Vulvar pain syndromes: Causes and treatment of vestibulodynia

Dr. Haefner: The response to treatment in many pain patients depends on the amount of time that the pain has been present. Someone who has had pain for 30 years will probably not be cured 3 months after starting treatment. However, someone with a short duration of pain often gets good improvement. One hundred percent improvement is rare, however. Many patients are able to approach the 80% improvement mark.

Dr. Edwards: I would say that these conditions are manageable more than curable, although pure vestibulodynia—which is uncommon—is curable with surgery.

Vestibulectomy technique
(A) Incision. In many cases, the incision needs to extend up to the opening of the Skene’s ducts on the vestibule before it is carried down laterally along Hart’s line to the perianal skin, with the mucosa undermined above the hymeneal ring. (B) Excision. Remove the tissue superior to the hymeneal ring. (C) Advancement of vaginal mucosa. Further undermine the mucosa and advance it to close the defect. (D) Suturing. Close the defect in two layers using absorbable suture.

Is vestibulectomy definitive treatment?

Dr. Lonky: Does vestibulectomy work as a definitive treatment for PVD?

Dr. Gunter: Vestibulectomy—that is, resection of the vestibule and advancement of vaginal mucosa—is well described for women who have localized vestibulodynia. The complication rate is low, with only 3% of women reporting worsening of symptoms after the procedure.^19,20 Success rates range from 17% to 89%, although many studies are retrospective reviews or include nonhomogenous populations, or both.^19–21 A prospective study (Level II) indicates a 52% reduction in pain scores for women 6 months after vestibulectomy—and the scores continued to improve at evaluation at 2.5 years.^22,23

Prospective studies indicate that vestibulectomy improves pain scores more than cognitive behavioral therapy, biofeedback, oral despiramine, and topical lidocaine.^22,23 However, even surgery carries a robust placebo response rate, and vulvar biopsy alone has been associated with an improvement in pain scores in 67% of women.^24,25

I offer surgery for vestibulodynia after the patient has failed at least two therapies (two topical treatments or one topical and one oral treatment). I offer injections before proceeding, and almost all patients opt to try them. I do not offer vestibulectomy to patients who have unprovoked pain or pain outside of resection margins.

Dr. Haefner: Surgical excision of the vulvar vestibule has met with success, in some studies, in more than 80% of cases, but it should be reserved for women who have longstanding and localized vestibular pain in whom other management options have failed.

The patient should undergo cotton-swab testing to outline areas of pain before anesthesia is administered in the operating room. Often, the incision will need to extend up to the opening of the Skene’s ducts on the vestibule (FIGURE). The incision is carried down laterally along Hart’s line to the perianal skin, and the mucosa is undermined above the hymeneal ring. The specimen is excised superior to the hymeneal ring. The vaginal tissue is further undermined and brought down to close the defect in two layers using absorbable suture. A review of this technique with illustrations has been published.²⁶

Dr. Lonky: Thank you all again for sharing your considerable expertise, experience, and insight.