Do you know about the vulval vestibule?

In today's episode, I delve into the intricate anatomy of the vulvar vestibule and its significance in sexual health. I discuss how this unique area, formed from the endodermis, contains an increased concentration of nerve endings which can result in heightened sensitivity and pain for some individuals.

I explain the curious case where patients with too many nerve endings at the vestibule also report an unusual sensitivity at their belly button upon touch. Additionally, I touch upon neuroproliferative vestibulodynia, a condition that can be acquired due to inflammation or allergies, leading to hypertonic pelvic floor muscles and even secondary vaginismus.

I emphasize the complexity of treating such conditions, noting that while therapies targeting vaginismus and pelvic floor issues can be effective, they may not entirely eliminate the pain. I recommend a q-tip test for severe pain evaluation and a vestibular anesthesia test using topical anesthetics for diagnosis.

It's worth noting that many patients, after treatment, report a significant pain reduction in their vestibule, which can be initially triggered by activities such as wearing tight clothes or swimming.

Options for treatment, I mention include pelvic floor therapy, topical anesthetic agents, and capsaicin—known for its receptor desensitization properties. For severe cases, vestibulectomy is a surgical option, where the entire vestibule is removed, replaced with a vaginal flap, and followed by a recovery phase that includes pelvic floor therapy and potentially vaginal botox administration, eventually allowing for pain-free sexual experiences.

Throughout the episode, I stress the importance of pelvic floor therapy in comprehensively managing sexual pain and vaginismus, the utility of cognitive behavioral therapy, and the value of mind-body connection techniques as outlined in 'The Pleasure Prescription.'

I share how challenging it can be for patients to navigate sexual pain but also provide hope and point to resources available for assistance, including directing listeners to a website where clinicians are available to aid in dealing with sexual pain.

Furthermore, I advocate for patient education and empowerment in handling their own sexual health needs. I also clarify the causes of vestibulodynia by highlighting its sensitivities and hormone-related fluctuations. I discuss the three main categories—hormonally mediated, neuroproliferative, and inflammatory—each with distinct diagnostic markers and symptoms, like the hormonal deficiencies leading to vulvar tissue changes in hormonally mediated vestibulodynia.

Additionally, I address the impact of birth control pills on sexual health, and potentially necessary genetic need for more testosterone in some patients. I pinpoint other medications and conditions that can result in hormonal deficiencies and underline how these deficiencies can manifest in symptoms like dryness, urinary frequency, UTIs, and pain during sexual activity.

In treating pelvic pain, I describe the approach of assessing pain on a scale of one to ten and considering hormonal levels via blood work. The treatment strategy includes a biopsychosocial approach, combining pelvic floor therapy, cognitive behavioral therapy, and sex therapy. Special attention is given to patients with a history of lifelong pelvic pain and trauma, recognizing their uniquely complex treatment needs.

I round up the episode by reaffirming my commitment as a board-certified gynecologist and an advocate for health issues often stigmatized and shamed, with a focus on educating and addressing conditions related to painful sex and the side effects of contraception on libido. My aim is to equip my listeners with knowledge and empathy towards these delicate health matters.

Mentioned:

The Pleasure Prescription

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