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Vulval vestibulitis A cause of painful sex

What is it?

The vestibule is where the vulva meets with the vagina. It is an extremely sensitive part of your body and contains the Bartholin’s glands (which lubricates your vagina), the urethra (where you pass urine) and a number of the small glands. Vulval vestibulitis literally means inflammation of the vestibule.

How common is it?

This is difficult to say. We certainly know that it is an under-recognised condition. In a recent survey nearly 50 % of GP’s saw one woman with chronic vulva pain and soreness a month. However the problem is probably much larger as many women, who have vulva vestibulitis, will have been given an incorrect diagnosis (usually thrush).

What causes it?

In most cases we don’t know. Some women develop symptoms after a specific event, commonly put down to thrush. Once the attack of thrush settles following treatment, soreness and burning may persist as vestibulitis. Some women complain of vestibulitis after childbirth. Others notice a problem when they use a certain bubble bath, soaps or antiseptics in the bath e.g. Dettol. If your symptoms have gradually come on over time, it may be difficult to identify the cause. Some women with a bladder condition called interstitial cystitis also suffer from the condition. The reason why the two conditions are connected remains unknown.

What are the symptoms?

Most women complain of pain when pressure is applied to the vestibule such as during sexual intercourse and when putting in tampons. The degree of pain is variable. Some women have pain, but are able to tolerate intercourse, whereas for others, any pressure ( including tight clothes and even light touch) to the area causes soreness and tenderness. Itching is not usually a feature of the condition.

What is there to see on examination?

The vestibule may be red and can be tender to touch. Very often the appearances are more subtle and can only be seen with good lighting and by a doctor familiar with the condition.

What tests should be done?

Vulval vestibulitis should be diagnosed after ruling out infections and vulval skin conditions, which may cause similar symptoms. Many women will have already had repeated treatment for ‘thrush’. Many of these treatments e.g. canesten, can aggravate the condition.

How is it treated?

As there is no obvious cause for symptoms, it is difficult for many women (and some doctors) to understand the condition. We do know that it is not related to cancer. It will not spread to other parts your body and you will not pass it on to your partner. The main way that the condition is managed is with creams in the first instance.

Some cases of vestibulitis may be related to candida infection. In these cases a long course of ketoconazole cream (Nizoral) may help.

Steroid creams are often useful as in other skin conditions e.g. eczema. They vary in strength from weak to very potent. Usually a small amount of the cream or ointment is applied to the affected area a day (you may want to use a mirror). The use of steroid creams needs to be supervised as they can cause the skin to become to thin. Many women notice an irritation when they first use the creams. This can resolve with time but if it continues it is best to stop and use one of the other creams. Steroid creams should only be used on the advice of your doctor.

Zinc oxide cream is sometimes useful for women with vulval vestibulitis. Zinc may help to reduce the inflammation and increase healing.

Sometimes a tablet called amitryptilline (which is often used for people who are depressed)
may help the soreness. This is given in a very small dose at night. If you are prescribed this it is not because you are depressed!

Your doctor may also give you to a local anaesthetic cream or gel to use about 30-40 minutes before intercourse to see if it takes away the pain. When you first use the anaesthetic cream, you will probably experience a short spell of burning before things go numb. If this approach makes sex tolerable, then a simple operation called vestibulectomy may sort out your problem. This is an operation where the inflamed skin is removed and the area covered by the back wall of the vagina. This gives an excellent cosmetic result and cures or improves the problem in about 80% of women treated. It is not, however, a suitable treatment for all women with vestibulitis and women need to be selected carefully for surgery.

Treatment you can buy without prescription

Aqueous cream is a very bland plain emollient (soothing cream) that is usually used for treating dry cracked skin. It is perfume free and is therefore less likely to irritate than the steroid creams. Many women gain benefit using this cream as it soothes and rehydrates the skin. Some women keep the cream in the fridge as this helps even further. It can be used indefinitely and as frequently as you like. It is available without prescription. Other women have found that Aloe Vera Gel provides relief. Research from America has suggested that a diet low in oxalates (a salt present in the diet passed out in the urine) may be effective in women with vulval soreness. Oxalates can cause symptoms, as they are irritating to skin. We can provide you with a diet sheet so you can tell which foods are high in oxalate.

Medical treatment may not always give 100% relief from symptoms and you need to try several different treatments. On the other hand, spontaneous recovery, often after several years, happens in some women.

Advice following a Fenton’s Vestibulectomy

Why is it painful?

The area of the body where you have had surgery has a very good blood supply and also has many nerves. It is also very difficult to stop movement around the area, as a consequence, local bruising and swelling may occur and lead to quite a lot of local discomfort. This will be most likely in the first 2 weeks after surgery. The tenderness should gradually subside after that.

Helping with discomfort

During this period the discomfort can be eased with simple pain relief (paracetamol, Brufen, Voltarol) taken on a regular basis and the application of ice to the affected area (a small bag of frozen peas is quite good for this as it will mould to the area) 

There are no special dressings as these would just fall off, but it is important to keep the area clean and twice daily showering or bathing is recommended. You need not put anything in the bathwater, rather than using a towel to dry the area, you may use a hairdryer instead, and this usually is more comfortable. After the first week the swelling will be beginning to subside and you can now start to gently rub the oestrogen cream that you have been prescribed in to the area where the stiches are. This helps the skin to remain flexible and also the muscle around the vaginal opening to relax. A good time to rub oestrogen cream in is just after bathing.

The Stiches

After 2 weeks some of the stiches may start to fall out. This is entirely normal. There are 2 types of stitches in place. A quickly dissolving sort that come out between 2-4 weeks, and a more long lasting type that can last up to 3 months. The long lasting stiches have been put in to hold the vagina in to its new position. If necessary these can removed when you are next seen in clinic.

Infection

Superficial infection is very common indeed. If the area becomes infected it will be reddened, swollen and may be associated with a smelly discharge. Whilst this level of infection is relatively uncommon, even this will eventually heal with no serious after-effects. Your GP may wish to give you a course of antibiotics if he/she feels that the level of infection warrants this.

Back to normal

After 2 weeks most patients feel able to go about their routine-business without much or any discomfort and you should be able to go back to work if this is the case. Not everyone is the same however and some woman take a little longer to feel confident enough to return to work. You will have had an appointment arranged to re-attend the hospital for between 6-8 weeks after your surgery. Do not try to have sex or use tampons until that visit. If your remaining stiches are causing discomfort, apply some local anaesthetic cream that we gave you before the operation about an hour before your clinic appointment. This will make removing the remaining stiches easier.

Support groups and other resources

The Vulval Pain Society (VPS) provides women with information
on vulvodynia and other vulval disorders.

Vulval Pain Society
PO Box 514
Slough
Berks
SL1 2BP
UK

National lichen sclerosus support group:

http://www.hiway.co.uk/lichensclerosus/

Interstitial cystitis support group of the uk:

http://www.interstitialcystitis.co.uk/

National vulvodynia association:

http://www.nva.org/

Vulvar pain foundation:

http://vulvarpainfoundation.org/

Vulvodynia.com

Http://vulvodynia.com/

Interstitial cystitis association:

http://www.ichelp.com/

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