Diagnostic nerve block of the vestibule
A diagnostic marcaine-epinephrine nerve block of the vestibule can be performed in individuals who are suspected as having neuro-proliferastive vestibulodynia, have failed conservative therapies, and do not have any infections or dermatologic causes of provoked vestibulodynia. Should administration of marcaine 0.25% with 1:200,000 epinephrine result in absence of pain to cotton swab testing and digital palpation at the introitus, it has been our experience that in this setting the diagnosis is likely neuro-proliferative vestibulodynia, and that complete vestibulectomy has a high rate of success. Physical examination including cotton swab testing of the vestibule is performed prior to the nerve block. The minor vulvar vestibular glands at 1:00, 5:00, 7:00, 9:00 and 11:00 are examined for erythema and for allodynia discomfort to cotton swab testing. Poviodne-iodine is then applied to the introitus. A total of 20 ml marcaine 0.25% with 1:200,000 epinephrine is administered submucosally around the introitus. Ten minutes following the nerve block, cotton swab testing of the vestibule is re-assessed. Digital palpation around the vestibule is performed. The patient is allowed to go home and assess the degree of discomfort and pain symptoms. Patients who achieve a great relief of symptoms have a positvie is diagnostic nerve block test. This is considered consistent with the existence of local vestibular pathology such as high density of pain nerve fibers in the vestibule - neuro-proliferative vestibulodynia. A positive test is in our experience consistent with high success following complete vestibulectomy surgery.
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