Vulvodynia Pain Stopped and Started Again
Vulvodynia and Vulvar Vestibulitis: Challenges in Diagnosis and Management
Am Fam Physician. 1999 Mar xv;59(half dozen):1547-1556.
See related patient information handout on vulvodynia, written past the author and Elizabeth South. Smoots, Grand.D..
Commodity Sections
- Abstract
- Epidemiology
- Diagnostic and Management Challenges
- Subsets of Vulvodynia
- Evaluation
- Treatment and Management of Vulvodynia and Vulvar Vestibulitis
- Concrete Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Final Comment
- References
Vulvodynia is a trouble nigh family physicians can expect to encounter. It is a syndrome of unexplained vulvar pain, often accompanied by physical disabilities, limitation of daily activities, sexual dysfunction and psychologic distress. The patient's vulvar pain usually has an acute onset and, in almost cases, becomes a chronic problem lasting months to years. The hurting is ofttimes described every bit called-for or stinging, or a feeling of rawness or irritation. Vulvodynia may have multiple causes, with several subsets, including cyclic vulvovaginitis, vulvar vestibulitis syndrome, essential (dysesthetic) vulvodynia and vulvar dermatoses. Evaluation should include a thorough history and physical examination as well every bit cultures for leaner and mucus, KOH microscopic examination and biopsy of any suspicious areas. Proper treatment mandates that the correct type of vulvodynia be identified. Depending on the specific diagnosis, treatment may include fluconazole, calcium citrate, tricyclic antidepressants, topical corticosteroids, physical therapy with biofeedback, surgery or laser therapy. Since vulvodynia is often a chronic condition, regular medical follow-up and referral to a support group are helpful for virtually patients.
Vulvodynia is often misdiagnosed. In a general gynecologic do population, the prevalence of this condition may be as high as 15 percent.1 Earlier the 1980s, very trivial was written about vulvodynia. In the 1980s, renewed interest was generated with the publication of articles by Friedrich, Lynch and McKay.2–4
Epidemiology
- Abstract
- Epidemiology
- Diagnostic and Management Challenges
- Subsets of Vulvodynia
- Evaluation
- Treatment and Management of Vulvodynia and Vulvar Vestibulitis
- Physical Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Final Comment
- References
Vulvodynia is a syndrome of unexplained vulvar pain that is frequently accompanied by physical disabilities, limitation of daily activities (such as sitting and walking), sexual dysfunction and psychologic disability.2 Originally suggested by McKay,four the term "vulvodynia" has also been suggested past the International Society for the Study of Vulvar Disease Job Strength to describe any vulvar pain. The incidence and prevalence of vulvodynia have non been well studied.1 Age distribution for the condition may range from the 20s to the 60s, and it is limited almost exclusively to white women.2 Obstetric and gynecologic history is unremarkably unremarkable. Run a risk-taking sexual behavior is rare, and few patients accept a history of sexually transmitted diseases.five Vulvar pain usually has an acute onset, at times associated with episodes of vaginitis or sure therapeutic procedures of the vulva (cryotherapy or laser therapy). In nigh cases, vulvodynia becomes a chronic problem lasting months to years. Vulvar pain is ofttimes described as burning or stinging, or a feeling of rawness or irritation.4
Near patients consult several physicians before being diagnosed. Many are treated with multiple topical or systemic medications, with minimal relief. In some cases, inappropriate therapy may even make the symptoms worse.6 Since physical findings are few and cultures and biopsies are oftentimes negative, patients may be told that the problem is primarily psychologic, thus invalidating their pain and adding to their distress.7(pp1–15)
Diagnostic and Management Challenges
- Abstract
- Epidemiology
- Diagnostic and Management Challenges
- Subsets of Vulvodynia
- Evaluation
- Handling and Direction of Vulvodynia and Vulvar Vestibulitis
- Concrete Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Final Comment
- References
ILLUSTRATIVE Instance 1
A 23-twelvemonth-old adult female was treated twice for a suspected urinary tract infection while traveling in Europe. The patient did not know what antiobiotic she had taken. On returning to the United states, she continued to experience dysuria and urgency with vaginal soreness, slight itching and dyspareunia. Urinalyses, urine cultures and vaginal and cervical cultures were negative. Over the course of two months, the patient went to emergency departments twice and visited four unlike family physicians. She was treated with numerous antibiotics, including trimethoprimsul-famethoxazole, cephalexin and ciprofloxacin, for presumed cystitis. She too was treated with oral fluconazole and over-the-counter topical anticandidal preparations for presumed candidal infection, with only temporary relief.
During the following ii months, the patient experienced dyspareunia with intermittent vulvar pain and irritation. She later saw 4 gynecologists, a urologist and two primary care physicians. Pelvic examination revealed erythema of the posterior fourchette and a reaction of mild tenderness on swab examination. A biopsy of this area was normal. The patient was treated with doxycycline for possible cervicitis; the symptoms were not relieved. She was so given a diagnosis of vulvodynia and was prescribed gradually increasing dosages of amitriptyline, along with oral calcium gluconate three times daily and a low-oxalate diet. She was referred to a support group for persons with vulvodynia and to a physical therapist specializing in women'due south health bug for pelvic strengthening, relaxation grooming and biofeedback training. Over the next three months, the patient reported a 70 to 90 percent improvement in her symptoms, with occasional balmy exacerbations.
ILLUSTRATIVE CASE ii
A 45-twelvemonth-old adult female with a history of one term pregnancy developed urgency, erythema in the vulvar area and irritation at the base of the clitoris that began suddenly after intercourse one evening. Subsequent symptoms included burning, rawness and dyspareunia, which increased with walking, sitting and intercourse, and as well increased one calendar week earlier catamenia. The use of terconazole cream acquired farther called-for and irritation. Over the side by side five months the patient saw a nurse practitioner and two family physicians. She received treatment numerous times for yeast vaginitis and bacterial vaginosis with topical antifungal medications, fluconazole and metronidazole gel. Any improvement was temporary, and the symptoms invariably returned.
Vaginal cultures grew diverse enteric organisms, and no yeasts were detected on KOH test. Conjugated estrogen vaginal cream gave no significant relief. Over the post-obit two months the patient saw two gynecologists and was diagnosed with vestibulitis. She was treated with triamcinolone-nystatin cream for two months and felt comeback in the first week but after developed farther irritation of the vulvar and clitoral surface area. No biopsies were performed. She was referred to a third gynecologist, who instructed her to end all topical medications. She began taking calcium citrate 3 times daily, started a depression-oxalate diet and was referred to a vulvar pain support group. Over the next year, she was treated with fluconazole, 150 mg in one case weekly for two months, and then one time every other week for two months. She too began biofeedback preparation and physical therapy for pelvic muscle relaxation and strengthening. The patient underwent a total of ii and one one-half years of treatment. During her terminal year of treatment, she experienced a ninety per centum improvement in symptoms.
Subsets of Vulvodynia
- Abstract
- Epidemiology
- Diagnostic and Management Challenges
- Subsets of Vulvodynia
- Evaluation
- Treatment and Management of Vulvodynia and Vulvar Vestibulitis
- Concrete Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Final Annotate
- References
Several subsets of vulvodynia have been identified.4,8 Since vulvodynia is a multifactorial condition, sure subsets may also coexist with others. Proper treatment necessitates appropriate identification by clinicians (Tabular array 1).half-dozen
Tabular array one
Characteristics of Vulvodynia and Treatment Options
| Subset of vulvodynia | Typical history | Physical findings | Treatment |
|---|---|---|---|
| Cyclic vulvovaginitis | Pain is worse only before or during menses Hurting is exacerbated by intercourse (peculiarly on the side by side day) Some relatively symptom-free days Frequent use of antibiotics for other conditions | Variable erythema and edema Minimal vaginal discharge | Refer to support group Fluconazole (Diflucan), 150 mg weekly for 2 months, then twice monthly for ii to 4 months Concrete therapy with biofeedback Low-oxalate diet Oral calcium citrate (Citracal) |
| Vulvar vestibulitis syndrome | Usually premenopausal Entry dyspareunia or hurting with insertion of tampon Possible history of carbon dioxide laser therapy, cryotherapy, allergic drug reactions or contempo use of chemical irritants | Positive swab test (vestibular indicate tenderness when touched with cotton fiber swab) Focal or diffuse vestibular erythema | Refer to back up group |
| Topical estradiol cream, 0.01% (Estrace Vaginal Foam) twice daily | |||
| Intralesional interferon injection | |||
| Physical therapy with biofeedback | |||
| Low-oxalate diet | |||
| Oral calcium citrate | |||
| Dysesthetic vulvodynia (essential vulvodynia) | Normally postmenopausal or perimenopausal Diffuse, unremitting burning pain that is not circadian Less dyspareunia or betoken tenderness than in vulvar vestibulitis | Usually no erythematous cutaneous changes | Refer to back up group Tricyclic antidepressants in gradually increasing amounts (6 or more months of therapy) Physical therapy with biofeedback |
| Papulosquamous vulvar dermatoses | Itching is prominent Variable chronic symptoms | Erythema Thick and/or scaly lesions May have additional skin lesions elsewhere on body Biopsy required | Topical corticosteroids (two.5% hydrocortisone ointment or 0.1% triamcinolone ointment) for psoriasis, lichen planus, contact dermatitis, lichen simplex chronicus Topical 2% testosterone propionate for lichen sclerosis Topical imidazole creams for tinea cruris |
| Vesiculobullous vulvar dermatoses | Itching or burning Variable chronic symptoms | Blisters or ulcers that are not related to scratching Biopsy may be required | Depends on condition |
| Neoplastic vulvar lesions | Variable persistent lesion | Variable; possible white plaques, ulcers or erythema | Refer to gynecologic oncologist |
| Biopsy required | |||
| Vestibular papillomatosis | Normal anatomic variant Variable history of homo papillomavirus infection Many are asymptomatic | Papillomatous appearance of mucosal surfaces Biopsy to dominion out koilocytosis or human papillomavirus infection if symptomatic or questionable | No treatment required Care for for human papillomavirus infection merely if biopsy is positive |
VULVAR VESTIBULITIS SYNDROME
Vulvar vestibulitis syndrome is also known equally adenitis or focal vulvitis. Information technology is characterized past entry dyspareunia, discomfort at the opening of the vagina, a positive swab test, tenderness localized within the vulvar vestibulum, and focal or lengthened vestibular erythema6,eight (Figures 1 and two).
Effigy one.
Vulvar expanse in a twenty-yr-onetime patient with chronic vulvar irritation and no history of sexual practice. Her symptoms preceded surgery for imperforate hymen, which was performed 18 months earlier this photograph was taken.
FIGURE 2.
Vulvar vestibulitis associated with condyloma acuminata in a 21-year-former patient. Biopsy of the posterior fourchette showed severe koilocytotic changes that were related to human papillomavirus infection.
Chronic vestibulitis lasts for months to years, and patients may experience entry dyspareunia and pain when attempting to insert a tampon.6,viii The etiology of vulvar vestibulitis syndrome is unknown. Some cases seem to be provoked past yeast vaginitis. Other suspected causes include recent employ of chemical irritants, a history of destructive therapy such as carbon dioxide laser or cryotherapy, or allergic drug reactions.5 When surgical specimens were evaluated by polymerase chain reaction, homo papillomavirus was nowadays in many women with vulvar vestibulitis syndrome.9–13
Histologic examination of symptomatic vestibular tissue has confirmed the presence of mixed chronic inflammatory infiltrates in the superficial stroma, but inflammatory cells take not been constitute to invade the vestibular glands or gland lumens, vessels or fretfulness.2
CYCLIC VULVOVAGINITIS
Cyclic vulvovaginitis is probably the almost common cause of vulvodynia and is believed to exist caused past a hypersensitivity reaction to Candida.xiv,15 While vaginal smears and cultures are not consistently positive, microbiologic proof should exist sought by obtaining candidal or fungal cultures during an asymptomatic stage. Pain is typically worse just before or during menstrual bleeding. It as well may be exacerbated later intercourse, specially on the following twenty-four hour period.4,viii Findings on pelvic or colposcopic exam are ordinarily normal. The diagnosis of circadian vulvitis is made retrospectively based on the patient's report of cyclic symptomatic flare-ups (or, conversely, symptom-free days). The diagnosis is suggested prospectively past the patient's study of symptomatic improvement later the administration of long-term topical or systemic anticandidal therapy.3
DYSESTHETIC VULVODYNIA
Dysesthetic vulvodynia (essential vulvodynia) typically occurs in women who are peri- or postmenopausal.sixteen Pain that occurs in women with this subtype of vulvodynia is unremarkably a diffuse, unremitting, burning pain that is not cyclic. Patients with dysesthetic vulvodynia take less dyspareunia or signal tenderness than patients with vulvar vestibulitis syndrome.xvi The physical examination shows no testify of vestibulitis or cutaneous changes.6 Urethral or rectal discomfort is frequently associated with vulvar pain.v The hyperesthesia is believed to result from contradistinct cutaneous perception, either centrally or at the nerve root. Patients draw burning pain similar to that occurring in cases of postherpetic neuralgia or glossodynia (burning tongue syndrome).16 Some authors believe that pudendal neuralgia (pain along the pudendal nerve) is one of the causes of essential vulvodynia.17
VULVAR DERMATOSES
Vulvar dermatoses may be manifested past itching and, in some cases, pain (Figures 3 through v). Vulvar dermatoses include papulosquamous (thick and scaly) lesions. Erosions or ulcers may effect from excessive scratching. If the patient has blisters or ulcers and denies scratching, the crusade may be a vesiculobullous illness. Differential diagnoses of papulosquamous lesions and vesiculobullous lesions are included in Table ii.6 Neoplastic lesions include extramammary Paget's disease, squamous cell carcinoma, lichen sclerosis and vulvar intraepithelial neoplasia.half-dozen Colposcopy and biopsy as indicated are recommended to rule out dermatoses or neoplastic lesions (Figure 6). A recent study showed the most common cause of symptomatic vulvar disease (itching or burning) to be dermatitis or another dermatosis.18
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FIGURE three.
Effigy four.
Psoriasis of the vulva.
Figure v.
Seborrhea of the vulva.
TABLE 2
Dermatoses of the Vulva
| Papulosquamous vulvar dermatoses |
| Psoriasis |
| Tinea cruris |
| Lichen planus |
| Lichen sclerosis |
| Seborrheic dermatitis |
| Contact or irritant dermatitis |
| Lichen simplex |
| Bullous dermatoses with potential involvement of the vulva |
| Erythema multiforme |
| Bullous pemphigoid |
| Pemphigus |
| Beneficial familial pemphigus |
| Systemic diseases with potential involvement of the vulva |
| Behçet's disease |
| Lupus erythematosus |
| Reiter'southward disease |
The rightsholder did not grant rights to reproduce this particular in electronic media. For the missing item, encounter the original print version of this publication.
Figure vi.
PAPILLOMATOSIS
Vestibular papillomatosis is the term describing the presence of multiple small-scale (1-to three-mm) papillae over the unabridged inner labia (Figure 7). These papillae are probably congenital in origin and are a normal anatomic variant.19 A link with human papillomavirus has not been confirmed.xx,21 Patients with vulvar hurting and papillomatosis should undergo a colposcopically directed biopsy to rule out pathology. The significance of papillomatosis identified in the vulvar anteroom with acetowhitening is uncertain.22
Effigy 7.
Micropapillomatosis of the vulva.
Evaluation
- Abstract
- Epidemiology
- Diagnostic and Direction Challenges
- Subsets of Vulvodynia
- Evaluation
- Treatment and Management of Vulvodynia and Vulvar Vestibulitis
- Physical Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Final Comment
- References
The evaluation of patients with vulvar vestibulitis or vulvodynia should include a thorough history, pelvic exam, fungal and bacterial cultures, and KOH microscopic examination. Biopsy of any suspicious areas should be performed using acetowhitening and/or colposcopy to rule out dermatoses or neoplastic lesions.vi A swab test (which involves palpation of the vestibulum with a moist, cotton-tipped swab) may arm-twist betoken tenderness or abrupt pain in the posterior vestibulum, the inductive vestibulum, or both.half-dozen
In patients with vulvar vestibulitis, erythema may commonly exist visualized at the 5 and seven o'clock positions or on a horseshoe-shaped expanse of the lower vestibulum.23 The foyer comprises the area betwixt the labia minora and the hymenal ring, which marks the beginning of the vaginal mucous membrane. It extends from the frenulum of the clitoris anteriorly to the fourchette of the vaginal introitus posteriorly. This area includes the Bartholin's glands, Skene's glands and numerous minor vestibular glands (Effigy 8).
Figure 8.
Anatomy of the vulva.
Handling and Direction of Vulvodynia and Vulvar Vestibulitis
- Abstruse
- Epidemiology
- Diagnostic and Management Challenges
- Subsets of Vulvodynia
- Evaluation
- Treatment and Direction of Vulvodynia and Vulvar Vestibulitis
- Physical Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Final Annotate
- References
MEDICAL THERAPY
Some treatments are specific to the subtype of vulvodynia that can be most closely associated with the patient. Vulvodynia is multifactorial in cause, and each subset probably has a different etiology. Cyclic vulvovaginitis is believed to be a reaction to yeast, which may be detected at times and not detected at other times with KOH training or fungal cultures. Some physicians may use a test for anticandidal antibodies in directing handling. Because of the link with Candida, treatment for circadian vulvovaginitis may include anticandidal medication even if cultures are not positive. I regimen is fluconazole (Diflucan), 150 mg orally once weekly for two months and and so once every other week for two months. Other anticandidal agents that may be used include long-term therapy with topical nystatin (Micostatin Cream, Mytrex Foam), miconazole nitrate (Monistat-Derm Cream) and clotrimazole (Lotrimin).4
Vulvar vestibulitis syndrome has been treated successfully in some cases with topical estrogen cream (about a pea-sized corporeality), applied two times a mean solar day for four to 8 weeks, or longer. Intralesional injections of interferon in thirteen women with vulvar vestibulitis resulted in meaning improvement of dyspareunia in 50 pct.24 Severe, recalcitrant cases may be treated with vestibulectomy or light amplification by stimulated emission of radiation therapy. Tricyclic agents (amitriptyline [Elavil], imipramine [Tofranil] or desipra mine [Norpramin]) have been successful in the treatment of dysesthetic vulvodynia. A recommended regimen begins with x mg daily, gradually increasing to twoscore to sixty mg daily. Patients should go on taking the highest tolerable dosage that gives symptom relief for iv to half-dozen months and then gradually decrease the dosage to the minimum amount required to control symptoms.fourteen
Since some patients do not wish to accept a psychiatric drug, it is of import to explicate that the medication is existence used for its result on cutaneous nerves. In i study, the average fourth dimension required for effective treatment with amitriptyline was seven months, afterwards which therapy was either discontinued or tapered.xiv
Other treatments that have been helpful in patients with vulvodynia are a depression-oxalate nutrition and, in some cases, the addition of oral calcium citrate (Citracal), two tablets (200 mg/950 mg each) orally iii times a day to neutralize oxalates in the urine. One theory is that oxalate may irritate the vestibulum and may exist a contributing cause to vulvodynia pain over a long period.7(p16), 25
Therapy with potent topical corticosteroids should be express to brief or curt-term use. Long-term apply may induce telangiectasias, pare friability, striae formation and like shooting fish in a barrel bruising. Potent steroids tin can also cause periorificial dermatitis, a rebound inflammatory reaction with erythema and a called-for sensation that occurs as the steroid is withdrawn. A cycle of vulvar dermatitis may get worse as the patient treats the erythema and discomfort with the same potent topical steroids that started the problem.6 Self-help tips for patients with vulvodynia vulvar vestibulitis are included in the patient data handout that follows this article.
Physical Therapy and Biofeedback
- Abstract
- Epidemiology
- Diagnostic and Management Challenges
- Subsets of Vulvodynia
- Evaluation
- Treatment and Management of Vulvodynia and Vulvar Vestibulitis
- Concrete Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Final Annotate
- References
Since vaginal muscle spasm aggravates the pain and discomfort of vulvodynia, concrete therapy using biofeedback and gynecologic instruments has been successful in many patients with vaginismus (spasm of the vaginal musculus) and instability of the pelvic floor. Biofeedback grooming helps patients learn exercises to strengthen weakened pelvic floor muscles and to relax these same muscles, with a resultant reduction in pain.
Surgical and Laser Therapy
- Abstract
- Epidemiology
- Diagnostic and Direction Challenges
- Subsets of Vulvodynia
- Evaluation
- Handling and Direction of Vulvodynia and Vulvar Vestibulitis
- Concrete Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Concluding Comment
- References
Laser or surgical treatment should exist reserved for utilise in cases in which all forms of medical treatment have failed. Many cases of vulvar vestibulitis that are refractive to medical therapy respond to vulvar vestibulectomy or handling with excited dye laser. According to Marinoff and Turner,26 surgery should exist reserved for use in patients with hurting of at least 6 months' duration, pain that partly or completely prevents sexual intercourse and patients who have undergone failed treatment for a specific subset of vulvodynia or in whom no crusade can be established. Surgical excision of vulvar tissue containing vestibular glands has been reported to convalesce symptoms in up to two thirds of patients.24,27 Complications include wound hematoma, partial or complete wound dehiscence, uneven healing requiring minor revision, and stenosis of the Bartholin's duct with cyst formation.26
Flashlamp-excited dye laser therapy for the handling of idiopathic vulvodynia has been used with some success and may reduce the need for resective surgery in many cases.28
Psychologic Considerations
- Abstract
- Epidemiology
- Diagnostic and Management Challenges
- Subsets of Vulvodynia
- Evaluation
- Treatment and Direction of Vulvodynia and Vulvar Vestibulitis
- Concrete Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Last Annotate
- References
Vulvodynia may cause drastic alterations in lifestyles. Information technology may decrease the patient'due south ability to walk, exercise, sit for long periods or participate in sexual activities. All of these normal activities may exacerbate the vulvar hurting.five Many women with vulvodynia have been diagnosed with a psychologic trouble because of the lack of physical findings.15 Patients may become anxious or angry as diagnosis is delayed after numerous physician visits and as their concerns increase that the condition may exist a serious health problem. Many patients with vulvodynia worry that they volition never recover.
The prevalence of physical and sexual abuse in patients with vulvodynia does not appear to be increased.29 Family physicians can be of immense help by making the diagnosis of vulvodynia equally early as possible, identifying a specific subtype, educating the patient and beginning a direction programme. Patients should be supported with the acknowledgement that vulvodynia does not appear to be a psychosomatic condition and that it has no predisposition toward cancer or other life-threatening atmospheric condition. It should be explained that improvement volition occur with appropriate handling, but that successful treatment may accept months or years, and patients may have intermittent exacerbations and remissions.
Many patients benefit from referral to a group that provides information and emotional back up.
Terminal Comment
- Abstruse
- Epidemiology
- Diagnostic and Management Challenges
- Subsets of Vulvodynia
- Evaluation
- Treatment and Management of Vulvodynia and Vulvar Vestibulitis
- Concrete Therapy and Biofeedback
- Surgical and Laser Therapy
- Psychologic Considerations
- Terminal Annotate
- References
Enquiry indicates that vulvodynia and vulvar vestibulitis are being identified by physicians with increasing frequency. Since the physician "sees just what he already knows," family physicians must be enlightened of and recognize this condition early. Failure to consider vulvodynia as the cause of vulvar pain is the near common reason for misdiagnosis.
Vulvodynia is a multifactorial problem with subsets that may overlap. Proper direction is based on identification of the subsets of vulvodynia and identification of any concurrent infections that may be appropriately treated. Family physicians working together with gynecologists who are experienced in treating patients with vulvodynia can properly diagnose vulvodynia, identify subsets and establish the management plan that tin best do good the patient. Family physicians are in an ideal position to help and support the patient psychologically with validation, education and referral to support groups. Advisable medical handling should be instituted and, when indicated, physical therapy with biofeedback training should exist considered.
More enquiry is needed to further identify patients with subsets of vulvodynia and to evaluate diverse treatment modalities.
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Figures iii through seven from Apgar BS, Cox JT. Differentiating normal and abnormal findings of the vulva. Am Fam Physician 1996;53:1171.
REFERENCES
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1. Goetsch MF. Vulvar vestibulitis: prevalence and historic features in a general gynecologic exercise population. Am J Obstet Gynecol. 1991;164:1609–16. ...
2. Friedrich EG Jr. Vulvar vestibulitis syndrome. J Reprod Med. 1987;32:110–4.
3. Lynch PJ. Vulvodynia: a syndrome of unexplained vulvar pain, psychologic disability and sexual dysfunction. J Reprod Med. 1986;31:773–80.
4. McKay M. Vulvodynia. A multifactorial clinical problem. Arch Dermatol. 1989;125:256–62.
5. Paavonen J. Diagnosis and treatment of vulvodynia. Ann Med. 1995;27:175–81.
6. McKay Thousand. Vulvitis and vulvovaginitis: cutaneous considerations. Am J Obstet Gynecol. 1991;165:1176–82.
7. Gottleb A. Mail traumatic stress disorder and vulvar pain. The Vulvar Pain Newsletter. Graham, Northward.C.: Vulvar Pain Foundation, Fall 1995.
8. McKay K. Subsets of vulvodynia. J Reprod Med. 1988;33:695–8.
ix. Turner ML, Marinoff SC. Association of man papillomavirus with vulvodynia and the vulvar vestibulitis syndrome. J Reprod Med. 1988;33:533–7.
10. Umpierre SA, Kaufman RH, Adam E, Woods KV, Adler-Storthz Thousand. Human papillomavirus Dna in tissue biopsy specimens of vulvar vestibulitis patients treated with interferon. Obstet Gynecol. 1991;78:693–5.
11. Wilkinson EJ, Guerrero E, Daniel R, Shah Yard, Stone IK, Hardt NS, et al. Vulvar vestibulitis is rarely associated with man papillomavirus infection types 6, 11, 16, or 18. Int J Gynecol Pathol. 1993;12:344–9.
12. Bazin S, Bouchard C, Brisson J, Morin C, Meisels A, Fortier M. Vulvar vestibulitis syndrome: an exploratory case-command report. Obstet Gynecol. 1994;83:47–50.
13. Bornstein J, Shapiro S, Rahat M, Goldshmid N, Goldik Z, Abramovici H, et al. Polymerase concatenation reaction search for viral etiology of vulvar vestibulitis syndrome. Am J Obstet Gynecol. 1996;175:139–44.
14. Witkin SS, Jeremias J, Ledger WJ. Recurrent vaginitis every bit a issue of sexual transmission of IgE antibodies. Am J Obstet Gynecol. 1988;159:32–6.
15. Ashman RB, Ott AK. Autoimmunity equally a gene in recurrent vaginal candidosis and the small vestibular gland syndrome. J Reprod Med. 1989;34:264–6.
16. McKay M. Dysesthetic ("essential") vulvodynia. Treatment with amitriptyline. J Reprod Med. 1993;38:9–xiii.
17. Turner ML, Marinoff SC. Pudendal neuralgia. Am J Obstet Gynecol. 1991;165:1233–six.
eighteen. Fischer GO. The commonest causes of symptomatic vulvar disease: a dermatologist'south perspective. Australas J Dermatol. 1996;37:12–8.
19. Apgar BS, Cox JT. Differentiating normal and abnormal findings of the vulva. Am Fam Md. 1996;53:1171–80.
xx. Bergeron C, Ferenczy A, Richart RM, Guralnick 1000. Micropapillomatosis labialis appears unrelated to human papillomavirus. Obstet Gynecol. 1990;76:281–6.
21. Welch JM, Nayagam M, Parry 1000, Das R, Campbell M, Whatley J, et al. What is vestibular papillomatosis? A study of its prevalence, aetiology and natural history. Br J Obstet Gynaecol. 1993;100:939–42.
22. McKay Thousand, Frankman O, Horowitz BJ, Lecart C, Micheletti L, Ridley CM, et al. Vulvar vestibulitis and vestibular papillomatosis. Written report of the ISSVD Committee on Vulvodynia. J Reprod Med. 1991;36:413–5.
23. Woodruff JD, Parmley TH. Infection of the small-scale vestibular gland. Obstet Gynecol. 1983;62:609–12.
24. Mann MS, Kaufman RH, Brown D Jr, Adam Eastward. Vulvar vestibulitis: meaning clinical variables and treatment outcome. Obstet Gynecol. 1992;79:122–5.
25. Solomons CC, Melmed MH, Heitler SM. Calcium citrate for vulvar vestibulitis. A case report. J Reprod Med. 1991;36:879–82.
26. Marinoff SC, Turner ML. Vulvar vestibulitis syndrome: an overview. Am J Obstet Gynecol. 1991;165:1228–33.
27. Woodruff JD, Friedrich EG Jr. The antechamber. Clin Obstet Gynecol. 1985;28:134–41.
28. Reid R, Omoto KH, Precop SL, Berman NR, Rutledge LH, Dean SM, et al. Flashlamp-excited dye laser therapy of idiopathic vulvodynia is safe and efficacious. Am J Obstet Gynecol. 1995;172:1684–701.
29. Stewart DE, Reicher AE, Gerulath AH, Boydell KM. Vulvodynia and psychological distress. Obstet Gynecol. 1994;84:587–90.
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