Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Sexual pain disorders involving pathology within the vestibule: current techniques

Andrew T Goldstein, Irwin Goldstein

Introduction

It is estimated that 10-15% of women are afflicted with sexual pain disorders that, in many, greatly interfere with quality of life, cause significant distraction, and often preclude satisfactory sexual activity1-3 (see Chapters 12.1-12.6 of this book). There are multiple hypotheses of the pathophysiologies of these sexual pain syndromes, and, accordingly, multiple management options delivered by various health-care professionals. Women afflicted with sexual pain disorders frequently consult numerous healthcare providers. After undergoing history taking and physical examination, patients often receive multiple, conservative, medical and behavioral focused treatments, with few evidence- based outcome reports supporting their use.4 There are more than 20 different treatments reported in the medical literature, including topical and intralesional steroids,5 interferon,6 biofeedback,capsaicin,8 lidocaine,9 intravaginal physical therapy,10 amitriptyline,11 cognitive-behavioral therapy,12 acupuncture,13 and dietary changes.14 Safety and efficacy data concerning these treatment regimens are published, for the most part, in small case series that are neither randomized nor placebo-controlled.

A step-care process is rational for the management of women with sexual pain disorders. Such a step-care process should first engage strategies that are the least invasive and end, if conservative treatments are unsuccessful, with strategies that are the most invasive, such as surgery. It is important that there are available published data concerning safety and efficacy outcome with surgical management of sexual pain disorders. Such data will provide worried patients with the information to make informed management choices.

This chapter will consider those women whose sexual pain disorder can be attributed to disorders of organs and tissues within the vestibule. Conditions involving vestibular contents include disorders of the clitoris, prepuce, frenulum, labia majora, labia minora, urethral meatus, major vestibular glands, minor vestibular glands, and hymen. The aim of this chapter is to provide information to health-care practitioners treating women with sexual pain disorder secondary to vestibular disorder that fail conservative treatment options and electively consider surgery.

Anatomy and embryology of the vestibule

The vulvar vestibule is defined as the tissue between Hart’s line and the hymen. Hart’s line marks the transition from the squamous mucosa of the vestibule to more keratinized mucosa of the labia minora (see Chapters 4.1—4.3). The vestibule extends from the frenulum of the clitoris anteriorly to the fourchette posteriorly (Fig. 15.1.1).

The embryonic origins of the various women’s genital tissues are important and are therefore reviewed in this chapter. By week 6 of embryonic life, female embryos start to develop the genital ridge, the Wolffian duct lateral to the genital ridge, and the Müllerian duct. The lower part of the Müllerian duct fuses with the opposite Müllerian duct to form the uterovaginal canal. The upper part forms the body and cervix of the uterus, while the lower part forms the upper four-fifths of the vagina.

Figure 15.1.1. Anatomy of the vestibule: Hart's line laterally, the hymenal ring medially, the frenulum anteriorly, and the posterior fourchette.

The lower fifth of the vagina develops from the urogenital sinus. The Müllerian duct reaches down to the urogenital sinus and, at the meeting point, forms the Müllerian tubercle. The lower portion of the uterovaginal canal is canalized by a process of central desquamation, and the peripheral cells become the vaginal epithelium. The clitoris develops from the genital tubercle. The labia majora develop from the genital swellings. The labia minora develop from the genital folds.

The vestibule, the topic of focus for this chapter, develops from the lower most part of the urogenital sinus. The mucosa of the vestibule is thus embryonically derived from the urogenital sinus. This makes the tissue of the vestibule similar to the mucosa of the urethra and bladder, which is also derived from the urogenital sinus. This also differentiates the vestibule from the vaginal mucosa, which is derived from Müllerian tissue. This further differentiates the clitoris and labia from the vestibule, since the former are derived from the genital tubercle.

Sexual pain disorders of the vestibule

There are women whose sexual pain disorder can be attributed to pathologic conditions involving organs and tissues within the vestibule. Such women may have sexual pain disorders of the vestibule involving the clitoris, prepuce, frenulum, labia majora, labia minora, urethral meatus, major vestibular glands, minor vestibular glands, and hymen.

The most common vestibular pathology is vulvar vestibulitis syndrome, otherwise known as vestibulodynia or vestibular adenitis. Vulvar vestibulitis syndrome is thought to be the most frequent cause of dyspareunia in premenopausal women.1,2 Vulvar vestibulitis syndrome was first described in the medical literature in 1880 by Thomas, as a medical syndrome in which there is “excessive sensibility of the nerves supplying the mucous membranes of some portions of the vulva; sometimes ... confined to the vestibule”.15 Vulvar

Figure 15.1.2. Vulvar vestibulectomy: excision of the vestibular mucosa.

In a further attempt to minimize the invasiveness of surgery for vulvar vestibulitis syndrome, some surgeons have recommended vestibuloplasty; excision of localized painful areas of vestibular mucosa without vaginal advancement.20 Whereas vestibulectomy or perineoplasty is performed under general or regional anesthesia in an operative suite, vestibuloplasty can be performed with local anesthesia. Prior to the procedure, a cotton swab is used to delineate painful areas of the vestibule. These areas are outlined with a marking pen and then injected with lidocaine 1% with epinephrine. A scalpel is used to excise the tender superficial mucosa, including the tissue at the base of the hymen. The defects are closed with interrupted sutures of 4-0 Vicryl.

During perineoplasty and vestibulectomy, the vaginal advancement covers the ostia of the Bartholin glands, thereby increasing the risk of postoperative Bartholin gland cysts. Some authors recommend surgical excision of Bartholin’s glands during perineoplasty or vestibulectomy. However, other authors specifically reject prophylactic Bartholin gland excision, as the risk of Bartholin gland cyst is only 1%, and excision increases intraoperative blood loss and scar tissue formation.21

Several studies have utilized laser surgery for treatment of vulvar vestibulitis syndrome. In one study, a carbon dioxide laser was used to ablate the vestibular mucosa up to a depth of vestibulitis syndrome is characterized by three criteria described by Friedrich3 in 1987: exquisite tenderness when the vestibule is palpated with a cotton swab, vestibular erythema (often at the ostia of the major and minor vestibular glands), and severe pain at attempted vaginal entry with a penis, speculum, tampon, etc.

Pathophysiology of vulvar vestibulitis syndrome

Although millions of women around the world are afflicted by vulvar vestibulitis syndrome, limited research has been performed on the underlying pathophysiology. Recently, with US National Institutes of Health funding, new information has become available and progress has been made in understanding pathologic changes in vulvar vestibulitis syndrome. Bohm-Starke and colleagues used PGP 9.5 immunohistochemistry to demonstrate a proliferation of intraepithelial nerve endings in the vestibular mucosa in women with vulvar vestibulitis syndrome. In addition, they further characterized these nerve endings by showing calcitonin gene-related peptide, which is known to exist only in C- afferent nociceptors, to be the only neuropeptide detected in these nerve endings.16 Bornstein and colleagues confirmed these results and used computer-assisted histomorphometry to show that the total nerve fiber area in women with vulvar vestibulitis syndrome is 10 times higher than in controls.17 This increased density of C- afferent nociceptors may explain the allodynia and hyperpathia that women with vulvar vestibulitis syndrome experience with vestibular touch (see Chapter 12.1).

Surgery for vulvar vestibulitis syndrome

Woodruff et al. first described surgery for vulvar vestibulitis syndrome in 1983, calling it “modified perineoplasty”.19 Since then, there have been 33 different case series compromising a total of 1159 patients. These reports represent several different surgical procedures, as there have evolved variations and modifications of the basic surgical excision and reconstructive procedure for management of vulvar vestibulitis syndrome.

In the original procedure, Woodruff et al. excised a semicircular segment of perineal skin, the mucosa of the posterior vulvar vestibule, and the posterior hymeneal ring. Over time, modifications have emerged to limit the invasiveness of Woodruff’s original surgical technique. Specifically, in a procedure known as vulvar vestibulectomy, the posterior incision extends only to the posterior fourchette and does not include excision of perineal skin (Fig. 15.1.2). Three centimeters of the vaginal mucosa is then undermined (Fig. 15.1.3) and approximated to the perineum (Fig. 15.1.4). A complete vulvar vestibulectomy includes excision of the mucosa adjacent to the urethra, whereas, in a modified vestibulectomy, the excision of mucosa is limited to the posterior vestibule.

Figure 15.1.2. Vulvar vestibulectomy: excision of the vestibular mucosa.

In a further attempt to minimize the invasiveness of surgery for vulvar vestibulitis syndrome, some surgeons have recommended vestibuloplasty; excision of localized painful areas of vestibular mucosa without vaginal advancement.20 Whereas vestibulectomy or perineoplasty is performed under general or regional anesthesia in an operative suite, vestibuloplasty can be performed with local anesthesia. Prior to the procedure, a cotton swab is used to delineate painful areas of the vestibule. These areas are outlined with a marking pen and then injected with lidocaine 1% with epinephrine. A scalpel is used to excise the tender superficial mucosa, including the tissue at the base of the hymen. The defects are closed with interrupted sutures of 4-0 Vicryl.

During perineoplasty and vestibulectomy, the vaginal advancement covers the ostia of the Bartholin glands, thereby increasing the risk of postoperative Bartholin gland cysts. Some authors recommend surgical excision of Bartholin’s glands during perineoplasty or vestibulectomy. However, other authors specifically reject prophylactic Bartholin gland excision, as the risk of Bartholin gland cyst is only 1%, and excision increases intraoperative blood loss and scar tissue formation.21

Several studies have utilized laser surgery for treatment of vulvar vestibulitis syndrome. In one study, a carbon dioxide laser was used to ablate the vestibular mucosa up to a depth of 1 cm.22 This technique had limited success and often caused exacerbations of symptoms. More recently, a less invasive laser, the flashlamp-excited dye laser, has been used with a lower complication rate and a slightly higher success rate.23 In general, the results of laser surgery are less successful than surgical techniques as previously described.

Figure 15.1.3. Vulvar vestibulectomy: vaginal mucosa is separated from the fascia of the rectovaginal septum to create an advancement flap.

Figure 15.1.4. Vulvar vestibulectomy: the vaginal advancement flap is approximated to the perineum to complete the procedure.

Most authors suggest that no one surgical technique is appropriate for all women with vulvar vestibulitis syndrome. It is suggested that the surgeon choose the least invasive procedure that adequately treats an individual patient’s symptoms. For example, if a patient has tenderness confined to a small portion of the vestibule, vestibuloplasty would be the most appropriate procedure. However, if a woman has allodynia in her entire vestibule and recurrent fissuring at the posterior fourchette, perineoplasty would be the correct procedure.

Closure techniques vary between different studies and surgeons. However, modifications of closure technique have been used to limit the risk of hematoma, scar tissue, vaginal stenosis, and wound dehiscence. Marinoff and others have described several changes to vestibulectomy that have reduced complications and improved the success rates of this procedure.26 Specifically, the vaginal advancement flap should be anchored in an advanced position by several mattress sutures of 3-0 Vicryl. These mattress sutures minimize tension along the suture line, thereby limiting the risk of wound dehiscence. The mattress stitches should be thrown in an anterior-posterior direction to prevent compromise of the vaginal diameter. In addition, the vaginal advancement flap should be approximated to the perineum with interrupted stitches of 4-0 Vicryl to help prevent hematoma and wound disruption.

Success of surgical correction of vulvar vestibulitis syndrome also depends on appropriate postoperative care. In the immediate postoperative period, liberal use of ice packs prevents swelling and helps with pain. Sitz baths starting several days after the surgery can help with postoperative pain and may help prevent infection. Physical activity should be limited for the first 4-8 weeks required for the surgical site to heal, to help prevent wound dehiscence. Close communication and frequent visits to a certified woman’s physical therapist specializing in such pelvic floor disorders are encouraged. Under monitoring by the physical therapist and biofeedback pelvic floor electromyography, vaginal dilators can be used after the surgical site has healed to help the postoperative patient resume normal sexual functioning.

Complications of surgery

Patients considering surgery need to be informed that complications of vestibuloplasty, vestibulectomy, and perineoplasty do occur, although they are infrequent. The risks of surgery increase with the invasiveness of the procedure performed. Specifically, complications include bleeding, infection, increased pain, hematoma, wound dehiscence, vaginal stenosis, scar tissue formation, and Bartholin duct cyst formation.27 The risk of these complications can be reduced if appropriate surgical techniques are utilized. Surgical intervention is offered as a treatment alternative in women who have failed conservative medical, psychologic, and/or physical therapy.26,28

Review of the literature on surgical treatment of vulvar vestibulitis syndrome

Evaluation of the risks and benefits among the various surgical strategies is difficult because there is no standardized terminology, nor have any comparison trials been performed.18

Table 15.1.1. Summary of papers on vulvar vestibulitis syndrome

Authors

Procedure

Number of patients

Length of follow-up (in months)

Complete resolution of pain

Partial (significant) resolution of pain

No significant resolution of pain

Complete or significant reduction in pain

Woodruff et al.19

Perineoplasty

18

6-60

18

0

0

100%

Woodruff et al.19

Perineoplasty

14

6-36

12

2

0

100%

Woodruff and

Perineoplasty

44

NS*

36

6

2

95%

Friedrich30

             

Peckham et al.31

Perineoplasty

9

NS

9

0

0

100%

Friedrich3

Perineoplasty

38°

NS

23

 

15

60%

Michlewitz et al.32

Perineoplasty

16

NS

16

   

100%

Bornstein and

Perineolpasty (modified)

20

6-36

14

4

2

90%

Kaufman33

             

Marinoff and

Perineoplasty

73

12-36

60

11

2

97%

Turner27

             

Westrom34

Modified vestibulectomy

12

15-19

10

1

1

92%

Schover et al.35

Vestibuloplasty

38

1-24

18

14

6

84%

Mann et al.36

Perineoplasty

56

6-54

37

12

7

88%

Barbaro et al.37

Modified vestibulectomy

21

1-3

19

2

 

100%

Abramov et al.38

Vestibulectomy

7

12

7

   

100%

Bornstein et al.39

Perineoplasty

11

6

9

1

1

91%

Foster et al.40

Perineoplasty

93

>48

51

31

11

88%

Chaim et al.41

Perineoplasty (modified)

16

10-70

15

 

1

94%

de Jong et al.42

Perineoplasty

14

36-84

3

3

8

43%

Baggish and Miklos43

Vestibulectomy

15

12

13

 

2

87%

Goetsch20

Vestibuloplasty

12

6-72

10

2

 

100%

Kehoe and Luesley44

Modified vestibulectomy

37

3-34

22

11

4

89%

Weijmar Schultz et al.45

Vestibulectomy

13

2-36

7

4

2

85%

Bergeron et al.46

Vestibulectomy

38

13-120

24

 

14

68%

Bergeron et al.12

Vestibulectomy

22

6

15

 

7

68%

Bornstein et al.47

Perineoplasty

79

12

60

19

 

100%

Berville et al.48

Vestibulectomy

12

8

6

4

2

83%

Marinoff26

Perineoplasty

1 07

3-48

70

18

19

82%

Westrom and Willen49

Modified vestibulectomy

42

6

33

5

4

90%

Kehoe and Luesley50

Vestibulectomy

54

2-42

33

15

6

89%

Hopkins51

Perineoplasty

21

NS

19

 

2

90%

McKormack and Spence52

Perineoplasty

42

12-120

16

19

7

83%

Schneider et al.53

Vestibulectomy

54

6

30

15

9

83%

Gaunt et al.54

Vestibulectomy

42

6-24

28

10

4

90%

Goldstein and Klingman28

Vestibulectomy

69

12-60

31

30

7

88%

Total

 

1159

         

*NS: length of follow-up not stated.

Includes 13 patients who had a previous surgical failure by another surgeon

Figure 15.1.5. Phimosis of the clitoral prepuce may lead to balanitis of the clitoral glans (A) with associated sexual pain. If conservative treatment, such as antifungal treatment, fails, a dorsal slit procedure may be performed (B-D).

This chapter will review 33 papers in the English literature regarding the surgical management of vulvar vestibulitis syndrome (Table 15.1.1). This review reveals that the surgical success rate was greater than 80% in 29 of the studies cited. However, it is difficult to compare these studies. Techniques and terminology used to describe the various procedures varied significantly. Different authors referred to widely different surgeries characterized by the same name. Often there are changes to the techniques employed even within the same series of patients. The outcome criteria for “surgical success” are often poorly defined, and rarely are standard procedures employed to assess success. The evaluation of success is always nonblinded, rendering it biased and highly subjective. Patient selection criteria are usually not mentioned within a given series. Most studies did not distinguish between various forms of vestibulitis (primary or secondary vestibulitis, constant pain, or pain only with provocation). There is a great degree of variability in the length of follow-up even within a given series, and follow-up is rarely long-term. Therefore, determining the rate of recurrence of vulvar vestibulitis syndrome after surgery is very difficult to assess.

The rationale for performing surgery is based on the underlying pathology. One hypothesis of the pathophysiology of vulvar vestibulitis syndrome is that there is extreme hypersensi tivity of the vestibular tissue associated with increased nerve density in the vestibular mucosa. Surgery is successful because excision of the mucosa removes the neuronal hyperplasia. The fact that the vestibule is embryonically derived from tissue different than the vagina may explain why there is very little recurrence of symptoms after surgical resection of the vestibule with vaginal advancement.

Surgical treatment of vulvar vestibulitis syndrome results in significant resolution of dyspareunia in more than half of the patients operated. In addition, a clinically meaningful reduction in dyspareunia is reported in approximately two-thirds of the remaining patients. There is a high degree of patient satisfaction with surgical treatment of vulvar vestibulitis syndrome.

Surgery for other sexual pain disorders within the Vestibule

Disorders of the various tissues within the vestibule may cause sexual pain. For example, phimosis of the clitoral prepuce may lead to balanitis of the clitoral glans with associated sexual pain. If conservative treatment fails, such as antifungal treatment, a dorsal slit procedure may be performed (Fig. 15.1.5). A clitoral tumor may also cause pain. We have performed multiple excisions of clitoral fibroepitheliomas (Fig. 15.1.6). A sebaceous cyst may involve the prepuce and lead to severe pain and swelling of the prepucial tissue. Incision and drainage of the abscess may be required (Fig. 15.1.7).

Figure 15.1.7. A sebaceous cyst may involve the prepuce and lead to severe pain and swelling of the prepucial tissue. Incision and drainage of the abscess may be required. A shows an intra-operative photo at the completion of the dorsal slit procedure. B is an office photograph at 6 months follow-up showing healing of the incision with the exposed glans clitoris.

Dermatologic conditions of the vestibule or vulva may require surgical intervention when conservative treatment with ultrapotent topical steroids fails. Perineoplasty surgery can be used for treatment of lichen sclerosus, a chronic cutaneous disorder with a predilection for the vulva. The chronic inflammation associated with lichen sclerosus often causes destruction of the vulvar architecture with scarring of the posterior fourchette and perineum. Rouzier et al. described a series of 62 women with introital stenosis caused by lichen sclerosus who underwent perineoplasty.24 Ninety percent of these women had significant improvement in their sexual function after surgery. Perineoplasty can also be used successfully for women who have recurrent idiopathic fissuring at the posterior fourchette, especially since perineoplasty widens the introitus. While simple excision of recurrent fissures is a less invasive procedure, narrowing of the introitus may result.25 Urethral prolapse may be a cause of vestibular pain. Should conservative treatments, such as local estrogen therapy, fail, surgery may be a management option (Fig. 15.1.8). Bartholin’s cysts may present as vestibular pain. Marsupialization of the cyst can be performed to obviate the sexual pain (see Chapter 22.2).

Conclusion

In the step-care process of the management of women with sexual pain, conservative treatments are performed first. Should psychologic, medical, and/or psychologic management fail, surgery is a safe and effective treatment for women with sexual pain dis- order.18,29 The most common disorder in women with sexual pain is vulvar vestibulitis syndrome. There are limitations of the surgical safety and efficacy outcome data. Nevertheless, there are also limited outcome studies showing the safety and efficacy of conservative (psychologic, medical, or physical therapy) treatment approaches for vulvar vestibulitis syndrome. While surgery poses risks of infection, scar tissue, increased pain, Bartholin’s cysts, disfigurement, and recurrence of symptoms after surgery, contemporary literature reveals that these risks are low.

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