Content written by Andrew T. Goldstein, MD

Cotton Swab or Q-tip Testing is part of a multidisciplinary approach to the assessment of sexual pain, especially, vulvodynia or vestibulodynia, in women. For evaluation of vulvodynia, a mental health professional performs the psychologic interview. The biologic focused health care provider, such as the sexual medicine physician, gynecologist or physical therapist conducts the clinical interview and the physical examination. The interview should provide the clinician with extensive information about the woman’s history of pain as well as her current reasons for seeking treatment, pain mediators and the impact that pain has on various aspects of her life, comorbid disorders, and treatment history and outcomes. Standardized self-administered questionnaires measure pain, sexual and psychological functioning, and relationship adjustment.

After the clinical interview, the physical examination is performed with the patient placed in the lithotomy position in stirrups. The patient is asked to relax as much as possible. The health care provider is positioned comfortably and communicates all maneuvers with the patient. A gauzpad is used to gently retract the labia minora laterally to expose the vestibule. The vestibule consists of the region bounded by Hart’s line at the midway of the inner labia minora and passes to the hymenal remnant tissue.

The cotton swab test or Q-tip test is the current standard vulvodynia assessment for diagnosing provoked vestibulodynia. This cotton swab test or Q-tip test consists of using a cotton swab or Q-tip to palpate multiple vulvar and vestibular sites in a randomized fashion to control for sensitization while recording the woman’s pain ratings upon palpation. The vestibule is organized into locations based on a clock face where the urethral meatus is at 12:00. The 1:00 position is the part of the vestibule just left of the patient’s urethral meatus. The 6:00 position is the posterior fourchette. The 11:00 position is just to the right of the urethral meatus. A classic reading would be that the individual with a sexual pain history and consideration for vulvodynia would have, for example, a pain rating of 5/10 at the 1:00 position, while at the 9:00 position she may have a pain rating of 10/10. At the 5:00 position, she may have a pain rating of only 2/10. Traditionally, all clock regions 1:00, 3:00, 5:00, 6:00, 7:00, 9:00 and 11:00 are randomly tested and given pain ratings. There are many variations that health care providers use, as long as each provider uses a reproducible system to map out the regions of the vestibule and vulva along with the simultaneous documentation of the patient’s pain rating.

The cotton swab or Q-tip test has good clinical utility. There is some measurement error due to inconsistency of the amount of pressure applied to each region. For clinical research purposes, the cotton swab or Q-tip test may be replaced with a vulvalgesiometer This is a tool that exerts standardized pressure to the vestibule or vulva to measure pressure pain thresholds in a clinical research setting, and can be useful in detecting differences in pain sensitivity as a result of treatment.