Vestibulectomy

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A vestibulectomy is a gynecological surgical procedure that can be used to treat vulvar pain, specifically in cases of provoked vestibulodynia. Vestibulodynia (vulvar vestibulitis) is a chronic pain syndrome that is a subtype of localized vulvodynia [1] where chronic pain and irritation is present in the vulval vestibule, which is near the entrance of the vagina. [2] Vestibulectomy may be partial or complete. [3]

Contents

Vulvar vestibulectomy is primarily supported as an intervention for people who suffer from provoked vestibulodynia, which causes sexual pain to women. [4] It is not indicated as appropriate for people living with generalized vulvar pain disorders and non-provoked vestibulodynia. [1]

Vestibulectomy is not considered a first-line treatment option for provoked vestibulodynia, [5] but it is considered an effective treatment for the long-run and has recorded high levels of satisfaction from the patients. [6] One review found that significant pain relief was reported by 79% of patients. [7]

Procedure

The surgery takes place below the urinary meatus, down to the border of the perineal area and includes the fourchette. Incisions are made on each side adjacent and parallel to the labia minora. The structures removed are the hymen, mucous membrane, Bartholin glands ducts and minor vestibular glands. In some surgeries, the amount of tissue removed is not so extensive. Vaginal mucosa tissue remains attached and then is pulled downward to cover the area where tissue was removed. This surgery is also used to treat lichen sclerosus. [8] "The complete surgery removes the entire lateral hymenal tissues to the lateral vestibular walls at Hart’s line, and involves removal of the entire posterior fourchette from the posterior hymenal remnants down to the perineum" which barring complications, enables the entire procedure to be over within an hour. [9]

The procedure involves minimal bleeding and is usually done under spinal or general anesthesia. [10] The amount of tissue removed during the surgery can vary with respect to the pain.

Complications

Complications related to vestibulectomy include bleeding and infection. Long-term complications can be weakness of the anal muscles, cosmetic changes, development of a Bartholin's cyst, or a decline in vaginal lubrication. Reports of satisfaction with the outcome of the surgical procedure can be as high as 90%. [11]

The procedure has been known to be unsuccessful in rare cases, where the pain remained constant even after surgery. [12] In such cases, alternative treatments like oral medicines or more surgeries may be considered, depending on the severity of the persisting pain. [13]

Recovery

The recovery period is about 6–12 weeks, depending on the amount of vulvar tissues removed. Post-surgery, the patient might need further physical and possible mental therapy to avoid scarring and lead a regular sexual life. [12]

Epidemiology

In a study done in 2006, it was discovered that 93% of patients who had undergone the surgery recommended it for vulvar pain. Only 11% of women continued to have issues in their sex lives post-surgery. [14]

Related Research Articles

Vulvodynia is a chronic pain condition that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least three months.

<span class="mw-page-title-main">Bartholin's gland</span> Mucous glands located near the vaginal opening

The Bartholin's glands are two pea-sized compound alveolar glands located slightly posterior and to the left and right of the opening of the vagina. They secrete mucus to lubricate the vagina.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term dyspareunia covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. Medically, dyspareunia is a pelvic floor dysfunction and is frequently underdiagnosed. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

<span class="mw-page-title-main">Bartholin's cyst</span> Medical condition

A Bartholin's cyst occurs when a Bartholin's gland within the labia becomes blocked. Small cysts may result in minimal or no symptoms. Larger cysts may result in swelling on one side of the vaginal opening, as well as pain during sex or walking. If the cyst becomes infected, an abscess can occur, which is typically red and very painful. If there are no symptoms, no treatment is needed. Bartholin's cysts affect about 2% of women at some point in their life. They most commonly occur during childbearing years.

<span class="mw-page-title-main">Lichen sclerosus</span> Itchy skin rash usually affecting the genitals

Lichen sclerosus (LS) is a chronic, inflammatory skin disease of unknown cause which can affect any body part of any person but has a strong preference for the genitals and is also known as balanitis xerotica obliterans (BXO) when it affects the penis. Lichen sclerosus is not contagious. There is a well-documented increase of skin cancer risk in LS, potentially improvable with treatment. LS in adult age women is normally incurable, but improvable with treatment, and often gets progressively worse if not treated properly. Most males with mild or intermediate disease restricted to foreskin or glans can be cured by either medical or surgical treatment.

An imperforate hymen is a congenital disorder where a hymen without an opening completely obstructs the vagina. It is caused by a failure of the hymen to perforate during fetal development. It is most often diagnosed in adolescent girls when menstrual blood accumulates in the vagina and sometimes also in the uterus. It is treated by surgical incision of the hymen.

<span class="mw-page-title-main">Cystocele</span> Medical condition

The cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.

<span class="mw-page-title-main">Vaginectomy</span> Surgical removal of the vagina

Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area.

Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis, is vulvodynia localized to the vulvar vestibule. It tends to be associated with a highly localized "burning" or "cutting" type of pain. Until recently, "vulvar vestibulitis" was the term used for localized vulvar pain: the suffix "-itis" would normally imply inflammation, but in fact there is little evidence to support an inflammatory process in the condition. "Vestibulodynia" is the term now recognized by the International Society for the Study of Vulvovaginal Disease.

<span class="mw-page-title-main">Vulvar cancer</span> Cancer involving the vulva

Vulvar cancer is a cancer of the vulva, the outer portion of the female genitals. It most commonly affects the labia majora. Less often, the labia minora, clitoris, or Bartholin's glands are affected. Symptoms include a lump, itchiness, changes in the skin, or bleeding from the vulva.

Hematocolpos is a medical condition in which the vagina is pooled with menstrual blood due to multiple factors leading to the blockage of menstrual blood flow. The medical definition of hematocolpos is 'an accumulation of blood within the vagina'. It is often caused by the combination of menstruation with an imperforate hymen. It is sometimes seen in Robinow syndrome, uterus didelphys, or other vaginal anomalies.

Genital leiomyomas are leiomyomas that originate in the dartos muscles, or smooth muscles, of the genitalia, areola, and nipple. They are a subtype of cutaneous leiomyomas that affect smooth muscle found in the scrotum, labia, or nipple. They are benign tumors, but may cause pain and discomfort to patients. Genital leiomyoma can be symptomatic or asymptomatic and is dependent on the type of leiomyoma. In most cases, pain in the affected area or region is most common. For vaginal leiomyoma, vaginal bleeding and pain may occur. Uterine leiomyoma may exhibit pain in the area as well as painful bowel movement and/or sexual intercourse. Nipple pain, enlargement, and tenderness can be a symptom of nipple-areolar leiomyomas. Genital leiomyomas can be caused by multiple factors, one can be genetic mutations that affect hormones such as estrogen and progesterone. Moreover, risk factors to the development of genital leiomyomas include age, race, and gender. Ultrasound and imaging procedures are used to diagnose genital leiomyomas, while surgically removing the tumor is the most common treatment of these diseases. Case studies for nipple areolar, scrotal, and uterine leiomyoma were used, since there were not enough secondary resources to provide more evidence.

Female genital disease is a disorder of the structure or function of the female reproductive system that has a known cause and a distinctive group of symptoms, signs, or anatomical changes. The female reproductive system consists of the ovaries, fallopian tubes, uterus, vagina, and vulva. Female genital diseases can be classified by affected location or by type of disease, such as malformation, inflammation, or infection.

<span class="mw-page-title-main">Perineoplasty</span>

Perineoplasty denotes the plastic surgery procedures used to correct clinical conditions of the vagina and the anus. Among the vagino-anal conditions resolved by perineoplasty are vaginal looseness, vaginal itching, damaged perineum, fecal incontinence, genital warts, dyspareunia, vaginal stenosis, vaginismus, vulvar vestibulitis, and decreased sexual sensation. Depending upon the vagino-anal condition to be treated, there are two variants of the perineoplasty procedure: the first, to tighten the perineal muscles and the vagina; the second, to loosen the perineal muscles.

<span class="mw-page-title-main">Vulva</span> External genitalia of the female mammal

In mammals, the vulva consists of the external female genitalia. The human vulva includes the mons pubis, labia majora, labia minora, clitoris, vulval vestibule, urinary meatus, vaginal opening, hymen, and Bartholin's and Skene's vestibular glands. The vulva allows entry to the vagina, which leads to the uterus, and provides a double layer of protection for this by the folds of the outer and inner labia. Pelvic floor muscles support the structures of the vulva. Other muscles of the urogenital triangle also give support.

Labial fusion is a medical condition of the vulva where the labia minora become fused together. It is generally a pediatric condition.

<span class="mw-page-title-main">Postcoital bleeding</span> Medical condition

Postcoital bleeding (PCB) is non-menstrual vaginal bleeding that occurs during or after sexual intercourse. Though some causes are with associated pain, it is typically painless and frequently associated with intermenstrual bleeding.

A vulvar disease is a particular abnormal, pathological condition that affects part or all of the vulva. Several pathologies are defined. Some can be prevented by vulvovaginal health maintenance.

<span class="mw-page-title-main">Vaginal cysts</span> Benign growths of the vaginal epithelium

Vaginal cysts are uncommon benign cysts that develop in the vaginal wall. The type of epithelial tissue lining a cyst is used to classify these growths. They can be congenital. They can present in childhood and adulthood. The most common type is the squamous inclusion cyst. It develops within vaginal tissue present at the site of an episiotomy or other vaginal surgical sites. In most instances they do not cause symptoms and present with few or no complications. A vaginal cyst can develop on the surface of the vaginal epithelium or in deeper layers. Often, they are found by the woman herself and as an incidental finding during a routine pelvic examination. Vaginal cysts can mimic other structures that protrude from the vagina such as a rectocele and cystocele. Some cysts can be distinguished visually but most will need a biopsy to determine the type. Vaginal cysts can vary in size and can grow as large as 7 cm. Other cysts can be present on the vaginal wall though mostly these can be differentiated. Vaginal cysts can often be palpated (felt) by a clinician. Vaginal cysts are one type of vaginal mass, others include cancers and tumors. The prevalence of vaginal cysts is uncertain since many go unreported but it is estimated that 1 out of 200 women have a vaginal cyst. Vaginal cysts may initially be discovered during pregnancy and childbirth. These are then treated to provide an unobstructed delivery of the infant. Growths that originate from the urethra and other tissue can present as cysts of the vagina.

References

  1. 1 2 Rosen, Natalie O.; Dawson, Samantha J.; Brooks, Melissa; Kellogg-Spadt, Susan (2019). "Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches". Drugs. 79 (5): 483–493. doi:10.1007/s40265-019-01085-1. ISSN   1179-1950. PMID   30847806. S2CID   73485304.
  2. ↑ "Vulvodynia and vestibulodynia | Skin Support". skinsupport.org.uk. Retrieved 2018-10-27.
  3. ↑ "Vulvar Vestibulitis - Austin Urogynecology". Austin Urogynecology. 2015-02-10. Archived from the original on 2018-10-28. Retrieved 2018-10-27.
  4. ↑ Lavy, Yuval; Lev-Sagie, Ahinoam; Hamani, Yaron; Zacut, David; Ben-Chetrit, Avraham (2005-05-01). "Modified vulvar vestibulectomy: simple and effective surgery for the treatment of vulvar vestibulitis". European Journal of Obstetrics, Gynecology, and Reproductive Biology. 120 (1): 91–95. doi:10.1016/j.ejogrb.2004.04.039. ISSN   0301-2115. PMID   15866093.
  5. ↑ Bautrant, Eric; Porta, Oriol; Murina, Filippo; Mühlrad, Hanna; Levêque, Christine; Riant, Thibaut; Ploteau, Stephane; Valancogne, Guy; Levesque, Amélie (2019-10-01). "Provoked vulvar vestibulodynia: Epidemiology in Europe, physio-pathology, consensus for first-line treatment and evaluation of second-line treatments". Journal of Gynecology Obstetrics and Human Reproduction. 48 (8): 685–688. doi:10.1016/j.jogoh.2019.04.011. ISSN   2468-7847. PMID   31051298. S2CID   145024370.
  6. ↑ Eva, Lois J.; Narain, Sumana; Orakwue, C. Obi; Luesley, David M. (2008). "Is modified vestibulectomy for localized provoked vulvodynia an effective long-term treatment? A follow-up study". The Journal of Reproductive Medicine. 53 (6): 435–440. ISSN   0024-7758. PMID   18664062.
  7. ↑ Tommola, Päivi; Unkila-Kallio, Leila; Paavonen, Jorma (2010). "Surgical treatment of vulvar vestibulitis: a review". Acta Obstetricia et Gynecologica Scandinavica. 89 (11): 1385–1395. doi:10.3109/00016349.2010.512071. ISSN   1600-0412. PMID   20955094. S2CID   19466615.
  8. ↑ Williams gynecology. Barbara L. Hoffman, J. Whitridge Williams (2nd ed.). New York: McGraw-Hill Medical. 2012. p. 1070. ISBN   978-0-07-171672-7. OCLC   779244257.{{cite book}}: CS1 maint: others (link)
  9. ↑ "Vestibulectomy | San Diego Sexual Medicine". www.sandiegosexualmedicine.com. Retrieved 2018-10-27.
  10. ↑ Haefner, Hope K.; Collins, Michael E.; Davis, Gordon D.; Edwards, Libby; Foster, David C.; Hartmann, Elizabeth (Dee) Heaton; Kaufman, Raymond H.; Lynch, Peter J.; Margesson, Lynette J.; Moyal-Barracco, Micheline; Piper, Claudia K. (2005). "The Vulvodynia Guideline". Journal of Lower Genital Tract Disease. 9 (1): 40–51. doi: 10.1097/00128360-200501000-00009 . ISSN   1089-2591. PMID   15870521. S2CID   18081230.
  11. ↑ Unger, C.A.; Kow, N.; Jelovsek, J. (2014). "Vestibulectomy: A Review of Technique". Journal of Minimally Invasive Gynecology. 21 (2): S45. doi:10.1016/j.jmig.2013.12.077. ISSN   1553-4650.
  12. 1 2 "Surgery for vulval pain - Vulval Pain Society". Vulval Pain Society. Retrieved 2018-10-27.
  13. ↑ Ventolini, Gary (2011). "Measuring Treatment Outcomes in Women With Vulvodynia" (PDF). Journal of Clinical Medicine Research. 3 (2): 59–64. doi:10.4021/jocmr526w. PMC   3140924 . PMID   21811531. Archived from the original (PDF) on 2017-08-09.
  14. ↑ Goldstein, Andrew T.; Klingman, Daisy; Christopher, Kurt; Johnson, Crista; Marinoff, Stanley C. (2006). "ORIGINAL RESEARCH—SURGERY: Surgical Treatment of Vulvar Vestibulitis Syndrome: Outcome Assessment Derived from a Postoperative Questionnaire". The Journal of Sexual Medicine. 3 (5): 923–931. doi:10.1111/j.1743-6109.2006.00303.x. hdl: 2027.42/74334 . PMID   16942537. S2CID   25781480.

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