Diagnosis and Management of Vulvar Vestibulitis Syndrome in 559 Women (1991-2011)

Objective: This study was carried out to determine factors involved in the etiology and propagation of vulvar vestibulitis syndrome. The study benchmarked elimination of vulvar pain and capability of engaging in pain-free intercourse as objective parameters for determining the effectiveness of nonsurgical versus surgical treatment. Study Design: This was a prospective evaluation of 502 women, all of whom participated in a structured medical regimen of treatment for vulvar vestibulitis syndrome for a minimum of 4 months, and 404 women who underwent surgery. Materials and Methods: Between 1991 and 2011, 559 women were diagnosed and treated for vulvar vestibulitis syndrome. Of these women, 502 were available for follow-up. Each woman was given a minimum of 4 months of conservative therapy. This program consisted of systemic medications for neuropathic pain, biofeedback by a specifically trained physical therapist, a low-oxalate diet, calcium citrate, abstention from intercourse for 6 weeks, and elimination of all topical agents. Each patient had a complete vaginal culture profile and a colposcopic examination of the vulva, vagina, and cervix (if present). After 4 months, those patients with no or marginal improvement were offered a surgical option of either vestibulectomy only or vestibulectomy and excision of the Bartholin glands. Results: Of the 502 women, 98 continued on the medical regimen and had low levels of pain or no pain with intercourse. The remaining 404 underwent vestibulectomy, with or without Bartholin-gland removal. Of the women undergoing surgery, 391 were able to have pain-free intercourse. Fifteen percent of women who had gland excision developed postoperative pudendal neuralgia. Five percent of women who underwent vestibulectomy only developed cysts secondary to Bartholin-gland secretion coupled with the absence of a duct. Conclusions: Vulvar vestibulitis is a problem affecting a substantial number of women numbering in the millions. The symptoms include pruritus, burning, and stinging pain limited to the vulvar vestibule. Nonsurgical therapy results in a small number of remissions and an even lower number of cures. Vulvar vestibulectomy coupled with excision of the paraurethral ducts and vaginal advancement lead to > 90% elimination of pain.