Evaluation Of Sexual Function In Brazilian Women With Recurrent Vulvovaginal Candidiasis And Localized Provoked Vulvodynia

Introduction. Recurrent vulvovaginitis is an important trigger for inflammatory processes that in many cases may result in vulvovaginal pain. Vulvodynia, a vulvar disorder, can also cause a lot of pain in the female genitals. The sexual function in women with vulvodynia or recurrent vulvovaginitis will possibly be negatively affected and therefore should be evaluated. Aim. To assess sexual function in women with recurrent vulvovaginal candidiasis (RVVC) and localized provoked vulvodynia (LPV) in comparison with women without lower genital tract dysfunction. Methods. A 1-year cross-sectional study evaluated sexual function in 58 women (11 with RVVC, 18 with LPV, and 29 controls) seen at a university outpatient clinic. Sexual function was assessed by taking into account the results obtained from the application of the Female Sexual Function Index (FSFI) questionnaire. Kruskal-Wallis, Mann-Whitney, chi-square, and Fisher's tests were used for statistical analysis. Main Outcome Measure. FSFI, a validated questionnaire in Portuguese. Results. There were no significant differences in the three groups with respect to age, marital status, schooling, race, body mass index, contraceptive method, and parity. The FSFI questionnaire total score found was 25.51 (±5.12), 21.17 (±5.15), and 29.56 (±3.87) for the RVVC, LPV, and control groups, respectively. The scores were significantly statistically lower in the study groups compared with the control group (P<0.05). Women with RVVC and LPV also had lower total scores compared with 26.55 values, considered a cutoff score for sexual dysfunction in literature. The LPV group showed a significant difference and scored worse in the domains of arousal, lubrication, orgasm, satisfaction, and pain but not in the domain of sexual desire. The same occurred with the RVVC group but only for the domains of orgasm and satisfaction. Conclusion. Women with RVVC and LPV had significantly more symptoms of sexual dysfunction than women without lower genital tract diseases. © 2011 International Society for Sexual Medicine.93805811Stewart, D., Whelan, C., Fong, I., Tessler, K., Psychosocial aspects of chronic, clinically unconfirmed vulvovaginitis (1990) Obstet Gynecol, 76, pp. 852-856Masheb, R., Lozano-Blanco, C., Kohorn, E., Minkin, M., Kerns, R., Assessing sexual function and dyspareunia with the Female Sexual Function Index (FSFI) in women with vulvodynia (2004) J Sex Marital Ther, 30, pp. 315-324Abdo, C., Fleury, H., Aspectos diagnósticos e terapêuticos das disfunções sexuais femininas (2006) Rev. psiquiatr. Clín, 33, pp. 162-167Development of the World Health Organization Quality of Life Assessment instrument (the WHOQOL) (1994) Quality of life assessment: International perspectives, pp. 41-69. , The WHOQOL Group. Orley J, Kuyken W, eds. Heidelberg: Springer VerlagNyirjesy, P., Peyton, C., Weitz, M., Mathew, L., Culhane, J., Causes of chronic vaginitis: Analysis of a prospective database of affected women (2006) Obstet Gynecol, 108, pp. 1185-1191Geiger, A., Foxman, B., Sobel, J., Chronic vulvovaginal candidiasis: Characteristics of women with Candida albicans, C glabrata and no candida (1995) Genitourin Med, 71, pp. 304-307Sobel, J.D., Candidal vulvovaginitis (1993) Clin Obstet Gynecol, 36, pp. 153-165Eckert, L.O., Hawes, S.E., Stevens, C.E., Koutsky, L.A., Eschenbach, D.A., Holmes, K.K., Vulvovaginal candidiasis: Clinical manifestations, risk factors, management algorithm (1998) Obstet Gynecol, 92, pp. 757-765van Lankveld, J.J.D.M., Granot, M., Weijmar Schultz, W.C.M., Binik, Y.M., Wesselmann, U., Pukall, C.F., Bohm-Starke, N., Achtrari, C., Women's sexual pain disorders (2010) J Sex Med, 7, pp. 615-631Haefner, H., Report of the International Society for the Study of Vulvovaginal Disease terminology and classification of vulvodynia (2007) J Low Genit Tract Dis, 11, pp. 48-49Harlow, B., Stewart, E., A population-based assessment of chronic unexplained vulvar pain: Have we underestimated the prevalence of vulvodynia? (2003) J Am Med Womens Assoc, 58, pp. 82-88Meana, M., Binik, Y.M., Khalifé, S., Cohen, D., Dyspareunia: Sexual dysfunction or pain syndrome? (1997) J Nerv Ment Dis, 185, pp. 561-569Giesecke, J., Reed, B., Haefner, H., Giesecke, T., Clauw, D., Gracely, R., Quantitative sensory testing in vulvodynia volunteers and increased peripheral pressure pain sensitivity (2004) Obstet Gynecol, 104, pp. 126-133Tympanidis, P., Terenghi, G., Dowd, P., Increased innervation of the vulval vestibule in patients with vulvodynia (2003) Br J Dermatol, 148, pp. 1021-1027Jantos, M., Vulvodynia: A psychophysiological profile based on electromyographic assessment (2008) Appl Psychophysiol Biofeedback, 33, pp. 29-38Glazer, H., Jantos, M., Hartmann, E., Swencionis, C., Electromyographic comparisons of the pelvic floor in women with dysesthetic vulvodynia and asymptomatic women (1998) J Reprod Med, 43, pp. 959-962Boardman, L.A., Stockdale, C.K., Sexual pain (2009) Clin Obstet Gynecol, 52, pp. 682-690Ponte, M., Klemperer, E., Sahay, A., Chren, M., Effects of vulvodynia on quality of life (2009) J Am Acad Dermatol, 60, pp. 70-76Gates, E.A., Galask, R.P., Psychological and sexual functioning in women with vulvar vestibulitis (2001) J Psychosom Obstet Gynaecol, 22, pp. 221-228Ehrström, S., Kornfeld, D., Rylander, E., Bohm-Starke, N., Chronic stress in women with localized provoked vulvodynia (2009) J Psychosom Obstet Gynaecol, 30, pp. 73-79Spoelstra, S.K., Diijkstra, J.R., van Driel, M.F., Weijmar Schultz, W.C., Long-term results of an individualized, multifaceted, and multidisciplinary therapeutic approach to provoked vestibulodynia (2011) J Sex Med, 8, pp. 489-496Abdo, C.H., Oliveira Jr, W.M., Moreira Jr, E.D., Fittipaldi, J.A., Prevalence of sexual dysfunctions and correlated conditions in a sample of Brazilian women-results of the Brazilian Study on Sexual Behavior (BSSB) (2004) Int J Impot Res, 16, pp. 160-166Laumann, E.O., Paik, A., Rosen, R.C., Sexual dysfunction in the United States. Prevalence and predictors (1999) JAMA, 281, pp. 537-544Fugl-Meyer, K.S., Female sexual disorders: Psychiatric aspects (2002) Can J Psychiatr, 47, pp. 419-425Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., Ferguson, D., D'Agostino Jr, R., The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function (2000) J Sex Marital Ther, 26, pp. 191-208Thiel, R.R., Dambros, M., Palma, P., Thiel, M., Riccetto, C., Ramos, M.F., Translation into Portuguese, cross-national adaptation and validation of the Female Sexual Function Index (2008) Rev Bras Ginecol Obstet, 30, pp. 504-510Wiegel, M., Meston, C., Rosen, R., The Female Sexual Function Index (FSFI): Cross-validation and development of clinical cutoff scores (2005) J Sex Marital Ther, 31, pp. 1-20Jeremias, J., Ledger, W.J., Witkin, S.S., Interleukin 1 receptor antagonist gene polymorphism in women with vulvar vestibulitis (2000) Am J Obstet Gynecol, 182, pp. 283-285Graziottin, A., Serafini, A., Palacios, S., Aetiology, diagnostic algorithms and prognosis of female sexual dysfunction (2009) Maturitas, 63, pp. 128-134Ramage, M., Female sexual dysfunction (2006) Psychiatry, 6, pp. 105-110Donaldson, R.L., Meana, M., Early dyspareunia experience in young women: Confusion, consequences, and help-seeking barriers (2011) J Sex Med, 8, pp. 814-82

Electromyography And Vaginal Pressure Of The Pelvic Floor Muscles In Women With Recurrent Vulvovaginal Candidiasis And Vulvodynia

Objective: To evaluate the electrical potentials and pressure exerted by the pelvic floor muscles in women with recurrent vulvovaginal candidiasis (RVVC) or vulvodynia as compared to control women. Study Design: A crosssectional study performed in the Female Outpatient Clinic of Genital Infections in the Department of Obstetrics and Gynecology of the Universidade Estadual de Campinas analyzed and compared electromyography (EMG) and vaginal pressure of the pelvic floor muscles in 61 women. Of these 61 women, 19 had vulvodynia, 12 had RVVC and 30 women had no disorder (control group). For data collection, the instrument used was the Miotool Uro device and its software Biotrainer (Miotec Ltd., Porto Alegre, Rio Grande do Sul, Brazil). Results: The EMG evaluation of the pelvic floor muscles showed significantly lower values in the vulvodynia group (tonic contractions) and RVVC group (phasic and tonic contractions) when compared to the control group. No significant differences in basal tone EMG and vaginal pressure values at rest or during pelvic floor muscle contractions were found among groups. The maximum time of sustained contraction in patients with RVVC or vulvodynia was significantly lower (p < 0.0001) than in controls. Conclusion: Women with vulvodynia and RVVC have more frequent pelvic floor muscle dysfunction than controls when observed by EMG evaluation. © Journal of Reproductive Medicine®, Inc.57141147Haefner, H.K., Report of the International Society for the Study of Vulvovaginal Disease terminology and classification of vulvodynia (2007) J Low Genit Tract Dis, 11, pp. 48-49Nyirjesy, P., Peyton, C., Weitz, M.V., Causes of chronic vaginitis: Analysis of a prospective database of affected women (2006) Obstet Gynecol, 108, pp. 1185-1191Geiger, A.M., Foxman, B., Sobel, J.D., Chronic vulvovaginal candidiasis: Characteristics of women with Candida albicans, C glabrata and no candida (1995) Genitourin Med, 71, pp. 304-307Sobel, J.D., Candidal vulvovaginitis (1993) Clin Obstet Gynecol, 36, pp. 153-165Giraldo, P.C., Ribeiro Filho, A., Simões, J., Vulvovaginites: Aspectos habitualmente não-considerados (1997) J Bras Ginec, 107, pp. 89-93Stewart, D.E., Whelan, C.I., Fong, I.W., Psychosocial aspects of chronic, clinically unconfirmed vulvovaginitis (1990) Obstet Gynecol, 76, pp. 852-856Glazer, H.I., Jantos, M., Hartmann, E.H., Electromyographic comparisons of the pelvic floor in women with dysesthetic vulvodynia and asymptomatic women (1998) J Reprod Med, 43, pp. 959-962Witkin, S.S., Gerber, S., Ledger, W.J., Differential characterization of women with vulvar vestibulitis syndrome (2002) Am J Obstet Gynecol, 187, pp. 589-594Sobel, J.D., Vulvovaginitis: When Candida becomes a problem (1998) Dermatol Clin, 16, pp. 763-768Reissing, E.D., Brown, C., Lord, M.J., Pelvic floor muscle functioning in women with vulvar vestibulitis syndrome (2005) J Psychosom Obstet Gynaecol, 26, pp. 107-113Moyal-Barracco, M., Lynch, P.J., 2003 ISSVD terminology and classification of vulvodynia: A historical perspective (2004) J Reprod Med, 49, pp. 772-777Harlow, B.L., Stewart, E.G., A population-based assessment of chronic unexplained vulvar pain: Have we underestimated the prevalence of vulvodynia? (2003) J Am Med Womens Assoc, 58, pp. 82-88Nunns, D., Mandal, D., Byrne, M., Guidelines for the management of vulvodynia (2010) Br J Dermatol, 162, pp. 1180-1885Glazer, H.I., Marinoff, S.C., Sleight, I.J., Web-enabled Glazer surface electromyographic protocol for the remote, real-time assessment and rehabilitation of pelvic floor dysfunction in vulvar vestibulitis syndrome: A case report (2002) J Reprod Med, 47, pp. 728-730Zolnoun, D., Hartmann, K., Lamvu, G., A conceptual model for the pathophysiology of vulvar vestibulitis syndrome (2006) Obstet Gynecol Surv, 61, pp. 395-401Bachmann, G.A., Rosen, R., Pinn, V.W., Vulvodynia: A state-of-the-art consensus on definitions, diagnosis and management (2006) J Reprod Med, 51, pp. 447-456Reed, B.D., Haefner, H.K., Edwards, L., A survey on diagnosis and treatment of vulvodynia among vulvodynia researchers and members of the International Society for the Study of Vulvovaginal Disease (2008) J Reprod Med, 53, pp. 921-929Haefner, H.K., Collins, M.E., Davis, G.D., The vulvodynia guideline (2005) J Low Genit Tract Dis, 9, pp. 40-51Payne, K.A., Binik, Y.M., Amsel, R., When sex hurts, anxiety and fear orient attention towards pain (2005) Eur J Pain, 9, pp. 427-436Piassarolli, V.P., Hardy, E., Andrade, N.F., Pelvic floor muscle training in female sexual dysfunctions [Article in Portuguese] (2010) Rev Bras Ginecol Obstet, 32, pp. 234-240Pagano, R., Value of colposcopy in the diagnosis of candidiasis in patients with vulvodynia (2007) J Reprod Med, 52, pp. 31-34Mann, M.S., Kaufman, R.H., Brown Jr., D., Vulvar vestibulitis: Significant clinical variables and treatment outcome (1992) Obstet Gynecol, 79, pp. 122-125Sobel, J.D., Wiesenfeld, H.C., Martens, M., Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis (2004) N Engl J Med, 351, pp. 876-883Graven-Nielsen, T., Arendt-Nielsen, L., Peripheral and central sensitization in musculoskeletal pain disorders: An experimental approach (2002) Curr Rheumatol Rep, 4, pp. 313-321Frawley, H.C., Galea, M.P., Phillips, B.A., Reliability of pelvic floor muscle strength assessment using different test positions and tools (2006) Neurourol Urodyn, 25, pp. 236-242Bø, K., Sherburn, M., Evaluation of female pelvic-floor muscle function and strength (2005) Phys Ther, 85, pp. 269-282Nappi, R.E., Ferdeghini, F., Abbiati, I., Electrical stimulation (ES) in the management of sexual pain disorders (2003) J Sex Marital Ther, 29, pp. 103-110Jantos, M., Vulvodynia: A psychophysiological profile based on electromyographic assessment (2008) Appl Psychophysiol Biofeedback, 33, pp. 29-38White, G., Jantos, M., Glazer, H., Establishing the diagnosis of vulvar vestibulitis (1997) J Reprod Med, 42, pp. 157-160Bergeron, S., Brown, C., Lord, M.J., Physical therapy for vulvar vestibulitis syndrome: A retrospective study (2002) J Sex Marital Ther, 28, pp. 183-192Rosenbaum, T.Y., Physiotherapy treatment of sexual pain disorders (2005) J Sex Marital Ther, 31, pp. 329-340Danielsson, I., Torstensson, T., Brodda-Jansen, G., EMG biofeedback versus topical lidocaine gel: A randomized study for the treatment of women with vulvar vestibulitis (2006) Acta Obstet Gynecol Scand, 85, pp. 1360-1367Butrick, C.W., Pelvic floor hypertonic disorders: Identification and management (2009) Obstet Gynecol Clin North Am, 36, pp. 707-722Murina, F., Bernorio, R., Palmiotto, R., The use of amielle vaginal trainers as adjuvant in the treatment of vestibulodynia: An observational multicentric study (2008) Medscape J Med, 10, p. 2

Clinical And Therapeutic Aspects Of Vulvodynia: The Importance Of Physical Therapy

Vulvodynia affects a large number of women worldwide. It is estimated that the prevalence rate of vulvodynia is 16% in women aged 18 to 64 years, resulting in constant demand for specialized medical care, although little therapeutic success is achieved. Furthermore, the cause of this disorder remains unknown and involves different symptoms that are implicated in important chronic vulvar pain with disastrous consequences for the afflicted women. In view of these data, the authors have proposed a bibliographic review of the pathophysiology and treatment of vulvodynia. The aim of this review was to assist in clinical diagnosis and elucidate the multidisciplinary treatment that appears to be associated with a higher success rate in these women. Physical therapy using diverse techniques has an important role in multidisciplinary care, obtaining satisfactory results in the treatment of pelvic floor muscle dysfunction and thus improving the symptoms and quality of life in women with vulvodynia.645437445Harlow, B.L., Stewart, E.G., A population-based assessment of chronic unexplained vulvar pain: Have we underestimated the prevalence of vulvodynia? (2003) J Am Med Women's Assoc, 58, pp. 82-88Nyirjesy, P., Peyton, C., Weitz, M.V., Mathew, L., Culhane, J.F., Causes of chronic vaginitis: Analysis of a prospective database of affected women (2006) Obstetrics and Gynecology, 108 (5), pp. 1185-1191. , DOI 10.1097/01.AOG.0000239103.67452.1a, PII 0000625020061100000020Petersen, C.D., Lundvall, L., Kristensen, E., Giraldi, A., Vulvodynia. Definition, diagnosis and treatment (2008) Acta Obstet Gynecol Scand, 87, pp. 893-901Bachmann, G.A., Rosen, R., Pinn, V.W., Utian, W.H., Ayers, C., Basson, R., Vulvodynia: A state-of-the-art consensus on definitions, diagnosis and management (2006) J Reprod Med, 51, pp. 447-456Glazer, H., Marinoff, S., Sleight, I., Web-enabled Glazer surface electromyographic protocol for the remote, real-time assessment and rehabilitation of pelvic floor dysfunction in vulvar vestibulitis syndrome. A case report (2002) J Reprod Med, 47, pp. 728-730Zolnoun, D., Hartmann, K., Lamvu, G., As-Sanie, S., Maixner, W., Steege, J., A conceptual model for the pathophysiology of vulvar vestibulitis syndrome (2006) Obstetrical and Gynecological Survey, 61 (6), pp. 395-401. , DOI 10.1097/01.ogx.0000219814.40759.38Glazer, H.I., Jantos, M., Hartmann, E.H., Swencionis, C., Electromyographic comparisons of the pelvic floor in women with dysesthetic vulvodynia and asymptomatic women (1998) Journal of Reproductive Medicine for the Obstetrician and Gynecologist, 43 (11), pp. 959-962Rosenbaum, T.Y., Physiotherapy treatment of sexual pain disorders (2005) Journal of Sex and Marital Therapy, 31 (4), pp. 329-340. , DOI 10.1080/00926230590950235Mandal, D., Nunns, D., Byrne, M., McLelland, J., Rani, R., Cullimore, J., Guidelines for the management of vulvodynia (2010) Br J Dermatol, 162, pp. 1180-1885Moyal-Barracco, M., Lynch, P.J., 2003 ISSVD terminology and classification of vulvodynia: A historical perspective (2004) Journal of Reproductive Medicine for the Obstetrician and Gynecologist, 49 (10), pp. 772-777Haefner, H.K., Report of the International Society for the Study of Vulvovaginal Disease Terminology and Classification of Vulvodynia (2007) Journal of Lower Genital Tract Disease, 11 (1), pp. 48-49. , DOI 10.1097/01.lgt.0000225898.37090.04, PII 0012836020070100000012Friedrich, E.J., Vulvar vestibulitis syndrome (1987) J Reprod Med, 32, pp. 110-114Goetsch, M., Morgan, T., Korcheva, V., Li, H., Peters, D., Leclair, C., Histologic and receptor analysis of primary and secondary vestibulodynia and controls: A prospective study (2010) Am J Obstet Gynecol, 202, pp. 614.e1-8Granot, M., Friedman, M., Yarnitsky, D., Tamir, A., Zimmer, E., Primary and secondary vulvar vestibulitis syndrome: Systemic pain perception and psychophysical characteristics (2004) Am J Obstet Gynecol, 191, p. 13842Witkin, S., Gerber, S., Ledger, W., Differential characterization of women with vulvar vestibulitis syndrome (2002) Am J Obstet Gynecol, 187, pp. 589-594Foster, D., Piekarz, K., Murant, T., LaPoint, R., Haidaris, C., Phipps, R., Enhanced synthesis of proinflammatory cytokines by vulvar vestibular fibroblasts: Implications for vulvar vestibulitis (2007) Am J Obstet Gynecol, 196, pp. 346.e1-8Tympanidis, P., Terenghi, G., Dowd, P., Increased innervation of the vulval vestibule in patients with vulvodynia (2003) British Journal of Dermatology, 148 (5), pp. 1021-1027. , DOI 10.1046/j.1365-2133.2003.05308.xPagano, R., Value of colposcopy in the diagnosis of candidiasis in patients with vulvodynia (2007) Journal of Reproductive Medicine for the Obstetrician and Gynecologist, 52 (1), pp. 31-34Mann, M., Kaufman, R., Brown, D.J., Adam, E., Vulvar vestibulitis: Significant clinical variables and treatment outcome (1992) Obstet Gynecol, 79, pp. 122-125Sobel, J., Wiesenfeld, H., Martens, M., Danna, P., Hooton, T., Rompalo, A., Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis (2004) N Engl J Med, 351, pp. 876-883Origoni, M., Rossi, M., Ferrari, D., Lillo, F., Ferrari, A.G., Human papillomavirus with co-existing vulvar vestibulitis syndrome and vestibular papillomatosis (1999) International Journal of Gynecology and Obstetrics, 64 (3), pp. 259-263. , DOI 10.1016/S0020-7292(98)00156-8, PII S0020729298001568Morin, C., Bouchard, C., Brisson, J., Fortier, M., Blanchette, C., Meisels, A., Human papillomaviruses and vulvar vestibulitis (2000) Obstetrics and Gynecology, 95 (5), pp. 683-687. , DOI 10.1016/S0029-7844(99)00623-7, PII S0029784499006237Tribo, M.J., Andion, O., Ros, S., Gilaberte, M., Gallardo, F., Toll, A., Ferran, M., Banos, J.E., Clinical characteristics and psychopathological profile of patients with vulvodynia: An observational and descriptive study (2008) Dermatology, 216 (1), pp. 24-30. , DOI 10.1159/000109354Ponte, M., Klemperer, E., Sahay, A., Chren, M., Effects of vulvodynia on quality of life (2009) J Am Acad Dermatol, 60, pp. 70-76Payne, K.A., Binik, Y.M., Amsel, R., Khalife, S., When sex hurts, anxiety and fear orient attention towards pain (2005) European Journal of Pain, 9 (4), pp. 427-436. , DOI 10.1016/j.ejpain.2004.10.003, PII S1090380104001272Jantos, M., Vulvodynia: A psychophysiological profile based on electromyographic assessment (2008) Appl Psychophysiol Biofeedback, 33, pp. 29-38Reissing, E.D., Brown, C., Lord, M.J., Binik, Y.M., Khalife, S., Pelvic floor muscle functioning in women with vulvar vestibulitis syndrome (2005) Journal of Psychosomatic Obstetrics and Gynecology, 26 (2), pp. 107-113. , DOI 10.1080/01443610400023106Graven-Nielsen, T., Arendt-Nielsen, L., Peripheral and central sensitization in musculoskeletal pain disorders: An experimental approach (2002) Curr Rheumatol Rep, 4, pp. 313-321Glazer, H., Rodke, G., Swencionis, C., Hertz, R., Young, A., Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature (1995) J Reprod Med, 40, pp. 283-290Nappi, R.E., Ferdeghini, F., Abbiati, I., Vercesi, C., Farina, C., Polatti, F., Electrical stimulation (ES) in the management of sexual pain disorders (2003) Journal of Sex and Marital Therapy, 29 (SUPPL. 1), pp. 103-110Caruso, S., Agnello, C., Intelisano, G., Farina, M., Di, M.L., Cianci, A., Sexual behavior of women taking low-dose oral contraceptive containing 15 microg ethinylestradiol/60 microg gestodene (2004) Contraception, 69 (3), pp. 237-240. , DOI 10.1016/j.contraception.2003.11.001Gordon, A.S., Panahian-Jand, M., McComb, F., Melegari, C., Sharp, S., Characteristics of women with vulvar pain disorders: Responses to a web-based survey (2003) Journal of Sex and Marital Therapy, 29 (SUPPL. 1), pp. 45-58Arnold, L., Bachmann, G., Rosen, R., Kelly, S., Rhoads, G., Vulvodynia: Characteristics and associations with comorbidities and quality of life (2006) Obstet Gynecol, 107, pp. 617-624Giesecke, J., Reed, B.D., Haefner, H.K., Giesecke, T., Clauw, D.J., Gracely, R.H., Quantitative sensory testing in vulvodynia patients and increased peripheral pressure pain sensitivity (2004) Obstetrics and Gynecology, 104 (1), pp. 126-133. , DOI 10.1097/01.AOG.0000129238.49397.4eGreenstein, A., Militscher, I., Chen, J., Matzkin, H., Lessing, J., Abramov, L., Hyperoxaluria in women with vulvar vestibulitis syndrome (2006) J Reprod Med, 51, pp. 500-502Kingdon, J., Vulvodynia: A comprehensive review (2009) Nurs Women's Health, 13, pp. 48-57Masheb, R.M., Lozano-Blanco, C., Kohorn, E.I., Minkin, M.J., Kerns, R.D., Assessing sexual function and dyspareunia with the Female Sexual Function Index (FSFI) in women with vulvodynia (2004) Journal of Sex and Marital Therapy, 30 (5), pp. 315-324. , DOI 10.1080/00926230490463264Masheb, R., Kerns, R., Lozano, C., Minkin, M., Richman, S., A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy (2009) Pain, 141, pp. 31-40Goldstein, A., Burrows, L., Vulvodynia (2008) J Sex Med, 5, pp. 5-14Edwards, L., Subsets of vulvodynia: Overlapping characteristics (2004) Journal of Reproductive Medicine for the Obstetrician and Gynecologist, 49 (11), pp. 883-887Munday, P., Buchan, A., Ravenhill, G., Wiggs, A., Brooks, F., A qualitative study of women with vulvodynia II. Response to a multidisciplinary approach to management (2007) Journal of Reproductive Medicine for the Obstetrician and Gynecologist, 52 (1), pp. 19-22Ventolini, G., Barhan, S., Duke, J., Vulvodynia, a stepwise therapeutic prospective cohort study (2009) J Obstet Gynaecol, 29, pp. 648-650Ventolini, G., Balasko, B., Psycho emotional impact of women with provoked vestibulodynia (2011) Minerva Psichiatrica, 52, pp. 97-99Reed, B., Haefner, H., Edwards, L., A survey on diagnosis and treatment of vulvodynia among vulvodynia researchers and members of the International Society for the Study of Vulvovaginal Disease (2008) J Reprod Med, 53, pp. 921-929Zolnoun, D.A., Hartmann, K.E., Steege, J.F., Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis (2003) Obstetrics and Gynecology, 102 (1), pp. 84-87. , DOI 10.1016/S0029-7844(03)00368-5Danielsson, I., Torstensson, T., Brodda-Jansen, G., Bohm-Starke, N., EMG biofeedback versus topical lidocaine gel: A randomized study for the treatment of women with vulvar vestibulitis (2006) Acta Obstet Gynecol Scand, 85, pp. 1360-1367Bergeron, S., Brown, C., Lord, M.-J., Oala, M., Binik, Y.M., Khalife, S., Physical therapy for vulvar vestibulitis syndrome: A retrospective study (2002) Journal of Sex and Marital Therapy, 28 (3), pp. 183-192. , DOI 10.1080/009262302760328226Haefner, H.K., Collins, M.E., Davis, G.D., Edwards, L., Foster, D.C., Hartmann, E.H., Kaufman, R.H., Wilkinson, E.J., The vulvodynia guideline (2005) Journal of Lower Genital Tract Disease, 9 (1), pp. 40-51. , DOI 10.1097/00128360-200501000-00009Hartmann, D., Strauhal, M.J., Nelson, C.A., Treatment of women in the United States with localized, provoked vulvodynia: Practice survey of women's health physical therapists (2007) Journal of Reproductive Medicine for the Obstetrician and Gynecologist, 52 (1), pp. 48-52Butrick, C., Pelvic floor hypertonic disorders: Identification and management (2009) Obstet Gynecol Clin North Am, 36, pp. 707-722Bergeron, S., Binik, Y.M., Khalife, S., Pagidas, K., Glazer, H.I., Meana, M., Amsel, R., A randomized comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis (2001) Pain, 91 (3), pp. 297-306. , DOI 10.1016/S0304-3959(00)00449-8, PII S0304395900004498Oyama, I., Rejba, A., Lukban, J., Fletcher, E., Kellogg-Spadt, S., Holzberg, A., Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction (2004) Urology, 64, pp. 802-805Telles, E.R., Amaral, V.F., Estimulação elétrica transcutênea (TENS) em Ginecologia e Obstetrícia: Alternativa nas síndromes dolorosas (2007) Femina, 35, pp. 697-702Murina, F., Bianco, V., Radici, G., Felice, R., Di, M.M., Nicolini, U., Transcutaneous electrical nerve stimulation to treat vestibulodynia: A randomised controlled trial (2008) BJOG: An International Journal of Obstetrics and Gynaecology, 115 (9), pp. 1165-1170. , DOI 10.1111/j.1471-0528.2008.01803.xMurina, F., Bernorio, R., Palmiotto, R., The use of amielle vaginal trainers as adjuvant in the treatment of vestibulodynia: An observational multicentric study (2008) Medscape J Med, 10, p. 2