The Vestibule

This is an extremely important part of the female anatomy.  It is the reason 50% of women with painful sex have painful sex.  The vestibule is a very specific tissue at the opening of the vagina.  It is made of the same kind of tissue as the lining of the urethra and the bladder.  That is why about 50% of women with painful sex also complain about frequent urinary tract infections (UTI’s) and needing to urinate often or very intensely or even complain of urinary leakage.

 Anatomy

Lots of people, providers and patients alike, do not know use the correct words when describing female genitals. Let’s start from the outside and go in.  When a woman lies down naked and you look at her genitals, that is her vulva.  The clitoris, the labias, even the opening of the vagina – though you are unlikely to see this without spreading the labias – it’s all vulva. 

The tissue at the opening of the vagina is the vestibule.  Vestibule means hallway or entry way.  The vestibule is the path to the vagina.  The vestibule covers the the opening of the vagina and extends past that into vagina just a bit.  “Just a bit” is a medical term.  I argue with a lot of textbooks that say the vestibule tissue ends at the remnants of the original hymen.  Women who have discomfort at the vestibule will say that a penetrating item going into the vagina hurts at the opening and then there is a spot where the pain subsides.  My huge theory is that this is where the sidewalk, err, the vestibule ends. 

The vagina is the dark cave inside the body.  You cannot actually see the vagina unless you are using a medical device to spread the opening of the vagina and look inside.  You can put a finger inside the vagina and feel it, but you cannot actually see it. 

The human body is made up of three different types of tissue when in the mother’s womb.  These are called germ cells.  The study of these tissues is called embryology.  Embryologically, the three layers are ectoderm, endoderm and mesoderm.  When speaking about the female genitals, the vulva is ectoderm, the vestibule is endoderm and the vagina is mesoderm.  It’s all different!  It’s a world of difference right there at the genitals!  It is exciting!  It requires understanding.  I’m essentially saying it’s like the vulva is made up of cotton, the vestibule is made up of rayon and the vagina is made up of silk.  Three different materials.  We cannot treat it all the same.  What that vestibule rayon can feel like if not well tended to by appropriate sex hormones (and even diet for some) is sand paper.  Or fire.  The vestibule must stay healthy to feel like rayon.  Because that things gets pissed really easily.

Here’s where it’s just not fair:  When I give lectures or talks, I often compare the female and male anatomies.  There is nothing like the vestibule on a man.  (Though, men do have pelvic pain.)

I do the same analogy because it creates a lasting impression.  I tell the audience to look at the wall.  I then have them imagine a massive penis coming out of the wall.  I then move way back and have them imagine that I am at the tip of the penis – the glans.  At the glans of the penis is the hole called the urethal meatus.  This is where urine and ejaculate come out.  I then have the audience imagine that I am crawling into the urethral meatus – I am crawling into the hole that urine and ejaculate come out of.  Lining that hole is the urethra.  That urethral tissue (that endodermal tissue), I then tell the audience, is what I grab and as I work my way back out of the urethra and outside of the penis and I then take that tissue and fold it back over the tip of the penis.  Now the tip of the penis (the glans) is covered with urethral tissue.  Completely exposed to the elements.  Now the male is much more likely to feel urinary symptoms and much more likely to potentially have discomfort with sex.  But, in real life, in a world where I do not crawl into a massive penis attached to a wall and pull the urethra out…the man’s urethral tissue is never exposed.  But it is exposed on a woman.  And that is why it is not fair. 

How the vestibule gets irritated

The vestibule likes a lot of things, but I don’t think it’s asking for too much.  All it wants is food, room to move and gentle touch.  This translates to appropriate sex hormones and appropriate bacteria, normal muscle tension and avoidance of scrubbing.  Isn’t that what we all need in life?  Who can blame it?

The vestibule needs a decent environment to thrive.  When it thrives, you don’t even know it is there.  It requires decent levels of estrogen and testosterone.  It requires normal levels of good bacteria.  Bacteria levels and estrogen are quite connected.  If good bacteria is removed, then you are likely to have lower estrogen levels in the vulvovaginal area.  Good bacteria is removed with use of antibiotics and by using soap at the genitals.  Appropriate sex hormones and flora also help create the vagina acidic.  This helps to fight off infection and keep tissue healthy.  When you become more basic because of the change in sex hormones and flora, you start to become symptomatic. You cannot always see that the vestibule is lacking estrogen and testosterone or good bacteria.

When the pelvic floor muscles are too tight and stay too tight all the time, then they don’t create good blood flow.  This is called ischemia.  Muscles that attach towards the vestibule can tug on the vestibule.  This creates more ischemia.  And now the vestibule is irritated.  You cannot always see that the vestibule is ischemic. 

Then there is this:  when the vestibule doesn’t have appropriate sex hormones and good bacteria, then it is likely to cause pelvic floor muscle tension which causes ischemia.  Once will cause the other!  Ridiculous, I say! 

When you don’t have appropriate sex hormones and good bacteria and/or your pelvic floor muscles are tense, you are more likely to develop a true urinary tract infection (UTI) or just symptoms of a UTI.  You might get prescribed antibiotics more often and now you are killing whatever good bacteria you may have had left.  Now you are really stuck in a loop.  And then you know that some docs will prescribe antibiotics even if you don’t actually have an infection or if you don’t know if you actually have an infection.  This snowball keeps getting bigger and bigger.  You cannot always see that you have an infection.

And then, you might be someone who keeps getting true UTI’s over and over again or maybe a yeast infection over and over again.  Now your vestibule is pissed off.  It’s super irritated and inflamed.  Now it’s sitting in the house of rising inflammation and you do not know how to get out of it.  Get the hell out of New Orleans!  You cannot always see that you have inflammation.

Washing the genitals with something rough…like a loofah, even if no soap is used is too abrasive.  The vestibule needs to be handled like a rose petal.  You wouldn’t scrub a rose petal, would you?  You usually can see if the vestibule has small cuts and tears, but it requires knowing what the vestibule is and looking at it with light and at times with magnification.  If your physician is looking at your vestibule with use of a speculum – they are not looking at your vestibule at all.  They are probably tearing your vestibule a bit more and causing you excruciating amounts of pain. 

Symptoms of an irritated vestibule

·      Painful urination

·      Frequent urination

·      Intense urges to urinate

·      Waking frequently at night to urinate

·      Not feeling empty after urinating

·      Urinary leakage

·      Bladder pain

·      Urethral pain

·      Vaginal pain

·      Vestibule pain

·      Painful sex

·      Pain with sitting

·      Pain with wearing underwear or pants