Vestibulectomy for Vulvar Vestibulitis

Abstract

This randomized, prospective study was performed to compare 2 techniques used to reduce the size of an enlarged uterus before vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH). Thirty patients scheduled to undergo vaginal hysterectomy or LAVH were randomized to have uterine reduction performed using either bisection/morcellation (group I, n ϭ 14) or myometrial coring (group II, n ϭ 16). The 2 groups were comparable in clinical and demographic characteristics, including preoperative uterine size, operating times, surgical outcomes, and use of laparoscopic assistance. There were no conversions to laparotomy and no major perioperative complications. The uterus was successfully removed in all cases. The uterus weighed more than 280 g in 81% of the patients in group I (bisection/morcellation) and in 73% of the patients in group II (myometrial coring). There were no significant differences between the 2 groups in operative details except for the rate of extraction failure. In 4 patients (25%) in group II, myometrial coring failed to reduce the size of the uterus, necessitating the use of the bisection/morcellation technique to complete the operation. All reduction attempts were successful in group I (P ϭ 0.06 for difference). Blood loss and transfusion rate were similar in both groups (3 transfusions required in group I and 2 in group II). Postoperative data were similar in both groups with the exception of a greater number of patients with postoperative fever (28%) among those who had myometrial coring compared with bisection/morcellation (P ϭ 0.03). Most uterine characteristics were similar in women in whom uterine reduction with myometrial coring was or was not successful. However, myometrial coring failure occurred more often when the uterus was narrow (68.3 Ϯ 2.3 mm) compared with wide (83.9 Ϯ 9.6 mm; P ϭ 0.01) and less often in uteri heavier than 280 g. EDITORIAL COMMENT(There are many advantages to vaginal hysterectomy, and the skilled gynecologic surgeon will find the vaginal approach in the patient with an enlarged uterus both challenging and, hopefully, satisfying. However, there are several ad-vanced surgical techniques that are required to facilitate the removal of an enlarged uterus. In this article, Nazah and his colleagues from Paris compared bisection and morcellation with myometrial coring in a prospective, randomized, GYNECOLOGY Volume 59, Number 2 OBSTETRICAL AND GYNECOLOGICAL SURVEY ABSTRACT At the Mayo Clinic, vulvar vestibulitis is treated with vestibulectomy consisting of simple excision of the vulvar vestibule as described by Bornstein and Kaufman. The authors conducted a review of the medical records of their patients who underwent vestibulectomy between 1986 and 2002, and identified 45 who met the definition of vestibulitis described by Friedrich: 1) focal, reproducible points in the vestibule exquisitely tender to light touch; 2) coincident focal area of erythema; and 3) a history of superficial dyspareunia or severe pain on attempted vaginal entry. In addition, a ...

Hypersensitivity and hyperinnervation of the rat hind paw following carrageenan-induced inflammation

“…It remains unclear as to the extent to which hyperinnervation may contribute to sustaining chronic pain after acute inflammation subsides. However, in cases of provoked vulvodynia (vulvar vestibulitis) characterized by proliferation of vestibular sensory axons [5, 6, 34], excision of the tissue containing the abundant fibers provides pain relief in up to 80% of the cases [7, 13]. While this procedure does more than simply eliminate numbers of peripheral axons, it is consistent with the idea that hyperinnervation is a contributing factor in some chronically painful conditions.…”

Vulvodynia Interventions—Systematic Review and Evidence Grading

“…18,[26][27][28]52,53,[62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78] There was insufficient evidence to describe the size of the effect with certainty, due to risk of bias inherent in pain intervention studies without placebo controls. Case series of 1138 patients and randomized trials of 118 patients reported an effect of 31% to 100%, with a median of 79% for patients who reported at least some improvement to complete relief.…”

Transcutaneous electrical nerve stimulation to treat vestibulodynia: a randomised controlled trial

“…23,24 Surgery success rates vary from 40 to 100%. 25,26 Although comparison between these studies is limited by differences in the number of patients, the presence of associated symptoms, definition of success and duration of follow up, our results on TENS treatment appear as effective, in particular when compared with surgery, with the advantage of being conservative. Specifically for studies that addressed the efficacy of surgery, medical treatments at the time of surgery and the lack of a standardised technique are additional variables.…”