Treatment

Education

Women diagnosed with vulvar vestibulitis, particularly at specialty centers, have usually seen multiple clinicians, received numerous courses of medications for infections, and have often been told the problem is psychological. Giving patients a firm diagnosis, reassuring them the problem is real and not "in their head," and using the examination to educate them on their genital anatomy can assuage many of their anxieties and increase compliance with recommended therapy.

Elimination of Potential Irritants

Removing all possible irritants is a critical component of successful treatment. Women with vulvar vestibulitis should discontinue use of all hygiene products, creams, and lubricants. Minimizing the irritative effect of urine on the vulvar vestibule is also important. Women are instructed to spread their labia before initiation of voiding to reduce contact with urine. We place all patients on a low oxalate diet (Table 9-2.1), and recommend taking calcium citrate (Citracal) as a binding agent with each meal to reduce urinary excretion of oxalates. The currently available diet is by no means comprehensive, and oxalates may not be the only irritating dietary factor in the urine. Patients are informed to be diet conscious and look for temporal relationships between certain foods and worsening of their symptoms.

Medications

Topical corticosteroids and interferon have been used in an attempt to reduce the chronic inflammatory changes, but significant response rates are disappointing. Topical estrogen cream has been shown to be beneficial. Women are instructed to use the cream at a dose of 1 g intravagi-nally two times a week and to digitally apply a small amount daily to the vestibule. The cream is soothing and over time thickens the vestibular epithelium, which may distance the nociceptors from the surface of the skin. Alone, local estrogen has produced, generally, disappointing results. There may also be a direct effect of estrogen on vestibular nerve fibers. We routinely use estrogen warn in one multi-modality treatment of vulvar vestibulitis.

Table 9-2.1. Oxalate content of common foods

Low Oxalate

Medium Oxalate

High Oxalate

Cola

Coffee

Cocoa

Apple juice

Fruit juices

Most berry juices

Milk

Grape

Blackberries

Butter

Orange

Blueberries

Yogurt

Tomato

Raspberries

Cheese

Apples

Strawberries

Mayonnaise

Pineapples

Whole wheat bread

Red wine

White bread

Peanuts

Grapes

Pasta

Soy products

Lemons

Asparagus

Celery

Melons

Broccoli

Collards

Raisins

Carrots

Green peppers

Rice

Corn

Popcorn

Coconut

Cucumber

Spinach

Bacon

Garlic

Tomato sauce

Beef

Lettuce

Yams

Chicken

Mushrooms

Eggs

Onions

Fish

Peppers

Squash

Potato and potato chips

Zucchini

Tomato

Peas

Source: Adapted from Rowan's Resources. More dietary selections and additional

information available at www.vulvarpainfoundation.org.

Pelvic floor muscle hypertonicity is not infrequently a contributing factor to the dyspareunia associated with vestibulitis. Biofeedback with therapists experienced in managing the pelvic floor can notably reduce the degree of spasm in these muscles, providing a useful adjunct to treatment.

Alteration of Pain Sensation

Decreasing the sensitivity of the vestibular nociceptors is another valuable step in successful treatment. Locally, a brief course of 2% Xylocaine gel applied regularly (two to three times per day) may provide relief while additional treatment avenues are initiated. Patients should be warned, however, that the Xylocaine may burn with initial application.

Centrally, pain sensation can be altered with tricyclic antidepressants. These agents are widely used for management of chronic pain and are useful in the improvement of vulvar vestibulitis symptoms. Amitriptyline (Elavil), imipramine (Tofranil), nortriptyline (Pamelor, Aventyl), and desipramine (Norpramin) can all have significant side effects (dry mouth, dry eyes, constipation, sedation, palpitations, etc.) and should be slowly increased from a low dose to the usual therapeutic dose. We typically add Elavil (10 mg at bedtime) if a low oxalate, local Xylocaine, and estrogen cream do not result in significant relief.

Surgery

Because the etiology of vulvar vestibulitis remains unclear, surgery to remove the affected tissue has been controversial. However, it remains the single most effective treatment option for vestibulitis, with most studies reporting success rates of 70% to 80%. A randomized prospective trial comparing treatment with surgery, cognitive therapy, and biofeedback noted significantly greater improvement in the

surgery group.23

The key to effectively treating with surgery is proper patient selection. Nonsurgical options, as noted above, should have been attempted and failed. We also suggest a course of psychological counseling to help identify and address any potentially unfounded factors such as previous sexual abuse. The patient must have pain specifically localized to the vestibule. This requires careful pain mapping. Women with more generalized vaginal, vulvar, or pelvic pain are not candidates for surgery.

Numerous procedures have been described to treat vulvar vestibulitis including laser, highly localized excision, and undercutting for denervation. Most of these have had variable success. At our center, because the inflammatory process involves the entire vestibule, we believe a vestibulectomy with vaginal advancement should be performed. This will connect thick vaginal mucosa directly to vulvar skin.

The vestibulectomy incision should be made in a horseshoe manner and include the hymen, periurethral mucosa, and posterior fourchette to the perineal skin pigmented border (Figures 9-2.2-9-2.4). The vaginal mucosa is then undermined and advanced to close the defect without tension. Our success rates with this technique have exceeded 80% in allowing reinitiation of sexual intercourse.

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