Vulvar vestibulectomy is a surgical treatment for neuroproliferative vestibulodynia where the vestibule tissue is removed. Women who haven’t responded to conservative treatments, e.g. topical nerve blockers, capsaicin, are a candidate for surgery. (1) However, given the high success rate, it has been suggested that vestibulectomy should be viewed as a first line of treatment rather than a “last resort.” (2)

What is a vestibulectomy?

The surgical procedure was first described in the early 1980s; since then improvements have been made. The procedure today involves the formation of a vaginal advancement flap, hence the name ‘vestibulectomy with vaginal advancement.’ If you want to read the details of the surgical procedure, you can find them in reference 2 (link). There is also a YouTube video (not for the faint of heart!). My personal favorite diagrams can be found here.

Note that some surgeons will also offer a partial vestibulectomy, where only the lower portion of the vestibule tissue is removed. Today, this is somewhat controversial among surgeons with some refusing to offer it.

Generally, the process involves removing the surface layer ( ~3 mm deep) of the vestibule tissue. The vestibule is delineated by Hart’s line on the outer edges (left to right). It is removed from just below the urethra at the top (12 o’clock) and the posterior fourchette at the bottom (6 o’clock). The vaginal advancement flap refers to a portion of vaginal tissue pulled forward and attached to cover the posterior vestibule (6 o’clock).

Recovery from vestibulectomy

Vestibulectomy is an outpatient procedure and you will go home the same day, after successfully urinating. In the first few days, ice helps to reduce swelling and pain. Frequent sitz baths in the first few weeks help reduce pain and prevent infection. A sitz bath involves soaking only the genitals, often in a small basin that can be placed on the toilet. Pain relievers are also used to manage pain.

Movement is very limited the first week, typically bed rest. Movement is still limited for the next 3 to 5 weeks after surgery, with gradual increase as healing progresses. After full healing, roughly 8-12 weeks, physical therapy and dilator therapy can begin again.

Potential complications of vestibulectomy

As with any surgery, potential complications include bleeding, infections, increased pain, hematoma, wound separation, and scar tissue formation. (1) Fortunately, these complications are infrequent. (2)

The most common complication, and specific to vestibulectomy, is Bartholin’s cyst formation. The Bartholin’s glands are located at 5 and 7 o’clock, on either side of the vaginal opening. They produce natural lubricant during arousal. The ducts of these glands typically open into the vestibule tissue, therefore, when the vestibule tissue is removed, the ducts may be closed over. If the duct is blocked (occluded), the fluid will not be able to escape, and the gland can become enlarged and painful. If its close the surface, it may appear as a blister. Bartholin’s cysts also occur spontaneously in women and are considered common. (3)

Treatment is typically managed at home, as most resolve on their own. Sitz baths may help the cyst to resolve. Sometimes, surgical drainage is required. If the cysts continue to appear, other surgical interventions may be necessary.

It’s difficult to say what the likelihood of post-surgical bartholin’s cysts is. I think that the rate mostly depends on the individual surgeon, their technique, and level of experience, so you should ask your surgeon what the rate of complications is in their patients specifically. I found a study that looked at the medical charts from 155 women who had a vestibulectomy between 1989 and 2007; they reported that 9% of women had blisters, about half of which were painful and half had some treatment. (4) Very recently, work was presented at the 2019 ISSWSH/ISSM annual meeting reporting a rate of 20% in one practice’s patients from 2013 - 2017. (5)

Is vestibulectomy successful?

Surgery may seem like an extreme measure to some, however, given the high success rates (especially compared to most vulvodynia treatments), it is a valuable option for women with neuroproliferative vestibulodynia. In 2010, a meta-analysis of 33 published papers showed that 78.5% of women had significant relief, and 88.8% had at least some relief. (6) Additional studies have shown similar encouraging results: 80% pain free at one year (7), 89% of women reporting comfortable intercourse (5), and 100% of women saying they would not change their choice to have the surgery (5).

I chose to have a vestibulectomy after eight months of “conservative” treatment. You can read more about my journey on the About Me page, and more details about my experience with the surgery on the Blog. I’ve written a three part series about my surgery and recovery, as well as a post about the insurance coverage for my surgery.

References

1. Irwin Goldstein, Anita H. Clayton, Andrew T. Goldstein, Noel N. Kim, and Sheryl A. Kingsberg. 2018. Textbook of Female Sexual Function and Dysfunction, Diagnosis and Treatment. John Wiley & Sons Ltd., Hoboken, NJ. https://onlinelibrary.wiley.com/doi/book/10.1002/9781119266136

2. King M, Rubin R, and AT Goldstein. 2014. Current Uses of Surgery in the Treatment of Genital Pain. Current Sexual Health Reports 6(4) 252-8. https://link.springer.com/article/10.1007/s11930-014-0032-8

3. Mayo Clinic: Bartholin’s cyst https://www.mayoclinic.org/diseases-conditions/bartholin-cyst/symptoms-causes/syc-20369976

4. Goetsch MF. 2009. Incidence of Bartholin’s duct occlusion after superficial localized vestibulectomy. American Journal of Obstetrics and Gynecology 200(6) 688. https://www.ncbi.nlm.nih.gov/pubmed/19376494

5. Rubin RS, Malphrus E, Mayuga C, Treene L, and JA Simon. Single-Center Experience with Vestibulectomy for the Treatment of Vulvodynia and Dyspareunia. Poster presented at the 2019 ISSWSH/ISSM Joint Meeting, March 2019, Atlanta, GA. https://www.jsm.jsexmed.org/article/S1743-6095(19)31082-3/fulltext

6. Tommola P, Unkila-Kallio L and J Paavonen. 2010. Surgical treatment of vulvar vestibulitis: a review. Acta obstetricia et gynecologica Scandinavica 89(11) 1385-95. https://www.ncbi.nlm.nih.gov/pubmed/20955094

7. Rubin R, Winter A, Plascencia P, and I Goldstein. 2017. V9-02 Complete Vestibulectomy for Neuroproliferative Vestibulodynia (NPVD): Urologic Surgical Technique and Outcomes. The Journal of Urology 197(4) Supplement: e1056. https://www.jurology.com/article/S0022-5347(17)33904-6/abstract