Examining the Evidence
Topical lidocaine eases pain of vulvar vestibulitis
To assess the efficacy of nightly 5% lidocaine ointment for vulvar vestibulitis.
After 7 weeks of treatment, 76% of 61 women were able to have intercourse, compared with 36% before therapy (P = .002). The intercourse-related pain score—based on a 100-mm visual analog scale—was 39.11 points lower after treatment (95% confidence interval [CI] 30.39–47.83; P<.001), with a decrease of 10.37 points in the daily pain score (95% CI 3.53–17.21; P = .004). Although few patient characteristics predicted treatment response, women with interstitial cystitis and other vulvar conditions were least likely to benefit.
Vulvar vestibulitis, a perplexing syndrome of chronic burning/pain with few overt physical findings, has repsonded poorly to medical therapies. When these fail, the only treatment demonstrated to give any improvement is surgical excision of the vestibule, a rather extreme treatment with side effects that can be severe.
Recently, less invasive vestibulitis treatments have been described, with rates of improvement that approach those of surgical excision. For example, Murina and colleagues1 showed that repeated submucous vestibular injection of lidocaine and methylprednisolone yields substantial improvement in 68% of subjects, a rate similar to that of vestibulectomy—without the side effects.
Now Zolnoun et al report that a topical lidocaine application, even less invasive than submucosal injections, leads to a similar rate of improvement. Patients applied lidocaine 5% ointment to the vestibule via a saturated cotton ball every night and removed it about 8 hours later. Side effects were limited to transient burning at the application site in some patients.
Findings confirm anecdotal evidence. Local lidocaine application is one of several vestibulitis therapies that heretofore was supported only by anecdotal evidence. Zolnoun and colleagues are to be complimented for summarizing patient outcomes, which make it possible for us to quote benefits and risks for topical lidocaine ointment to our patients.
Weaknesses. Investigators failed to include a control group, but many reports of vestibulitis therapies suffer from this shortcoming. However, the history of severe, persistent vestibular pain in the patients in this study makes it unlikely that their pain abated from the emollient effects of the petrolatum base. It will be interesting to see how this treatment fares in a randomized controlled trial.
In light of the safety, simplicity, and low expense of topical lidocaine, it seems reasonable to consider its use in patients with pain isolated to the vestibule who have achieved a normal pattern of vaginal flora free of fungal organisms.
A 2-month trial certainly should be considered before resorting to more drastic treatments such as vestibulectomy.
1. Murina F, Tassan P, Roberti P, Bianco V. Treatment of vulvar vestibulitis with submucous infiltrations of methylprednisolone and lidocaine. An alternative approach. J Reprod Med. 2001;46:713-716.