Those patients have almost no physical findings. They are perfectly normal in every aspect of examination. Women who have vestibulitis, on the other hand, have very few visible physical findings but always have exquisite tenderness of those delicate tissues at the entrance to the vagina when those tissues are lightly touched with a Q-tip, for example. That area of the body also includes the urinary meatus - the outlet from the bladder and various glands that surround those structures. The physician then in examining that area uses a cotton tipped applicator, which is simply a Q-tip.
Some physicians prefer that it be wet and others just take it dry.
The secret though, is very, very light pressure along specific points in that area and where there is tenderness, asking the patient to characterize the tenderness on a scale of 0-10, whether it's no pain or exquisite pain and then plotting that on a diagram. Let's turn just a little bit down to treatment of these different conditions. I know vulvodynia is a fairly broad category, so let's think primarily of the dysesthetic vulvodynias first, and give us some idea about how you approach that in your treatment. The mainstay of treatments for these women is in the use of tricyclic antidepressants, not because we think that these women are depressed but because we know that these drugs are effective in various pain syndromes, such as the neuralgia that women get after an attack of shingles. So that these drugs, I think of all of the pharmacologic agents that have been composed for this syndrome are the most effective, and I would say that's the mainstay.