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Painful intercourse can be divided into two major categories:
Of the diagnoses associated with painful intercourse at the
entrance to the vagina, one of the most difficult to diagnose is
vulvar vestibulitis. Vestibulitis stands for inflammation of the
vestibule of the vagina which is the moist pink skin area just in front of the
hymen and goes to where the dry skin starts. It is usually less
than an inch (2 cm.) wide and extends from about 3 o'clock to 9
o'clock around the vaginal opening. In vulvar vestibulitis, this
area gets so sensitive that even touching it with a Q-tip (cotton-tipped
applicator stick) elicits moderate to severe pain.
The diagnosis is often missed because aside from some redness of
the skin and the pain, there are no signs of infection, bleeding,
discharge or any lesions that can be seen or felt. If a
vestibule biopsy is performed it only shows inflammatory cells and
slightly increased blood vessel supply under the microscope.
In a recent article, Westrom LV and Willen R: Vestibular nerve
proliferation in vulvar vestibulitis syndrome. Obstet Gynecol
1998;91:572-6, these authors did special nerve stains on the
biopsy tissue of vestibule skin. They found increased numbers of
nerve fibers present. These are similar findings to
what investigators have found in Crohn disease (an inflammatory
condition of the bowel) and interstitial cystitis (a chronic
inflammatory condition of the bladder which produces pain and
frequent urination without a bacterial infection present). The
increased number of nerve endings may explain the increased pain
that is present.
The significance of this report is that physicians may have a
new way of confirming their clinical impression of vulvar
vestibulitis by asking their pathologist to do a nerve stain
(S-100 immunostain was the one used in this study) on the biopsy
specimen in addition to the regular microscopic exam. If there
appears to be increased nerve proliferation on the biopsy
specimen, that would add certainty to the diagnosis. Keep in mind
that the doctor can make the diagnosis on just clinical findings.
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