Surgery is often performed in cases of severe vulvar vestibulitis recalcitrant to medical management.214 Excision of a localized painful area, such as the anterior and posterior vestibule, or the lateral vestibule with vaginal advancement can be performed. The Woodruff procedure is a U-shaped excision that includes the hymeneal ring and the adjacent 0.5 cm of tissue. The incision extends from 5 mm beneath the urethra to the fourchette and is 2-5 mm in depth. The adjacent vaginal tissue is then mobilized to cover the excised area. In the literature, success rates based on nonrandomized, retrospective studies range from 47 to 100 percent. Success, however, diminishes to 40-60 percent as the length of follow-up increases.191,192 [III] One study that randomized patients to either vestibuloplasty or peri-neoplasty found no improvements in all ten patients who had vestibuloplasty and complete resolution of symptoms in patients who received a perineoplasty.215 [III] Progressive introital dilation using vaginal dilators is also recommended by some and should be used for six weeks prior to intercourse.192 Patients with vestibulitis associated with dyspareunia since their first sexual episode tend to have an incomplete response.214 Complications include bleeding, infection, hematoma, complete or partial wound separation, Bartholin duct cyst formation, anal sphincter weakness, uneven healing requiring further surgery, vaginismus, and vaginal


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