[Burning Vulva: Significance of Surgery in Inflammatory and Precancerous Vulvar Pathologies]. / Vulväres Brennen: Stellenwert der Chirurgie bei entzündlichen und präkanzerösen Vulvapathologien.

Vuval pathologies manifested by allodynia and burning sensations can be due to infection, inflammatory dermatoses or other causes. Infective as well as certain inflammatory diseases, e.g. drug eruptions, allergic eczemas, irritative dermatitis/vulvitis, Behcet's Syndrome and pemphigus/pemphigoid usually respond well to conservative treatment. The category of inflammatory diseases also contains pathologies that in certain circumstances do require a surgical intervention, e.g. Lichen ruber planus/Lichen sclerosus, Condyloma, scars, premalignant lesions (VIN, genital M. Paget) and cancer. Vulodynia also can cause some stinging to the vulvar skin. The surgical aspects relating to the treatment of the benign and premalignant pathologies indicated above are mentioned in this mini-review.

Treatment of clitoral hypertrophy containing an os clitoris and urethra in a young greyhound dog: a detailed surgical description.

This report provides a detailed description and images of a clitorectomy with a urethral transposition. As described, the clitorectomy is a straight-forward procedure, creating more normal female-like anatomy, and it resolves the clinical signs resulting from the exposed clitoris.

Traitement d'une hypertrophie du clitoris contenant un orifice de clitoris et l'urètre chez un jeune chienne Greyhound: description chirurgicale détaillée. Ce rapport fournit une description détaillée et des images d'une clitorectomie avec une transposition urétérale. Tel que décrite, la clitorectomie est une intervention simple, qui crée une anatomie femelle plus normale et règle les signes cliniques découlant d'un clitoris exposé.(Traduit par Isabelle Vallières).

Human papillomavirus in vulvar vestibulitis syndrome.

OBJECTIVE: To investigate the prevalence of human papillomavirus (HPV) in patients with vulvar vestibulitis syndrome by using a recently developed polymerase chain reaction (PCR) primer set that detects known papillomavirus types. STUDY DESIGN: We retrospectively identified 38 patients with vulvar vestibulitis who underwent therapeutic surgical excision of the vestibule. Eleven controls without vestibulitis who underwent vestibular excision for conditions unrelated to HPV infection were identified prospectively. Surgical specimens were examined for the presence of HPV DNA by PCR amplification. DNA sequencing was used to determine HPV type. RESULTS: The prevalence of HPV among patients with vestibulitis was 21% vs. 36% among controls. Group B HPV types accounted for 4 of the 10 (40%) HPV types found in patients with vestibulitis. Overall, in both patient and control samples, a spectrum of HPV types was identified, encompassing many branches of the HPV phylogenetic tree. No etiologic association was apparent. CONCLUSION: This study did not support an association of HPV with vulvar vestibulitis. The low rate of observed infection in women with and without vestibulitis and the diversity of HPV types identified suggest incidental virus carriage rather than direct cause and effect. The underlying cause of this debilitating condition remains unknown.

Surgical treatment of vulvar vestibulitis syndrome: outcome assessment derived from a postoperative questionnaire.

INTRODUCTION: Vulvar vestibulitis syndrome (VVS) is the most common pathology in women with sexual pain. Surgery for VVS was first described in 1981. Despite apparently high surgical success rates, most review articles suggest that surgery should be used only "as a last resort." Risks of complications such as bleeding, scarring, and recurrence of symptoms are often used to justify these cautionary statements. However, there are little data in the peer-reviewed literature to justify this cautionary statement. AIMS: To determine patient satisfaction with vulvar vestibulectomy for VVS and the rate of complications with this procedure. METHODS: Women who underwent a complete vulvar vestibulectomy with vaginal advancement by one of three different surgeons were contacted via telephone by an independent researcher between 12 and 72 months after surgery. MAIN OUTCOME MEASURES: The primary outcome measurement of surgical success was overall patient satisfaction with surgery. Additional secondary outcome measurements included improvement in dyspareunia, changes in coital frequency, and occurrence of surgical complications. RESULTS: In total, 134 women underwent surgery in a 5-year period. An independent research assistant was able to contact 106 women, and 104 agreed to participate in the study. Mean duration since surgery was 26 months. A total of 97 women (93%) were satisfied, or very satisfied, with the outcome of their surgery. Only three patients (3%) reported persistently worse symptoms after surgery and only seven (7%) reported permanent recurrence of any symptoms after surgery. Prior to surgery, 72% of the women were completely apareunic; however, after surgery, only 11% were unable to have intercourse. DISCUSSION: In this cohort of patients, there was a high degree of satisfaction with surgery for VVS. In addition, the risks of complications with this procedure were low, and most complications were transient and the risk of recurrence after surgery was also found to be low.

Surgical treatment for the vulvar vestibulitis syndrome.

OBJECTIVE: To study the outcome and complications of surgical treatment for vulvar vestibulitis syndrome and to identify patient characteristics that may have influenced the outcome. METHODS: Relevant patient characteristics were extracted retrospectively from the medical records of 155 women aged 40 years or younger who had received surgical treatment for vulvar vestibulitis syndrome. To assess outcome and complications, 126 of these 155 women (81%) participated in a telephone interview, conducted 1 to 4 years after surgery. RESULTS: After surgery 93% of the patients could have sexual intercourse compared with 78% before surgery; this increase was statistically significant (Mantel-Haenszel odds ratio 3.43, 95% confidence interval [CI] 1.48-7.96). In 62% of the women (95% CI 53-70%), sexual intercourse was painless after surgery. Eighty-nine percent (95% CI 84-95%) would recommend surgical treatment to other women experiencing vulvar vestibulitis syndrome. There were no major complications. Decreased lubrication during sexual arousal was the most frequently reported adverse effect (24%, 95% CI 16-32%), followed by the development of a Bartholin's cyst (6%, 95% CI 2-10%). More of the women aged 30 years or younger reported that they could have sexual intercourse after surgery, and more of them would recommend surgical treatment to other patients than women aged 31 years or older. CONCLUSION: Surgical treatment for vulvar vestibulitis syndrome achieved high success rates with an acceptable rate of complications. Age of 30 years or younger was associated with a better outcome. LEVEL OF EVIDENCE: III.

Modified vulvar vestibulectomy: simple and effective surgery for the treatment of vulvar vestibulitis.

OBJECTIVE: To evaluate the success of a simple modified vestibulectomy in treating vulvar vestibulitis. STUDY DESIGN: Fifty-nine patients with vulvar vestibulitis refractory to nonsurgical treatment underwent modified vestibulectomy. Response was defined as return to normal coitus and was graded as complete, partial or non-responsive. RESULTS: The postoperative follow-up period was 6 months-10 years. Thirty-nine (73.6%) patients reported complete response, 7 (13.2%) had partial response, and 7 (13.2%) were non-responsive to surgery. CONCLUSION: Surgery is an effective treatment for vulvar vestibulitis refractory to conservative treatment. Simple modified vestibulectomy is considerably less invasive, technically simpler and probably less time consuming. Postoperative results employing this surgical procedure are found to be in line with postoperative results reported by others who employ surgical methods that are more extensive.

Increased innervation of the vulval vestibule in patients with vulvodynia.

BACKGROUND: Vulval vestibulitis is a condition characterized by the sudden onset of a painful burning sensation, hyperalgesia, mechanical allodynia, and occasionally pruritus, localized to the region of the vulval vestibulus. It is considered the commonest subset of vulvodynia. Pain precipitated in the absence of nociceptor stimuli might be triggered by previous peripheral nerve injury, or by the release of neuronal mediators, which set off inappropriate impulses in nonmyelinated pain fibres sensitizing the dorsal horn neurones. The pathophysiology of vulval vestibulitis is still unclear. OBJECTIVES: The objective of this study was to evaluate the nerve fibre density and pattern, in specimens of vulval vestibulus, in normal subjects and in patients with vestibulitis, and provide objective diagnostic criteria for this condition. Methods Twelve patients with a history of the vestibulitis type of vulvodynia, and eight normal subjects underwent biopsy of the posterior wall of the vulval vestibule. Quantitative immunohistochemistry was performed, using antisera to the general neuronal marker protein gene product (PGP) 9.5, and to the neuropeptide calcitonin gene-related peptide (CGRP), on 15- microm sections. RESULTS: There was a statistically significant increase of density and number of PGP 9.5 immunoreactive in the papillary dermis of patients with vulvodynia of the vestibulitis type, compared with those of controls. However, the distribution pattern of the innervation showed no significant change. There were no significant differences in CGRP staining between patients and controls. CONCLUSIONS: It is concluded that the increase of PGP 9.5 immunoreactive nerve fibres, in patients with vulvodynia, may be either secondary to nerve sprouting, or may represent neural hyperplasia. Increased innervation may be applied as an objective diagnostic finding in vulval vestibulitis syndrome.

Outcome of surgical treatment for superficial dyspareunia from vulvar vestibulitis.

OBJECTIVE: To evaluate the results of surgical treatment for superficial dyspareunia, as manifested by patient satisfaction, as well as epidemiologic characteristics of women with this medical problem. STUDY DESIGN: A questionnaire was sent to 69 women six months after the operation. It included questions about treatment before surgery and the impact of pain on the sexual relationship before and after the operation. Demographic, social and general health data were recorded before the operation. All patients returning the questionnaire were examined. RESULTS: Fifty-four (78%) patients replied. Half of those abstained from sexual relations before surgical treatment. Sixty-seven percent of patients required more than six visits to various physicians, before vestibulitis was diagnosed. Prior to surgery, 80% of patients received conservative treatment, whereas after surgery only 34% required it. A moderate to excellent improvement was reported after surgery by 45 (83%) patients. Repeat surgery (n = 7) resulted in further improvement in four patients. There were no major operative complications. Forty-five patients (83%) were satisfied with the results and would recommend the surgery to other women with this clinical problem. CONCLUSION: Surgical treatment for superficial dyspareunia from vestibulitis is quite safe and results in a high rate of patient satisfaction.

Evaluation of the surgical treatment of vulvar vestibulitis.

OBJECTIVE: To assess the efficacy of perineoplasty in the management of vulvar vestibulitis. STUDY DESIGN: Forty-two women who had undergone operative perineoplasty for the treatment of vulvar vestibulitis completed a questionnaire, a mean of 4.8 years postoperatively. RESULTS: Vulvodynia was constant or daily in 29 (69%) before surgery and in eight (19%) of respondents after surgery. In all, 27 (80%) of 34 women who had preoperative vulvar discomfort reported that the discomfort was much better or absent following surgery. Before surgery, 26 (70%) of 37 women who were not celibate for reasons other than vulvar vestibulitis, were celibate because of vulvar vestibulitis or always had pain during coitus and sometimes had to discontinue coitus because of pain. In contrast, only two (5.7%) of 35 women had this degree of dyspareunia following surgery. Similarly, 28 (85%) of 33 sexually active women who had dyspareunia before surgery reported that intercourse was much less painful or pain-free following surgery. CONCLUSION: Perineoplasty has a role in the management of vulvar vestibulitis for women who do not achieve satisfactory relief of vulvodynia and/or dyspareunia with nonoperative treatments.

Vulvar vestibulitis treated by modified vestibulectomy.

OBJECTIVE: A prospective study to evaluate the success of a modified vestibulectomy in treating vulvar vestibulitis. METHODS: Fifty seven consecutive women with vulvar vestibulitis and suitable for surgery based on the criteria: superficial dyspareunia, erythematous vestibular region, positive Q-tip test, symptoms reduced with local anesthetic cream. A modified vestibulectomy with or without a modified Fentons procedure was performed. Response was based on return to normal coitus, 3 months after surgery. RESULTS: Most women suffered from chronic conditions (median duration of symptoms = 18 months). The median age was 28 years (range 18-53). Any infections were treated prior to surgery. All but 4 (7%) had histological abnormalities, mainly non-specific inflammation. In 18% of women who had cervical cytology some abnormality was detected. Mean follow-up time was 12 months (range 2-42). Three women were not evaluable. Complete response to surgery was achieved in 33 (61.1%) of the women, partial response was achieved in 15 (27.8%). Six (11.1%) had persistent symptoms, four of whom has psychosexual problems. CONCLUSION: Presently, surgery remains the most successful intervention for vulvar vestibulitis. Modified surgery which is less destructive seems to afford acceptable results. The completion of randomized studies are needed to recognise the optimum surgical procedure.

Vulvar vestibulitis: physical or psychosexual problem?

OBJECTIVE: To examine whether vestibulitis has a physical or a psychosexual etiology. DATA SOURCES: MEDLINE was searched to retrieve publications dating from January 1981 through June 1998 that evaluated the outcomes of surgical treatment and the psychosexual theory of the origin of vestibulitis. INTEGRATION: Articles were analyzed for methods of subject selection and surgery, surgical outcome, and length of follow-up. RESULTS: A significant decrease in symptoms (complete responses + partial responses) was reported by 89% of 646 women who had perineoplasty for vulvar vestibulitis. Complete resolution of dyspareunia with surgical treatment was reported in 72% of 512 women whose cases were reviewed in studies in which complete responses and partial responses were evaluated separately. Women with vestibulitis did not differ from the normal population with respect to marital satisfaction, psychologic distress, or psychopathology. A suggestion that childhood sexual abuse caused vestibulitis has not been confirmed. The findings of somatization and shyness might be explained as results rather than causes of vulvar vestibulitis. CONCLUSION: We do not agree that vestibulitis is a psychosexual problem and one that should not be treated surgically. A high rate of success can be achieved with proper surgical treatment.

Severe vulvar vestibulitis. Relation to HPV infection.

OBJECTIVE: To determine whether patients with human papillomavirus (HPV)-associated vestibulitis present differently from patients with HPV-negative disease and whether the presence of HPV is a predictor of the outcome of surgical treatment by perineoplasty. STUDY DESIGN: Thirty-eight women with severe vulvar vestibulitis who underwent surgical perineoplasty were found to have HPV DNA in the vestibule by polymerase chain reaction. Thirty-six other women with severe vestibulitis had no HPV DNA in the surgical specimen. The two groups were compared with regard to demographic, social and medical variables as well as physical findings in the vestibule and response to operative treatment. RESULTS: Both groups were found to be similar in respect to age (mean 25.9 +/- 7.93 versus 25.47 +/- 5.8, respectively), parity, education, smoking habits, contraceptive use, presence of primary vestibulitis, presence of dysuria and involvement of the whole vestibule (both anterior and posterior). More unmarried than married women were infected with HPV (P < .002). There was no significant correlation between the presence of HPV and the outcome of surgical treatment (P < .6, relative risk = 0.9, 95% confidence interval = 0.5-1.5). CONCLUSION: Although HPV DNA was found in more than half of women with vestibulitis, it appears to play no role in the presentation or response to surgical therapy for vulvar vestibulitis.

Predicting the outcome of surgical treatment of vulvar vestibulitis.

OBJECTIVE: To identify predictive factors for success or failure of perineoplasty for severe vulvar vestibulitis. METHODS: Seventy-nine women with severe vulvar vestibulitis underwent perineoplasty by a single surgeon during 1992-1994. Sixty (76%) who experienced a complete response were compared with 19 (24%) who had an incomplete response. Using univariate and then multivariate (logistic regression) analysis, the two groups were compared with regard to preoperative demographic, social, and medical variables, as well as physical findings in the vestibule. RESULTS: The complete- and incomplete-response groups were similar in all comparisons except for constant vulvar pain of vestibular origin (in addition to dyspareunia) and the presence of symptoms since first coitus. On multiple logistic regression, these characteristics had odds ratios (and 95% confidence intervals) of 4.97 (1.49, 16.63) and 5.83 (1.74, 19.55), respectively. CONCLUSION: An incomplete response to perineoplasty may be anticipated in women with vulvar vestibulitis associated with dyspareunia since their first episode of intercourse and in those with associated persistent vulvar pain. Treatment approaches other than surgery should be considered for such patients.

[Treatment of vulvar vestibulitis by posterior vestibulectomy. Twelve case reports]. / Traitement de la vestibulite vulvaire par vestibulectomie postérieure. A propos de 12 cas.

Many patients with dyspareunia suffer from vulvar vestibulitis syndrome. When all conservative treatments have failed, surgery is attempted. We appreciated results and complications of this treatment. During 1993 and 1994, at the gynecological department of the intercommunal hospital of Creteil (France), twelve women suffering from this condition for longer than six months had undergone a posterior crescent-shaped vestibular excision followed by vaginal advancement. Three weeks after surgery, three partial dehiscences have been observed, which secondary healed. The average duration of follow-up was 8 months. The interview of the patients in January 1995 revealed: six patients obtained painless sexual intercourse, four patients improved significantly, one had no improvement and one complained of severe vulvar burning instead of dyspareunia. Our results are weighing against the initial enthusiasm to surgical treatment. Collaboration between gynecologists and psychologists to specify the indications and previous treatment of an associated vaginismus should be helpful for the treatment of these patients.

The surgical treatment of vulvar vestibulitis syndrome: a follow-up study.

This study evaluated the effectiveness of vestibulectomy in relieving coital pain and improving sexual function in women diagnosed with vulvar vestibulitis. Vulvar vestibulitis syndrome, a chronic, nonspecific inflammation of the vulvar vestibule, probably represents the most frequent subtype of premenopausal dyspareunia. Participants were 38 women who underwent vestibulectomy at a university hospital between 1986 and 1994. Telephone interviews were conducted to assess whether vestibulectomy or other subsequent treatments affected coital pain and sexual functioning. Length of postoperative follow-up ranged from 1.1 to 10 years, with a mean of 3.3 years. Vestibulectomy yielded a positive outcome for 63.2% of the participants and moderate to no improvement for the other 36.8%. The surgery was linked to a significant increase in intercourse frequency for the entire sample and to an increase in oral and manual stimulation for the women with successful surgical outcomes. No other factors were significantly associated with treatment outcome.