From the Research
The prognosis for secondary or acquired provoked vestibulodynia is generally favorable with appropriate treatment, and the most effective treatment approach is multimodal physical therapy, as evidenced by the most recent and highest quality study 1.
Treatment Approach
The treatment of secondary or acquired provoked vestibulodynia typically involves a multimodal approach, including:
- Identifying and removing potential triggers such as hormonal contraceptives, treating any underlying infections, and discontinuing irritants
- Pelvic floor physical therapy to address muscle dysfunction, which has been shown to be more effective than topical lidocaine in reducing pain intensity and improving sexual function 1
- Topical medications like lidocaine 2-5% ointment applied before intercourse or nightly
- Low-dose tricyclic antidepressants (amitriptyline starting at 10mg nightly, gradually increasing to 50-75mg as tolerated)
- Topical estrogen (such as estradiol cream 0.01%, applied nightly for 4-6 weeks, then 2-3 times weekly) may help if there's vulvar tissue atrophy
- Psychological interventions including cognitive behavioral therapy can address pain-related anxiety and sexual dysfunction, and have been shown to be effective in reducing pain unpleasantness and improving sexual distress 2
Key Considerations
- Patients should expect gradual improvement with consistent treatment rather than immediate resolution
- The condition results from neuroproliferation and inflammation in vulvar tissues, often triggered by recurrent infections, hormonal changes, or trauma, leading to peripheral and central sensitization
- A successful treatment outcome is more likely in patients with fewer other concomitant pain conditions, and women with secondary provoked vestibulodynia may report major improvement or complete recovery to a higher extent than women with primary provoked vestibulodynia 3
Refractory Cases
- For refractory cases, nerve blocks with bupivacaine or surgical intervention (vestibulectomy) may be considered
- However, the effectiveness of these treatments is not well established, and more research is needed to determine their efficacy 4