Surgery is generally reserved for the most refractive cases of VVS. The efficacy of surgical excision of painful vestibular tissue has been reviewed extensively elsewhere (67). Case series indicate that surgery is an effective form of therapy, with symptom relief in 60% to 90% of cases (35,53,68-70). It should be noted that the definition of a successful outcome (pain reduction, resumption of intercourse, etc.) varies among these studies and that most women served as their own control.

The most conservative surgical technique, vestibuloplasty, involves vertical excision of the posterior vaginal introitus without vaginal advancement. In partial vestibulectomy, the posterior portion of the vulvar vestibule is removed, with advancement of the vaginal epithelium to cover the excised portion. Perineoplasty, the most aggressive intervention, extends from just below the urethra to the fourchette; the vaginal epithelium is advanced laterally to the labia minora and posteriorly to the perineal body.

A comparative study involving 21 women found that vestibuloplasty failed to relieve symptoms in 10 patients, while perineoplasty resulted in complete remission in 9 of 11 patients (71). Removal of only the posterior vestibule, coupled with interferon treatment of the remaining anterior vestibule, was as effective as total perineoplasty and had fewer surgical complications (72).

A 10-year retrospective chart review at the Mayo Clinic provided substantial evidence for the effectiveness of vestibulectomy, lending further support for this more conservative approach (70).

A partially randomized and nonrandomized study involving 48 women comparing cognitive behavioral therapy (CBT) and CBT preceded by vestibu-lectomy found both treatments to be equally effective (73). Notably, although the study was to have been a randomized trial of CBT and surgery, it became difficult to continue assigning patients to surgery once it became apparent that the two treatments were equally effective; therefore, some patients were given the option of choosing surgical intervention prior to CBT. Because of the small group sizes (only 14 women participated in the randomized portion), the power of the statistical analysis and the study conclusions have been criticized (74). A later comparison of CBT, electromyographic biofeedback, and vestibu-lectomy found that all treatments resulted in improvements in pain perception and sexual function at a six-month follow-up, although vestibulectomy was significantly more successful (75). After two years, vestibulectomy remained superior in its impact on vestibular pain perception, but was no different to CBT, specifically with regard to coital pain (76). It is unclear whether the duration of the physical and psychosocial interventions (12 weeks) was sufficient for an effective comparison of these alternative measures.

It should be noted that the data supporting the efficacy of surgery are not accepted universally. Some investigators have challenged study methodologies and the assumptions involved in measuring success rates; they believe that the psychosocial aspects of the syndrome are underappreciated and view surgery as unwarranted for a condition that has no clearly defined etiology (52,77).

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