Vestibulitis, irritative R20.8

Usually chronic, persistent or intermittent clinical picture characterized by localized or diffuse sensations affecting the entire vulva or burning pain in the vulva. Vulvodynia is analogous to other painful conditions such as glossodynia and proctodynia and can be assigned to the dynia symptom complex.

The causes are unknown. A multifactorial genesis is assumed. Organic vulva diseases must be excluded. After exclusion of an underlying disease, a somatoform disorder must be considered.

• The following causes are discussed:
  • Exogenous trauma or irritation
  • Local hyperergic reactions to bacterial or mycotic pathogens
  • allergic or irritant reactions to deodorants and/or soaps
  • High levels of oxalic acid in urine
  • Muscle spasms in the pelvic floor.

Exclusion of the dermatological diseases listed under differential diagnosis, if necessary by means of punch biopsy.

Duration of complaints over months/years

Clinically unremarkable vestibulum

Normal vaginal flora without neutrophil granulocytes.

No pathogens detectable

Provocation tests, e.g. Emla® cream (result after 30 minutes exposure time), can be used to show the special reaction readiness of the skin (e.g. in case of atopic diathesis) (Petersen 2005). This is also helpful for the patient as her somatic complaints are made credible.

Vulvous diseases that can cause similar complaints:

• Lichen sclerosus et atrophicus
• Lichen simplex chronicus (Vidal)
• psoriasis vulgaris
• lichen planus
• Irritant or allergic contact dermatitis
• Steroidal withdrawal syndrome
• Bacterial vaginosis.
• Herpes simplex
• Zoster
• Fungal diseases
• Trichomoniasis
• Fissures in the context of infections

• Exclusion of locally irritating substances.
• In case of acute irritation of the vulva after mechanical stress (riding, cycling), alleviation of symptoms by cooling with cold water or cool packs.
• For cyclically occurring complaints (cyclical vulvovaginitis), good results are achieved with oral long-term treatment with Fluconazole (e.g. Diflucan) despite frequent negative evidence of fungus. Fluconazole 150 mg/day p.o as one-day therapy once/week for 2 months. Alternatively: Fluconazole 150 mg/day p.o. as one-day therapy every 2nd week for 2 months.

• Treatment of a frequently existing depressive mood of the patient.
• Identification of other factors associated with the first appearance of the symptoms (change of partner, traumatic delivery, currently destructive local therapy). In these cases, accompanying psychosomatic care is indicated.

Lukewarm or cold sitting baths, if necessary with an antiphlogistic additive (e.g. Tannolact).

Long-term fat care of the intimate area before any mechanical strain on the skin with high-quality, neutral care products without additives.

It is important to convey to patients that progress can only be achieved in small steps. Experience has shown that a significant improvement can only be achieved after months or years through the chronicity of the symptoms (pain pathway).

• Use underwear with cotton
• Do not wear tight trousers
• Do not expose skin to wet swimsuits for long periods of time
• Do not use fabric softener for underwear
• Do not use shampoos, soaps or deodorants on the vulva
• Avoidance of activities that can lead to mechanical irritation of the vulva (riding, cycling, endurance running)
• Avoid swimming pools with strongly chlorinated water
• No topical local anesthetics.

Remember! A warning is given against probatory local treatment with antimycotic ointments, as this will tend to intensify the symptoms!

1. Aerts L et al (2015) Are primary and secondary provoked vestibulodynia two different entities? A comparison of pain, psychosocial, and sexual characteristics. J Sex Med 12:1463-1473
2. Akopians AL et al (2015) Vulvodynia: The Role of Inflammation in the Etiology of Localized Provoked Pain of the Vulvar Vestibule (Vestibulodynia). Semin Reprod Med 33:239-245.
3. Edwards L (2003) New concepts in vulvodynia. On J Obstet Gynecol 189: S24-30
4. Lester RA et al (2015) Provoked Vestibulodynia and the Health Care
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8. Sadownik LA et al (2012) Provoked vestibulodynia-women's experience of participating in a multidisciplinary vulvodynia program. J Sex Med 9:1086-1093.
9. Smart OC et al (2003) Vulvodynia. Curr Opin Obstet Gynecol 15: 497-500