Treatment for vestibulitis is typically guided by the medical model. This model follows a traditional strategy of starting with conservative, non-invasive treatments and progressing to more invasive ones (89). Palliative interventions (e.g., sitz baths) to reduce the pain are the first-line treatment choice for dyspa-reunia. If these are not effective, treatment progresses to topical interventions (e.g., lidocaine, corticosteriods), systemic medications (e.g., oral corticosteriods, antifungals), followed by injectable medical treatments (e.g., interferon), "neuro-physiological" treatments (e.g., biofeedback, pharmacotherapy), and ending with surgical intervention (e.g., vestibulectomy). However, there is little evidence to support the use of topical, systemic, or injectable treatments. Although one placebo-controlled study of the effectiveness of cromolyn cream (90) and one randomized trial of fluconazole (91) found these treatments to be ineffective for relieving the symptoms of vulvar vestibulitis, one study found that long-term lidocaine ointment application decreased pain scores and re-established sexual activity in a group of vestibulitis sufferers (92). Follow-up data and a randomized clinical trial are needed in order to fully assess the effects of this kind of treatment, as local and systemic medications, such as creams, antibiotics, and injectable medical treatments may cause more harm than benefit (5). In addition, there is no empirical evidence for the success of any medication, such as antidepressants, for the pain of vestibulitis.
Cognitive-behavioral interventions for vulvar vestibulitis syndrome include cognitive-behavioral pain management, sex therapy, and pelvic floor biofeedback to target both pain reduction and sexual functioning. Success rates ranging from 43% to 86% have been reported in two uncontrolled studies in which sex therapy and pain management were combined (93,94). In 1996, Weijmar Schultz et al. (95) published a prospective and partially randomized treatment outcome study investigating the effectiveness of behavioral intervention with or without surgery. Results from this study indicated that women in both groups benefited in terms of pain reduction, with no significant differences between women who had undergone the behavioral intervention alone vs. those who underwent the combined treatment of behavioral intervention and surgery. The authors suggest that the behavioral approach should be the first line of treatment for ves-tibulitis sufferers, with the surgery acting as an additional form of treatment for refractory cases.
Biofeedback training has been used in an effort to reduce hypertonicity of the pelvic floor muscles (61). With the aid of a vaginal sensor, the patient is provided with direct visual feedback regarding their level of muscle tension, facilitating muscle training with respect to contraction, relaxation, and the acquisition of voluntary control. After ^4 months of training, subjective pain reports decreased an average of 83%, with 52% of the women reporting pain-free intercourse, and 79% of women who were abstaining from intercourse resuming activity posttreatment. However, this study contained a mixed group of women with vulvar pain and likely contained a high proportion of vaginismic women, considering that many participants were not engaging in intercourse at the beginning of the study. The effectiveness of physical therapy, which includes a pelvic floor biofeedback component in addition to soft tissue mobilization and other techniques specific to this treatment, has recently been evaluated in a retrospective study of vestibulitis sufferers (96). Results indicated that after an average of 16 months of treatment, physical therapy yielded a moderate to great improvement in over 70% of participants. Treatment resulted in significant pain reduction during intercourse and gynecological examinations, and increases in intercourse frequency and levels of sexual desire and arousal. These findings indicate that physical therapy is indeed a promising treatment modality for women who suffer from vulvar vestibulitis syndrome, although prospective studies are needed.
Vestibulectomy has been the most investigated treatment for vulvar vestibulitis to date with over 20 published outcome studies, yielding success rates ranging from 43% to 100% (42). This minor surgical procedure, preformed as day surgery under general anesthesia, consists of the excision of the hymen and sensitive areas of the vestibule to a depth of ^2 mm, with some procedures involving the mobilization of the vaginal mucosa to cover the excised area. Following this procedure, women are generally instructed to abstain from all forms of vaginal penetration for 6-8 weeks.
Our research group conducted a randomized treatment outcome study of vulvar vestibulitis comparing vestibulectomy, group cognitive-behavior therapy, and pelvic floor biofeedback (97). At posttreatment and 6-month follow-up, there was significant pain reduction for all three treatment groups. However, vestibulectomy resulted in approximately twice the pain reduction (47 -70% depending on the pain measure) of the two other treatments (19-38%); it was characterized by a high success rate and by elevated percentages of pain reduction. In addition, there were significant improvements in overall sexual functioning and self-reported frequency of intercourse at the 6-month follow-up, with no treatment differences. However, means for intercourse frequency for all three groups remained below the mean frequency of intercourse for healthy women of similar age. In a 2.5-year follow-up of this study (98), members of all three treatment groups continued to improve over time. Vestibulectomy remained superior to the other two treatments with respect to pain ratings on the cotton-swab test, whereas women in the group therapy condition reported equal improvements in terms of self-report measures of painful intercourse. Changes in overall sexual functioning and intercourse frequency were maintained, with no group differences. These results suggest that although the benefits of group therapy may take longer to appear, it can be just as effective as surgery in reducing the pain experienced during intercourse.
Alternative treatments for vulvar vestibulitis syndrome include acupuncture and hypnotherapy. Although few studies currently exist, there are promising data regarding the effect of acupuncture on pain reduction and overall quality of life (99). In addition, a recently published case study indicated that hypnosis reduced pain and helped re-establish sexual pleasure (100). Randomized controlled trials are needed in order to truly establish the effectiveness of these treatments. Alternative treatments seem promising, yet to date, only cognitive-behavioral therapy, biofeedback, and vestibulectomy have been empirically validated. It is also likely that concurrent treatment with multiple non-invasive methods may be even superior to single treatments, though this has yet to be investigated.
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HYPNOTISM is by no means a new art. True, it has been developed into a science in comparatively recent years. But the principles of thought control have been used for thousands of years in India, ancient Egypt, among the Persians, Chinese and in many other ancient lands. Learn more within this guide.