Obstetrics & Gynecology Email Alerts
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Obstetrics & Gynecology 2006;107:256-262
© 2006 by The American College of Obstetricians and Gynecologists
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Traas, M. A. F.
Right arrow Articles by Vierhout, M. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Traas, M. A. F.
Right arrow Articles by Vierhout, M. E.
Related Collections
Right arrow General gynecology
Right arrow General surgery
Right arrow Gynecologic surgery
Right arrow Psychology/psychiatry
Right arrow Sexuality

ORIGINAL RESEARCH

Surgical Treatment for the Vulvar Vestibulitis Syndrome

Maaike A. F. Traas, MD1, Ruud L. M. Bekkers, MD, PhD2, Julien M. J. Dony, MD, PhD2, Marlies Blom, MD3, Anneke W. P. van Haren, MD4, Jan C. M. Hendriks, PhD5 and Mark E. Vierhout, MD, PhD2

From the 1Department of Obstetrics and Gynecology, Rijnstate Hospital, Arnhem, the Netherlands; 2Department of Obstetrics and Gynecology, Radboud University Medical Centre Nijmegen, Nijmegen, the Netherlands; 3Department of Rheumatology, Radboud University Medical Centre Nijmegen, Nijmegen, the Netherlands; 4Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands; and 5Department of Epidemiology and Biostatistics, University Medical Centre Nijmegen, Nijmegen, the Netherlands.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
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

Vulvar vestibulitis syndrome is a major cause of superficial dyspareunia in premenopausal women. With an estimated prevalence of 15% in a general gynecologic population, it can be considered a common health problem in women.1 The syndrome was first described at the end of the 19th century, but it did not receive its current name until 100 years later.2,3 It consists of severe vestibular pain on touch or attempted vaginal entry, tenderness to pressure localized within the vulvar vestibule, and varying degrees of focal erythema.3 Complaints often persist for more than 6 months without any clear cause, such as infection. Vulvar vestibulitis syndrome mainly affects white, nulliparous women of reproductive age.4 Its cause is still unclear, although many hypotheses have been proposed and is most probably multifactorial.5 Appropriate therapy is controversial and ranges from conservative to surgical. The latter has often been regarded with scepticism, despite the good reported outcomes. Success rates of surgical treatment described in the literature ranged from 36% to 100%, with the majority of values concentrated around 60%. In contrast, conservative treatment resulted in complete relief of symptoms in 30% to 52% of patients. The aim of this study was to assess the outcome and complications of surgical treatment for vulvar vestibulitis syndrome and to identify patient characteristics that may have influenced the outcome as a preliminary attempt to improve future selection of patients for surgery. We evaluated the outcome of surgical treatment for vulvar vestibulitis syndrome in a population of 126 patients.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
From January 1998 until December 2001, 275 women with vulvar vestibulitis syndrome underwent surgical treatment at the Radboud University Medical Centre Nijmegen. In this period, surgery for vulvar vestibulitis syndrome was performed by 1 gynecologist in a uniform and well-documented manner. Patients were referred by their general practitioner or by gynecologists who did not have experience with surgical treatment for vulvar vestibulitis syndrome. A list was made of the names and dates of surgery of all consecutive patients. In 2002, the medical records were traced and this study was initiated. To select a homogeneous premenopausal population of patients, we excluded women aged older than 40 years at the time of surgery, women who had undergone previous surgical treatment for vulvar vestibulitis syndrome, and women who had undergone vestibulectomy combined with another operative procedure. Some women were excluded on the basis of more than 1 criterion and some were excluded because their medical records could not be traced.

One gynecologist (J.M.J.D.) diagnosed all the patients based on Friedrich’s criteria. These criteria were found to be reliable by Bergeron et al.21 All the patients had complaints of superficial dyspareunia, pain during the cotton-swab pressure test on the vestibular side of the hymenal base (cotton-swab test), and had no signs of other vulvar or vaginal disease. Surgery was performed by the same gynecologist (J.M.J.D.) on all the patients under general anesthesia in an outpatient or short admission setting. Although no predesigned protocol was in place, all patients underwent the same procedure, consisting of vestibulectomy and advancement plasty, as described by Nichols and Randall.22 In this procedure, shown in Figure 1, the hymen was removed completely, together with the full thickness of skin on the adjacent vestibulum, using Hart’s line and the fourchette as boundaries. When preoperative cotton-swab testing was positive in the paraurethral area, excision was extended to include this region. The defect was covered by vaginal wall after undermining and advancement. Approximation to the surrounding skin was realized with interrupted 3–0 polyglactin sutures. Follow-up was conducted by the same gynecologist (J.M.J.D.) at 6 and 12 weeks after surgery. If wound healing was sufficient after 6 weeks, the patients started vaginal dilation exercises with a mold and were encouraged to start or resume sexual intercourse. After another 6 weeks, an evaluation was made by telephone to check for unforeseen problems or complications. If there were any problems, new follow-up appointments were made.


Figure 19
View larger version (51K):
[in this window]
[in a new window]
  		Fig. 1. A. The painful area of vestibular skin is carefully demarcated preoperatively and an incision made lateral to this line of demarcation (dashed line). B. The full thickness of the skin, including the adjacent hymen, is removed, and any bleeding vessels clamped and ligated or electrocoagulated. C. The posterior vaginal wall is mobilized and pulled down (arrows) to cover the raw area. D. The full thickness of the vagina is sewn to the skin of the vulva by 2 layers of interrupted synthetic absorbable sutures. Raw areas anterior or lateral to the urethra may be left open to granulate and avoid stricture. Reprinted by permission from Nichols DH, Randall CL. Vaginal surgery. 4th ed. Baltimore (MD): Lippincott Williams & Wilkens; 1996. Copyright © 1996 Lippincott Williams & Wilkens.

Traas. Surgery for Vulvar Vestibulitis Syndrome. Obstet Gynecol 2006.

 

Medical history and relevant patient characteristics were extracted retrospectively from the medical files and noted on a chart abstraction form. Relevant patient characteristics were age, date of surgery, duration of symptoms before intake, primary or secondary dyspareunia, capacity to have sexual intercourse before surgery, pain during activities other than sexual intercourse, history of sexual abuse, child bearing, treatment for vulvar vestibulitis syndrome other than surgery, paraurethral extension of vulvar vestibulitis syndrome, and capacity to undergo vaginal examination before surgery. Information was also collected on the histopathologic diagnosis made in the excised tissue.

Eligible patients were sent a letter, including a stamped, addressed return envelope, to inform them about this follow-up study and to invite them to take part in a telephone interview. They were promised that their identity would be kept secret. In the letter the possibility to refuse participation without consequences for further treatment was offered. All women participating in the study gave informed consent, either in writing or orally, before starting the interview. The women who showed interest and those who did not respond within 1 month were approached by phone. Interviews were conducted by 2 female medical students (M.B. and A.W.P.vH.) and consisted of answering 5 short questions (box).


Figure 29
View larger version (102K):
[in this window]
[in a new window]
 
 

Based on the questions in the telephone interview, the following 4 outcome measures of surgical treatment were made: sexual intercourse possible, sexual intercourse painless, a satisfactory sexual life, and a positive recommendation of surgery. The variable, "intercourse painless," is an important outcome motivating this study. Literature showed that the probability of "intercourse painless" was 0.6. Furthermore, a difference in the probability of "intercourse painless" between 2 groups of a patient characteristic (ie, 2 age groups) of 20–25% is considered clinical relevant. A power analysis showed that a Fisher exact test with a 0.05 2-tailed significance level will have 81% power to detect the difference between a group 1 proportion of 0.475 and a group 2 proportion of 0.725 (that would refer to an odds ratio of 2.38) when the sample size in each group is 70. Data were analyzed in the software program SPSS (SPSS Inc., Chicago, IL). Multivariate logistic regression analysis was used to test differences in each of the outcome measures between groups, with specific patient characteristics adjusted for time to follow-up. The dependent variable was the outcome measure and the independent variables were the patient characteristic and the time to follow-up (months). The odds ratios adjusted for time to follow-up with 95% CIs are presented. The increase in intercourse possible after surgery compared with before surgery was tested for statistical significance using the method of Mantel-Haenszel for paired designs.23 The appropriate odds ratio with 95% confidence interval (CI) is presented.


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
A total of 155 of the 275 women were eligible to take part in this study. Women were excluded because they were older than 40 years (n = 59), had undergone previous surgical treatment for vulvar vestibulitis syndrome (n = 18), or because the surgery had been combined with another surgical procedure (n = 65). The medical record could not be traced in 6 patients. Median age of the participants was 26 years (range 18–39 years). Median duration of symptoms before intake was 36 months (range 2–264 months). We received 105 positive responses to the letter, 2 negative responses, and no reaction within 1 month from 48 patients. Ultimately, 23 women could not be reached and a further 6 refused to participate. This meant that 126 patients (81%) participated in the telephone interview. Median follow-up between surgery and the telephone interview was 37 months (range 13–57 months).

Table 1 presents the outcomes of surgical treatment derived from answers by the participants. Pain was the only reason sexual intercourse was impossible after surgery. The answers showed that 93% of the women (95% CI 89–98%) could have sexual intercourse and 62% (95% CI 53–70%) did not suffer from pain.


View this table:
[in this window]
[in a new window]
  		Table 1. Outcomes of Surgical Treatment Derived From the Responses to the Telephone Interview (N = 126)

 

Table 2 presents the complications of surgical treatment reported by the participants. In 77 of the 126 women (61%, 95% CI 52–70%) there had been no complications after surgery. The most frequently reported complication was decreased lubrication during sexual arousal (24%, 95% CI 16–32%). All the women had been informed about the risk of adverse effects preoperatively. In 8 patients (6%, 95% CI 2–10%) a Bartholin’s cyst developed. Other complications were infrequent.


View this table:
[in this window]
[in a new window]
  		Table 2. Complications of Surgical Treatment Derived From the Responses to the Telephone Interview (N = 126)

 

Patient characteristics are shown in Table 3. Before surgery 78% of the women could have sexual intercourse. Relations between patient characteristics and the outcome of surgical treatment are presented in Table 4. Differences in the number of positive outcomes between groups of patients with specific characteristics are presented as odds ratios (ORs) adjusted for time to follow-up. The ORs that reached statistical significance are indicated in the table. After surgery more women could have sexual intercourse than before (OR 3.43, 95% CI 1.48–7.96). More of the women aged 30 years or younger reported that they could have sexual intercourse after surgery (OR 8.20, 95% CI 1.54–43.73), and more of them would recommend surgical treatment to other patients (OR 4.74, 95% CI 1.42–15.82) than women aged 31 years or older. There was a negative association between the need for nonsurgical treatment other than standard vaginal dilation exercises after surgery and outcome. Women with pain when wearing tight pants before surgery reported less often that intercourse had become painless afterward and women with a history of sexual abuse reported less often that intercourse was possible after surgery than women without such a history. There was a positive association between a histopathologic diagnosis of moderate to severe inflammation and a positive recommendation of surgery to other women. Time to follow-up did not confound the relation between any of the patient characteristics and any of the outcome measures, and the ORs adjusted for time to follow-up were very similar to the crude ORs. Outcome of surgery was not influenced by parity, primary or secondary vulvar vestibulitis syndrome, capability to have sexual intercourse before surgery, or previous nonsurgical treatment.


View this table:
[in this window]
[in a new window]
  		Table 3. Characteristics of Women Who Participated in the Telephone Interview (N = 126)

 

View this table:
[in this window]
[in a new window]
  		Table 4. Odds Ratios of Outcome Measures for Different Patient Characteristics, Adjusted for Time to Follow-up, Using Multivariate Logistic Regression

 


   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
All the patients had been diagnosed and operated on by the same surgeon. The response was high at 81%. Success rates for surgical treatment were also high, which is encouraging, because our population contained many women who had been experiencing vulvar vestibulitis syndrome for a long time and almost one-half of them had received previous nonsurgical treatment to no avail.

Our simple telephone interview consisted of asking short, nonvalidated questions, most of which could be answered with yes or no. We did not gather more detailed information structurally, such as whether sexual intercourse had become less painful after surgery. Other aspects that we did not incorporate were the outcomes of the 29 nonresponders and comparisons of treatment methods other than surgery. In a small randomized controlled trial of 14 patients, Weijmar Schultz et al20 reported no difference in outcome between behavioral therapy preceded by surgery or behavioral therapy alone. Bergeron et al17 randomly assigned 87 women to either cognitive–behavioral therapy, electromyographic biofeedback, or vestibulectomy and reported that vestibulectomy was significantly more successful in reducing pain but that the 3 treatments were equally effective in improvement of psychological adjustment and sexual function.

In our study complications mainly developed in the longer term. The most frequently reported complication was diminished lubrication, but it was not considered to be a problem by most of the women, because they were able to manage adequately with artificial lubricants. The percentage of women who developed a Bartholin’s cyst was the same as that reported in a study by Peters.24 These 2 complications are probably the result of removal of the vestibulum and covering the defect, which caused obstruction of Bartholin’s ducts.

Owing to the invasive nature of surgical treatment and the risk of complications, it is important to formulate strict selection criteria. Selection should ideally be based on patient characteristics that are known to influence the outcome. However, at present little is known about such prognostic factors. Therefore, we aimed to relate patient characteristics to the outcome of surgery as a preliminary step to identify relevant issues. Age at the time of surgery proved to be the most important variable, because the results were better in young patients. Instead of withholding surgery, young women especially should be offered this therapeutic option. The negative association between outcome and the need for postoperative conservative treatment indicated that these women were probably still experiencing vulvar vestibulitis syndrome. Pain when wearing tight pants and a history of sexual abuse were also negatively associated with outcome. Perhaps the women with these characteristics were suffering from more than just vulvar vestibulitis syndrome and surgical treatment was not the right therapy for them. A histopathologic diagnosis of moderate to severe inflammation was positively associated with outcome. This could be used as a prognostic variable by taking biopsies from all of the patients preoperatively. However, we would not recommend taking biopsies as a standard procedure until further studies have been done, because we only found an association between focal inflammation and 1 of the 4 outcome measures and because histopathology does not form part of the diagnostic process in vulvar vestibulitis syndrome.22

Based on the results of this study, we conclude that surgical treatment deserves a role in the management of vulvar vestibulitis syndrome. In view of the small risk of surgical complications, it can be presented as a realistic option after failed nonsurgical treatment, especially in young women. Patients should be well informed about the risks involved with this therapy, and candidates should be selected according to strict criteria. To be able to offer optimal individualized treatment for vulvar vestibular syndrome, more studies are needed with prospective controlled designs.


   Footnotes
 
Corresponding author: Maaike A. F. Traas, MD, Department of Obstetrics and Gynecology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands; e-mail: M.Traas{at}obgyn.umcn.nl or: Mtraas{at}alysis.nl or Dijkman-Traas{at}fiberworld.nl.

doi:10.1097/01.AOG.0000195058.91506.ae


   REFERENCES
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
1. Goetsch MF. Vulvar vestibulitis: prevalence and historic features in a general gynecologic practice population. Am J Obstet Gynecol 1991;164:1609–14.[Medline]

2. Skene AJ. Treatise on the diseases of women. New York (NY): Appleton and Company; 1889.

3. Friedrich EG Jr. Vulvar vestibulitis syndrome. J Reprod Med 1987;32:110–4.[Medline]

4. Mariani L. Vulvar vestibulitis syndrome: an overview of non-surgical treatment. Eur J Obstet Gynecol Reprod Biol 2002;101:109–12.[Medline]

5. Danielsson I, Eisemann M, Sjoberg I, Wikman M. Vulvar vestibulitis: a multi-factorial condition. BJOG 2001;108:456–61.[Medline]

6. Bergeron S, Binik YM, Khalife S, Pagidas K. Vulvar vestibulitis syndrome: a critical review. Clin J Pain 1997;13:27–42.[Medline]

7. Bornstein J, Zarfati D, Goldik Z, Abramovici H. Vulvar vestibulitis: physical or psychosexual problem? Obstet Gynecol 1999; 93:876–80.[Abstract/Free Full Text]

8. Woodruff JD, Genadry R, Poliakoff S. Treatment of dyspareunia and vaginal outlet distortions by perineoplasty. Obstet Gynecol 1981;57:750–4.[Abstract/Free Full Text]

9. Mann MS, Kaufman RH, Brown D, Adam E. Vulvar vestibulitis: significant clinical variables and treatment outcome. Obstet Gynecol 1992;79:122–5.[Abstract/Free Full Text]

10. Bornstein J, Zarfati D, Goldik Z, Abramovici H. Perineoplasty compared with vestibuloplasty for severe vulvar vestibulitis. Br J Obstet Gynaecol 1995;102:652–5.[Medline]

11. Goetsch MF. Simplified surgical revision of the vulvar vestibule for vulvar vestibulitis. Am J Obstet Gynecol 1996;174:1701–5.[Medline]

12. Bornstein J, Goldik Z, Stolar Z, Zarfati D, Abramovici H. Predicting the outcome of surgical treatment of vulvar vestibulitis. Obstet Gynecol. 1997;89:695–8.[Abstract]

13. Bergeron S, Bouchard C, Fortier M, Binik YM, Khalife S. The surgical treatment of vulvar vestibulitis syndrome: a follow-up study. J Sex Marital Ther 1997;23:317–25.[Medline]

14. Kehoe S, Luesley D. Vulvar vestibulitis treated by modified vestibulectomy. Int J Gynaecol Obstet 1999;64:147–52.[Medline]

15. McCormack WM, Spence MR. Evaluation of the surgical treatment of vulvar vestibulitis. Eur J Obstet Gynecol Reprod Biol 1999;86:135–8.[Medline]

16. Schneider D, Yaron M, Bukovsky I, Soffer Y, Halperin R. Outcome of surgical treatment for superficial dyspareunia from vulvar vestibulitis. J Reprod Med 2001;46:227–31.[Medline]

17. Bergeron S, Binik YM, Khalife S, Pagidas K, Glazer HI, Meana M, et al. A randomized comparison of group cognitive–behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain 2001;91:297–306.[Medline]

18. Glazer HI, Rodke G, Swencionis C, Hertz R, Young AW. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med 1995;40:283–90.[Medline]

19. Bergeron S, Brown C, Lord MJ, Oala M, Binik YM, Khalife S. Physical therapy for vulvar vestibulitis syndrome: a retrospective study. J Sex Marital Ther 2002;28:183–92.[Medline]

20. Weijmar Schultz WC, Gianotten WL, van der MeijdenWI, van de Wiel HB, Blindeman L, Chadha S, et al. Behavioral approach with or without surgical intervention to the vulvar vestibulitis syndrome: a prospective randomized and non-randomized study. J Psychosom Obstet Gynaecol 1996;17:143–8.[Medline]

21. Bergeron S, Binik YM, Khalife S, Pagidas K, Glazer HI. Vulvar vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria. Obstet Gynecol 2001;98:45–51.[Abstract/Free Full Text]

22. Nichols DH, Randall CL. Vaginal surgery, fourth edition; C 4: 81–85. Williams and Wilkins, Baltimore 1996.

23. Breslow NE, Day NE. Statistical methods in cancer research. Volume 1 – The analysis of case-control studies. IARC Sci Publ 1980;32:5–338.

24. Peters WA 3rd. Bartholinitis after vulvovaginal surgery. Am J Obstet Gynecol 1998;178:1143–4.[Medline]





This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Traas, M. A. F.
Right arrow Articles by Vierhout, M. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Traas, M. A. F.
Right arrow Articles by Vierhout, M. E.
Related Collections
Right arrow General gynecology
Right arrow General surgery
Right arrow Gynecologic surgery
Right arrow Psychology/psychiatry
Right arrow Sexuality

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS