Vestibulodynia

Vestibulodynia is a chronic pain condition involving the vulvar vestibule, the area surrounding the vaginal opening. The pain is typically provoked by touch, pressure, or insertion and persists for at least three months. Patients commonly report sharp or burning sensations with sexual activity, tampon use, or gynecologic exams, and there may be accompanying tenderness to light touch (cotton-swab test).

Vestibulodynia is most often classified as provoked vestibulodynia, a subtype where pain is elicited by contact and occurs without constant, spontaneous pain. A smaller proportion of cases may be non-provoked or generalized. The condition is frequently labeled under the broader term vulvodynia.

Etiology is not fully understood. Contributing factors may include altered nerve sensitivity (neuropathic pain), inflammatory processes, hormonal changes, vulvar tissue fragility, and pelvic floor muscle hypertonicity. The interaction of biological, genetic, hormonal, and psychosocial factors is considered in most models. The onset may follow local infections, irritation from products, or childbirth; in many cases no clear trigger is identified.

Diagnosis relies on medical history and physical exam, particularly a cotton-swab test to map pain in the vestibule, and by excluding other vulvar disorders such as infections, dermatitis, lichen sclerosus, or vulvar cancer. Imaging or biopsy is rare and reserved for suspicious findings.

Management is typically multidisciplinary. Treatments include pelvic floor physical therapy, topical anesthetics (for example, lidocaine), and avoidance of irritants. Pharmacologic options include low-dose antidepressants or anticonvulsants, and hormonal therapy if vaginal atrophy is present. Psychological support and sex therapy are commonly recommended. Surgical vestibulectomy is only considered for severe, refractory cases after conservative therapies fail, and outcomes are variable. Prognosis varies; many patients improve with a combination of therapies, but some experience persistent symptoms.