From the Guidelines
Vestibulodynia treatment should prioritize a multimodal approach, starting with topical medications such as lidocaine 5% ointment, and progressing to oral medications like amitriptyline for neuropathic pain management, as this approach has been shown to be effective in reducing symptoms and improving quality of life 1. The causes of vestibulodynia are multifactorial, often including:
- Nerve irritation or damage
- Pelvic floor muscle dysfunction
- Hormonal factors, particularly low estrogen states
- Inflammatory processes
- Psychological factors that can amplify pain perception Treatment usually begins with conservative measures, such as:
- Avoiding irritants like soaps and detergents
- Wearing cotton underwear
- Using lubricants during intercourse Topical medications are often first-line treatments, including:
- Lidocaine 5% ointment, as recommended by the British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018 1
- Low-dose topical estrogen for those with hormonal influences Oral medications may include:
- Tricyclic antidepressants like amitriptyline, starting at a low dose and gradually increasing as tolerated, as suggested by the guidelines for the management of lichen sclerosus 1
- Anticonvulsants such as gabapentin
- SNRIs like duloxetine Pelvic floor physical therapy is crucial, typically involving 8-12 weekly sessions focusing on:
- Muscle relaxation techniques
- Trigger point release
- Dilator therapy For refractory cases, nerve blocks with bupivacaine or surgical interventions like vestibulectomy may be considered, as well as psychological support through cognitive behavioral therapy to manage pain perception and associated anxiety or depression 1.
From the Research
Causes of Vestibulodynia
- The exact causes of vestibulodynia are not fully understood, but studies suggest a multifactorial etiology, including hormonal effects, muscle dysfunction, personality, psychosocial factors, and inflammatory mediators 2.
- Both peripheral and central sensitization to pain have been implicated in the development of enhanced pain experienced by women with vestibulodynia 2.
- Vulvar hyperesthesia associated with pelvic floor muscle dysfunction is present in most cases of vestibulodynia, and vulvar erethism is also common 3.
- Comorbid pain or psychologic conditions are common in women with vestibulodynia, with at least one comorbid condition identified in nearly half of patients 3.
Treatments for Vestibulodynia
- Traditional therapies for vestibulodynia include topical medications and centrally acting oral medications, but these have not been well studied and few prospective placebo-controlled trials exist 2.
- Cognitive behavioral therapy and physical therapy/surface electromyographic biofeedback may be beneficial in the treatment of vestibulodynia, particularly in cases with pelvic floor muscle dysfunction 2.
- Botulinum toxin injections have been shown to be effective in reducing pain and improving quality of life in women with vestibulodynia, particularly in cases with muscular hyperactivity 4, 5, 6.
- Surgery may be an option for women with vestibulodynia who have failed to respond to traditional therapy, with success rates of 60% to 90% 2.
- Pelvic floor physiotherapy with biofeedback and amitriptyline may also be beneficial in the treatment of vestibulodynia, with some studies showing significant improvements in pain and quality of life 3.