Some women have had pain since their first penetration (primary vulvar vestibulitis) while some have had it after a period of time with pain-free penetration (secondary vulvar vestibulitis). Relationship problems often occur as the result of chronic frustration, disappointment, and depression associated with the condition. Causes
Little is known about the cause of vestibulodynia. A number of causes may be involved, including subclinical human papillomavirus infection, chronic recurrent candidiasis, or chronic recurrent bacterial vaginosis.Muscular causes have been implicated as well, since chronic vulvar pain may be the result of chronic hypertonic perivaginal muscles, leading to vaginal tightening and subsequent pain. Some investigators have postulated the existence of neurological causes, such as vestibular neural hyperplasia. In vestibulodynia the nerves of the vulva transmit signals of pain when they normally should indicate touch, pressure, heat, or stretch. Normal sensations are processed by the brain as abnormal, which result in a heightened sensitivity, i.e. hyperalgesia. Finally, psychological factors may contribute to or exacerbate the problem, since the anticipation of pain often results in a conditioned spasmodic reflex along with sexual desire and arousal problems. Diagnosis
Diagnosis is readily made by the cotton-swab test, in which pressure is applied in a circular fashion around the vulvar vestibule to assess complaints of pain. Laboratory tests are used to exclude bacterial, viral or yeast infection, and a careful examination of the vulvovaginal area is conducted to assess whether any atrophy is present. Treatment
Treatment consists of general advice about hygiene and sexual behaviour, pelvic floor and desensitisation exercises, and psychological treatment by a multidisciplinary team.
Though proximity to open watersheds was linked to incidence in some areas, suggesting that outdoor activity within the city may be connected to many cases, there is also an increasing body of evidence that even the interiors of buildings may be risk areas. An early case concerned a prisoner who was confined to prison during the whole of his likely blastomycotic incubation period. An epidemiological survey found that although many patients who contracted blastomycosis had engaged in fishing, hunting, gardening, outdoor work and excavation, the most strongly linked association in patients was living or visiting near waterways. Based on a similar finding in a Louisiana study, it has been suggested that place of residence might be the most important single factor in blastomycosis epidemiology in north central Wisconsin. Follow-up epidemiological and case studies indicated that clusters of cases were often associated with particular domiciles, often spread out over a period of years, and that there were uncommon but regularly occurring cases in which pets kept mostly or entirely indoors, in particular cats, contracted blastomycosis. The occurrence of blastomycosis, then, is an issue strongly linked to housing and domestic circumstances. Seasonal trends
Seasonality and weather also appear to be linked to contraction of blastomycosis. Many studies have suggested an association between blastomycosis contraction and cool to moderately warm, moist periods of the spring and autumn or, in relatively warm winter areas. However, the entire summer or a known summer exposure date is included in the association in some studies. Occasional studies fail to detect a seasonal link.