBT).

MAIN OUTCOME MEASURES

(i) A model of PVD to reflect its etiology, typical chronicity, and the detrimental effects on sexual function; (ii) Interventions of sexual rehabilitation based on principles underlying changes associated with CBT and mindfulness practice.

RESULTS

A model emerges which reflects how stress-induced changes of pain amplification (central sensitization), characteristic of chronic pain conditions, may impair sexual response in addition to sexual dysfunction that arises from conscious pain avoidance and/or fear-related inattention to sexual cues. Stress from low self-acceptance may be a major component of the allostatic load present in women with PVD, only to be exacerbated by the sexual dysfunction precipitated by the pain of intercourse. Mindfulness-based CBT appears promising to target both the pain and sexual suffering from PVD.

CONCLUSION

New findings on brain activity associated with recurrent clinical pain, functional brain changes associated with CBT and mindfulness, plus new data on stress systems within the skin along with data on increased stress load in women with PVD, support the use of mindfulness-based CBT for the recurrent pain and sexual suffering from PVD.

[Vulvar vestibulitis syndrome: a clinicopathological study of 14 cases]

BACKGROUND

Vulvar vestibulitis syndrome (VVS) is one of the most frequent causes of superficial dyspareunia in young women. VVS has a pronounced psychological impact. The results of pathological studies published thus far are controversial.

PATIENTS AND METHODS

Fourteen women with VVS were included in this study and underwent vestibular biopsy. Vulvar biopsies were taken from the orifice of Bartholin's gland. The biopsy samples were stained with a standard stain and PAS and 25 serial sections were prepared for each specimen.

RESULTS

The mean patient age was 26 years and VVS had been present for a mean 30 months. Extensive inflammation of mononuclear cells was observed in the vulvar chorionic epithelium. This inflammation was seen mainly around the minor vestibular glands. Mild exocytosis of lymphocytes was noted in the vestibular glands and ducts.

DISCUSSION

Most studies concerning this disease report chronic inflammation of the vulvar vestibular mucosa. This inflammation is seen mainly around the minor vestibular glands. We report the same pattern in our study. Moreover, we observed some exocytosis into the epithelium of minor vestibular glands and the excretory duct. This aspect has not been reported to date, further supporting the individual nature of this entity.

Involvement of heparanase in the pathogenesis of localized vulvodynia

Recently, we have shown that vestibular hyperinnervation and the presence of 8 or more mast cells in a 10 x 10 microscopic field can be used as diagnostic criteria in localized vulvodynia (vulvar vestibulitis). We have also documented that degranulation of mast cells occurs in these cases. The present study further examines the characteristics of vestibular hyperinnervation and mast cell function in localized vulvodynia to elucidate if the 2 processes-hyperinnervation and mast cell increase and degranulation-are related. We examined vestibular tissue from 7 women aged 18 to 48 with severe localized vulvodynia and from 7 healthy control women. Parallel sections were stained by Giemsa and then immunostained for CD117 and heparanase. Nerve fibers that expressed protein gene product 9.5 were examined. Tissues from women with localized vulvodynia documented a significant increase in vestibular mast cells, subepithelial heparanase activity, and intraepithelial hyperinnervation compared with healthy women. This is the first documentation of heparanase activity in localized vulvodynia. Heparanase, which is degranulated from mast cells, is capable of degrading the vestibular stroma and epithelial basement membrane, thus permitting stromal proliferation and intraepithelial extension of nerve fibers, as seen in the present study. The hyperinnervation has been thought to cause the vestibular hyperesthesia distinctive of localized vulvodynia.

The emerging presence of interstitial cystitis in gynecologic patients with chronic pelvic pain

Emerging data are changing the pelvic pain paradigm for gynecologic patients. Historically, interstitial cystitis (IC) was rarely considered as a cause of chronic pelvic pain (CPP), but recent data suggest that IC is a common cause of CPP in gynecologic patients and perhaps is even the most common cause. It is important to consider the bladder as a generator of symptoms early in the evaluation of the gynecologic patient with CPP. New tools have been developed to aid the gynecologist in ruling out IC in patients with CPP, including a new IC symptom questionnaire and the Potassium Sensitivity Test (PST). By determining whether the pain is of bladder origin, the physician can more successfully treat the patient with CPP.

Dyspareunia

Dyspareunia, better termed women's sexual pain, is a poorly understood disorder once believed to be purely psychologic. Thanks to cooperative research efforts from several specialties toward defining subsets of the disorder, understanding the etiology of subsets and their comorbidities and new concepts for diagnosis and management are being validated or are being put into practice. This review describes the surprising prevalence of sexual pain, outlines new definitions for subtypes of sexual pain and diagnostic criteria for them, and applies these diagnoses to the task of selecting treatment options.

Vulvar vestibulitis syndrome

Vulvar vestibulitis syndrome (VVS) is one of the most common causes of genital pain and pain with sexual intercourse, affecting up to 15% of women. The syndrome is characterized by severe pain on vestibular touch or attempted vaginal entry, exquisite tenderness to palpation with a cotton swab, and often subtle physical findings confined to vestibular erythema. The etiology of VVS is unknown. However, it is probably best to consider VVS as a chronic local inflammatory condition with a wide variety of etiologic causes. The heterogeneity of potential etiologies for VVS results in the use of multiple treatment regimens in clinical practice. Scientifically rigorous studies are sorely needed to determine the best treatment approach.

ORIGINAL RESEARCH—SURGERY: Surgical Treatment of Vulvar Vestibulitis Syndrome: Outcome Assessment Derived from a Postoperative Questionnaire

INTRODUCTION

Vulvar vestibulitis syndrome (VVS) is the most common pathology in women with sexual pain. Surgery for VVS was first described in 1981. Despite apparently high surgical success rates, most review articles suggest that surgery should be used only "as a last resort." Risks of complications such as bleeding, scarring, and recurrence of symptoms are often used to justify these cautionary statements. However, there are little data in the peer-reviewed literature to justify this cautionary statement.

AIMS

To determine patient satisfaction with vulvar vestibulectomy for VVS and the rate of complications with this procedure.

METHODS

Women who underwent a complete vulvar vestibulectomy with vaginal advancement by one of three different surgeons were contacted via telephone by an independent researcher between 12 and 72 months after surgery.

MAIN OUTCOME MEASURES

The primary outcome measurement of surgical success was overall patient satisfaction with surgery. Additional secondary outcome measurements included improvement in dyspareunia, changes in coital frequency, and occurrence of surgical complications.

RESULTS

In total, 134 women underwent surgery in a 5-year period. An independent research assistant was able to contact 106 women, and 104 agreed to participate in the study. Mean duration since surgery was 26 months. A total of 97 women (93%) were satisfied, or very satisfied, with the outcome of their surgery. Only three patients (3%) reported persistently worse symptoms after surgery and only seven (7%) reported permanent recurrence of any symptoms after surgery. Prior to surgery, 72% of the women were completely apareunic; however, after surgery, only 11% were unable to have intercourse.

DISCUSSION

In this cohort of patients, there was a high degree of satisfaction with surgery for VVS. In addition, the risks of complications with this procedure were low, and most complications were transient and the risk of recurrence after surgery was also found to be low.

Psychological aspects of vulvar vestibulitis syndrome

This review is based on a MEDLINE/PSYCHINFO search for all papers on psychological aspects of vulvar vestibulitis syndrome (VVS) published 1995-2002. VVS is a condition in which painful patches appear on the vulva which make intercourse painful. Causation, natural history and prevalence of VVS are unknown. Attempts to identify psychological characteristics typical of women with VVS have not yielded consistent results with some studies suggesting high levels of psychopathology and others not. It is suggested that inconsistencies in findings reflect not only decisions by women about whether and how to access health care but also the health care system acting to actively filter those reaching specialist services and selecting those with particular psychological characteristics. There is no compelling evidence that VVS per se is associated with any particular psychological or behavioural characteristics other than the sort of difficulties in sexual functioning which might be expected with chronic vulval pain. However there is evidence for high levels of psychological distress in some samples of women with VVS being seen in secondary care.

The Major Histopathologic Characteristics in the Vulvar Vestibulitis Syndrome

OBJECTIVE

In order to better understand the etiology of the vulvar vestibulitis syndrome, we examined the histopathologic parameters in vestibular mucosa, and compared the findings in specimens obtained from women with vulvar vestibulitis with those obtained from the control group.

STUDY DESIGN

Specimens of vestibulitis were obtained from 24 patients, undergoing circumferential vestibulectomy under general anesthesia due to the symptoms and signs consistent with vulvar vestibulitis. Control specimens were obtained from 16 women, without symptoms or signs of vulvar vestibulitis, undergoing reconstructive introital surgery due to roomy vagina, rectocele or painful episiotomy. All vestibular tissue specimens were examined for intensity of inflammation, extension of inflammatory cells into the epithelium, vascular proliferation, the presence of mast cells and proliferation of peripheral nerve bundles.

RESULTS

No significant difference was found regarding the degree of inflammation, the extension of inflammatory cells into the epithelium, the vascular proliferation and the presence of mast cells while comparing the study and the control groups. The only histopathologic feature, differentiating the patients with vulvar vestibulitis from the control group, was the proliferation of peripheral nerve bundles found in 19 out of 24 (79.1%) specimens expressing vestibulitis and in none of 16 control specimens (p < 0.0001).

CONCLUSION

Our results, therefore, support the existence of peripheral nerve hyperplasia in vestibular tissue obtained from patients with vulvar vestibulitis, and exclude the role of active inflammation or mast cells as probable etiologies for the vulvar vestibulitis syndrome.

Hyperinnervation and mast cell activation may be used as histopathologic diagnostic criteria for vulvar vestibulitis

OBJECTIVE

Vestibulitis is currently diagnosed based only on clinical criteria. To achieve histopathological diagnostic criteria, we carried out a computerized image analysis method.

METHODS

Vestibular tissues removed from 40 women with severe vestibulitis were immunostained for mast cell count and degranulation by C-kit and mast cell tryptase, respectively. Vestibular nerve cells total area was evaluated after S-100 stain. Controls were 7 women aged 18-48. The images were converted to a digital signal, and analyzed using Image Proplus V4 software.

RESULTS

We found a significant increase in inflammatory infiltrate, number of mast cells and degranulated mast cells in vestibulitis compared to normal controls. The inflammatory cells were localized around the superficial minor vestibular glands. The total nerve fiber area was ten times higher in vestibulitis patients than in controls. A significant positive correlation was found between the total nerve fiber area and the number of mast cells in the vestibulitis group of patients.

CONCLUSION

We documented two diagnostic histopathological criteria for vestibulitis: (1) the presence of eight or more mast cells per 10 x 10 microscopic field, and (2) the total calculated area of the nerve fibers is ten times higher than expected. These findings re-establish the inflammatory nature of the vestibulitis. It is speculated that the trigger for the local outburst of nerve fibers could be related to the activation of the mast cells by a topical agent.

Pain at the Vulvar Vestibule: A Web-Based Survey

OBJECTIVE

To assess the prevalence, characteristics, and ethnic distribution of pain in the vulvar vestibule among a national sample of women completing a web-based survey.

METHODS

Female participants of the SurveySpot Internet research panel (Survey Sampling International) were invited via e-mail to respond to a web-based questionnaire on women's health issues. The frequency and characteristics of reported pain of the vulvar vestibule were assessed among 994 respondents, using univariate and multivariate analyses.

RESULTS

Between May 24, 2002, and June 6, 2002, 730 non-African American women and 364 African American women responded to the invitation to participate, and 94.5% completed the survey. A history of pain at the vulvar vestibule was reported by 288 women (27.9%), with 80 (7.8% of the initial 1032) reporting pain within the past 6 months, 31 (3.0%) reporting pain that lasted 3 or more months, and 18 (1.7%) reporting vestibular pain lasting 3 or more months that occurred within the past 6 months. The prevalence of pain was similar in African American and non-African American women.

CONCLUSIONS

The prevalence of pain at the vulvar vestibule is more common than previously estimated. The perception that vulvar pain is rare among African American women was not supported in this survey.

New concepts in vulvodynia

Vulvodynia is chronic vulvar burning/pain without clear medical findings. The etiology of vulvodynia is unknown and health care professionals should thoroughly rule out specific, treatable causes or factors such as dermatoses or group B Streptococcus infections. Vulvodynia is divided into 2 classes: vulvar vestibulitis syndrome is vestibule-restricted burning/pain and is elicited by touch; dysesthetic vulvodynia is burning/pain not limited to the vestibule and may occur without touch/pressure. After diagnosis, critical factors in successful patient management include education and psychological support/counseling. Unfortunately, clinical trials on potential vulvodynia therapies have been few. Standard therapy includes treating neuropathic pain (eg, tricyclic medications, gabapentin) thought to play a role. Additional therapies may be considered: pelvic floor rehabilitation combined with surface electromyography, interferon alfa, estrogen creams, and surgery. Importantly, any therapy should be accompanied by patient education and psychological support. Because definitive data on effective therapies are lacking, further clinical investigations of treatment options are warranted.

Psychological profiles among women with vulvar vestibulitis syndrome: a chart review

The purpose of this study was to assess the prevalence and type of psychological distress in women with vulvar vestibulitis syndrome (VVS). A retrospective chart review was conducted of all women receiving a diagnosis of VVS referred to a tertiary care facility during a two-year period. Brief psychological questionnaires, including the Personality Assessment Screener, Fear of Negative Evaluation Scale, Golombok-Rust Inventory of Sexual Satisfaction, and the Phobia Rating Scale were administered. Fifty-consecutive cases were reviewed along with 12-15 month follow-up data for 41 cases. Phobic anxiety to vaginal touch or entry was significantly higher in women with VVS than normative data. Fear of Negative Evaluation was a strong associated feature, and for 30% approached clinically significant levels. Twenty-six percent showed a moderate, while another 26% showed a mild clinically distressed profile. Negative affect and social withdrawal were among the most frequently endorsed variables. Improvement in allodynia and intercourse were both related to these psychological variables, and a multiple regression analysis supported the use of psychological instruments in addition to standard medical assessment. A subgroup of women with VVS display clinically significant broad based psychological distress that warrants additional assessment. The use of psychological questionnaires in addition to medical assessment of women with VVS may provide valuable information predictive of treatment needs and response.

The prevalence of interstitial cystitis in gynecologic patients with pelvic pain, as detected by intravesical potassium sensitivity

OBJECTIVE

The purpose of this study was to determine the prevalence of interstitial cystitis in a large number of gynecologic patients with pelvic pain versus control subjects, as indicated by a positive result on a potassium sensitivity test.

STUDY DESIGN

Gynecologists at four US medical centers administered the potassium sensitivity test to consecutive unselected patients with pelvic pain and control subjects. Before testing, each patient with pelvic pain was given an initial clinical diagnosis on the basis of the chief symptomatic complaint(s) and was surveyed for urologic symptoms.

RESULTS

Of 244 patients with pelvic pain, 197 patients (81 %) had a positive result from a potassium sensitivity test. Positive potassium sensitivity test rates were comparable across all four sites and all clinical diagnoses that included endometriosis, vulvodynia (vulvar vestibulitis), and pelvic pain. Urologic symptoms were reported by 84% of patients, but only 1.6% of the patients had received an initial diagnosis of interstitial cystitis. None of the 47 control subjects were tested positive with the potassium sensitivity test.

CONCLUSION

Interstitial cystitis may be a common unrecognized cause of pelvic pain in gynecologic patients and deserves greater, if not primary, consideration in the differential diagnosis of pelvic pain.

Impact of pelvic floor disorders and prolapse on female sexual function and response

Pelvic floor disorders and FSD are prevalent and challenging problems. These disorders include prolapse of the uterus, cervix, vagina, bladder, and rectum and incontinence. These diseases likely affect women's sexual well-being through physical and emotional effects. Women with pelvic floor disorders often have co-existing urologic and sexual complaints. Patients who present with these urologic problems should be questioned about their sexual function. Surgical treatment in these patients may be curative of their sexual disorders (e.g., by repairing incontinence) but may also have undesired effects on sensation, blood flow, and the anatomy. These effects can affect sexual arousal and orgasm or cause dyspareunia. It is hoped that a better understanding of the anatomy of this area will guide us in a more targeted approach to management of these conditions.

A review of physical and psychological factors in vulvar vestibulitis syndrome

This review is based on a MEDLINE search of all papers on vulvar vestibulitis syndrome (VVS) published 1995-2000. The causation, natural history and prevalence of VVS are unknown. There is no convincing evidence that VVS is the result of an infection or of an allergy. It has been proposed that it is an atypical pain syndrome but there is currently no clear evidence that this is so. The usual diagnostic criteria used in VVS are of doubtful discriminative value. Findings from biopsies of women with VVS are inconsistent. While there is some evidence to suggest that women with VVS attending clinics differ psychologically from normal controls, it is not clear whether these differences reflect the effects of VVS, are the result of patient selection or influence the development of the disease. Several treatments, including biofeedback, psychosexual treatment and surgery have been reported to be successful in some patients but there is a lack of proper placebo-controlled trials on which to base estimates of efficacy. There is a vital need for further, high-quality, research in this area.

Cromolyn cream for recalcitrant idiopathic vulvar vestibulitis: results of a placebo controlled study

OBJECTIVE

Patients with chronic idiopathic vulvar vestibulitis have increased mast cells when biopsied, and cromolyn has been suggested as a treatment. The purpose of this study was to assess the efficacy of 4% cromolyn cream in women with vulvar vestibulitis.

METHODS

A prospective, double blind, randomised, placebo controlled study was initiated at two centres. Patients with vulvar vestibulitis were assigned to apply cromolyn or placebo cream to the vestibule. Symptoms (burning, irritation) and signs (erythema, extent of erythema, tenderness) were recorded on a 0-3 scale. In the sexually active patient subgroup, dyspareunia was also evaluated.

RESULTS

13 of the 26 evaluable patients received cromolyn. Patients in the cromolyn arm were more likely to have failed therapy with amitriptyline (p = 0.05), but the two groups were otherwise similar upon study entry. Overall, scores decreased from a median of 9 to 5 (p = 0.001) during the study, but the level of improvement was similar between both groups. Improvement was unrelated to duration of symptoms, fluconazole use, or sexual activity. Five patients (38%) taking cromolyn and six (46%) taking placebo felt they had a 50% or greater reduction in symptoms. In the 21 sexually active patients, the total score decreased from a mean of 12 to 8 (p = 0.005), but there was no statistically significant difference between study arms.

CONCLUSIONS

Cromolyn cream did not confer a significant benefit in patients with vulvar vestibulitis. The large placebo response suggests the need for large well controlled studies of other treatment modalities.

"Primary" versus "secondary" vulvar vestibulitis: one disease, two variants

OBJECTIVE

Our aim was to determine whether women with primary vestibulitis-since the first episode of sexual intercourse-differ in disease characteristics and outcome of operative treatment from women with secondary vestibulitis.

STUDY DESIGN

A total of 111 patients with severe vulvar vestibulitis underwent perineoplasty from 1991 to 1995. Thirty-nine (35%) of them had primary vestibulitis (ie, dyspareunia from the first attempt at sexual intercourse). They were compared with 72 (65%) who had secondary vestibulitis with regard to demographic, social, and medical variables, the presence of human papillomavirus deoxyribonucleic acid, physical and histopathologic findings in the vestibule, and surgical outcome.

RESULTS

Women with primary vestibulitis were 5 years younger than those who had secondary vestibulitis (22.9 +/- 2.9 years vs 27.7 +/- 8.6 years, respectively; P <.0001) and differed in their marital status (unmarried, 84% vs 56%, respectively; P <.008), parity (nulliparous, 97% vs 67%, respectively; P <.0002), and involvement of the whole vestibule (74% vs 93%, respectively; P <.006). The 2 groups were similar in all other variables, including use of oral contraception, smoking, presence of human papillomavirus, dysuria, success of perineoplasty (average, 83%), and histopathologic findings.

CONCLUSIONS

Women with primary vestibulitis were younger than women with secondary vestibulitis. Most other differences were dependent on the different ages of the 2 groups. Primary and secondary vestibulitis may therefore be two presentations of the same disease.

Vulvar Vestibulitis Syndrome: A Post-infectious Entity?

Vulvar vestibulitis syndrome, a condition characterized by inflammation of the vaginal introitus, causes chronic vulvar pain, particularly with intercourse. It occurs in at least 15% of women with chronic vulvovaginal symptoms, and it is a common cause of sexual dysfunction and resulting comorbidities. Because 80% of women with vulvar vestibulitis syndrome describe an acute onset of symptoms, an infectious etiology has been suspected but never proven. Initially, human papillomavirus infection was thought to be the cause, but recent controlled studies dispute this earlier supposition. Vulvovaginal candidiasis may play an important role in the development of this condition.

The female sexual response: a different model

Clarification of women's sexual response during long-term relationships is needed. I have presented a model that more accurately depicts the responsive component of women's desire and the underlying motivational forces that trigger it. The variety of arousal/orgasm responses is also acknowledged. The purpose is both to prevent diagnosing dysfunction when the response is simply different from the traditional human sex-response cycle and to more clearly define subgroups of dysfunction. The latter would appear to be necessary before progress in newer treatment modalities, including pharmacological, can be made.

Evaluation of the surgical treatment of vulvar vestibulitis

OBJECTIVE

To assess the efficacy of perineoplasty in the management of vulvar vestibulitis.

STUDY DESIGN

Forty-two women who had undergone operative perineoplasty for the treatment of vulvar vestibulitis completed a questionnaire, a mean of 4.8 years postoperatively.

RESULTS

Vulvodynia was constant or daily in 29 (69%) before surgery and in eight (19%) of respondents after surgery. In all, 27 (80%) of 34 women who had preoperative vulvar discomfort reported that the discomfort was much better or absent following surgery. Before surgery, 26 (70%) of 37 women who were not celibate for reasons other than vulvar vestibulitis, were celibate because of vulvar vestibulitis or always had pain during coitus and sometimes had to discontinue coitus because of pain. In contrast, only two (5.7%) of 35 women had this degree of dyspareunia following surgery. Similarly, 28 (85%) of 33 sexually active women who had dyspareunia before surgery reported that intercourse was much less painful or pain-free following surgery.

CONCLUSION

Perineoplasty has a role in the management of vulvar vestibulitis for women who do not achieve satisfactory relief of vulvodynia and/or dyspareunia with nonoperative treatments.

Epidemiology of vulvar vestibulitis syndrome: an exploratory case-control study

BACKGROUND

Vulvar vestibulitis syndrome (VVS) is a chronic, persistent syndrome characterised by vestibular pain, tenderness, and erythema. The aetiology of VVS is unknown and few of the hypothesised risk factors have been tested in controlled studies.

METHODS

Using a matched case-control study design, medical, sexual, health behaviour, and diet history of 28 women with VVS were compared with 50 friend controls without VVS to identify possible causal factors.

RESULTS

Cases were more likely than controls to report every vaginal and urinary symptom at the time of interview measured, particularly vaginal soreness or pain (60.7%) and pain during intercourse (64.3%). There were no significant differences between cases and controls with respect to sexual behaviour. Cases were more likely than controls to report self reported history of physician diagnosed bacterial vaginosis (OR = 22.2, 95% CI = 2.8, 177.2, p value = 0.0001), vaginal yeast infections (OR = 4.9, 95% CI = 1.4, 18.0, p value = 0.01), and human papillomavirus (OR = 7.1, 95% CI = 0.6, 81.2, p value = 0.08). There were no differences between cases and controls with respect to dietary intake of oxalate. Cases were more likely than controls to report poor health status (OR = 5.7, 95% CI = 1.1, 28.7, p value = 0.02) and history of depression for 2 weeks or more during the past year (OR = 4.4, 95% CI = 1.6, 12.3, p value = 0.002).

CONCLUSION

Self reported history of bacterial vaginosis, yeast infections, and human papillomavirus were strongly associated with VVS. An infectious origin for VVS should be pursued in larger controlled studies, using questionnaire and laboratory measures.