Vestibulectomy and Hymenectomy Surgery
Natalia C. Llarena
Mark D. Walters
M. Jean Uy-Kroh
General Principles: Vestibulectomy for Vulvodynia
Definition
Vulvodynia refers to “vulvar pain of at least 3 months duration without clear identifiable cause, which may have potential associated factors.”1 Vulvodynia is further characterized by distribution as generalized, localized (i.e., vestibulodynia or clitorodynia), or mixed, and by stimulus as provoked, spontaneous, or mixed. Vestibulodynia is a subset of localized vulvodynia, and refers to discomfort in the vestibule region. Patients often describe the pain as “burning or cutting” in nature. Provoked pain may be elicited by sexual contact, clothing pressure, fingertip pressure, or tampon use. The onset of vulvodynia is either primary or secondary and the temporal pattern is specified as intermittent, persistent, constant, immediate, or delayed (Table 16.1).
The misnomer vestibulitis is no longer used since inflammatory changes are not associated with the condition.
The etiology of vulvodynia remains unclear, but it is likely multifactorial and may include central and peripheral neurologic mechanisms, neuroproliferation, and musculoskeletal and hormonal disorders.2 In addition, patients with vulvodynia have an increased rate of comorbid chronic pain disorders, including fibromyalgia, irritable bowel syndrome, temporomandibular joint disorder, and interstitial cystitis.3,4
Table 16.1 Characteristics of Vulvodynia | ||||||||||
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Differential Diagnosis
Vulvar infection (e.g., candidiasis, herpes)
Inflammatory vulvar disorders (e.g., desquamative inflammatory vaginitis (DIV), lichen planus, lichen sclerosis, immunobullous disorders, severe atrophy)
Neoplastic vulvar disorders (e.g., Paget’s disease, squamous cell carcinoma)
Neurologic disorders (e.g., herpes neuralgia, spinal nerve compression)
Nonoperative Management
Vestibulectomy is the most effective available treatment for localized, provoked vestibulodynia, but is reserved for patients who have failed less invasive modes of management. We do not offer surgical treatment for generalized, unprovoked vulvodynia. A number of nonoperative treatments exist, but few data are available from randomized controlled trials comparing the effectiveness of these strategies.2,5 Medical approaches to vulvodynia and vestibulodynia include localized, topical application of lidocaine (5% ointment at bedtime for 7 weeks) and use of estrogen cream.5 In addition, off-label topical compounded gabapentin ointment may be used. Although topical corticosteroids are not useful, injections of bupivacaine (0.25%) provide relief for some patients.4 Oral therapies including amitriptyline and gabapentin are commonly used. Additionally, biofeedback and pelvic floor physical therapy often benefit these patients.2
Imaging and Other Diagnostics: Vestibulectomy for Vulvodynia
Vulvodynia often occurs in the absence of visible findings; therefore, it is critical to perform a detailed history and physical examination to exclude other etiologies of vulvar pain.
A detailed history often reveals the most significant clues that guide successful treatment. Questionnaires help collate a comprehensive history that includes the location, onset, duration, quality, temporality, and severity of the pain, aggravating and relieving factors, and prior therapies (see Table 16.1).
Inquire about the functional impact her pain has had on her sexuality, quality of life, and her relationships as well as her treatment goals.
Symptoms that suggest an alternative diagnosis include abnormal vaginal bleeding or discharge, vulvar itch, pain with bowel movements, or neurologic symptoms suggestive of pudendal neuralgia.6
A history of atopic or inflammatory skin conditions may suggest a dermatologic cause of vulvar symptoms. Any history of vulvovaginal trauma (including birth trauma) or recurrent vulvar candidiasis should also be elicited.
Sexual history, including dyspareunia and history of abuse or trauma.
Vulvar hygiene regimen, including use of soaps and feminine products that may contribute to discomfort, and type of undergarment fabric worn.
Physical examination.
Even a visual inspection of the perineum can evoke trepidation and fear for patients who suffer from vestibulodynia; therefore, patience and patient partnership are essential to performing a successful examination. Patients can aid in the examination by holding magnifiers, mirrors, retracting their own anatomy, and identifying the exact location of the most tender sites. This method also alleviates patient anxiety and provides her a measure of control during the examination.
Perform a magnified, visual inspection, without any tactile stimulus, from the mons to the anus to evaluate for infectious, inflammatory, or neoplastic etiologies of vulvar discomfort. Note any skin erosions, plaques, erythema, fissures, nodules, ulcers, and architectural changes such as loss of labia minora, burying of the glans clitoris, and agglutination.6 Of note, bilateral erythema surrounding the Bartholin ducts and minor vestibular ducts is typically a normal finding and may not be relevant to the diagnosis of vulvodynia.7
Colposcopic investigation of the vulva with biopsies should be considered when symptoms are refractory to therapy, the diagnosis is unclear, or there is a suspicion for malignancy. Furthermore, the traditional, routine use of dilute acetic acid should be reconsidered as it rarely improves tissue examination and more often causes pain exacerbation and significant patient discomfort.
Although a patient may have concomitant disease such as genital warts or cysts in addition to vulvodynia, the findings must not account for vulvar pain.
Cotton swab testing is used to identify and diagram painful areas. Introduce the soft q-tip swab to the patient’s nongenital skin such as the inner thigh. Confirm that this q-tip palpation is perceived as soft and nonpainful. Explain to the patient the series of palpations that will ensue and indicate her answer choices for each palpation. Then, use the moistened q-tip to first palpate lateral to Hart’s line and then medial to Hart’s line. Palpate the vestibule at 1 and 11 o’clock positions near the Skene’s ostia and then at 4 and 8 o’clock positions at the Bartholin’s ostia. Finally, palpate the vestibule at 6 o’clock. Locations of the pain should be diagrammed and documented in the patient’s medical record to assist with monitoring the pain over time.2
Gently palpate the levator muscles with one finger in the vagina to examine for muscle tightness, tension, or tenderness.
Vulvodynia cannot be diagnosed by laboratory or imaging studies. However, a saline wet prep, vaginal pH testing, and cultures for aerobic bacteria, yeast, and herpes can help rule out atrophic, inflammatory, or infectious vaginitis.
Preoperative Planning: Vestibulectomy for Vulvodynia
Vaginismus is a spasm of the levator ani that contributes to dyspareunia and difficulty with vaginal penetration. Vaginismus frequently occurs in association with vulvodynia; however, data suggest that surgery is less effective in this patient population.2,8 Pelvic floor physical therapy, dilators, and trigger point injections may benefit these patients.
Sexual counseling may be considered preoperatively, as it may reduce vaginismus, and has been shown to improve outcomes after vestibulectomy.8
Prior to anesthetizing the patient in the operating room, painful areas of the vestibular mucosa should be identified with a cotton swab and marked to target excision.
Surgical Management: Vestibulectomy for Vulvodynia
Vestibulectomy (Fig. 16.1) is typically performed for localized, provoked vulvodynia that has failed medical management. In general, it is more effective for secondary than primary localized vulvodynia. However, there are no evidence-based guidelines regarding a treatment algorithm, in large part because the etiology of vulvodynia is unknown and both medical and surgical treatments are understudied.5 Among the studied interventions, surgical management has the most robust evidence and has been shown to be significantly more effective than medical management. Future randomized studies comparing operative techniques and outcomes may further our understanding of how best to surgically manage these patients and their pain.
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