DEFINITION

VVS is a chronic (>6 months) inflammation of the vestibular glands, located at the entrance of the vagina (the vestibule). It is characterized by erythema (redness) and severe pain elicited only by touch. The main presenting symptoms of patients with VVS is dyspareunia (painful vaginal intercourse) and terminal dysuria (vulvar burning caused by urination).

INCIDENCE

It is reported that up to 15% of women in private gynecologic practices suffer from VVS. It can affect women of all ages, but is most common in the 18-45 years age group. Afflicted patients are often misdiagnosed, have had the symptoms for many years, and have seen several doctors before their condition is properly diagnosed.

ETIOLOGY

1. Anatomical variations: Women with a narrow vaginal introitus and short perineums (space between vagina and rectum) are more liable to suffer from tearing and scarring of the vestibule during sex. The vestibular glands are subjected to intense friction, often resulting in subsequent inflammation.

2. The Human Papilloma Virus (HPV): HPV (the same virus that causes genital warts and cervical dysplasia) has also been shown to be associated with VVS. Patients documented to have this condition, may benefit from interferon (antiviral) therapy.

3. Recurrent vaginitis: Patients with recurrent candidal vaginitis (yeast infection) or cytolytic vaginitis (due to an overgrowth of lactobacilli) may be at an increased risk of developing VVS.

4. Chemical or surgical trauma: Extensive laser vaporization of the vulva or the local application of such chemicals as acetic acid, podophyllin, podofilox, or imiquimod ( commonly used for genital warts) can initiate the inflammation of the vestibular glands. The same may occur after surgical trauma, e.g. episiotomy.

5. Allergens/Irritants: A large percentage of patients with VVS suffers also from seasonal and food allergies, pointing to the possibility that allergens may play a role in this ailment. Women using scented tampons, soaps, or detergents , as well as non-cotton underwear, are thought to be at a higher risk for developing VVS.

6. Oxalates in urine: A high concentration of oxalate crystals in the urine, has been shown in one study to possibly exacerbate VVS. Placing these patients on a low oxalate diet, coupled with the intake of calcium citrate tablets (which bind the oxalate crystals) may help.

ASSOCIATED CONDITIONS

A number of conditions are associated with VVS. Some can be present simultaneously, while others can precede or follow it.

1. Cervicitis: Inflammation or infection of the cervix often results in leukorrhea (discharge) that can further irritate the vestibular glands and result in further worsening of the condition. Treatment of these patients with antibiotics or cryotherapy is usually helpful.

2. Vulvitis: Not uncommonly VVS presents itself as part of a generalyzed inflammation of the vulva (vulvitis). Although the acute onset vulvitis usually responds readily to therapy, the inflammation of the vestibular glands may persist.

3. Interstitial cystitis: Almost one out of four interstitial cystitis patients suffers concurrently from VVS. This is not surprising, considering the fact that both the bladder and the vulva are derived from the same embryonic cells (endoderm).

4. Vaginismus: Most patients with long lasting dyspareunia secondary to VVS, develop vaginismus (involuntary painful contraction of the vaginal muscles upon penetration of the vagina). After the VVS has been successfully treated (either medically or surgically), the patient has to be helped to overcome her vaginismus with the use of dilators and vaginal relaxation exercises.

5. Emotional stress / Marital disharmony: The severe dyspareunia that always accompanies VVS, prevents loving couples from having sexual intercourse. When this condition persists for years, it often results in some degree of stress, depression, and marital disharmony. Psychosexual therapy is often helpful in providing guidance and support during this period of crisis.

6. Vulvar cancer: Vulvar biopsies obtained from patients with chronic vulvar irritation, occasionally reveal vulvar cancer (Vulvar Intraepithelial Neoplasia). The incidence is higher among patients infected with the HPV.