Treatment of Vulvar Vestibulitis with Submucous Infiltrations of Methylprednisolone and Lidocaine
Abstract & Commentary
Synopsis: Submucosal vulvar injection of methylprednisolone may result in complete or partial remission of the symptoms associated with vulvar vestibulitis.
Source: Murina F, et al. J Reprod Med. 2001;46:
713-716.
The purpose of this study was to determine whether injections of depot methylprednisolone can improve the symptoms of patients with vulvar vestibulitis.
Murina and colleagues accept the classic definition of the disease set forth by Friedrich in 1987: superficial dyspareunia, erythema of the vestibule, and tenderness to light touch with a cotton swab. In the introduction, Murina et al agree that the etiology of vulvar vestibulitis is unknown and that treatment to date of the condition has been only partially successful.
During a period extending for more than 6 years, Murina et al treated 22 patients with weekly injections of depot methylprednisolone. Unfortunately, it is not clear from the article whether these were consecutive patients or whether there was some selection of cases involved.
Murina et al injected 40 mg of methylprednisolone and 10 mg of lidocaine into the subcutaneous area of the vestibule and followed it 1 week later with 50% of the initial dosage. During the second week, a further reduction in dosage was injected.
Two thirds of the patients had a favorable response to treatment. Approximately one third had complete remission, one third had a decrease in symptoms, and one third did not respond. Murina et al state that they do not know why their treatment resulted in positive results, but that biopsies from the areas involved suggest that vulvar vestibulitis might be an immunologic disorder.
Murina et al note that a prospective randomized study will be needed in order to determine whether the injections were a placebo or a true effect of the medication.
Comment by Kenneth L. Noller, MD
I was very interested to see this article in print as I have been using depot methylprednisolone (DepoMedrol®) for the treatment of some patients with vulvar vestibulitis for the past 6 or 7 years. Typically, I reserve such therapy for patients who seem to have, in addition to these superficial skin components, pain deeper in the area of the Bartholin glands. I usually inject 80 mg of depot methylprednisolone monthly for 3 months. In many cases, complete or moderate relief is obtained. I have been much less successful in those few cases in which I have attempted injection when there is only a superficial "skin" component present.
There are problems with this paper. Murina et al strictly define vulvar vestibulitis according to the Friedrich criteria, but then mention that many of their patients had "burning." Typically, burning is a symptom of dyesthetic vulvodynia or pudendal neuralgia rather than the "pure" form of vulvar vestibulitis. Also, I strongly suspect that their 22 patients were highly selected. If they only saw 22 patients with vulvar vestibulitis in 6 years I would be amazed.
Murina et al do make one good observation: If one is to use this treatment, it is very important to massage the tissue into which the methylprednisolone is injected or the drug can precipitate and form long-lasting "lumps."
I certainly hope someone will perform a randomized clinical trial using this treatment at sometime in the near future.
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