Complete Vestibulectomy in Women with Persistent Entrance Dyspareunia Following Partial Posterior Vestibulectomy

Abstract

ABSTRACT Introduction Neuroproliferative vestibulodynia (NPV), characterized in 2004, is associated with increased density of mast cells and nerves as demonstrated by immunohistochemical staining of multiple regions of excised vestibular specimens, showing it to be a field disease. It has been reported that 16% of women experience persistent entrance dyspareunia which may lead to abstinence, disruption of social life, and/or depression. In patients with suspected NPV, complete vestibulectomy with vaginal advancement flap reconstruction, performed by providers trained in sexual medicine, has resulted in resolution of persistent entrance dyspareunia in approximately 80% of patients. Objective Many surgeons not trained in sexual medicine perform only a partial posterior vestibulectomy with vaginal advancement flap reconstruction in patients with suspected NPV. Recent pathologic evidence, however, shows NPV to be a field disease of the entire vestibule. To salvage patients who have not experienced resolution of their persistent entrance dyspareunia following a partial posterior vestibulectomy, we perform a complete vestibulectomy. We herein report on the results of complete vestibulectomy in this population. Methods This is a review of complete vestibulectomy surgeries performed by a sexual medicine specialist since January 2019 (n=47). Post-operatively patients were assessed for the ability to have pain-free penetration. Immunohistochemical staining was performed on all vestibular specimens in multiple locations using CD 117 and PGP 9.5 to assess for density of mast cells and nerves, respectively. Results 14 (30%) patients (mean age 26 ± 7 years) with persistent entrance dyspareunia following partial posterior vestibulectomy presented to our clinic, two of whom had undergone partial posterior vestibulectomy twice and one, three times. All patients had a history consistent with NPV after excluding all other forms of vestibulodynia. Cotton tipped swab testing showed severe pain primarily around the urethral meatus between 1:00 and 3:00 and between 9:00 and 11:00; 79% also had pain at 12:00. All had a positive response to vestibular anesthesia testing. During complete vestibulectomy surgery in patients with prior partial posterior vestibulectomy, vestibular fibrosis in the posterior vestibule resulted in more difficult dissection with approximately 33% increased blood loss (mean 200 ml vs 150 ml in women without prior partial posterior vestibulectomy). Surgical techniques were otherwise similar in women with or without prior partial posterior vestibulectomy. The vestibule was excised from around the urethral meatus and Hart's line to the hymen, and the urethral meatus and vulva were anastomosed to the vagina. All vestibular specimens exhibited high density of CD117 and PGP 9.5 positive staining cells consistent with NPV. Most importantly, 71% of women who had persistent entrance dyspareunia after partial posterior vestibulectomy had pain-free penetration post complete vestibulectomy. Conclusions Women with persistent entrance dyspareunia from NPV have a field disease involving excess density of mast cells and nerves in the entire vestibule, therefore performing a partial posterior vestibulectomy in women with suspected NPV is not a logical surgical strategy. Salvaging such patients with complete vestibulectomy is safe and effective. Disclosure No