Skip to main content

Vestibulectomy for Localized Provoked Vestibulodynia

Vestibulectomy is excision of the painful vestibular mucosa, with advancement of adjacent vaginal mucosa to resurface the defect, performed for localized provoked vestibulodynia (PVD) that remains refractory after conservative and medical management. It is reserved for carefully selected patients because it is an irreversible procedure directed at a chronic pain condition rather than a structural lesion.[1][2] For diagnosis, including the cotton-swab clock-face test that localizes vestibular pain, and for first-line and medical management of vestibulodynia, see Chronic Pelvic Pain.

Terminology and Patient Selection​

The 2015 ISSVD/ISSWSH/IPPS consensus classifies vulvodynia by location (localized, generalized or mixed), by whether pain is provoked, spontaneous or mixed, and by onset and temporal pattern. Localized provoked vestibulodynia (previously called vulvar vestibulitis syndrome) denotes provoked pain confined to the vestibule, and is the phenotype vestibulectomy addresses; it is not the appropriate terminology or target for generalized or spontaneous (unprovoked) vulvar pain.[2]

Surgery follows a biopsychosocial first-line pathway (patient education, pelvic-floor physical therapy, topical and oral neuromodulatory agents, and psychosexual support) and is considered only when PVD remains refractory to that management.[1][2] On cotton-swab clock-face mapping, pain concentrated anteriorly (near the 12 o'clock position below the clitoris and above the urethral meatus) is a frequent finding in the neuroproliferative, hormonally mediated PVD phenotype that surgery targets; pain limited to the posterior vestibule without anterior involvement points more toward pelvic-floor hypertonicity as the primary driver and favors physical therapy over surgery.[2]

Surgical Technique​

The sequence below follows a chapter-described technique attributed to contributing author Irwin Goldstein, used by his group; it is one described approach rather than a universal operative standard, and other vestibulectomy and perineoplasty techniques exist in the literature.[1]

  1. Excision. The vestibular mucosa is completely excised from the periurethral/Skene-gland region anteriorly, laterally, and posteriorly to the hymen.
  2. Posterior vaginal advancement. The posterior vaginal wall is mobilized and advanced to resurface the resulting defect.
  3. Fixation of the advancement flap. Interrupted 3-0 absorbable braided (Vicryl) horizontal mattress sutures secure the advancement flap in an anterior-to-posterior direction.
  4. Perineal approximation. The remaining mucosal flap is approximated to the perineum with interrupted 4-0 absorbable braided (Vicryl) suture.[1]

A related, more extensive operation, perineoplasty, is used when pain or structural scarring extends beyond the vestibule into the perineal body; the two procedures are often discussed together in the surgical literature on provoked vulvodynia and are not interchangeable terms for the same operation.[3]

Complications​

Reported complications include bleeding, infection, pain, hematoma, wound-healing problems, vaginal or introital stenosis, scarring and Bartholin-duct cyst or obstruction.[1] A 2024 systematic review of surgery for provoked vulvodynia (29 studies) reported Bartholin cysts in up to 9% of cases as the most commonly reported complication.[3]

Outcomes​

That same 2024 systematic review found that surgery, most often vestibulectomy or perineoplasty, is typically offered only after conservative treatment has failed. Across the 15 studies that defined success as a significant reduction in dyspareunia, reported success rates ranged from 52% to 97%, depending on the outcome measure used; six studies using validated pain scales found a significant reduction in vulvar pain after surgery (p < .001); two studies reported improved sexual function in 57% to 87% of patients; and three studies found that 89% to 97% of women regained the ability to have intercourse. Patient satisfaction ranged from 79% to 93%. The review's authors concluded that surgery appears to be an effective and reasonably safe option for refractory provoked vulvodynia, while noting that randomized trials with standardized outcome measures are still needed to compare approaches and minimize operative risk.[3]

See Also​

References​

1. Uloko M, Goldstein I. Female Sexual Dysfunction. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 1: Clinical Perspectives. 5th ed. CRC Press; 2023:713-729.

2. Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. J Sex Med. 2016;13(4):607-612. doi:10.1016/j.jsxm.2016.02.167

3. Saçıntı KG, Razeghian H, Bornstein J. Surgical Treatment for Provoked Vulvodynia: A Systematic Review. J Low Genit Tract Dis. 2024;28(4):379-390. doi:10.1097/LGT.0000000000000834