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Chronic Vestibulitis

Dyspareunia secondary to extremely tender skin at the vulvar introitus was described more than a century ago, yet the condition was relatively rare until recently. Although there are many causes of vulvar discomfort, chronic vestibulitis is characterized by 1) extreme pain at the introitus on penile entry; 2) erythema of the vulvar vestibule, most often in the 3-9 o'clock position; and 3) marked sensitivity of the introital skin to light touch. In most cases, the onset of the condition is relatively acute. The condition may last for months or years if treatment is not attempted.

There is no known etiology for this disease. Many different theories have been proposed, but none have yet been shown to be the cause of the disorder. The disease is not due to infection with HPV or herpes simplex virus. Disorders of oxalate excretion do not appear to be the cause. The disease is diagnosed by exclusion. That is, if the patient presents with the signs and symptoms noted above, and if there is no evidence of any other vulvar disease, the problem is labeled chronic vestibulitis.

As with all diseases of unknown etiology, treatment tends to be nonspecific and varied. Indeed, at least a dozen different therapies have been proposed and are currently being used by practitioners in the United States. Some women respond to each of these methods. In general, it is best to start with the simplest and least-invasive therapy first and proceed slowly.

Some women with this problem will respond to the topical application of 2% testosterone propionate or a progestin in petrolatum. These preparations tend to thicken the skin of the introitus and may cause improvement.

Although yeast organisms have never been shown to be the cause of this condition, up to one third of all patients will respond to the prolonged use of oral antifungal agents such as fluconazole or ketoconazole. Daily use of these agents for 3-6 months.

Some patients seem to become symptom free when placed on a low-oxalate diet. Although these individuals have not been shown to have any abnormality of oxalate excretion, it is possible that the introital skin is very sensitive to the occasional oxalate crystal that may be passed through the urine. Because oxalate crystals are very "pointed" (sharp on both ends).

Excision of the involved introital skin with primary closure of the defect has been reported. Unfortunately, since the success rate with this procedure is only 50-60%, surgery should be reserved for those cases in which medical therapy has been ineffective. While the cosmetic result is generally good, the patient should be fully informed before the procedure.

Recently, the use of the flashlamp-excited dye laser has been suggested for treatment of chronic vestibulitis. This laser is used by many dermatologists in the treatment of hemangiomas. The laser energy is absorbed by the color red. Theoretically, the destruction of the fine vessels that cause the erythema in this disease also destroys fine nerve endings that are responsible for the pain. This treatment can be accomplished in a clinic with the use of a topical local anesthetic.

Several therapies have been suggested in the past, but should no longer be used. Injection of the vulvar skin with saline or water solutions can lead to chronic ulceration and scarring. The technique has a very low success rate. The application of 5-fluorouracil cream often makes the patient's symptoms worse. Likewise, the use of the CO₂ laser to ablate the involved areas.