Question: How effective and safe is vestibulectomy, a surgical procedure that involves the excision of the posterior aspect of the vaginal vestibule, in treating localized provoked vulvodynia (LPV), and what are the potential histopathological findings in the excised tissue?
Introduction
Localized provoked vulvodynia (LPV) is a chronic and debilitating condition characterized by pain and discomfort in the vulvar vestibule, often triggered by touch or attempted sexual intercourse. While conservative treatments, such as pelvic floor physical therapy and topical medications, are often the first line of management, some patients may not respond adequately and may require more invasive interventions, such as vestibulectomy.
Vestibulectomy is a surgical procedure that involves the excision of the posterior aspect of the vaginal vestibule, with the goal of removing the affected tissue and providing relief from the pain associated with LPV. However, the efficacy and safety of this procedure, as well as the potential histopathological findings in the excised tissue, warrant further investigation. This research paper aims to evaluate the effectiveness and safety of vestibulectomy in treating LPV and to analyze the potential histopathological findings in the excised tissue.
Methods
A retrospective analysis of patient data from a single-center study was performed, evaluating the outcomes of vestibulectomy in a cohort of women with LPV. The study population consisted of 55 women (aged 19-45 years) who underwent vestibulectomy between January 2016 and December 2018.
The diagnosis of LPV was made using the modified Friedrich criteria, and the surgical intervention was performed under sedation anesthesia by a single surgeon. During vestibulectomy, the vulvar vestibule mucosa was excised between 1 and 11 o’clock, sparing the urethral orifice.
The histopathological findings of the excised vestibular tissue were analyzed, with a focus on identifying any underlying pathological conditions, such as vulvar intraepithelial lesions or neuroproliferative changes.
A vestibulectomy is a gynecological surgical procedure performed to treat vulvar pain, specifically in cases of provoked vestibulodynia. Provoked vestibulodynia, also known as vulvar vestibulitis, is a chronic pain syndrome characterized by pain and irritation in the vulval vestibule, which is the area near the entrance of the vagina.
The vestibulectomy procedure involves removing specific tissues from the vulvar vestibule area, including the hymen, mucous membrane, Bartholin’s glands ducts, and minor vestibular glands. The extent of tissue removal can vary depending on the severity of the pain.
While vestibulectomy is not considered a first-line treatment option for provoked vestibulodynia, it has been found to be an effective long-term treatment, with high levels of patient satisfaction reported. One review found that 79% of patients experienced significant pain relief after the procedure.
The surgery is typically performed under spinal or general anesthesia and involves minimal bleeding. The recovery period can range from 6 to 12 weeks, depending on the amount of vulvar tissue removed. During the recovery phase, patients may require physical and psychological therapy to prevent scarring and facilitate a regular sexual life.
Potential complications of vestibulectomy include bleeding, infection, weakness of the anal muscles, cosmetic changes, development of a Bartholin’s cyst, or a decline in vaginal lubrication. However, satisfaction rates with the procedure can be as high as 90%.
In rare cases, the surgery may be unsuccessful, and the pain may persist, requiring alternative treatments such as oral medications or additional surgical interventions.
A study conducted in 2006 revealed that 93% of patients who underwent vestibulectomy recommended the procedure for vulvar pain, while only 11% of women continued to experience issues with their sex lives post-surgery.
Results
Of the 55 women who underwent vestibulectomy, the histopathological results of 38 patients (69%) were available. In 21 of the 38 patients (55.2%), the pathological reports revealed vestibulitis, characterized by edematous connective tissues, ectactic capillaries, and mononuclear cells under the vacuolized vestibular epithelium. In 14 cases (36.8%), the findings were concordant with Low-Grade Squamous Intraepithelial Lesions (LGSIL), with focal koilocytic atypia in the squamous epithelium. In three patients (7.8%), the pathology was reported as Lichen Simplex Chronicus.
At three months post-surgery, 50 patients (90%) reported full recovery from dyspareunia after vestibulectomy and cognitive behavioral therapy. Five patients continued to have minimal pain, but this did not affect their sexuality.
The literature reports high satisfaction rates of vestibulectomy, ranging from 78 to 91% in women refractory to conservative management. A previous study found that 83% of patients would recommend the procedure as an effective treatment for LPV, with an overall mean satisfaction score of 8.3 out of 10.
Discussion
The findings of this study suggest that vestibulectomy can be an effective treatment option for women with LPV who have not responded to conservative management. The high satisfaction rates and recovery from dyspareunia reported by the majority of patients in this study and the existing literature support the efficacy of this surgical intervention.
However, it is important to note that the effect of vestibulectomy may be temporary, as a previous study found no long-term benefit in terms of pain relief and quality of life compared to conservative treatment alone. Additionally, the complication rate after vestibulectomy was reported to be 18.8% in one study.
The histopathological findings in this study reveal the presence of vestibulitis, LGSIL, and Lichen Simplex Chronicus in the excised vestibular tissue. These findings suggest that there may be underlying pathological conditions contributing to the development of LPV in some patients. The presence of LGSIL in particular warrants further investigation, as it may be associated with human papillomavirus (HPV) infection.
Conclusion
Vestibulectomy can be an effective short-term treatment option for women with LPV who have not responded to conservative management. However, the long-term benefits of this surgical intervention remain unclear, and the potential for complications should be considered.
The histopathological findings in this study suggest that there may be underlying pathological conditions contributing to the development of LPV in some patients. Further research is needed to better understand the etiology of LPV and to identify the most effective treatment strategies for this chronic and debilitating condition.
