According to a 2015 consensus statement on vulvar pain terminology, vulvodynia is defined as vulvar pain of at least three months duration without clear identifiable causes which may have potential associated factors. Vulvodynia is a diagnosis of exclusion. It includes a thorough history and physical exam. The physical exam should include cotton swab testing to evaluate areas of tenderness on the vestibule. Classically, those with vulvodynia will have erythema of the vestibule. Various tests should be performed to rule out other causes of vulvar pain such as wet mount, pH, and yeast culture. You may also consider biopsy of certain abnormal appearing tissue. Additionally, assessment of the pelvic floor muscles should be performed to rule out any aspect of high tone pelvic floor dysfunction. Vulvodynia is classified based on four categories including the site of the pain, whether the pain is provoked, spontaneous, or mixed, the onset of the pain, and whether there's a temporal pattern of the pain such as intermittent, persistent, constant, immediate, or delayed. Vulvodynia is treated in a stepwise approach starting with vulvar care measures then transitioning to medications such as topical or oral medications like tricyclic antidepressants, biofeedback and physical therapy have also been shown to help as well as transcutaneous electrical nerve stimulation, and lastly, surgical management. Vestibulectomy, a procedure originally described in the 1980s, is a treatment for refractory vulvodynia not responding to medications and other methods of treatment. The success rate ranges from about 60% to 90% in the literature and it involves surgical excision of the vestibule from the hymen to the lateral vestibule edge or Hart's line. Note the relevant anatomy. The vestibule lies between the labia minora and is bordered by the Hart's line, the white dotted line on the image. The vestibule from superior to inferior includes the urethra, the bilateral skein's glands, the vagina which is surrounded by minor vestibular glands, and the bilateral ducts to the Bartholin's glands. According to Tulane's operative gynecology, the vestibulectomy includes an excision of a horseshoe-shaped portion of the vestibule, the outer border being that along Hart's line, which is depicted in blue on the image, and the inner border being that proximal to the hymen, which is depicted in red. As you can see, the excision includes the minor vestibular glands on either side of the vagina, as well as the Bartholin gland ducts and the hymen, and possibly the periurethral skein's glands, depending on your preoperative pain mapping. The basic steps of the procedure include positioning and dorsal lithotomy, pre-anesthesia cotton swab pain mapping, administration of anesthesia, excision of the vestibule according to preoperative pain mapping, the use of minimal cautery, the creation of a vaginal advancement flap to cover the surgical site, closure of the vaginal advancement flap to the perineum using interrupted sutures, and possible 5mm punch biopsy excisions of the bilateral skein's glands according to preoperative pain mapping. The case we're reviewing today is that of a 28-year-old female with a long-standing history of vulvodynia refractory to conservative medical therapies. Pain mapping is completed prior to induction of anesthesia. This is performed while the patient is awake and alert, and a cotton swab Q-tip test is used to identify areas of tenderness along the vestibule. This particular patient showed tenderness along the entire vestibule, extending from the bilateral skein's glands down to the bilateral ducts of the bartholin glands, but excluding the area of the posterior foreshadow. Once identified, a local anesthetic is injected using a 22-gauge needle into these tender spots along the vestibule, and a repeat cotton swab test is performed to demonstrate resolution of the tenderness. At this point, the patient has been prepped and draped in normal sterile fashion. A sterile marker has been used to demarcate the areas seen on pain mapping. 1% lidocaine with epinephrine is used to inject within the surgical site for hemostasis and hydrodissection. Using a self-retaining retractor for proper visualization, a 15-blade scalpel is used to create the initial incision along Hart's line, or the lateral edge of the vestibule. Based on this particular patient's preoperative pain mapping, the patient's entire vestibule, extending from bilateral skein's glands down to the bilateral bartholin gland ducts, was the planned area of surgical excision. The incision is continued in a horseshoe-shaped pattern across the entire length of Hart's line. Of note, this patient's preoperative pain mapping did not reveal tenderness in the posterior foreshed, which is the reason that a pedicle island slab was not necessary for this procedure. The second incision is also made in a horseshoe shape, but is proximal to the hind. Included within this incision are the bilateral minor vestibular glands, which lie just lateral to the vaginal orifice. Once the incision is performed, a vaginal advancement flap is created using sharp dissection with metzenbaum scissors. The fibromuscular layer between the posterior aspect of the vagina and the rectum is split using sharp dissection to ensure the creation of a thick vaginal flap that maintains a healthy blood supply. After creation of the vaginal flap, it is secured to the perineum using interrupted, delayed, absorbable sutures. During this process, special care is taken to avoid placing excess tension on the vaginal flap. As you can see, hemostasis is achieved with closure of the vaginal flap to the perineum, thereby allowing us to use minimal cautery. Here, you can see the vaginal flap secured in place. This patient's preoperative pain assessment showed tenderness of the schienes glands. Therefore, a 5mm punch biopsy was taken of the bilateral schienes glands and the biopsy site closed with a single interrupted suture. At the conclusion of the procedure, the patient is instructed to use SIDS baths, pelvic rest, and to follow up in two weeks for a postoperative exam.

vulvodynia

vulvar pain

diagnosis

treatment

vestibulectomy