Chapter 16 Vestibulectomy and Hymenectomy Surgery. Operative Techniques

 Chapter 16 Vestibulectomy and Hymenectomy Surgery

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 VulvodyniaDifferential 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 excludeother 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.

■ Patient selection is critical for ensuring the success of vestibulectomy.

Careful consideration must be given to operating on patients with mixed

vulvodynia or concurrent vaginismus, in whom the procedure has lower

success rates.2,8

Approach

■ Several approaches to surgery for vestibulodynia have been described,

including local excision, total vestibulectomy, partial vestibulectomy with

vaginal flap, and perineoplasty.2,5,8 Local excision involves identification

and removal of painful vestibular tissue, including tissue at the base of the

hymen, without vaginal advancement. A total or partial vestibulectomy

identifies and excises painful vestibular mucosa, then mobilizes the distal

vagina to cover the excised area. In a total vestibulectomy, the incision

typically extends from the periurethral region to the fourchette, although in

some cases a limited incision from the fourchette partially up the labia

minora may be sufficient. Finally, the perineoplasty includes a

vestibulectomy with extension of the tissue excision to the perineum.

Vestibuloplasty, in which the vestibule is denervated but painful tissue is

not excised, is not an effective procedure. Partial vestibulectomy with

vaginal flap is the procedure best described in the literature and most

commonly performed. It will be the focus of the technical discussion that

follows.

Positioning

■ The patient should be placed in the dorsal lithotomy position using

adjustable stirrups to allow access to the vestibule and perineum. Care

should be taken to avoid hyperextension or hyperflexion of the lower

extremities.

Figure 16.1. Total Vestibulectomy in four steps. A: Incise the vestibule and create a

vaginal flap. B: Excise vestibular tissue. C: Advance the vaginal flap. D: Place

interrupted sutures to secure the vaginal flap.

Procedures and Techniques: Vestibulectomy for

Vulvodynia/Partial Vestibulectomy with Vaginal Flap (see

Tech Fig. 16.2, Video 16.1)

Identify anatomic landmarks and preoperatively map the patient’s pain and

region to be excised

■ The vestibule is the tissue between the hymenal ring and Hart’s line. Hart’s line,

located on the inner fold of the labia minora, is the lateral border of the vestibule.

Anteriorly, the vestibule is bordered by the frenulum of the clitoris and, posteriorly,

by the fourchette (Tech Fig. 16.1). It comprises the Bartholin, Skene,

periurethral, and minor vestibular glands.

■ The extent of the incision in the anterior–posterior direction should be

determined by the patient’s preoperative pain mapping, but typically extends from

the periurethral area at the opening of the Skene ducts inferiorly to the fourchette.

■ A Lone Star retractor is placed to optimize visualization (Tech Fig. 16.2).

Tech Figure 16.1. Vestibular anatomy.

Tech Figure 16.2. The Lone Star retractor assists with visualization.

Incise the vestibule

■ Prior to making the initial incision, a solution of lidocaine 0.5% with 1:200,000 of

epinephrine is injected into the vestibule subcutaneously and subdermally to

assist with hydrodissection and hemostasis (Tech Fig. 16.2).

■ A U-shaped vestibular incision is made (Tech Fig. 16.3) over the marked tissue

with a no. 10 scalpel. The lateral border of the incision is made along Hart’s line,

the lateral border of the vestibule, and the medial border of the incision is made

proximal to the hymeneal ring. Care must be taken when incising the periurethral

area to avoid damaging the urethra.

■ The Bartholin glands should be palpated for any nodular or cystic component. If

cysts or nodules are present, the gland should be removed.

Tech Figure 16.3. Vestibular incision.

Create the vaginal flap

■ Dissect the posterior vaginal wall epithelium from the underlying tissue to create

a vaginal flap. This may be accomplished using Allis clamps and Mayo scissors

taking special care to avoid damaging the rectum.

Excise the vestibule

■ Excise the U-shaped region of the vestibule including the skin, hymen, and the

minor vestibular glands (Tech Fig. 16.4).

Tech Figure 16.4. Vestibular excision.

Mobilize the vaginal flap

Mobilize the flap distally to cover the defect; it must be advanced adequately to

avoid placing excessive tension on the incision line (Tech Fig. 16.5A,B).

■ Excellent hemostasis must be achieved to prevent hematoma and wound

dehiscence.

Tech Figure 16.5. A and B: Advancement of the vaginal flap.

Wound closure

■ The closure is accomplished in two layers (Tech Fig. 16.6). First, place a deep

layer of interrupted 3-0 absorbable sutures (Vicryl or Polysorb) in a U-shaped

fashion to facilitate approximation of the vaginal wall to the edge of the vestibulardefect. Second, re-approximate the vaginal epithelium to the perineal skin using

interrupted 4-0 absorbable sutures.

Tech Figure 16.6. Wound closure.PEARLS AND PITFALLS: VESTIBULECTOMY FOR VULVODYNIA

Outlining the area of excision may be done either in the operating room or in the

clinic. Prior to anesthetizing the patient in the operating room, map out and mark

painful regions of vestibular mucosa to appropriately target areas for tissue excision.

The anterior–posterior extent of the incision should be based on pain mapping.

Alternatively, if done in the clinic, be sure to descriptively document the excision

margins.

If the incision is extended to the opening of the Skene ducts, take care to avoid

urethral injury. Similarly, the incision should never be extended too far toward the

anus since chronic fissuring and anal sphincter weakness may result.

Prior to incising the vestibule, lidocaine with epinephrine may be injected

subcutaneously and subdermally to assist with hydrodissection and hemostasis.

Take care to ensure that the vaginal flap is not under excessive tension when it is

approximated to the edge of the excised vestibule. If it is under excessive tension, it

may result in postoperative vestibular contraction and dyspareunia.

Ensure that excellent hemostasis is achieved prior to wound closure. This may be

done using coagulation or suture. Inadequate hemostasis may result in hematoma or

wound dehiscence.

POSTOPERATIVE CARE: VESTIBULECTOMY FOR VULVODYNIA

■ Vestibulectomy is performed as an outpatient procedure.

■ Patients should receive immediate postoperative analgesia with

nonsteroidal anti-inflammatory medications and narcotics, if necessary.

Local injection of bupivacaine and epinephrine intraoperatively into the

labia and peri-incisional regions can help minimize pain as well as

intraoperative bleeding. Sitz baths and ice packs also assist with pain

control.

■ Patients should receive a stool softener and be advised to eat high-fiber

foods to avoid constipation.

■ Use of a vaginal dilator may help reduce vestibular contraction and pain.

This can be instituted a few weeks after surgery in the office when the pain

has subsided and after an examination and instructions.

■ Patients should be advised to abstain from intercourse for 6 to 8 weeks, or

until a postoperative visit when the incision is evaluated for appropriate

healing.

OUTCOMES: VESTIBULECTOMY FOR VULVODYNIA

■ Prospective studies evaluating the resolution of vulvar pain after

vestibulectomy report success rates ranging from 61% to 83%.5 Thesestudies vary in terms of how they define success, some reporting a positive

outcome only after complete resolution of symptoms, and others equating

success with a “significant improvement” in symptoms.8

■ One prospective study comparing vestibulectomy to no treatment and to

nonsurgical treatments found that 79% of patients who had surgery

experienced a significant improvement in pain, whereas only 48% of

patients who received nonoperative treatment and 12% of patients who

received no treatment, experienced an equivalent improvement in pain.9

Similarly, a randomized controlled trial comparing vestibulectomy to

cognitive behavioral therapy (CBT) and to biofeedback found a 68% rate of

complete relief or great improvement of pain with vestibulectomy versus a

39% improvement for the CBT group and a 36% improvement for the

biofeedback group.10

■ Some data suggest that up to 15% of women experience a minor

postsurgical complication, such as pruritis, hematoma, local infection, or

Bartholin duct stenosis, and as many as 17% of patients require a follow-up

surgery.11

COMPLICATIONS: VESTIBULECTOMY FOR VULVODYNIA

■ Complications are typically minor, and may include the following:

■ Blood loss

■ Wound infection or dehiscence

■ Bartholin gland cyst formation

■ Failure to reduce vulvar pain

■ Vaginal stenosis

■ Vaginismus

GENERAL PRINCIPLES: IMPERFORATE HYMEN

Definition

■ The hymen is a remnant of the connection between the sinovaginal bulbs

and the urogenital sinus. During normal fetal development, the inferior

aspect of the vaginal endplate canalizes to allow for an opening between

the vaginal canal and the perineum.12 An imperforate hymen is the result of

perforation failure during the fetal period. Other hymeneal abnormalities

include microperforate, cribriform, and septate hymens.

■ In the neonatal period, infants with imperforate hymen may have

mucocolpos due to secretion of mucus in response to maternal estradiol.

This may manifest as a bulging mass at the vaginal introitus. Often the

mass is asymptomatic and regresses spontaneously.

■ During adolescence, patients may accumulate menstrual blood behind theimperforate hymen resulting in hematometra and hematocolpos. They may

present with a blue bulge at the vaginal introitus, cyclic abdominal pain, an

abdominal mass, constipation, or urinary obstruction.

Differential Diagnosis

■ Transverse vaginal septum

■ Distal vaginal atresia

■ Vaginal agenesis

■ Hymeneal cyst

■ Labial adhesions

IMAGING AND OTHER DIAGNOSTICS: IMPERFORATE HYMEN

■ Imperforate hymen is evident on physical examination. The condition is

occasionally diagnosed during the neonatal period or childhood, but

diagnosis is often delayed until adolescence, when patients present with

amenorrhea, abdominal pain, or an abdominal mass associated with

hematometra. Examination of the genitalia during childhood by

pediatricians is advised to allow for appropriate management of

imperforate hymen and avoidance of symptoms with the onset of

menarche. We recommend referral to a pediatric gynecologist or

gynecologist with surgical experience when this diagnosis is made.

■ Rarely, the diagnosis of imperforate hymen is made on prenatal ultrasound,

when bladder outlet obstruction is noted due to mucocolpos.13

■ When an imperforate hymen is noted on physical examination, obtain a

transabdominal or transvaginal pelvic ultrasound to evaluate for

hematocolpos, and to exclude more complex anomalies such as a vaginal

septum or Müllerian agenesis. If a Müllerian anomaly is detected, we

recommend pelvic MRI and renal ultrasound.

■ We recommend surgical and medical referral to a pediatric gynecologist or

gynecologist experienced with imperforate hymen and Müllerian anomaly

management.

SURGICAL MANAGEMENT: IMPERFORATE HYMEN