Vestibulectomy for provoked vulvodynia: not just a last resort

Abstract

This video highlights anatomical landmarks when performing a vestibulectomy and outlines tools and techniques for optimal tissue resection and clinical success. Provoked vulvodynia is a chronic vulvar pain condition lasting 3 months or more without any other identifiable cause affecting approximately 16% of women in the general population. It is characterized by burning, stinging, irritation, sharp stabbing pain, or pressure that occurs as a result of physical contact. Treatment of this condition is challenging, and surgical excision is often reserved for refractory cases. The vestibule is embryologically unique and arises from the endoderm of the cloacal membrane that breaks down as the urogenital sinus opens between the genital folds forming the vestibule. This tissue is also unique histologically being densely populated with site-specific fibroblasts that have an enhanced pro-inflammatory response, likely contributing to pain thresholds. Hart’s line represents the change of external vulvar skin and demarcates the vestibular edge from the labia minora. The boundaries of resection should include Hart’s line laterally, the hymenal ring medially, and include the fossa navicularis extending to the posterior forchette. The epithelium overlying the greater and lesser vestibular glands, also known as the Bartholin’s and Skene’s glands, should be included. Dissection of the vaginal epithelium should include Colle’s fascia, approximately 3mm in depth. Needlepoint cautery is helpful for precise excision and hemostasis. Pleating stitches are used for reapproximation of the underlying tissue, hemostasis, and to reduce tension on the epithelial closure. Intraoperative pudendal blocks can be performed for pain control. Vestibulectomy for provoked vulvodynia is an effective treatment and should be considered earlier in the treatment algorithm. This video demonstrates preferred techniques for a successful procedure.