To the Editor,
Vulvodynia, defined as vulvar pain persisting for at least three months without an identifiable cause, potentially accompanied by associated factors, is common yet remains enigmatic (1). “Vulvodynia” and “vaginismus” are frequently confused by both laypeople and healthcare professionals. Vaginismus is characterized by involuntary spasms of the pelvic floor muscles, which can be primary or secondary; secondary vaginismus may result from vulvodynia.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders included dyspareunia and vaginismus into the newly created category of “genito-pelvic pain/penetration disorder”, which remains a theoretical concept, lacking scientific validation (2). This change may have increased confusion, potentially denying women the appropriate diagnosis and, consequently, the correct management.
It appears that vulvodynia was addressed as early as 1825 BC in ancient Egyptian papyri. Some authors arguably sustain that “satyriasis” (excessive or abnormal sexual desire), described by Soranos (1st century AD) may correspond to vulvodynia. Possible descriptions of vulvodynia can be found in books from Thomas (3), Kellogg (4), and Skene (5), in 1868, 1891, and 1898, respectively. The latter proposed surgical removal of the area of “excessive sensitivity” (5).
The term “vaginismus” was coined by Sims (6), a controversial yet pivotal figure in medical history, in 1862. In his seminal work, he described five cases of women who were either unable to engage in intercourse (four cases) or had only experienced it a few times, incompletely, due to severe pain (Table 1). One woman had an “irritable bowel,” which may have corresponded to irritable bowel syndrome. Each woman reported intense pain upon light touching of the vulvar vestibule and hymen. He stated, “the gentlest touch with the finger, a probe, or even a feather, produces the most excruciating agony.” Given this description, we believe that these cases represent vulvodynia, rather than vaginismus. Although many women with vulvar pain may develop some degree of secondary vaginismus, introital pain alone does not define vaginismus.
The solution proposed for the problem was surgical: complete excision of the hymen and a V-shaped incision extending from above the hymen to the perineal raphe, followed by the use of dilators. He advised starting using glass or metal dilators within 24 hours after the surgery. While they experienced some soreness, it was not comparable to their previous pain levels. This outcome is unexpected for vaginismus but aligns with what might be anticipated for localized provoked vulvodynia (vestibulodynia).
He concluded that this condition was not uncommon as he and a colleague observed 17 cases over a 24-month period. He reported a surprisingly high success rate (88%), with some women even achieving pregnancy a few months post-procedure. This success rate aligns closely with current outcomes reported for the surgical treatment of localized provoked vulvodynia, despite the differences between his technique and the current ones (7, 8).
To our knowledge, the most accurate detailed description of vulvodynia, which included a highly successful treatment approach, was provided by Sims (6). Juliet famously questioned, “What’s in a name?”. In this instance, an inaccurate term has led to a common condition remaining largely unknown and understudied for over one and a half centuries since its first description.
