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Vulvar vestibulitis is a condition of unknown etiology. Itinvolves the acute and chronic inflammation of the vestibu-lar glands, which lie just inside the vaginal introitus near the hymeneal ring. The involved glands may be circumferential to include areas near the urethra, but this condition most commonly involves posterolateral vestibular glands between the 4 and 8 o’clock positions (Fig. 42.2). The diagnosis shouldbe suspected in all patients who present with new onset insertional dyspareunia. Patients with this condition frequently com-plain of progressive insertional dyspareunia to the point where they are unable to have intercourse. The history may go on for a few weeks, but most typically involves progres sive worsening over the course of 3 or 4 months. Patients also complain of pain on tampon insertion and at times dur-ing washing or bathing the perineal area.
Physical examination is the key to diagnosis. Because the vestibular glands lie between the folds of the hymenal ring and the medial aspect of the vulvar vestibule, diagno-sis is frequently missed when inspection of the perineum does not include these areas: Once the speculum has been placedin the vagina, the vestibular gland area becomes impossible to identify. After carefully inspecting the proper anatomic area,a light touch with a moistened cotton applicator recreates the pain exactly and allows for quantification of the pain. In addition, the regions affected are most often evident as small, reddened, patchy areas.
Because the cause of vestibulitis is unknown, treatments vary and range from changing or eliminating environmen-tal factors, temporary sexual abstinence, and application of cortisone ointments and topical lidocaine (jelly); to more radical treatments such as surgical excision of the vestibular glands. A combination of treatment modalities may be nec-essary. Treatment must be individualized, based on the severity of patient symptoms and the sexual disability.
Some patients may benefit from low-dose tricyclic medication (amitriptyline and desipramine) or fluoxetine to help break the cycle of pain. Other limited reports suggest the use of calcium citrate to change the urine composition by removing oxalic acid crystals. Those advocating chang-ing the urine chemistry cite evidence to suggest that oxalic acid crystals are particularly irritating when precipitated in the urine of patients with high urinary oxalic acid composi-tion. Other modalities include biofeedback, physical ther-apy with electrical stimulation, or intralesional injections with triamcinolone and bupivacaine.
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