Surgeon's Corner
Surgical management of neuroproliferative-associated vestibulodynia: a tutorial on vestibulectomy with vaginal advancement flap

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Provoked vestibulodynia is an often underdiagnosed and mismanaged medical condition that impacts the lives of many women. When symptoms are due to a dramatically increased density of pain fibers in the vestibular endoderm, the condition is referred to as neuroproliferative-associated vestibulodynia. Unfortunately, assessment of pain fiber density can only be performed after surgery during histologic examination. First-line therapies for this condition often include topical or oral medications targeting hyperalgesia and allodynia at the vulvar vestibule. However, in the setting of refractory disease, surgical treatment should be considered. The surgical video (Video 1) highlights anatomical landmarks as well as key surgical steps when performing a vulvar vestibulectomy with a vaginal advancement flap for the treatment of neuroproliferative-associated vestibulodynia. Surgeons should have a thorough understanding of pertinent vulvar anatomical landmarks before performing this procedure (Figure 1). The goal of vulvar vestibulectomy, as described in this video, is to excise the entirety of the vestibule containing the pathologic density of afferent pain fibers. This tutorial serves to identify key anatomical landmarks including Hart’s line as well as outline the meticulous dissection required for successful completion of this procedure. We describe our surgical instrumentation as well as provide insight into steps that can be taken to minimize postoperative morbidity.

Section snippets

Problem

Sexual dysfunction is a far-reaching problem impacting the lives of countless women and is often overlooked, misdiagnosed, and under-reported.1 Sexual pain is a nebulous term that can create unease for practicing clinicians lacking proper training to appropriately manage this clinical conundrum. In 2015 at a conference sponsored by 3 societies centered on female sexual health, new nomenclature was proposed referred to as the “2015 classification.”2 The proposed classification centered on 2

Our Solution

In this surgical video tutorial (Video 1), we highlight a surgical technique when performing a vestibulectomy with a vaginal advancement flap for refractory NAV. The video highlights key anatomical landmarks (Figure 1)6 that surgeons should understand before performing this procedure. We provide detailed instructions for identifying Hart’s line (Figure 2) as well as outline the course of dissection to safely perform this procedure (Figure 3). Our dissection technique stresses meticulous

References (6)

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Cited by (6)

  • Inflammation, lipids, and pain in vulvar disease

    2023, Pharmacology and Therapeutics
  • Vaginal Microbiome Is Associated With Vulvodynia, Vulvar Pain Syndrome: A Case-Control Study

    2021, Sexual Medicine
    Citation Excerpt :

    Some studies have proposed that vulvodynia is caused by genital infections, recurrent vulvovaginal candidiasis, herpes simplex virus, human papilloma virus (HPV), contact dermatitis, irritants, or vulvar trauma, but findings have been inconsistent.6 However, given that the presentations and responses to treatments are relatively diverse, some patients are responsive to medical treatments; however, some patients are refractory to the medical treatments and surgical treatment options including vestibulectomy should be considered;7 therefore, the optimal vulvodynia care requires a multimodal therapeutic approach8 and the cause of vulvodynia is most likely multifactorial including microbiota. Burton et al first reported the association between the vaginal ecosystem and infection in 2003.9

  • Vulvar vestibulectomy

    2020, Female Sexual Pain Disorders: Evaluation and Management

A.G. has received research funding from Ipsen, Endoceutics, SST, The Cellular Medicine Association, The Gynecologic Cancers Research Foundation, and Elen and is a consultant to Ipsen, SST, Amag, and Lupin. The other authors have nothing to disclose.

Cite this article as: Wu C, Goldstein A, Klebanoff JS, et al. Surgical management of neuroproliferative-associated vestibulodynia: a tutorial on vestibulectomy with vaginal advancement flap. Am J Obstet Gynecol 2019;221:525.e1-2.

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