What are the treatment options for vulvar vestibulitis?

Treatment Options for Vulvar Vestibulitis

Vulvar vestibulitis syndrome requires a multimodal treatment approach, with topical lidocaine being the most effective first-line treatment based on the most recent evidence. 1, 2

Symptoms and Diagnosis

Vulvar vestibulitis syndrome (VVS) is characterized by:

• Severe pain with attempted vaginal penetration
• Pain with pressure applied to the vestibule
• Erythema and tenderness of the vulvar vestibule
• Significant impact on sexual function and quality of life

Treatment Algorithm

First-Line Treatments:

1. Topical Lidocaine Therapy

   • Nightly application of 5% lidocaine ointment has shown significant effectiveness 1
   • Apply to the vestibule nightly for approximately 7 weeks
   • Results show 76% of women regain ability to have intercourse compared to 36% before treatment
   • Significant reduction in intercourse-related pain scores (39.11 point reduction on 100mm VAS)

2. Physical Therapy and Biofeedback

   • Addresses pelvic floor muscle dysfunction which is common in VVS 3
   • Women with VVS demonstrate:
     • Vaginal hypertonicity
     • Lack of vaginal muscle strength
     • Restriction of vaginal opening
   • EMG biofeedback has shown significant improvement in pain thresholds and sexual functioning 2

Second-Line Treatments:

1. Novel Drug Delivery Systems

   • Mucoadhesive biodissolvable thin films containing lidocaine 4
   • Two formulations available:
     • Rapid release (<5 minutes) for use prior to intercourse
     • Long-acting release (≥120 minutes) for prolonged relief throughout the day

2. Surgical Intervention

   • Consider for patients who fail conservative treatments 5
   • Vestibulectomy techniques have evolved over time
   • Generally effective but should be reserved for refractory cases
   • Lack of randomized trials and insufficient data on complication rates

Special Considerations

For Severe Cases

• Consider combination therapy with both topical lidocaine and physical therapy 2
• A randomized study showed both treatments were effective with no significant differences between them at 12-month follow-up

For Cases with Comorbidities

• Women with interstitial cystitis and other vulvar conditions may be less responsive to lidocaine therapy 1
• These patients may require more specialized and intensive treatment approaches

Common Pitfalls to Avoid

1. Inadequate duration of treatment

   • Topical lidocaine requires consistent nightly application for approximately 7 weeks
   • Short-term or episodic use may not provide sufficient relief

2. Overlooking pelvic floor dysfunction

   • Pelvic floor pathology appears to be reactive in nature and should be addressed 3
   • Treatment must recognize the conditioned, protective muscle guarding response

3. Premature progression to surgery

   • Conservative treatments should be exhausted before considering surgical options
   • Surgery should be viewed as a last resort for refractory cases

4. Failure to address psychological aspects

   • VVS impacts quality of life and psychosocial adjustment
   • Comprehensive treatment should include attention to these dimensions

By following this treatment algorithm and addressing both the physical and psychological aspects of vulvar vestibulitis, most patients can achieve significant improvement in symptoms and quality of life.