learning objectives - university of michigan...12/26/2018 1 vestibulectomy hope k. haefner, md...
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Vestibulectomy
Hope K. Haefner, MD
Michigan Medicine
Ann Arbor, MI USA
Learning Objectives
At the end of this lecture, the participant will:• Understand the surgical techniques used to treat localized vulvodynia
• Recognize that this is generally the last resort (other treatments have failed)
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Important Thoughts Prior to Surgery
•Rule out vaginismus
•Determine area to excise
• ? Remove or conserve hymen
•Methods for hemostasis
•Undermining posterior and lateral vaginal walls
•Bartholin's gland ?
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JOL DeLancey, MD collection
Hart’s line
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Classic ClosureTechnique
Classic ClosureTechnique
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Newer Thoughts?
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V to Y Flaps
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Role of Vestibulectomy
•Use only when all else has failed?•Use in selected patients?
•Differentiate primary vs secondary vestibulodynia
Role of Vestibulectomy
•Use only when all else has failed?•Use in selected patients?
•Differentiate primary vs secondary vestibulodynia
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Role of Vestibulectomy
•Use only when all else has failed?•Use in selected patients
•Differentiate primary vs secondary vestibulodynia
Results of Vestibulectomy
• Bornstein et al, 1995
• Vestibuloplasty (0/10) v perineoplasty (9/11)
• Schneider et al, 2001
• 83% moderate to excellent improvement
• Goldstein et al, 2006
• 134 pts – 104 = 97 (93%)satisfied / very satisfied
• Traas et al, 2006
• 275 pts – 155: 93% coitus – 62% no pain
• Goetsch et al, 2007 & 2008• 111 pts: muscle therapy: 64% dyspareunia resolved
• 133 pts: 119: 68% cured, 24% lessened
• Eva et al, 2008• 110 pts: 83% would recommend procedure
• Bohm‐Starke & Rylander,2008• 67 pts: 56% complete or major improvement
…
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More Recent Articles on Vestibulectomy
Donders GG, Bellen G, Peperstraete B, Folens S. Simple posterior vestibuloplasty for central introital dyspareunia. Gynecological Surgery 2012;9:297‐302.
• Eighty percent had less pain during intercourse
• Longitudinal incision of the mucosa and underlying muscle over a length of 4 cm and depth of about 1.5 cm
Swanson CL, Rueter JA, Olson JE, Weaver AL, Stanhope CR. Localized provoked vestibulodynia: outcomes after modified
vestibulectomy J Reprod Med 2014;59(3‐4):121‐6.
• 202 patients received modified vestibulectomy for localized provoked vestibulodynia (Mayo Clinic in Rochester, Minnesota)
• 115 patients returned the questionnaire• 71 patients had pain with tampon insertion, 52 reported attempting to insert a tampon after surgery‐90.4% noticed moderate to substantial improvement
• Pain with sexual intercourse in 97.3% patients before surgery
‐84.1% noted moderate to substantial improvement in their pain
• Modified vestibulectomy is a successful treatment for localized provoked vestibulodynia
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Kliethermes CJ, Shah M, Hoffstetter S, Gavard JA, Steele A. Effect of vestibulectomy for intractable vulvodynia J Min Inv Gyn 2016; 23(7):1152‐7.
• 31 patients
•Vestibulectomy is an effective treatment for vulvodynia
• For those with intractable pain, vestibulectomy is an appropriate next step after unsuccessful medical treatment
Surgical Complications
•Vestibule too tight•Hematoma
•Separation •Bartholin’s cyst•Granulation tissue•Surgical failure / persisting symptoms
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What About Surgery for Other Forms of Vulvodynia?
What about the nerves?
Surgery in nongynecologic areas?
Vallinga MS, Spoelstra SK, Hemel IL, van de Wiel HB, Weijmar Schultz WC.
Transcutaneous electrical nerve stimulation as an additional treatment for women suffering from therapy‐resistant provoked vestibulodynia: a feasibility study. J Sex Med 2015; 12(1):228‐37.
Andres JD. Sanchis‐Lopez N. Asensio‐Samper JM. Fabregat‐Cid G. Dolz VM. Peripheral subcutaneous vulvar stimulation in the management of severe and refractory vulvodynia. Obstet Gynecol 2013;121(2 Pt 2 Suppl 1):495‐8.
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Neuromodulation with Sacral Nerve Stimulator
Modulation of efferent signals to spinal cord
Refractory pain in distribution of specific nerve root (S3 or S4)
Pudendal Nerve
Pudendal Nerve Entrapment
Pudendal Nerve
Pudendal Nerve Entrapment
Rectum: symptomsPerineum: symptomsClitoris: symptoms
Rectum: symptomsPerineum: symptomsClitoris: symptoms
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Dellon AL. Pain with sitting related to injury of the posterior femoral cutaneous nerve,Microsurgery April 2015;35(6).
Ilioinguinal n.
Neuroma vs. Compression of Branches of the Pudendal Nerve
NEUROMA COMPRESSION NEUROMA COMPRESSION
PUDENDAL NERVE BRANCH
DORSAL INJURY CYCLING, ?PGAD INJURY CYCLING
PERINEAL EPISIOTOMY,VESTIBULECTOMY
CYCLING,SURGERY
WEIGHT LIFTING
CYCLING,SURGERY
RECTAL HEMORRHOID SURGERY
INJURY HEMORRHOID SURGERY
INJURY
FEMALE MALE
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COMPRESSION DORSAL BRANCH PUDENDAL NERVE IN FEMALE:FEMALE (PERSISTANT GENITAL AROUSAL DISORDER
Dellon, AL, Coady, D, Harris, D,Pelvic pain of pudendal nerve origin: surgical outcomes and learning curve lessons.J Reconstr Microsurg, 31:283‐290, 2015