Autonomic neurophysiologic implications of disorders comorbid with bladder pain syndrome vs myofascial pelvic pain.

AIMS: The neuropathophysiology of a debilitating chronic urologic pain condition, bladder pain syndrome (BPS), remains unknown. Our recent data suggests withdrawal of cardiovagal modulation in subjects with BPS, in contrast to sympathetic nervous system dysfunction in another chronic pelvic pain syndrome, myofascial pelvic pain (MPP). We evaluated whether comorbid disorders differentially associated with BPS vs MPP shed additional light on these autonomic differences. METHODS: We compared the presence and relative time of onset of 27 other medical conditions in women with BPS, MPP, both syndromes, and healthy subjects. Analysis included an adjustment for multiple comparisons. RESULTS: Among 107 female subjects (BPS alone = 32; BPS with MPP = 36; MPP alone = 9; healthy controls = 30), comorbidities differentially associated with BPS included irritable bowel syndrome (IBS), dyspepsia, and chronic nausea, whereas those associated with MPP included migraine headache and dyspepsia, consistent with the distinct autonomic neurophysiologic signatures of the two disorders. PTSD (earliest), anxiety, depression, migraine headache, fibromyalgia, chronic fatigue, and IBS usually preceded BPS or MPP. PTSD and the presence of both pelvic pain disorders in the same subject correlated with significantly increased comorbid burden. CONCLUSIONS: Our study suggests a distinct pattern of comorbid conditions in women with BPS. These findings further support our hypothesis of primary vagal defect in BPS as compared with primary sympathetic defect in MPP, suggesting a new model for chronic these pelvic pain syndromes. Chronologically, PTSD, migraine, dysmenorrhea, and IBS occurred early, supporting a role for PTSD or its trigger in the pathophysiology of chronic pelvic pain.

Incidence and Risk Factors for Pelvic Pain After Mesh Implant Surgery for the Treatment of Pelvic Floor Disorders.

STUDY OBJECTIVE: Our aim was to assess incidence and risk factors for pelvic pain after pelvic mesh implantation. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Single university hospital. PATIENTS: Women who have undergone surgery with pelvic mesh implant for treatment of pelvic floor disorders including prolapse and incontinence. INTERVENTIONS: Telephone interviews to assess pain, sexual function, and general health. MEASUREMENTS AND MAIN RESULTS: Pain was measured by the McGill Short-Form Pain Questionnaire for somatic pain, Neuropathic Pain Symptom Inventory for neuropathic pain, Pennebaker Inventory of Limbic Languidness for somatization, and Female Sexual Function Index (FSFI) for sexual health and dyspareunia. General health was assessed with the 12-item Short-Form Health Survey. Among 160 enrolled women, mean time since surgery was 20.8 ± 10.5 months, mean age was 62.1 ± 11.2 years, 93.8% were white, 86.3% were postmenopausal, and 3.1% were tobacco users. Types of mesh included midurethral sling for stress incontinence (78.8%), abdominal/robotic sacrocolpopexy (35.7%), transvaginal for prolapse (6.3%), and perirectal for fecal incontinence (1.9%), with 23.8% concomitant mesh implants for both prolapse and incontinence. Our main outcome, self-reported pelvic pain at least 1 year after surgery, was 15.6%. Women reporting pain were younger, with fibromyalgia, worse physical health, higher somatization, and lower surgery satisfaction (all p < .05). Current pelvic pain correlated with early postoperative pelvic pain (p < .001), fibromyalgia (p = .002), worse physical health (p = .003), and somatization (p = .003). Sexual function was suboptimal (mean FSFI, 16.2 ± 12.1). Only 54.0% were sexually active, with 19.0% of those reporting dyspareunia. CONCLUSION: One in 6 women reported de novo pelvic pain after pelvic mesh implant surgery, with decreased sexual function. Risk factors included younger age, fibromyalgia, early postoperative pain, poorer physical health, and somatization. Understanding risk factors for pelvic pain after mesh implantation may improve patient selection.

Anatomic variability of the lateral femoral cutaneous nerve: Value of 3T MRI in identifying anomaly for surgical intervention.

The anatomic variability of the lateral femoral cutaneous nerve (LFC) creates diagnostic as well as therapeutic problems. A case is reported in which a woman with complaints of pain in the anterior and lateral thigh was referred for evaluation. Symptoms arose after an abdominal hysterectomy. Her symptoms were the territory of the LFC and not of the L2/L3 dermatome. She had a Tinel sign that was positive for the LFC skin territory, but this was located over the anterior superior iliac spine (ASIS), instead of medial to it. For this reason, a 3-Tesla MR neurography imaging was obtained. This showed the LFC as crossing over the ASIS, instead of being located either within or beneath the inguinal ligament. MRI imaging facilitated successful surgical treatment. This is the first report of the MR neurography and intraoperative appearance of this least common anatomic course for the LFC.

2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia.

INTRODUCTION: In 2014, the Executive Council of the International Society for the Study of Vulvovaginal Disease (ISSVD), the Boards of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS) acknowledged the need to revise the current terminology of vulvar pain, based on the significant increase in high quality etiologic studies published in the last decade. METHODS: The new terminology was achieved in four steps. The first involved a terminology consensus conference with representatives of the three societies, held in April 2015. Then, an analysis of the relevant published studies was used to establish a level of evidence for each factor associated with vulvodynia. The terminology was amended based on feedback from members of the societies. Finally, each society's board accepted the new terminology. RESULTS AND CONCLUSION: In 2015, the ISSVD, ISSWSH, and IPPS adopted a new vulvar pain and vulvodynia terminology that acknowledges the complexity of the clinical presentation and pathophysiology involved in vulvar pain and vulvodynia, and incorporates new information derived from evidence-based studies conducted since the last terminology published in 2003.

2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia.

INTRODUCTION: In 2014, the executive council of the International Society for the Study of Vulvovaginal Disease, the boards of directors of the International Society for the Study of Women's Sexual Health, and the International Pelvic Pain Society acknowledged the need to revise the current terminology of vulvar pain, on the basis of the significant increase in high-quality etiologic studies published in the last decade. MATERIALS AND METHODS: The new terminology was achieved in the following 4 steps. The first involved a terminology consensus conference with representatives of the 3 societies, held in April 2015. Then, an analysis of the relevant published studies was used to establish a level of evidence for each factor associated with vulvodynia. The terminology was amended on the basis of feedback from members of the societies. Finally, each society's board accepted the new terminology. RESULTS AND CONCLUSIONS: In 2015, the International Society for the Study of Vulvovaginal Disease, International Society for the Study of Women's Sexual Health, and International Pelvic Pain Society adopted a new vulvar pain and vulvodynia terminology that acknowledges the complexity of the clinical presentation and pathophysiology involved in vulvar pain and vulvodynia, and incorporates new information derived from evidence-based studies conducted since the last terminology published in 2003.

The Evidence-based Vulvodynia Assessment Project. A National Registry for the Study of Vulvodynia.

OBJECTIVE: To create a national registry for the study of vulvodynia in order to enhance classification of vulvodynia based on multiple phenotypic domains such as pain characteristics, clinical examination, sexual function, psychological functioning, and distress. STUDY DESIGN: Methodology for this prospective cohort registry was institutional review board approved and implemented at 8 enrollment sites starting in 2009. Women underwent gynecologic evaluation and pressure sensory testing for assessment of pain sensitivity in the vaginal mucosa and vaginal muscles. Psychometric questionnaires were used to assess self-described pain, distress, sexual function, and quality of life. RESULTS: More than 300 women were enrolled and 176 charts were analyzed. This cohort had a median age of 29 years and median pain duration of 25.5 months. A total of 84% of participants were previously or currently sexually active in spite of pain. The most common pain comorbidities reported by the women were migraines (34%), chronic pelvic pain (22%), and irritable bowel syndrome (20%). Anxiety affected 41% of the cohort. More than 90% presented with localized vestibular pain, and 90% had muscular examination abnormalities. CONCLUSION: A national registry for the study of vulvodynia was established with successful enrollment of participants at 8 sites. In addition to the cotton swab evaluation for vulvar allodynia, women with vulvar chronic pain should also be routinely screened for musculoskeletal dysfunction, emotional distress with specific emphasis on anxiety, and comorbid pain conditions.

Trends in pharmacy compounding for women's health in North Carolina: focus on vulvodynia.

OBJECTIVES: To identify trends in compounding pharmacies with a focus on women's health and, more specifically, the types and combinations of medications used in the treatment of vulvodynia. METHODS: This survey study was conducted with 653 nonchain pharmacies that compound medications. Each pharmacy was asked to complete a 19-item online survey assessing general practice and common compounding indications, focusing on women's health. RESULTS: Of the 653 pharmacies contacted, 200 (31%) responded to our survey. Women's health issues ranked third (19%) among the common indications for compounding, preceded by otolaryngology (30%) and dermatology (28%). Of the medications compounded for women's health, the most common indication was bioidentical hormone therapy (73%) followed closely by vaginal dryness (70%) and low libido (65%). Vulvodynia, or vulvar pain, was the fourth most common indication for compounding medication for women's health issues (29%). Vulvovaginal infections were reported as an indication for compounding medications by 16% of respondents. CONCLUSIONS: Vulvovaginal symptoms are a common indication for compounding medications in women's health. Further research in understanding the rationale for using compounded medications, even when standard treatments are available for some of these symptoms (eg, vaginal dryness, vulvovaginal infections), is warranted.

Superimposed methicillin-resistant Staphylococcus aureus infection of vulvar eczematous dermatitis: a case report.

BACKGROUND: Vulvar eczematous dermatitis predisposes patients to superimposed infections, which may result in late diagnosis and architectural destruction. Methicillin-resistant Staphylococcus aureus (MRSA) infection is on the rise in genitalia and lower extremities. CASE: A 44-year-old woman presented with recurrent vulvar lesions and pain. A diagnosis of MRSA in the setting of eczema was achieved with concomitant use of photography and dermatopathologic review. Antibiotics were tailored to the resistant infection and preventative moisturization therapy was utilized. CONCLUSION: Awareness of dermatologic conditions affecting the vulva is principal in routine gynecologic care. Barrier protection of eczematous vulvar skin may prevent superficial infections. The regular use of photographic documentation and dermatopathology may decrease time to diagnosis with infrequent or rare conditions.

Bilateral accessory breast tissue of the vulva: a case report introducing a novel labiaplasty technique.

INTRODUCTION: We present the case of a 23-year-old female with bilateral ectopic breast tissue of the vulva, the repair of which necessitated a novel labiaplasty technique. Labiaplasty is becoming an increasingly frequent cosmetic procedure, and the popularity of brief didactic labiaplasty courses has risen in response to consumer demand. There is a paucity of detailed anatomic description of female sensory innervation patterns to the clitoris and surrounding structures. This places patients at risk for denervation of clitoral structures during labiaplasty procedures. Our novel technique proposes a method of individualized patient neurosensory mapping preoperatively, which allows for surgical planning to avoid injury to the sensory branches of the dorsal clitoral nerve. METHODS: A 23-year-old female presented with bilateral vulvar masses that involved the clitoral complex, which had first become apparent during the second trimester of pregnancy, and failed to resolve in the postpartum period. We describe the preoperative planning and intraoperative approach and dissection to labiaplasty in this patient, which was complex given the size of the masses, and specifically designed to avoid injury to sensory branches of the dorsal clitoral nerve. DISCUSSION: As labiaplasty becomes more common, it is important to approach labiaplasty patients with a detailed understanding of the sensory innervation of the clitoris and surrounding structures, to avoid nerve injury and resultant sexual dysfunction. Traditional labiaplasty approaches may violate the sensory innervation patterns of the clitoral region, thus causing a sensory loss that affects patient sexual function. Our novel approach to preoperative clitoral nerve sensory mapping provides an alternative method of labiaplasty that may avoid denervation injury.

Association of Hormonal Contraceptive Use with Headache and Temporomandibular Pain: The OPPERA Study.

AIMS: To determine the relationship between hormonal contraceptive (HC) use and painful symptoms, particularly those associated with headache and painful temporomandibular disorders (TMD). METHODS: Data from the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) prospective cohort study were used. During the 2.5-year median follow-up period, quarterly health update (QHU) questionnaires were completed by 1,475 women aged 18 to 44 years who did not have TMD, menopause, hysterectomy, or hormone replacement therapy use at baseline. QHU questionnaires evaluated HC use, symptoms of headache and TMD, and pain of ≥ 1 day duration in 12 body regions. Participants who developed TMD symptoms were examined to classify clinical TMD. Headache symptoms were classified based on the International Classification of Headache Disorders 3 (ICHD-3). Associations between HC use and pain symptoms were analyzed using generalized estimating equations and Cox models. RESULTS: HC use, endorsed in 33.7% of QHU questionnaires, was significantly associated with concurrent symptoms of TMD (odds ratio [OR]: 1.20, 95% CI: 1.06 to 1.35) and headache (OR: 1.26, 95% CI: 1.11 to 1.43). HC use was also significantly associated with concurrent pain of ≥ 1 day duration in the head (OR: 1.38, 95% CI: 1.16 to 1.63), face (OR: 1.44, 95% CI: 1.13 to 1.83), and legs (OR: 1.22, 95% CI: 1.01 to 1.47), but not elsewhere. Initiation of HC use was associated with increased odds of subsequent TMD symptoms (OR: 1.37, 95% CI: 1.13 to 1.66) and pain of ≥ 1 day in the head (OR: 1.37, 95% CI: 1.01 to 1.85). Discontinuing HC use was associated with lower odds of subsequent headache (OR: 0.82, 95% CI: 0.67 to 0.99). HC use was not significantly associated with subsequent onset of examiner-classified TMD. CONCLUSION: These findings imply that HC influences craniofacial pain, and that this pain diminishes after cessation of HC use.

A genetic polymorphism that is associated with mitochondrial energy metabolism increases risk of fibromyalgia.

Alterations in cellular energy metabolism have been implicated in chronic pain, suggesting a role for mitochondrial DNA. Previous studies reported associations of a limited number of mitochondrial DNA polymorphisms with specific pain conditions. In this study, we examined the full mitochondrial genomes of people with a variety of chronic pain conditions. A discovery cohort consisting of 609 participants either with or without a complex persistent pain conditions (CPPCs) was examined. Mitochondrial DNA was subjected to deep sequencing for identification of rare mutations, common variants, haplogroups, and heteroplasmy associated with 5 CPPCs: episodic migraine, irritable bowel syndrome, fibromyalgia, vulvar vestibulitis, or temporomandibular disorders. The strongest association found was the presence of the C allele at the single nucleotide polymorphism m.2352T>C (rs28358579) that significantly increased the risk for fibromyalgia (odds ratio [OR] = 4.6, P = 4.3 × 10). This relationship was even stronger in women (OR = 5.1, P = 2.8 × 10), and m.2352T>C was associated with all other CPPCs in a consistent risk-increasing fashion. This finding was replicated in another cohort (OR = 4.3, P = 2.6 × 10) of the Orofacial Pain: Prospective Evaluation and Risk Assessment study consisting of 1754 female participants. To gain insight into the cellular consequences of the associated genetic variability, we conducted an assay testing metabolic reprogramming in human cell lines with defined genotypes. The minor allele C was associated with decreased mitochondrial membrane potential under conditions where oxidative phosphorylation is required, indicating a role of oxidative phosphorylation in pathophysiology of chronic pain. Our results suggest that cellular energy metabolism, modulated by m.2352T>C, contributes to fibromyalgia and possibly other chronic pain conditions.

Evaluation and treatment of dyspareunia.

Dyspareunia affects 8-22% of women at some point during their lives, making it one of the most common pain problems in gynecologic practice. A mixture of anatomic, endocrine, pathologic, and emotional factors combine to challenge the diagnostic, therapeutic, and empathetic skills of the physician. New understandings of pain in general require new interpretations concerning the origins of pain during intercourse, but also provide new avenues of treatment. The outcomes of medical and surgical treatments for common gynecologic problems should routinely go beyond measures of coital possibility, to include assessment of coital comfort, pleasure, and facilitation of intimacy. This review will discuss aspects of dyspareunia, including anatomy and neurophysiology, sexual physiology, functional changes, pain in response to disease states, and pain after gynecologic surgical procedures.

Open-label trial of lamotrigine focusing on efficacy in vulvodynia.

OBJECTIVE: Chronic pelvic pain (CPP) affects 15% of women and has a high rate of psychiatric comorbidity. Vulvodynia, a vulvar pain syndrome that includes vulvar vestibulitis, is the most common subtype of CPP. This study examined the efficacy of lamotrigine for the treatment of CPP using an open-label design. STUDY DESIGN: Forty-three women with CPP were recruited from a specialty pelvic pain clinic. Of these, 31 completed 8 weeks of active treatment. Outcome variables included the McGill Pain Rating Index and subscales of pain intensity and the Hamilton Depression and Anxiety Rating Scales. RESULTS: We found significant reductions in all pain and mood measures at the 8-week visit compared to baseline. In particular, women with vulvodynia-type CPP (N = 17) had robust reductions in pain and mood symptoms. CONCLUSION: CPP is a heterogeneous disorder, with psychiatric comorbidity and poor treatment response. This open-label study suggests that treatment with lamotrigine in women with the vulvodynia subtype of CPP may be helpful in addressing both the pain and mood symptoms associated with this disorder.

Overlap between orofacial pain and vulvar vestibulitis syndrome.

OBJECTIVES: To explore the prevalence of orofacial pain (OFP) among patients with vulvar vestibulitis syndrome (VVS) and to examine the relationship between signs and symptoms of OFP and clinical characteristics of women with VVS, we investigated differences in psychologic characteristics and severity of painful intercourse. METHODS: In this cross-sectional exploratory study, 137 women with VVS completed questionnaires that assessed levels of pain, anxiety, somatization, and presence of signs and symptoms suggestive of clinical and subclinical OFP. Demographic data were gathered from medical records. RESULTS: OFP was found to be a highly prevalent (78%) condition among women with VVS. Compared with women who had no OFP symptoms (n=30), those with symptoms (n=64) reported higher levels of anxiety (45.0 vs. 37.8, Bonferroni adjusted P=0.017), somatization (125.2 vs. 96.0, Bonferroni adjusted P<0.001), and psychologic distress (62.8 vs. 56.0, Bonferroni adjusted P=0.002). Although we observed a similar trend among women with subclinical OFP (n=43), this trend only reached statistical significance with respect to somatization. Differences were not detected for demographics, duration of pain, and severity of pain during intercourse across the 3 groups. DISCUSSION: OFP is a common condition among women with VVS. Because severity and duration of painful intercourse did not differ by OFP classification but psychologic characteristics did, we must begin to question a unidimensional focus on vestibular mucosa as a reason for pain and persistent distress.

Somatization and psychological distress among women with vulvar vestibulitis syndrome.

OBJECTIVE: To investigate the distribution of psychological characteristics and pain reporting among women with vulvar vestibulitis syndrome (VVS). METHODS: In this exploratory study, 109 women with VVS completed a battery of questionnaires to assess pain with intercourse and psychological characteristics (e.g. somatization, anxiety, distress). The distribution of these characteristics was compared, first with a conventional binary classification schema (primary and secondary) and subsequently with a 3-category schema (primary, latent primary, secondary). RESULTS: Severity of pain with intercourse did not differ among the subgroups using either classification schema. Women with primary VVS consistently showed higher levels of somatization, anxiety, and distress compared with those with secondary VVS. Using a 3-tiered classification system, we found no difference between latent primary diagnosis and the other 2 groups (primary and secondary). CONCLUSION: This study highlights the critical need for research on subtype definition and the role of psychological factors in VVS.

Patient perceptions of vulvar vibration therapy for refractory vulvar pain.

The objective of this study was to describe acceptability of vulvar vibration therapy (VVT), a novel treatment approach to vulvodynia. We included women with vulvodynia who attended the Pelvic Pain Clinic and had used VVT for at least two weeks. Participants completed a three-page, 65-item, questionnaire assessing demographics, VVT usage and responses to Likert statements regarding accessibility, comfort and symptom response to VVT. Of 69 qualifying patients, results from 49 (72%) were eligible for analysis. Participants were primarily white, married and well-educated, with a median age of 30 (range 19-68 years). Median duration of vulvar pain and dyspareunia was two years (0-23) and three years (0-30), respectively. Median duration of VVT was five months (1-18) and three days per week (0.5-7). Fully, 83% said that, "vibrator treatment is an acceptable treatment", 83% said that they were "satisfied with vibrator treatment", 76% endorsed vibrator as comfortable to use, 73% indicated that sex is less painful since starting vibration treatment and 88% would recommend VVT to others. We conclude that the therapeutic rationale for VVT is based on the anti-nocioceptive properties of vibration and on the favorable response of vulvodynia to physical therapy. Vulvar vibration therapy is safe, inexpensive and, in this survey, acceptable to most patients, many of whom described improvement in symptoms.

Trauma and posttraumatic stress disorder in women with chronic pelvic pain.

OBJECTIVE: To examine the effect of abuse history, other major trauma, and posttraumatic stress disorder (PTSD) on medical symptoms and health-related daily functioning in women with chronic pelvic pain. METHODS: We administered a questionnaire to 713 consecutive women seen in a referral-based pelvic pain clinic. RESULTS: We found that 46.8% reported having either a sexual or physical abuse history. A total of 31.3% had a positive screen for PTSD. Using regression and path analysis, controlling for demographic variables, we found that a trauma history was associated with worse daily physical functioning due to poor health (P<.001), more medical symptoms (P<.001), more lifetime surgeries (P<.001), more days spent in bed (P<.001), and more dysfunction due to pain (P<.001). Furthermore, a positive screen for PTSD was highly related to most measures of poor health status (P<.001) and somewhat explained the trauma-related poor health status. CONCLUSION: The association of trauma with poor health may be due in part to the development of PTSD resulting from trauma. These findings demonstrate the importance of screening for trauma and PTSD in women with chronic pelvic pain. LEVEL OF EVIDENCE: II.

Identification of diagnostic subtypes of chronic pelvic pain and how subtypes differ in health status and trauma history.

OBJECTIVE: Our primary aim was to identify subtypes of chronic pelvic pain and to compare the cases of women with the identified subtypes on health status and trauma history. We hypothesized that women with diffuse abdominal/pelvic pain would have greater health impairment and report more lifetime trauma than women with vulvovaginal pain or cyclic pain. STUDY DESIGN: We collected questionnaire data on 289 consecutive women patients from a university chronic pelvic pain clinic. From patient records, 1 gynecologist identified chronic pelvic pain subtypes on the basis of reported symptoms and the localization of pain during examination. We used analysis of covariance with pairwise contrasts. RESULTS: Seven diagnostic subtypes were identified. Patients with diffuse abdominal/pelvic pain had more trauma and worse mental and physical health status compared with patients with vulvovaginal pain and cyclic pain. Those patients with abdominal/pelvic pain also had poorer health than patients with neuropathic and fibroid pain. Endometriosis was unrelated to health status. CONCLUSION: There is immense need for further research to define subtypes of chronic pelvic pain.

Long-term outcomes after surgical and nonsurgical management of chronic pelvic pain: one year after evaluation in a pelvic pain specialty clinic.

OBJECTIVE: The purpose of this study was to describe long-term outcomes for women with chronic pelvic pain (CPP) after evaluation in a CPP specialty clinic. STUDY DESIGN: This was a prospective observational cohort study of women treated for CPP at the UNC Pelvic Pain clinic between 1993 and 2000. The primary outcome was improvement in pain and the main exposure was treatment group: primarily medical (pharmacotherapy, psychotherapy, physical therapy, or combinations of the 3) or surgical (hysterectomy, resection or ablative procedures, oophrectomy, diagnostic surgery, pain mapping, vulvar or vestibular repair). Univariate, bivariate, and multivariable analyses were performed to look for relationships between background characteristics, treatment group, and improvement in pain. RESULTS: Of 370 participants; 189 had surgical treatment and 181 had medical treatment. One year after evaluation, 46% reported improvement in pain and 32% improvement in depression. Improvement in pain was similar in both treatment groups and odds of improvement were equal even after adjusting for background characteristics, psychosocial comorbidity, and previous treatments. CONCLUSION: One year after evaluation in a CPP specialty clinic, women experienced modest improvements in pain and depression after recommended surgical or nonsurgical treatment.

A conceptual model for the pathophysiology of vulvar vestibulitis syndrome.

UNLABELLED: Vulvar vestibulitis syndrome (vestibulitis), the most common type of chronic vulvovaginal pain, impairs the psychologic, physical, and reproductive health of approximately 10% of women at some point in their lives. Research on the pathophysiology of vestibulitis suggests abnormalities in 3 interdependent systems: vestibular mucosa, pelvic floor muscles, and central nervous system pain regulatory pathways. To date, causes and relative contributions of these abnormalities to the development and maintenance of vestibulitis remain poorly understood. Research consistently supports the conceptualization of vestibulitis as a chronic pain disorder-akin to fibromyalgia, irritable bowel disorder, and temporomandibular disorder (TMD)-that is far more complex than vestibular hypersensitivity alone. Nevertheless, the clinical diagnosis of vestibulitis continues to rely on subjective report of pain during intercourse and vestibular sensitivity on clinical examination after exclusion of other gynecologic disorders. We propose that current diagnostic criteria, which are based on highly subjective patient and clinician measures, are not sufficient to describe and properly classify the heterogeneous clinical presentations of this disorder. To inform clinical care or research, we must be able to objectively characterize women with vestibulitis. This narrative review critically appraises current conceptualization of vestibulitis and presents a context for studying vestibulitis as a chronic pain disorder, emphasizing the need for objective assessment of clinical features. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to state that vulvar vestibulitis is common; recall that the disorder has three major pathophysiological pathways and that understanding of these pathways is important in selecting treatment options, and explain that the clinician must attempt to properly classify the clinical presentations of the disorder.