Introduction: Neuroproliferative vestibulodynia (NPV), characterized in 2004, is associated with increased density of mast cells and nerves in excised vestibular specimens. Women with congenital NPV have life-long persistent entrance dyspareunia (PED); those with acquired NPV only have PED after allergic reaction to a topical agent applied to the vestibule. It has been reported that 16% of women experience PED. This sexual dysfunction may lead to abstinence, disruption of social life, and/or depression. In patients with suspected NPV, complete vestibulectomy with vaginal advancement flap reconstruction (CV), performed by providers trained in sexual medicine, has resulted in resolution of PED in 80% of patients. Despite NPV being a field disease of the entire vestibule, many patients undergo partial posterior vestibulectomy with vaginal advancement flap (PPV) reconstruction without resolution of PED. We report on the technique and results of CV in women with PED following PPV.
Methods: This is a review of CV surgeries performed by a sexual medicine specialist since January 2019 (n=45). Immunohistochemical staining was performed on all vestibular specimens using CD 117 and PGP 9.5 to assess for density of mast cells and nerves, respectively.
Results: 14 (28%) patients (mean age 26 ± 7 years) presented to our clinic with PED following PPV. 2 patients underwent PPV twice and 1 underwent PPV three times. All patients had a history consistent with NPV after excluding all other forms of vestibulodynia. Cotton tip swab testing showed severe pain primarily around the urethral meatus between 1:00 and 3:00 and between 9:00 and 11:00; 79% also had pain at 12:00. All had a positive response to vestibular anesthesia testing. During CV surgery in patients with prior PPV, vestibular fibrosis in the posterior vestibule resulted in more difficult dissection with a 25% increased blood loss (mean 200 ml vs 150 ml in women without prior PPV). Surgical techniques were otherwise similar in women with or without prior PPV: excising the vestibule from around the urethral meatus and Hart’s line to the hymen, and anastomosing the urethral meatus and vulva to the vagina. All vestibular specimens revealed high density of CD117 and PGP 9.5 positive staining cells consistent with NPV. 71% of women who had PED after PPV had pain-free penetration post CV.
Conclusions: Women with PED from NPV have a field disease involving excess density of mast cells and nerves in the entire vestibule. Performing a PPV in women with NPV is not an effective treatment for PED. Salvaging such patients with CV is safe and effective.
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