(039) Vestibular Anesthesia Test: Assessment of Localized Vestibulodynia

Abstract Introduction Localized provoked vestibulodynia is a common cause of female sexual pain and often leads to significant disruption in daily functioning, sexual relationships, and overall quality of life. The vestibular anesthesia test (VAT) helps clinicians determine whether pain originates from the vestibular mucosa itself or from other sources such as pelvic floor muscle tension, pudendal neuralgia, or hormonal deficiencies. A positive VAT result supports a clinical diagnosis of localized provoked vestibulodynia. This test builds on the cotton-swab test, a simple diagnostic tool used to map pain within the vulvar vestibule. The vestibule is bordered by Hart’s line and lies external to the mesodermal vagina. Pain may be localized to distinct clock-face regions, where 12:00 is located inferior to the clitoral frenulum and 6:00 lies superior to the posterior fourchette. Objective The objective of this video presentation is to demonstrate a case of female sexual pain, its evaluation using the vestibular anesthesia test, and subsequent management following a positive result. Methods The video demonstrates the initial cotton-swab test, in which a moist cotton swab is lightly brushed against each clock-face region while the patient reports pain severity on a scale from 0 to 10. Posterior pain may indicate referred pain resulting from hypertonic pelvic floor muscles, while diffuse or predominantly anterior pain is more consistent with localized provoked vestibulodynia. To further clarify the pain source, a topical anesthetic-typically a benzocaine–lidocaine–tetracaine formulation-is applied uniformly across the vestibule. Once absorbed, the cotton-swab test is repeated. A clinically significant reduction in pain supports a diagnosis of localized provoked vestibulodynia. Hormonal serology should be performed to evaluate for hormonally mediated vestibulodynia. In perimenopausal patients or those with history of androgen depleting medications, empirical treatment with vaginal estrogen or DHEA can help address the primary source of pain. If pain is determined not to be hormonally mediated, findings are more consistent with neuroproliferative vestibulodynia. Results The video then outlines common conservative management strategies for neuroproliferative vestibulodynia, including topical lidocaine, topical neuromodulators such as gabapentin or compounded amitriptyline, topical capsaicin, oral neuromodulators including gabapentin and low-dose tricyclic antidepressants, pelvic floor physical therapy for muscle down-training, and psychosexual therapy as adjunctive support. A vestibulectomy with a vaginal advancement flap is highlighted as a highly effective surgical option, particularly for those with confirmed neuroproliferative disease. Conclusions The vestibular anesthesia test provides a practical, noninvasive method for confirming localized provoked vestibulodynia and guiding patients toward management strategies that directly address the primary source of their sexual pain. By distinguishing vestibular mucosal pain from pain arising from other regions or disease processes, the VAT promotes accurate diagnosis and informed, individualized treatment planning. Disclosure No.