Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Difficult cases: surgical treatment of female sexual dysfunction

Irwin Goldstein

Introduction

Sexual dysfunction in women is common and may interfere with quality of life1,2 (see Chapters 2.1-2.4 of this book). Sexual dysfunctions are the result of interactions among numerous mind, body, and relationship factors.3 Therefore, ideal management of women with sexual problems would be in a multidisciplinary setting with psychologic- and biologic-focused health-care professionals.4,5 Management of women with sexual dysfunction should be performed in a step-care paradigm in which treatments selected evolve from the least invasive to progressively more invasive management strategies.1,3-6 Surgery for the treatment of a woman’s sexual dysfunction should be considered only as the last resort.

This chapter reviews difficult surgical cases of sexual dysfunction, comprising five cases of women who presented for management of sexual dysfunction in a multidisciplinary setting, and who ultimately required surgical intervention as part of the care provided to manage the sexual complaint. This surgical care was provided, in all cases, in addition to other biologic and psychologic interventions. The purpose of the chapter is to illustrate some typical cases in which surgical intervention strategies are utilized in the management of women with sexual health problems. When appropriate, photographs are provided. As with all medical conditions, in cases of failed conservative interventions, not only is surgery indicated, but also it is the one therapy that may resolve the overall sexual dysfunction. As in other portions of this textbook relating to difficult case management, all efforts have been made to protect the privacy of patients and to maintain the management strategies utilized in the case for teaching purposes.

Case 1

KS is a 26-year-old, healthy, sexually active woman who has no health problems and takes no medication. She states that, when she was a teenager, during sexual arousal, her vagina produced a significant amount of clear, viscous, slimy, “egg white-like” lubrication that soaked through her clothes. In college, she noticed that during sexual stimulation the inside of her vaginal walls would produce some fluid, but not the same volume and quality of lubrication she had experienced as a teenager. In her second year of college, she noticed a small red bubble on the labia minora. When KS touched this bubble, it burst, and a small amount of fluid came out. She went to her gynecologist, but nothing abnormal was observed. During KS’s final years of college, her labia minora would generally become swollen when she was aroused, and it would take days for the swelling to go away.

For the 4 years following her graduation from college, when KS become sexually aroused, the labia minora would swell within minutes, and it felt as if “there were water balloons inside the flesh of my labia”. The swelling, especially on the left labium, increased to a volume larger than a “pecan in its shell”. She observed that the membrane of the “water balloon” surrounding the fluid was easily palpable inside the skin of the labia minora. On the right side, the swelling was located just inside the vaginal introitus. After sexual stimulation, when the swelling developed, KS felt a burning discomfort. Although the bilateral swelling occurred within minutes, it could take weeks for it to dissipate completely. If KS was frequently sexually aroused, the swelling got larger and larger. This condition was very painful because “the swelling distended the delicate labia”, and anything that contacted the labia caused pain, including her clothing. It could even be painful to sit. If the labia remained swollen for a long time, the skin became desensitized, and there was more of a distressing discomfort than pain. Despite having a healthy sexual interest, KS avoided relationships and sexual experiences because of this problem.

KS had been to a series of physicians, and she had many different diagnoses, but none helped to alleviate the problem. One gynecologist told her the swelling was “trauma from oral sex”. The physician used a syringe to aspirate the fluid, giving significant relief. KS’s boyfriend then “shaved his beard”, but that made no difference. Another physician biopsied the membrane of the “water balloon”. Another physician surgically removed the cyst from her left labium, but the swelling started to recur, dramatically related to sexual arousal but to no other time. KS was frustrated that the relationship of the swelling to sexual arousal remained unexplained. KS would seek relief by repeated office visits for needle aspiration until she started to do this by herself. When she touched the aspirated fluid, it felt exactly like the vaginal lubrication she had been “missing since college”.

KS decided to seek a new opinion, going for the first time to a multidisciplinary sexual medicine clinic. She was initially evaluated by the psychologist as follows. KS is currently emotionally stable without medication. There is no history of sexual abuse, substance abuse, or trauma. She is concerned about the long-term implications of this problem.

KS subsequently underwent history taking and physical examination, but this failed to reveal the disorder. She was advised to undergo duplex Doppler ultrasonography before and after audiovisual and vibratory sexual stimulation (see Chapter 14.3). This study revealed 3.5 x 5 cm right and 2.8 x 6 cm left, fluid-filled, irregular spaces with septa, consistent with Bartholin’s cysts (Fig. 15.2.1). KS was advised to undergo marsupialization of both Bartholin’s cysts. At the time, she was not sexually involved with anyone, so there was no problem. As KS felt that there were no appropriate means to “remove the cysts that weren’t there”, she decided to wait until she was in a relationship to have the problem corrected.

Approximately 1И years later, KS was in a new relationship and sought definitive surgical treatment. She presented to the operating room, having undergone sexual stimulation the night before. Under intraoperative ultrasound control, both cysts were localized, punctured, filled with saline, and marsupialized (Fig. 15.2.2). Postoperatively, KS happily stated that her fluid now flowed right out, as it did in high school. She had forgotten what she was missing. “It’s been so long since I self-lubricated like that - I am very, very glad it works.”

Comments

It is important to understand the anatomy, structure, and function of the multiple organs within the vestibule (see Chapters 4.1 and 4.2). A careful and detailed inspection of the vestibule is critical in women with sexual dysfunction. In this case, the sexual medical disorder was present only during sexual arousal. In such situations, we have found duplex Doppler ultrasonography before and after audiovisual and vibratory sexual stimulation to be very useful in observing the arousal-related disorder.

Sexual medicine physicians can be expected to encounter Bartholin’s duct cysts or gland abscesses in their female patients with sexual dysfunction, especially those who present with labial tissue swelling at the vaginal introitus associated with sexual stimulation and arousal causing local vaginal and intercourse discomfort. Bartholin’s glands are homologs of Cowper’s glands in males. Bartholin’s glands, which provide lubricant for the labia minora and vestibule, are located bilaterally at the base of the labia minora and drain through 2-2.5-cm-long ducts that empty into the vestibule at about the 4 o’clock and 8 o’clock positions. The glands rarely exceed 1 cm in size and are not palpable except in the presence of abnormal gland drainage. Bartholin’s duct cysts are the most common cystic growth in the vulva and occur in the labia majora. It is likely that Bartholin’s glands involute as a woman ages, so that Bartholin’s duct cysts are more common at 20-29 years of age. Obstruction of the distal Bartholin’s duct may result in the retention of secretions, with resultant dilation of the duct and formation of a cyst. The cyst may become infected, and an abscess may develop in the gland. The treatment of Bartholin’s duct cyst depends on the patient’s symptoms. An asymptomatic cyst may require no treatment, but symptomatic Bartholin’s duct cysts and gland abscesses require drainage by marsupialization.7,8

Case 2

FI, aged 25, with satisfactory sexual activity, had, since her teens, complained of episodes, once or twice a year, of painful swelling of the clitoris. Most of these episodes lasted hours to days and ultimately resolved spontaneously. The swelling episodes appeared unrelated to either self-stimulation or penetrative sexual activity. These occurrences were also unrelated to her menstrual cycle or to any physical activity. She took no medication other than an oral contraceptive that she had been using since college. She did not ride bicycles or horses and could not recall any episode of obvious blunt perineal trauma. During the episodes of clitoral swelling, the discomfort completely prevented sexual activity and the use of any clothing that would contact the tender region. FI mentioned these episodes to her gynecologist, but she was told all was normal on examination.

One year ago, FI had one episode of painful clitoral swelling that persisted beyond the usual few days. For the first time, FI went to a gynecologist with this condition in an active state. She was again informed that the examination was normal. FI was treated with a 5-day course of oral antibiotics, and over the next few days the swelling and discomfort resolved.

Approximately 6 months later, FI experienced another episode of painful clitoral swelling that again developed for no apparent reason. This episode also persisted and worsened over the next few days, preventing her from engaging in any form of sexual activity. FI contacted her gynecologist, who prescribed the same oral antibiotics. Unfortunately, despite 5 days of antibiotic treatment, the symptoms of clitoral swelling and pain persisted. FI was referred to a new gynecologist, who noted severe clitoral swelling of unknown etiology. FI wanted to know what the problem was. She was admitted to the hospital for intravenous antibiotics, observation, and pelvic ultrasound examination. The radiologist performing the examination could not rule out clitoral priapism.

FI was transferred for emergency opinion to a multidisciplinary sexual medicine clinic. Upon admission, FI underwent history taking and physical examination. The clitoral prepuce was markedly swollen and tender, and the glans clitoris could not be visualized by prepucial retraction (Figs 15.2.3 and 15.2.4). The preliminary psychologic interview failed to identify any history of trauma or abuse, or any contributing psychologic problems. FI was frustrated and anxious over the inability to understand what was happening “down there”, but she was happily married with a very supportive husband. FI had had a marked loss of interest, arousal, and orgasm after the birth of her two daughters. Sexual activity had become limited and was now associated with mild to moderate discomfort during penetration.

Figure 15.2.2. Under intraoperative ultrasound control, both cysts were localized, punctured, filled with saline, and marsupialized. The thick lubricating fluid was noted to emanate from the Bartholin's cyst.

Figure 15.2.3. The clitoral prepuce was markedly swollen and tender (A), and the glans clitoris could not be visualized by prepucial retraction. Under local anesthesia with sedation (B), a dorsal slit of the prepuce was utilized to gain clitoral glans exposure (C, D).

FI was advised to undergo duplex Doppler ultrasound examination of the clitoris. The peak systolic velocity in the right and left clitoral cavernosal arteries was 10-15 cm/s, and the end diastolic velocity was 5-7 cm/s. The right and left clitoral shaft diameters were 1.1 and 1.0 cm, respectively. There was evidence of a hypoechoic, fluid-filled space of 3.1 x 2.3 cm, underlying the right aspect of the prepuce, that appeared contiguous with pubic subcutaneous tissue and consistent with a prepucial abscess. Under local anesthesia with sedation, FI underwent emergency incision and drainage of the abscess, as well as a dorsal slit of the prepuce to gain clitoral glans exposure (Figs 15.2.3 and 15.2.4). FI did well postoperatively and was seen at 1-, 2-, and 6-month follow-up (Fig. 15.2.4). Her physical examination was unremarkable. She was informed that the recurrent symptoms she experienced were probably secondary to a repeated, intermittent, subcutaneous tissue infection, probably of a sebaceous cyst underlying the prepuce. FI was notified that if she was distressed or bothered by her changed sexual function since childbirth, she could undergo an evaluation, including sex steroid hormones.

Comments

Sebaceous cysts are often found in the genital area (see Chapters 9.5 and 12.2). Sebaceous cysts are formed when the release of the relatively thick fluid sebum produced by the sebaceous glands in the skin is obstructed. If cysts become infected or grow to a bothersome size, surgical intervention may be necessary. Sebaceous cysts can recur if they are not removed completely. In women with clitoral pain syndromes, careful physical examination of the clitoris and prepuce is aided by magnification with surgical loupes. Proper examination involves elevation of the lateral aspect of the clitoral shaft in a cephalic direction. The clitoral glans should be exposed fully. Nearby sebaceous cysts occur under the skin, vary in size, and tend to be smooth to the touch.9

Case 3

BT, aged 33, a healthy, single nurse, has been in a relationship for the last 8 years. At age 25, BT was prescribed the combined oral pill for contraception and control of irregular and painful menstrual periods. She has remained on the combined oral contraceptive for the last 8 years. From age 19 to 27, BT was interested in sexual activity, easily aroused, and enjoyed excellent quality orgasmic release. Over the last 6 years, BT noted progressively diminished interest in sexual activity, which had worsened significantly over the last 2 years. During the last 24 months, BT also suffered a raw, burning discomfort during penetration, described as like rubbing on sandpaper, that hurt for a day or two after a sexual encounter. She experienced the same discomfort when she wore tight clothing that contacted her genital area. BT also noted that during sexual activity she had less genital feeling, was drier, and did not lubricate as much any more. The sexual problems have been a huge predicament in the relationship, as her partner feels that BT is no longer attracted to him.

BT had sought advice from her local primary care physician. Physical examinations were always unremarkable and she was ultimately advised to “be a good actress”. She went to several gynecologists and was managed with topical estrogen creams and with oral and topical treatments for yeast infections. Due to persistence of the sexual problem, BT was referred to a multidisciplinary sexual medicine clinic.

BT was initially evaluated by the psychologist. She provided a history of abuse by an alcoholic father during adolescence. Her mother had divorced and remarried, and BT lived with her mother and stepfather for 7 years before moving in with her current boyfriend. BT had a problem with alcohol in her teens but underwent rehabilitation, went to nursing school, and enjoys her health-care profession. She does not use recreational drugs and is in a committed relationship. She hopes to have a family and continue with her nursing career.

BT underwent history taking and physical examination. She provided the above history and added that, compared to previous capabilities, her current sexual desire was estimated to be only 10%; peripheral arousal, lubrication, and engorgement only 25%; and orgasmic release, now only occurring rarely with deep penetration, was approximately 20%. Physical examination revealed a 1.5-cm mass on the left frenulum that involved the posterior aspect of the clitoral glans (Fig. 15.2.5). The urethral meatus was without lesion. There was 20% fusion of the posterior aspect of the labia minora to the labia majora bilaterally. There were multiple areas of erythema overlying ostia of minor vestibular glands. Q-tip testing was positive in multiple areas overlying the ostia of the minor vestibular glands.

Biothesiometric studies revealed that the vibration perception threshold was 3 V in the right and left pulp index fingers, and 12 V in the right and left labia. The clitoris was too tender for assessment. The overall impression was a history of sexual abuse and ethanol use; sexual dysfunction including low desire, arousal, and orgasm; mild genital atrophy; mild diminished genital sensation; and dyspareunia with a 1.5-cm clitoral- frenular mass and vestibular adenitis. The plan was to observe the mass over the next month, consider sex steroid blood testing, develop psychologic coping strategies with the psychologist, and engage in physical therapy consultation for the vestibular pain.

One month later, BT returned to review the blood-test results. Hormone studies revealed the following values: thyroid- stimulating hormone 2.1 (0.4-5.50 µIU/ml), follicle-stimulating hormone 0.2 (1.5-33.4 mIU/ml), luteinizing hormone 0.6 (0.5-76.3 mIU/ml), prolactin 13.7 (1.8-20.3 ng/ml), dehydroepiandrosterone sulfate 58 (35-430 |Jg/ml), androstenedione 1.0 (0.2-3.1 ng/ml), total testosterone 14 (15-70 ng/dl), free testosterone <0.5 (0.3-1.9 ng/dl), sex hormone-binding globulin 249 (17-120 nmol/l), and estradiol <20 (11-526 pg/ml).

Figure 15.2.5. Physical examination revealed a 1.5 cm mass on the left frenulum that involved the posterior aspect of the clitoral glans (A). At 6-month postoperative follow-up (B), physical examination revealed no evidence of tumor recurrence.

Repeat physical examination showed the clitoral-frenular mass to be potentially more tender. After discussion, it was decided to perform an excisional biopsy of the mass and, in the postoperative period, discontinue the oral contraceptive pill, consider alternative contraception, and contemplate beginning androgen therapy.

BT underwent excisional biopsy under local anesthesia, preserving as much clitoral and frenular tissue as possible. The diagnosis was fibroepithelioma. Although this is a benign tumor, it may recur. At 6-month postoperative follow-up, physical examination revealed no evidence of tumor recurrence (Fig. 15.2.5). BT had utilized androgen therapy and normalized many of the abnormal sex steroid blood test values, except for a persistent sex hormone-binding globulin value. She experienced marked improvement in sexual interest and arousal. Orgasm was now possible by both clitoral and internal stimulation. Concerning the fibroepithelioma, BT will continue to undergo surveillance physical examination on a regular basis.

Comments

In women with sexual dysfunction, a full physical examination involves examination of the entire vestibule under magnification with surgical loupes (see Chapters 9.5 and 12.2). Clitoral disorders, such as fibroepithelioma, are not always identified (BT had at least four pelvic examinations in the last 2 years) because most health-care professionals do not retract the prepuce and examine the glans clitoris.

Fibroepitheliomas are characterized histologically by a mix of primordial follicular epithelium with more mature follicular epithelium within nodular collections of stroma. Fibro- epitheliomas are usually found in the lower abdominal and perineal regions, or in the upper aspects of the lower extremities. Fibroepitheliomas can be precursors to basal cell carcinoma, but aggressive behavior in fibroepitheliomas is unusual.10

Case 4

NH, a 51-year-old, single, biotechnology consultant, was healthy until 6 years ago, and took only thyroid replacement for a hypothyroid condition that developed after an earlier pregnancy. NH had an excellent sex life with 100% desire, 100% arousal, and 100% orgasm from her teens until 6 years ago, when she was found to have a melanoma. She underwent surgical excision and, several weeks later, prophylactic chemotherapy. NH entered chemotherapy-induced menopause at age 46. She was happy before the chemotherapy and met a man with whom she had great sexual activity and satisfaction. Since the menopause, however, she has lost interest, and there has been significant pain and discomfort during penetration. On a business trip to London a year ago, she met another man and was very attracted to him. One month later, when they rendezvoused in Italy, NH was just not interested, and the sexual activity was very poor and painful. When premenopausal and performing self-stimulation, she would predictably reach orgasm in 15 min or less. Now it often takes more than 1 h and the orgasm is muted. NH is not even interested in trying. She is afraid of being alone, being onedimensional, and never having or wanting to have passion again. The sexual problem is affecting her work, her relationships, and her self-image.

NH informed her gynecologist of the sexual dysfunction. She was advised to initiate hormone therapy. After learning of the risks and benefits, NH chose to use an estrogen and progesterone patch. Unfortunately, while this made her feel better in general, the sexual symptoms persisted. NH was referred to a multidisciplinary sexual medicine clinic.

NH was seen initially by the psychologist. During chemotherapy, she became menopausal and began to experience severe hot flashes, claustrophobia, fatigue, loss of interest in many activities, poor concentration, and insomnia. She is currently on paroxetine, which helps to reduce her phobic reactions and hot flashes. She is feeling very distressed by her present situation, and is struggling with many life issues such as career and finances. She is currently not in a relationship, as initiating relationships is now difficult and her moods are very variable. She is able to experience orgasms of reduced intensity and lubricates to some degree when aroused, but still has low interest. She experiences “significant discomfort”, described as feeling like rubbing burnt tissue, when sexually active.

NH’s history was as above. In addition, she noted that, compared to previous capabilities, she had 20% desire, 20% arousal, and 10% orgasmic function. NH’s physical examination revealed a decrease in size and thickness of the clitoris glans and prepuce. The urethral meatus revealed no prolapse There was marked atrophy of the labia minora, with 90% fusion to the labia majora bilaterally. There were multiple areas of erythema overlying ostia of Skene’s glands/minor vestibular glands at 1, 2, 10, and 11 o’clock at the labial-hymenal junction (Fig. 15.2.6). Q-tip testing was markedly positive at all the sites of erythema with the patient describing pain intensity at a level of 5-10/10 at the various introital locations. The posterior fourchette of the vestibule was free of pain. The vagina was consistent with mild atrophic vaginitis, revealing a relatively dry mucosa and decreased rugae formation. Biothesiometric studies revealed a vibration perception threshold of 4 V at the right and left pulp index fingers, with 14 V noted for the right and left labia minora and clitoris. Hormone studies revealed the following values: thyroid-stimulating hormone 2.3 (0.4-5.50 µIU/ml), follicle-stimulating hormone 39.6 (1.5-33.4 mIU/ml), luteinizing hormone 63.8 (0.5-76.3 mIU/ml), prolactin 11.2 (2.8-29.2 ng/ml), dehydroepiandrosterone sulfate 46 (35-430 µg/ml), androstenedione 0.7 (0.2-3.1 ng/ml), total testosterone 12 (15-70 ng/dl), free testosterone 0.4 (0.3-1.9 ng/dl), sex hormone-binding globulin 73 (17-120 nmol/l), dihydrotestosterone 63 (50-250 pg/ml), and estradiol 28 (11-526 pg/ml).

The impression was menopause following chemotherapy, mild depression, anxiety, high stress, decreased genital sensation, genital atrophy, atrophic vaginitis, and sexual dysfunction including marked diminished desire, arousal, orgasm with vulvar vestibulitis syndrome (primarily Skene’s glands). The plan was to initiate psychologic consultation; physical therapy consultation in conjunction with local vestibular and intravaginal estrogen therapy; and systemic estrogen, progesterone, and androgen therapy.

At 3-month follow-up, NH was cautiously optimistic. She was found to have marked improvement in hormone blood tests. There was concomitant minor improvement in sexual interest, lubrication, and orgasmic intensity. The genital sexual pain persisted. Despite treatments, physical examination revealed persistence of the multiple areas of erythema overlying the ostia of multiple minor vestibular glands at the labial- hymenal junction. Q-tip testing was focally positive, overlying only the erythematous ostia with a range of pain of 5-10/10. She was placed on oral gabapentin but could not tolerate the medication due to drowsiness. She was then administered amitriptyline but realized only limited benefit.

At 1-year follow-up, despite ongoing psychologic counseling, biofeedback physical therapy, and systemic and local hormone therapy, NH was desperate for relief from the disabling genital sexual pain. The physical examination was essentially unchanged. She was advised to consider vestibulectomy. She underwent a diagnostic nerve block with 1% lidocaine, using a 31-gauge, 1-ml, 5/16-inch insulin syringe. After preparation with betadine, the injection revealed that Q-tip testing in the labial-hymenal junction was now negative.

NH was offered a modification of the complete vestibulectomy, involving excision exclusively of erythematous Skene’s glands/minor vestibular glands at the 1, 2, 10, and 11 o’clock positions at the labial-hymenal junction. The outpatient surgery was performed under local anesthesia with sedation (Fig. 15.2.6). Pathologic analysis revealed a chronic inflammatory infiltrate surrounding the excised vestibular glands, with replacement of the columnar epithelium of the vestibular gland by squamous metaplasia. At 4 weeks postoperatively, NH returned to the physical therapist to undergo slow, progressive, vaginal introital dilation under supervision. At 3 months postoperatively, NH was completely free of pain, and, as she maintained hormonal management throughout this period, she had improved desire, arousal, and orgasm to 75% of previous capabilities.

Comments

Rational health-care delivery for women with sexual dysfunction involves coordination and integration of mind, body and relationship factors (see Chapters 12.1-12.6). As it concerns biologic management, conservative treatment options should always be utilized first. If, however, conservative treatment applied for a “sufficient” period of time does not improve symptoms, invasive treatments should be considered. Of the various treatments for dyspareunia, surgery is associated with safe and effective treatment outcome.11

Case 5

NI, aged 28, and married for 5 years, has complained of severe vestibular pain since the delivery of her child 4 years ago. The birth involved a prolonged forceps delivery that was complicated by chronic pudendal neuropathy, leading to disabling left leg spasms and diminished genital sensation. The childbirth was also associated with a stage 3 perineal tear that was treated with a difficult repair of the posterior fourchette and perineum. Postpartum, NI underwent cauterization of granulation tissue at the perineal repair on four separate occasions, but the final cauterization led to chronic, severe pain in the vestibular region.

The 10/10 relentless pain in the vestibule in conjunction with the pudendal neuropathy has resulted in significant function impairment. NI is prevented from sitting for longer than 10 min, walking more than a quarter of a mile, or climbing stairs. She has painful defecation as well as a mild urinary and fecal incontinence. She cannot bend or twist, or carry her child. She cannot work in her capacity as an engineer. As a result, over the next 2 years, NI underwent several revisions of the posterior fourchette, treatment by pudendal nerve blocks, steroid injections, physical therapy, psychologic counseling, and oral gabapentin and amitriptyline. Her last good sexual intercourse was prior to the childbirth. She has distinct changes in desire, arousal, and, with the marked diminished genital sensation, she cannot achieve orgasm.

NI was referred to a multidisciplinary sexual medicine clinic. She was first seen by the psychologist, who reported as follows. This 28-year-old woman has significant vestibular pain since childbirth and posterior repair. She remains sexually active in a limited fashion but with severe pain during penetration. She is depressed, sees a therapist, and takes selective serotonin reuptake inhibitors. She is tearful during the interview. She is overwhelmed with the chronic pain and the significant reduction in functioning.

NI’s history was as above. In addition, she noted that compared to previous capabilities, she had 10% desire, 10% arousal, and 10% orgasmic function. Physical examination revealed a normal appearing clitoris and labia minora. There was positive Q-tip testing at focal locations at 5 and 7 o’clock. The entire posterior fourchette was tender and the skin surface appeared to be burgundy-colored, erythematous, and beefy-appearing consistent with chronic inflammation (Fig. 15.2.7). Bio- thesiometric studies revealed a vibration perception threshold of 3 V for the right and left pulp index fingers, with 24 V noted for the right and left labia minora and 30 V for the clitoris. Hormone studies, obtained 1 month prior to the sexual medicine evaluation, revealed mild androgen insufficiency. The impression was postpartum depression; diminished desire, arousal, and orgasm; severe vestibular pain; pudendal neuropathy; severe diminished genital sensation; and mild androgen insufficiency. The plan was psychologic counseling, physical therapy consultation, pudendal nerve blocks (using intravaginal ultrasound guided nerve blocks), and androgen therapy.

Concerning the severe pain, one option was wide excision of the chronically inflamed vestibular and subcutaneous tissue of the posterior fourchette, and repair of the area by developing and advancing a vaginal flap closure (Fig. 15.2.7). The procedure was eventually performed, taking approximately 90 min. Intraoperative findings revealed chronically scarred vestibular tissue.

At 3-, 6-, and 12-month follow-up, NI showed a dramatic reduction in vestibular pain. Rehabilitation with multiple disciplines, including androgen therapy, physical therapy, and psychologic counseling, has resulted in improved sexual and physical functioning. NI now has improved desire and sexual thoughts “on the radar screen”, resulting in her initiating sexual activity for the first time since the childbirth. NI still has not yet achieved a good orgasm, but treatment strategies are continuing.

Comments

In complicated cases such as above, surgical intervention can be very effective (see Chapters 12.1-12.6).

Discussion

Chapter 15.2 reviews some of the various surgical treatment strategies for women with sexual dysfunction. As can be seen from these highly selected cases, surgical intervention can result in a discernible improvement in an individual woman’s sexual function. In the management of women’s sexual health, treatment is stepwise, starting from the most noninvasive and advancing, if needed, to surgical intervention. In the field of sexual medicine, it will always be relevant to train specialists who are skilled in the performance of surgical strategies for selected women with sexual health concerns not responsive to conservative management.

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