Vulvodynia—An Evidence‐Based Literature Review and Proposed Treatment Algorithm

We searched the medical literature from the last 15 years (1998 to 2013) relating to the etiology, diagnosis, and treatment of vulvodynia. The evidence was reviewed supporting the therapeutic proposals currently in use and propose the incorporation of novel, minimally invasive, interventional therapies, within the context of a multidisciplinary approach.

[1]  P. Anand,et al.  Increased vanilloid receptor VR1 innervation in vulvodynia , 2004, European journal of pain.

[2]  A. Bulbena,et al.  Clinical Characteristics and Psychopathological Profile of Patients with Vulvodynia: An Observational and Descriptive Study , 2007, Dermatology.

[3]  G. Terenghi,et al.  Increased innervation of the vulval vestibule in patients with vulvodynia , 2003, The British journal of dermatology.

[4]  B. Ben-david,et al.  Gabapentin therapy for vulvodynia. , 1999, Anesthesia and analgesia.

[5]  F. Itza,et al.  Puesta al día en el diagnóstico y tratamiento de la vulvodinia , 2012 .

[6]  Eric M. Francisco,et al.  Altered Central Sensitization in Subgroups of Women With Vulvodynia , 2011, The Clinical journal of pain.

[7]  J. Bornstein,et al.  Perineoplasty compared with vestibuloplasty for severe vulvar vestibulitis , 1995, British journal of obstetrics and gynaecology.

[8]  H. Kress,et al.  Chronic pelvic pain treated with gabapentin and amitriptyline: A randomized controlled pilot study , 2005, Wiener klinische Wochenschrift.

[9]  D. Srivastava.  Efficacy of sacral neuromodulation in treating chronic pain related to painful bladder syndrome/interstitial cystitis in adults , 2012, Journal of anaesthesiology, clinical pharmacology.

[10]  M. Moyal-Barracco,et al.  Vulvar vestibulitis. Lack of evidence for a human papillomavirus etiology. , 1994, Journal of reproductive medicine.

[11]  N. Bohm-Starke,et al.  Medical and physical predictors of localized provoked vulvodynia , 2010, Acta obstetricia et gynecologica Scandinavica.

[12]  D. Papastergiou,et al.  Peripheral Subcutaneous Stimulation for the Treatment of Intractable Postherpetic Neuralgia: Two Case Reports and Literature Review , 2009, Pain practice : the official journal of World Institute of Pain.

[13]  R. Nappi,et al.  Electrical Stimulation (ES) in the Management of Sexual Pain Disorders , 2003, Journal of sex & marital therapy.

[14]  M. Moyal-Barracco,et al.  The Vulvodynia Guideline , 2005, Journal of lower genital tract disease.

[15]  J. E. Carter.  Surgical Treatment for Chronic Pelvic Pain , 1998, JSLS : Journal of the Society of Laparoendoscopic Surgeons.

[16]  D. Yarnitsky,et al.  Association between quantitative sensory testing, treatment choice, and subsequent pain reduction in vulvar vestibulitis syndrome. , 2004, The journal of pain : official journal of the American Pain Society.

[17]  L. Lundvall,et al.  Botulinum toxin type A-a novel treatment for provoked vestibulodynia? Results from a randomized, placebo controlled, double blinded study. , 2009, The journal of sexual medicine.

[18]  Y. Binik,et al.  Vulvar vestibulitis syndrome: a critical review. , 1997, The Clinical journal of pain.

[19]  M. Moyal-Barracco,et al.  2006 ISSVD classification of vulvar dermatoses: pathologic subsets and their clinical correlates. , 2007, The Journal of reproductive medicine.

[20]  M. Signaroldi,et al.  Electrodiagnostic Functional Sensory Evaluation of Patients With Generalized Vulvodynia: A Pilot Study , 2010, Journal of lower genital tract disease.

[21]  R. Pagano,et al.  Use of Amitriptyline Cream in the Management of Entry Dyspareunia Due to Provoked Vestibulodynia , 2012, Journal of lower genital tract disease.

[22]  J. Beco,et al.  Pudendal nerve decompression in perineology : a case series , 2004 .

[23]  C. Borg,et al.  Anticonvulsant pharmacotherapy for generalized and localized vulvodynia: a critical review of the literature , 2013, Journal of psychosomatic obstetrics and gynaecology.

[24]  M. Bishop,et al.  Psychological Factors in Chronic Pelvic Pain in Women: Relevance and Application of the Fear-Avoidance Model of Pain , 2011, Physical Therapy.

[25]  J. Fischer,et al.  Sacral Neuromodulation in the Treatment of Vulvar Vestibulitis Syndrome , 2009, Obstetrics and Gynecology.

[26]  Hong Li,et al.  Histologic and receptor analysis of primary and secondary vestibulodynia and controls: a prospective study. , 2010, American journal of obstetrics and gynecology.

[27]  S. Meltzer-Brody,et al.  Open-label trial of lamotrigine focusing on efficacy in vulvodynia. , 2009, The Journal of reproductive medicine.

[28]  C. Butrick.  Patient selection for sacral nerve stimulation , 2010, International Urogynecology Journal.

[29]  M. Dede,et al.  Successful treatment of persistent vulvodynia with submucous infiltration of betamethasone and lidocaine. , 2006, European journal of obstetrics, gynecology, and reproductive biology.

[30]  K. Renney,et al.  Pudendal entrapment as an etiology of chronic perineal pain: Diagnosis and treatment , 2007, Neurourology and urodynamics.

[31]  J. Rigaud,et al.  Les infiltrations du système nerveux sympathique dans la prise en charge thérapeutiques des douleurs pelvipérinéales chroniques , 2010 .

[32]  N. Kamdar,et al.  Improvement in vulvar vestibulitis with montelukast. , 2007, The Journal of reproductive medicine.

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[34]  M. Goetsch.  Vulvar vestibulitis: prevalence and historic features in a general gynecologic practice population. , 1991, American journal of obstetrics and gynecology.

[35]  J. Hendriks,et al.  Surgical Treatment for the Vulvar Vestibulitis Syndrome , 2006, Obstetrics and gynecology.

[36]  D. Gorenflo,et al.  Treatment of vulvodynia with tricyclic antidepressants: efficacy and associated factors. , 2006, Journal of lower genital tract disease.

[37]  I. Danielsson,et al.  The Result of Treatment on Vestibular and General Pain Thresholds in Women With Provoked Vestibulodynia , 2007, The Clinical journal of pain.

[38]  S. Witkin,et al.  Interleukin 1 receptor antagonist gene polymorphism in women with vulvar vestibulitis. , 2000, American journal of obstetrics and gynecology.

[39]  M. Tatagiba,et al.  Combined Spinal Cord and Peripheral Nerve Field Stimulation for Persistent Post‐Herniorrhaphy Pain , 2013, Neuromodulation : journal of the International Neuromodulation Society.

[40]  M. Staal,et al.  Subcutaneous Electrical Nerve Stimulation: A Feasible and New Method for the Treatment of Patients With Refractory Angina , 2011, Neuromodulation : journal of the International Neuromodulation Society.

[41]  G. Kirtschig,et al.  Guidelines for the management of vulvodynia , 2010, The British journal of dermatology.

[42]  D. Foster,et al.  Impact of genetic variation in interleukin-1 receptor antagonist and melanocortin-1 receptor genes on vulvar vestibulitis syndrome. , 2004, The Journal of reproductive medicine.

[43]  K. Cho,et al.  Radiofrequency Sacral Rhizotomy for the Management of Intolerable Neurogenic Bladder in Spinal Cord Injured Patients , 2012, Annals of rehabilitation medicine.

[44]  W. Ledger,et al.  Defective regulation of the proinflammatory immune response in women with vulvar vestibulitis syndrome. , 2002, American journal of obstetrics and gynecology.

[45]  K. Hartmann,et al.  Overnight 5% Lidocaine Ointment for Treatment of Vulvar Vestibulitis , 2003, Obstetrics and gynecology.

[46]  Histopathologic Characteristics of Menopausal Vestibulodynia , 2013, Obstetrics and gynecology.

[47]  M. Adelson,et al.  Vulvodynia and fungal association: a preliminary report. , 2013, Medical hypotheses.

[48]  S. Agrawal,et al.  Prevalences of and risk factors for vulvar diseases in Nepal: a hospital‐based study , 2011, International journal of dermatology.

[49]  L. Fertitta,et al.  Vulvar vestibulitis syndrome. , 1992, Nurse practitioner forum.

[50]  G. Donders,et al.  Cream With Cutaneous Fibroblast Lysate for the Treatment of Provoked Vestibulodynia: A Double-Blind Randomized Placebo-Controlled Crossover Study , 2012, Journal of lower genital tract disease.

[51]  L. Sadownik.  Etiology, diagnosis, and clinical management of vulvodynia , 2014, International journal of women's health.

[52]  J. Brisson,et al.  Human Papillomaviruses and Vulvar Vestibulitis , 2000, Obstetrics and gynecology.

[53]  C. Parsons,et al.  Prevalence of interstitial cystitis in vulvodynia patients detected by bladder potassium sensitivity. , 2010, The journal of sexual medicine.

[54]  M. Ghannoum,et al.  Cutaneous hypersensitivity to Candida albicans in idiopathic vulvodynia , 2005, Contact dermatitis.

[55]  C. Bates,et al.  Vulvodynia—new and more effective approaches to therapy , 2002, International journal of STD & AIDS.

[56]  G. Ventolini,et al.  Vulvodynia, a step-wise therapeutic prospective cohort study , 2009, Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology.

[57]  N. Mekhail,et al.  Spinal cord stimulation for intractable vulvar pain. A case report. , 2003, Journal of reproductive medicine.

[58]  F. Murina,et al.  Capsaicin and the treatment of vulvar vestibulitis syndrome: a valuable alternative? , 2004, MedGenMed : Medscape general medicine.

[59]  O. Calvillo,et al.  Computed Tomography-Guided Pudendal Nerve Block. A New Diagnostic Approach to Long-term Anoperineal Pain: A Report of Two Cases , 2000, Regional Anesthesia & Pain Medicine.

[60]  J. Paavonen,et al.  Long‐term well‐being after surgical or conservative treatment of severe vulvar vestibulitis , 2012, Acta obstetricia et gynecologica Scandinavica.

[61]  A. Mailis,et al.  Evidence-based guideline for neuropathic pain interventional treatments: spinal cord stimulation, intravenous infusions, epidural injections and nerve blocks. , 2012, Pain research & management.

[62]  L. Jerome.  Pregabalin-induced remission in a 62-year-old woman with a 20-year history of vulvodynia. , 2007, Pain research & management.

[63]  M. van Kleef,et al.  Pulsed and Continous Radiofrequency Current Adjacent to the Cervical Dorsal Root Ganglion of the Rat Induces Late Cellular Activity in the Dorsal Horn , 2005, Anesthesiology.

[64]  A. Yakovlev,et al.  Treatment of intractable hip pain after THA and GTB using peripheral nerve field stimulation: a case series. , 2010, WMJ : official publication of the State Medical Society of Wisconsin.

[65]  A. Shafik.  Pudendal canal syndrome as a cause of vulvodynia and its treatment by pudendal nerve decompression. , 1998, European journal of obstetrics, gynecology, and reproductive biology.

[66]  R. J. Leo.  A systematic review of the utility of anticonvulsant pharmacotherapy in the treatment of vulvodynia pain. , 2013, The journal of sexual medicine.

[67]  W. Grill,et al.  Effects of stimulation site and stimulation parameters on bladder inhibition by electrical nerve stimulation , 2012, BJU international.

[68]  B. Parratte,et al.  Efficacy of high doses of botulinum toxin A for treating provoked vestibulodynia , 2011, The British journal of dermatology.

[69]  V. Dolz,et al.  Peripheral Subcutaneous Vulvar Stimulation in the Management of Severe and Refractory Vulvodynia , 2013, Obstetrics and Gynecology.

[70]  Candace S. Brown,et al.  Self-management, amitriptyline, and amitripyline plus triamcinolone in the management of vulvodynia. , 2009, Journal of women's health.

[71]  J. Bornstein,et al.  Enoxaparin Treatment for Vulvodynia: A Randomized Controlled Trial , 2012, Obstetrics and gynecology.

[72]  R. Nappi,et al.  Interstitial cystitis is associated with vulvodynia and sexual dysfunction--a case-control study. , 2011, The journal of sexual medicine.

[73]  Erich O. Richter,et al.  Percutaneous Cephalocaudal Implantation of Epidural Stimulation Electrodes Over Sacral Nerve Roots—A Technical Note on the Importance of the Lateral Approach , 2011, Neuromodulation : journal of the International Neuromodulation Society.

[74]  C. Altgassen,et al.  Developing an interdisciplinary consultation service for vulvar disorders , 2012, Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG.

[75]  J. Hasday,et al.  Elevated tissue levels of interleukin‐1β and tumor necrosis factor‐alpha in vulvar vestibulitis , 1997, Obstetrics and gynecology.

[76]  R. Kaufman,et al.  Treating vulvar vestibulitis with electromyographic biofeedback of pelvic floor musculature. , 2001, The Journal of reproductive medicine.

[77]  M. Kuppermann,et al.  Chronic Pelvic Pain: Prevalence, Health‐Related Quality of Life, and Economic Correlates , 1996, Obstetrics and gynecology.

[78]  J. Salinas,et al.  [Update on the diagnosis and treatment of vulvodynia]. , 2012, Actas urologicas espanolas.

[79]  J. Quero,et al.  Peripheral Neurostimulation in the Management of Cervicogenic Headache: Four Case Reports , 2005, Neuromodulation : journal of the International Neuromodulation Society.

[80]  M. Spence,et al.  Evaluation of the surgical treatment of vulvar vestibulitis. , 1999, European journal of obstetrics, gynecology, and reproductive biology.

[81]  P. Nyirjesy,et al.  Topical Amitriptyline-Baclofen Cream for the Treatment of Provoked Vestibulodynia , 2009 .

[82]  L. Sadownik,et al.  Provoked vestibulodynia-women's experience of participating in a multidisciplinary vulvodynia program. , 2012, The journal of sexual medicine.

[83]  E. Bair,et al.  Psychosexual correlates of persistent postsurgical pain in patients with vulvodynia , 2011, International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics.

[84]  G. Bachmann,et al.  Vulvodynia: Characteristics and Associations With Comorbidities and Quality of Life , 2006, Obstetrics and gynecology.

[85]  J. Sobel,et al.  Onset of Vulvodynia in a Woman Ultimately Diagnosed With Creutzfeldt-Jakob Disease , 2010, Obstetrics and gynecology.

[86]  I. Danielsson,et al.  EMG biofeedback versus topical lidocaine gel: a randomized study for the treatment of women with vulvar vestibulitis , 2006, Acta obstetricia et gynecologica Scandinavica.

[87]  J. Bornstein,et al.  Combination of subtotal perineoplasty and interferon for the treatment of vulvar vestibulitis. , 1997, Gynecologic and obstetric investigation.

[88]  G. Donders,et al.  Characteristics of the pain observed in the focal vulvodynia syndrome (VVS). , 2012, Medical Hypotheses.

[89]  Augmented central pain processing in vulvodynia. , 2012, The journal of pain : official journal of the American Pain Society.

[90]  C. Habermann,et al.  CT-guided Blocks and Neuroablation of the Ganglion Impar (Walther) in Perineal Pain: Anatomy, Technique, Safety, and Efficacy , 2009, The Clinical journal of pain.

[91]  A. Borgida,et al.  Evaluation of Gabapentin in the Treatment of Generalized Vulvodynia, Unprovoked , 2007, The Journal of reproductive medicine.

[92]  M. van Kleef,et al.  Pulsed radiofrequency treatment for radicular pain: where do we stand and where to go? , 2012, Pain medicine.

[93]  J. Abbott.  The use of botulinum toxin in the pelvic floor for women with chronic pelvic pain-a new answer to old problems? , 2009, Journal of minimally invasive gynecology.

[94]  W. Ledger,et al.  A deficiency in interferon-α production in women with vulvar vestibulitis , 2002 .

[95]  L. Boardman,et al.  Sexual pain. , 2009, Clinical obstetrics and gynecology.

[96]  Michael J. Roberts,et al.  The vulvalgesiometer as a device to measure genital pressure-pain threshold , 2007, Physiological measurement.

[97]  Crista E. Johnson,et al.  Surgical treatment of vulvar vestibulitis syndrome: outcome assessment derived from a postoperative questionnaire. , 2006, The journal of sexual medicine.

[98]  Candace S. Brown,et al.  Rationale and design of a multicenter randomized clinical trial of extended release gabapentin in provoked vestibulodynia and biological correlates of response. , 2013, Contemporary Clinical Trials.

[99]  C. Butrick.  Pelvic floor hypertonic disorders: identification and management. , 2009, Obstetrics and gynecology clinics of North America.

[100]  S. Regauer,et al.  Diagnosis and management of vulvodynia should include biopsy and histological examination , 2010, The British journal of dermatology.

[101]  E. Cosman,et al.  Ultrastructural Changes in Axons Following Exposure to Pulsed Radiofrequency Fields , 2009, Pain practice : the official journal of World Institute of Pain.

[102]  P. Nyirjesy,et al.  Cromolyn cream for recalcitrant idiopathic vulvar vestibulitis: results of a placebo controlled study , 2001, Sexually transmitted infections.

[103]  B. Ghiringhello,et al.  Membranous hypertrophy of the posterior fourchette as a cause of dyspareunia and vulvodynia. , 1994, Journal of reproductive medicine.

[104]  S. Kothari,et al.  Neuromodulatory approaches to chronic pelvic pain and coccygodynia. , 2007, Acta neurochirurgica. Supplement.

[105]  M. Moyal-Barracco,et al.  2003 ISSVD terminology and classification of vulvodynia: a historical perspective. , 2004, The Journal of reproductive medicine.

[106]  T. Aziz,et al.  EFNS guidelines on neurostimulation therapy for neuropathic pain , 2007, European journal of neurology.

[107]  G. Barolat,et al.  Subcutaneous Peripheral Nerve Stimulation Treatment for Chronic Pelvic Pain , 2008, Neuromodulation : journal of the International Neuromodulation Society.

[108]  R. Meyer,et al.  Electrical stimulation at distinct peripheral sites in spinal nerve injured rats leads to different afferent activation profiles , 2011, Neuroscience Letters.

[109]  B. Harlow,et al.  A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? , 2003, Journal of the American Medical Women's Association.

[110]  H. Lawson,et al.  2013 Vulvodynia Guideline Update , 2014, Journal of lower genital tract disease.

[111]  G. Stefan,et al.  Immunological and genetic characterization of women with vulvodynia , 2008, Journal of Medicine and Life.

[112]  M. McKay,et al.  Dysesthetic ("essential") vulvodynia. Treatment with amitriptyline. , 1993, The Journal of reproductive medicine.

[113]  Y. Binik,et al.  The surgical treatment of vulvar vestibulitis syndrome: a follow-up study. , 1997, Journal of sex & marital therapy.

[114]  Ananda Sen,et al.  Prevalence and demographic characteristics of vulvodynia in a population-based sample. , 2012, American journal of obstetrics and gynecology.

[115]  M. Goetsch,et al.  KTP-nd:YAG laser therapy for the treatment of vestibulodynia: a follow-up study. , 2007, The Journal of reproductive medicine.

[116]  J. Bornstein,et al.  Pure versus Complicated Vulvar Vestibulitis: A Randomized Trial of Fluconazole Treatment , 2000, Gynecologic and Obstetric Investigation.

[117]  C. Swencionis,et al.  Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. , 1995, The Journal of reproductive medicine.

[118]  Mélanie Morin,et al.  Morphometry of the pelvic floor muscles in women with and without provoked vestibulodynia using 4D ultrasound. , 2014, The journal of sexual medicine.

[119]  I. Goldstein,et al.  Can oral contraceptives cause vestibulodynia? , 2010, The journal of sexual medicine.

[120]  C. Perniciaro,et al.  Two cases of vulvodynia with unusual causes. , 1993, Acta dermato-venereologica.

[121]  R. Murphy,et al.  Assessment and management of vulval pain , 2012, BMJ : British Medical Journal.

[122]  A. Graziottin,et al.  HPV infection in women: psychosexual impact of genital warts and intraepithelial lesions. , 2009, The journal of sexual medicine.

[123]  N. Bohm-Starke,et al.  Surgery for localized, provoked vestibulodynia: a long-term follow-up study. , 2008, The Journal of reproductive medicine.

[124]  M. Granot,et al.  Psychological Factors Associated with Perception of Experimental Pain in Vulvar Vestibulitis Syndrome , 2005, Journal of sex & marital therapy.

[125]  K. Whitmore,et al.  Capsaicin for the treatment of vulvar vestibulitis. , 2005, American journal of obstetrics and gynecology.

[126]  R. Kerns,et al.  Vulvodynia: an introduction and critical review of a chronic pain condition , 2000, Pain.

[127]  Ananda Sen,et al.  Relationship Between Vulvodynia and Chronic Comorbid Pain Conditions , 2012, Obstetrics and gynecology.

[128]  C. Raker,et al.  Topical Gabapentin in the Treatment of Localized and Generalized Vulvodynia , 2008, Obstetrics and gynecology.

[129]  P. Giraldo,et al.  Electromyography and vaginal pressure of the pelvic floor muscles in women with recurrent vulvovaginal candidiasis and vulvodynia. , 2012, The Journal of reproductive medicine.

[130]  B. Fenton.  Limbic associated pelvic pain: a hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain. , 2007, Medical hypotheses.

[131]  P. Munday.  Response to treatment in dysaesthetic vulvodynia , 2001, Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology.

[132]  E. Toeima,et al.  Junior doctors’ understanding of vulval pain/Vulvodynia: a qualitative survey , 2011, Archives of Gynecology and Obstetrics.

[133]  Candace S. Brown,et al.  Subjective and objective outcomes of botulinum toxin type A treatment in vestibulodynia: pilot data. , 2006, The Journal of reproductive medicine.

[134]  L. Calhoun,et al.  Anorgasmia and Withdrawal Syndrome in a Woman Taking Gabapentin , 2003, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[135]  J. Paavonen.  Diagnosis and treatment of vulvodynia. , 1995, Annals of medicine.

[136]  J. Bornstein,et al.  "Primary" versus "secondary" vulvar vestibulitis: one disease, two variants. , 2001, American journal of obstetrics and gynecology.

[137]  K. Aló,et al.  Lumbar and Sacral Nerve Root Stimulation (NRS) in the Treatment of Chronic Pain: A Novel Anatomic Approach and Neuro Stimulation Technique , 1999, Neuromodulation : journal of the International Neuromodulation Society.

[138]  C. Benedetto,et al.  Vulvodynia as a possible somatization disorder. More than just an opinion. , 2007, The Journal of reproductive medicine.

[139]  H. Haefner,et al.  A survey on diagnosis and treatment of vulvodynia among vulvodynia researchers and members of the International Society for the Study of Vulvovaginal Disease. , 2008, The Journal of reproductive medicine.

[140]  A. Good,et al.  Vestibulectomy for vulvar vestibulitis. , 2003, The Journal of reproductive medicine.

[141]  J. Fariello,et al.  Sacral neuromodulation stimulation for IC/PBS, chronic pelvic pain, and sexual dysfunction , 2010, International Urogynecology Journal.

[142]  L. McLean,et al.  Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program. , 2010, The journal of sexual medicine.

[143]  O. Tawfik,et al.  Botulinum toxin a for vulvodynia: a case report. , 2004, The journal of pain : official journal of the American Pain Society.

[144]  J. Bornstein,et al.  Treatment of a patient with vulvar vestibulitis by intramuscular interferon beta; a case report. , 1991, European journal of obstetrics, gynecology, and reproductive biology.

[145]  U. Nicolini,et al.  Transcutaneous electrical nerve stimulation to treat vestibulodynia: a randomised controlled trial , 2008, BJOG : an international journal of obstetrics and gynaecology.

[146]  P. Roberti,et al.  Treatment of vulvar vestibulitis with submucous infiltrations of methylprednisolone and lidocaine. An alternative approach. , 2001, The Journal of reproductive medicine.

[147]  Kevin L Wininger,et al.  Feasibility of combined epicranial temporal and occipital neurostimulation: treatment of a challenging case of headache. , 2011, Pain physician.

[148]  Lizheng Shi,et al.  Economic burden and quality of life of vulvodynia in the United States , 2012, Current medical research and opinion.

[149]  D. Segal,et al.  Submucous infiltration of betamethasone and lidocaine in the treatment of vulvar vestibulitis. , 2003, European journal of obstetrics, gynecology, and reproductive biology.

[150]  L. Bertolasi,et al.  Botulinum Neurotoxin Type A Injections for Vaginismus Secondary to Vulvar Vestibulitis Syndrome , 2009, Obstetrics and gynecology.

[151]  L. Eva,et al.  Is modified vestibulectomy for localized provoked vulvodynia an effective long-term treatment? A follow-up study. , 2008, The Journal of reproductive medicine.

[152]  J. Gavard,et al.  Role of Vulvar Care Guidelines in the Initial Management of Vulvar Complaints , 2012, Journal of lower genital tract disease.

[153]  M. Goetsch.  Patients' assessments of a superficial modified vestibulectomy for vestibulodynia. , 2008, The Journal of reproductive medicine.

[154]  J. de Andrés,et al.  Role of lumbosacral retrograde neuromodulation in the treatment of painful disorders. , 2013, Pain physician.

[155]  R. Amsel,et al.  A randomized comparison of group cognitive–behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis , 2001, Pain.

[156]  R. Dworkin,et al.  The Tampon Test for Vulvodynia Treatment Outcomes Research: Reliability, Construct Validity, and Responsiveness , 2009, Obstetrics and gynecology.

[157]  A. Rapkin,et al.  Multilevel local anesthetic nerve blockade for the treatment of generalized vulvodynia: a pilot study. , 2012, The journal of sexual medicine.

[158]  M. Abdelnoor,et al.  Vulvar vestibulitis and risk factors: a population-based case-control study in Oslo. , 2007, Acta dermato-venereologica.

[159]  G. del Priore,et al.  Spinal Cord Stimulator for the Treatment of a Woman With Vulvovaginal Burning and Deep Pelvic Pain , 2008, Obstetrics and gynecology.

[160]  K. Walsh,et al.  Safety and efficacy of topical nitroglycerin for treatment of vulvar pain in women with vulvodynia: a pilot study. , 2002, The journal of gender-specific medicine : JGSM : the official journal of the Partnership for Women's Health at Columbia.

[161]  B. Chalidis,et al.  Subcutaneous targeted neuromodulation technique for the treatment of intractable chronic postthoracotomy pain. , 2010, Journal of clinical anesthesia.

[162]  C. Swencionis,et al.  Electromyographic comparisons of the pelvic floor in women with dysesthetic vulvodynia and asymptomatic women. , 1998, The Journal of reproductive medicine.

[163]  T. Rosenbaum,et al.  The role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction (CME). , 2008, The journal of sexual medicine.

[164]  J. Hasday,et al.  Elevated Tissue Levels of Interleukin‐1β and Tumor Necrosis Factor‐α in Vulvar Vestibulitis , 1997 .

[165]  T. Morgan,et al.  Differences in Primary Compared With Secondary Vestibulodynia by Immunohistochemistry , 2011, Obstetrics and gynecology.

[166]  C. Wright,et al.  Recalcitrant vulvodynia. A clinicopathological study. , 1993, South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde.

[167]  G. Richard,et al.  Intralesional alpha interferon. Cost-effective therapy for vulvar vestibulitis syndrome. , 1993, The Journal of reproductive medicine.

[168]  Y. Binik,et al.  Physical Therapy for Vulvar Vestibulitis Syndrome: A Retrospective Study , 2002, Journal of sex & marital therapy.

[169]  J. Clemens,et al.  Symptoms of interstitial cystitis, painful bladder syndrome and similar diseases in women: a systematic review. , 2007, The Journal of urology.

[170]  J. Metts,et al.  Vulvodynia and vulvar vestibulitis: challenges in diagnosis and management. , 1999, American family physician.

[171]  R. Kerns,et al.  A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy , 2009, PAIN®.

[172]  J. Aikens,et al.  Depressive symptoms among women with vulvar dysesthesia. , 2003, American journal of obstetrics and gynecology.

[173]  R. Dworkin,et al.  Oral Desipramine and Topical Lidocaine for Vulvodynia: A Randomized Controlled Trial , 2010, Obstetrics and gynecology.

[174]  Ananda Sen,et al.  Vulvodynia Incidence and Remission Rates Among Adult Women: A 2-Year Follow-up Study , 2008, Obstetrics and gynecology.

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