CHAPTER 67

Surgery for Vulvar Vestibulitis Syndrome (Vulvodynia)

Vulvar vestibulitis syndrome is a disorder of unknown cause that produces erythema, hyperesthesia, and extreme discomfort to light pressure, principally around the Bartholin duct and the underlying Bartholin gland. Although other vulvar mucous glands (i.e., the paraurethral and minor vestibular glands) may be sensitive to touch, major signs and symptoms are related mainly to Bartholin glands (Fig. 67–1A through C). Afflicted women complain of a burning raw feeling during and after sexual intercourse to such a degree that apareunia eventuates. All patients in whom this diagnosis is made should undergo a conservative regimen over a period of 2 to 4 months. If conservative treatment does not lead to substantial amelioration of symptoms and an objective decrease in erythema and light touch–induced pain, then the patient should be offered the surgical option (Fig. 67–2).

Surgery for the treatment of vestibulitis presents two options. The first and simpler procedure is vestibulectomy with or without excision of the paraurethral duct(s) and vaginal advancement. This operation excises the inflamed tissue(s) to include depth into Colles’ fascia and margins to Hart’s line, as well as removal of a centimeter of the lower vagina. The advantage of this operation is shortened operative time (1.5 hours or less) and less morbidity in the form of postoperative pudendal neuralgia (Fig. 67–3A through E).

The alternative operation includes radical excision of the Bartholin glands, vestibulectomy, and vaginal advancement. This operation requires 2.5 hours to perform and is associated with a 15% to 20% risk of postoperative pudendal neuralgia. It is currently recommended for severe cases of vestibulitis; for cyst formation post simple vestibulectomy; and for failure of the simple vestibulectomy operation.

Success rates for the above procedures vis-à-vis elimination of entry pain associated with intercourse is greater than 90%. Additionally, the vestibular pain is unlikely to return. Both operations are performed with the patient in the low to medium lithotomy position. The operating microscope is recommended to perform this surgery most effectively.

Simple Vestibulectomy

Stay sutures of 0 Vicryl retract the labia to expose the vestibule, and a 1 : 100 solution of vasopressin is injected via a 25-gauge needle into the subdermis of the vestibule (Fig. 67–4A, B).

A carbon dioxide (CO2) laser is coupled to a microscope via a micromanipulator. The laser control is adjusted to deliver a 1- to 1.5-mm spot at a focal distance of 300 mm. The format is set for a superpulsed beam at 12 W power. The laser beam traces the dimensions of the incision, and the trace spots are then connected by incising the vestibular skin (Fig. 67–5A, B). The initial incision is U-shaped.

Next, with a Stevens tenotomy, the vestibule with attached Colles’ fascia is sharply excised (Fig. 67–6). Additionally, a 0.5- to 1-cm margin of the lower vagina (which includes the hymenal ring) is removed. Hemostasis and wound approximation are obtained by placing a series of pleating fascial stitches of 3-0 Vicryl (Fig. 67–7A). Next, the skin is closed with interrupted 3-0 Vicryl stitches. Cosmetically, the operative result is quite good. At the same time, the vaginal inlet has been reshaped and widened to permit two fingerwidths (2.5 to 4 cm) for easy coital entry (Fig. 67–7B).

Vestibulectomy With Radical Bartholin Gland Excision

This operation is more complex. It begins with the same trace incision described for simple vestibulectomy (Fig. 67–8A, B). A mosquito clamp is then inserted parallel to and along the outer wall of the vagina to develop a space 2 cm deep from the introital surface (Fig. 67–8C).

Next, the mosquito clamp is moved 1 to 1.5 cm laterally to develop a similar space into the fat of the ischiorectal fossa (Fig. 67–8D

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