Vulvar Vestibulitis Case File

Vulvar Vestibulitis Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 30

A 23-year-old Caucasian woman presents to her gynecologist with a chief complaint of dyspareunia. She relates that she had recently had the onset of severe coital pain on several occasions, which had not previously been present. Specific questioning reveals that the patient localizes the pain to the vaginal vestibule, and that this is exacerbated by touching the region, or by her partner attempting vaginal entry. Physical examination is negative for any evidence of vaginal inflammation, and wet mount examination of the vaginal secretions is negative for the presence of any vaginal pathogens. The vaginal vestibule is exquisitely sensitive when the vaginal speculum is inserted into the vagina, and applying pressure on the perineum exacerbates the patient’s pain sensation.

➤ What is the most likely diagnosis?

➤ What is the next step?

ANSWERS TO CASE 30:

Vulvar Vestibulitis

Summary: A 23-year-old woman has dyspareunia localized to the vaginal vestibule. Physical examination reveals tenderness to pressure and touch in this region, with no evidence of any inflammatory process in the vagina.

➤ Most likely diagnosis: Vulvar vestibulitis.

➤ Next step: Rule out other causes of labial pathology, and then discuss treatment options with the patient for treatment of this diagnosis.

ANALYSIS

Objectives

1. Be able to recognize and treat the benign conditions that are commonly seen on the labia.
2. Know how to perform diagnostic biopsy procedures to confirm these diagnoses.
3. Understand those benign conditions which the generalist gynecologist should be able to treat surgically with confidence, how to do those procedures, and to discern those which should be referred to the gynecologic oncologist.

Considerations

This 23-year-old woman has a recent history of dyspareunia which on examination is localized to the vaginal vestibule. There is no evidence of inflammation or other lesions. There is no evidence of infection by wet mount. On examination, the vaginal vestibule is very sensitive to touch. A careful inspection of the vagina and vulva is important especially to try to identify herpes simplex virus or other neurologic processes. Pain can be assessed and mapped by touching a cotton-tipped applicator to the vulva. In the evaluation process, a herpes assay for polymerase chain reaction (PCR) or culture should be performed. A careful psychosocial history should be taken to assess for sexual abuse or physical abuse. Once infection is ruled out, biopsy may be considered. Vulvar vestibulitis is a diagnosis of exclusion, and usually there is some erythema. Different treatments may be considered, with surgical excision being most successful.

APPROACH TO

Nonmalignant Vulvar Disease

DEFINITIONS

VULVAR VESTIBULITIS: A syndrome of severe pain of the vulvar introitus without inflammation.

VULVAR INTRAEPITHELIAL NEOPLASIA: Premalignant condition with dysplastic cells confined within the epithelium of the vulva.

BARTHOLIN GLAND CYST: Fluid within the greater vestibular gland causing swelling.

CLINICAL APPROACH

This chapter on vulvar surgery does not intend to describe surgical therapy for malignant vulvar disease. Rather, it is intended to define practical steps for the generalist gynecologist to use in making the diagnosis of labial disease, to delineate commonly encountered labial conditions amenable to surgical therapy, and to describe surgical approaches for those benign entities that will benefit from surgical therapy.

Vulvar lesions constitute a significant component of the gynecologist’s clinical practice. Authors stress the necessity of the labial biopsy to confirm the pathology before embarking on a course of treatment.1,2 The consultant gynecologist who makes the correct diagnosis and establishes the proper therapeutic plan is often the first physician to make a tissue diagnosis after multiple other physicians have tried a myriad number of ointments and creams without success. The gynecologist should have a close working relationship with the pathologist who is going to evaluate the tissue, and remember that communication with the pathologist regarding the patient’s history and gross appearance of the lesion may improve his/her diagnostic acumen under the microscope.

VULVAR VESTIBULITIS

Vulvar vestibulitis as an entity has been initially described by Friedrich as consisting of (1) severe pain on vestibular touch; (2) tenderness when pressure is applied in the vaginal vestibule; (3) erythema of the vestibule.3 Strenuous evaluation of the validity of these criteria has been established, and it has generally been upheld, except that the erythema of the vestibule has been questioned, and the pain and pressure components have been more accurately described, such that the pain in the vestibule has been described as having a “thermal” component, and the degree of severity is worse than that of severe dysmenorrhea. The etiology of this entity is still unclear, though studies have excluded the human papillomavirus (HPV) as causative, and no other infectious process has been implicated as being likely. Multiple therapeutic approaches have been utilized, though none have been demonstrated to be as effective as surgery for effective treatment of this problem. Success rates range from 36% to 100%, with the overall average being in the 60% range. Women younger than 30 years seem to benefit more from this procedure than those in older age ranges.4

The surgical procedure should include complete vestibulectomy, including excision of tissue up to the periurethral region if it is deemed to be involved on the basis of the preoperative evaluation. Undermining and advancement of the vaginal wall completes the operation. Complications of the surgical procedure include the lack of satisfactory lubrication in 24% and the development of Bartholin gland cysts in 6%, which occurs when the Bartholin gland duct is obstructed as part of the excision of the vaginal vestibule.4

Labial Biopsy

Office labial biopsy should be simple, fast, routine, and as painless as possible. Premedication of the area to be sampled with topical application of 2.5% lidocaine and 2.5% prilocaine prior to the sterile preparation and the injection of the local anesthetic will significantly reduce patient discomfort; many patients volunteer that they do not feel the injection itself if the cream has been on the labial surface for 5 minutes prior to the injection. Labial tissue has an abundant blood supply, so a mixture of lidocaine and 1:100,000 epinephrine is a good choice to provide good topical anesthesia and minimal bleeding at the biopsy site. Biopsy may be accomplished with tissue forceps and scissors or a punch biopsy instrument. Obtaining a full thickness of tissue down to the subcutaneous tissue is important; rarely is it necessary to remove so much tissue that suture closure for hemostasis is required. Most labial biopsy sites respond to simple application of silver nitrate and there is no need for antibiotic coverage. Homogenous appearing lesions should be sampled from the most representative site; the potential for labial squamous cell carcinoma to be surrounded by lichen sclerosus may require removal of a larger specimen or sampling of multiple biopsy sites.

Vulvar Intraepithelial Neoplasia

Vulvar intraepithelial neoplasia (VIN) should be considered as a diagnosis in the patient whose labial pruritus and chronic labial pain does not have a readily apparent explanation. This is a likely diagnosis in the patient who already has confirmed cervical dysplasia. The colposcope may also be used to evaluate the labia, and acetic acid applied to the labia will create the colposcopic appearance typically associated with dysplastic disease, which can then be confirmed with labial biopsy. Therapy depends on extent and severity of the disease process. Most VIN II and all VIN III lesions merit therapy; asymptomatic VIN I lesions may be followed expectantly in a reliable patient if she is willing to return for follow-up visits. Therapy may consist of topical imiquimod, fulguration, laser vaporization, or wide local excision. Before performing any procedure that eradicates tissue, such as fulguration or laser vaporization, it is critical to ascertain that there is no invasive disease present. Many of the procedures for treating VIN can be performed in the clinic with local anesthesia, or if the hospital OR is indicated, the surgery may frequently be done on an outpatient basis. It is important to stress to the patient that no matter which modality of therapy is chosen, and no matter how thorough and complete the therapy is to remove the affected tissue, there is always the chance for recurrent disease. Patients should be informed about the potentially premalignant nature of this disease process and the necessity for long-term follow-up.

Studies that have looked at cases series separated by several decades have noticed a distinct change in the nature of this disease process. Series from the 1960s to the 1980s describe women who average 50+ years of age, with many of these VIN lesions arising in area of lichen sclerosus and other skin abnormalities and not having an HPV infection association. Series from the 1990s report average patient ages dropping into the 30s, and showing a strong clinical correlation with positivity for HPV infection. Dysplasia elsewhere in the genital tract is strongly associated with VIN. Authors stress delay in diagnosis because VIN is confused with infection, and treatment for infection proceeds without a positive biopsy diagnosis. Smoking seems to be a cofactor in disease progression in many cases, and some cases can proceed from VIN to invasive disease in as little as 4 years.1

Surgical therapy needs to weigh the cosmetic and functional effects of excising excessive amounts of labia in the OR with a scalpel against using a laser too superficially to eradicate the disease process, which will likely allow for recurrent disease. Laser therapy of the labia minora should not go deeper than 1 mm, and therapy to the majora, the perineum, the fourchette, and skin around the anus should not exceed 2.5 mm. Any laser use should include consideration of the adjacent and deep thermal injury margins, which will increase the effective treatment area.

Bartholin Gland Surgery

Benign conditions of the Bartholin gland, such as cysts or abscesses, affect about 2% of women. Antibiotic therapy is usually prescribed for these lesions, but it is only marginally effective as definitive treatment, especially for cysts. Surgical therapy consists of hospitalization for marsupialization, or outpatient therapy using the Word catheter (WC), an attractive, inexpensive alternative therapy for these lesions.5 The WC allows for a relatively painless, rapid return to normal activity, including intercourse, and treatment results are comparable to marsupialization surgery. If marsupialization is used, suturing the edges of the abscess cavity to facilitate an adequate drainage window and long-term drainage is preferable to simple incision and drainage of the abscess.6 The CO2 laser has been used effectively on an outpatient basis for Bartholin gland abscesses and cysts. The Bartholin gland lesion which does not quickly and completely respond to one of the surgical modalities discussed earlier merits further evaluation, as Bartholin gland malignancies are frequently treated as infectious processes before a cancer diagnosis is established. Recurrent abscesses or cysts require a tissue diagnosis before the assumption is made that the recurrent process is in fact due to infection and not neoplasia.7 In contrast to initial outpatient therapy for cysts or abscesses, the decision to proceed with total excision of a Bartholin gland should not be made lightly. This is a challenging surgical procedure that should be done only after adequate informed consent and thorough familiarization with the operative procedure.

Labial Hypertrophy

Patient concerns regarding the size of their labia minora are not uncommon. Excessive size of the minora may be congenital, due to chronic stretching, irritation, or androgenic hormone therapy. Symptoms may include disparate appearance of one side versus the other, inability to wear tight fitting clothing, pain with exercise, or entrapment and resultant discomfort of the enlarged labia during coitus. Several reports describe patient satisfaction with operative procedures to reduce the size of the minora. Complications are infrequent, and the vast majority of surveyed patients would have the operation done again.8 The laser has been used to accomplish this procedure in some instances, and a wedge resection technique has also been described to remove a central portion of the labia while leaving the lateral border intact.9,10 Surgical techniques in this region need to be fastidious with appropriate attention to detail and hemostasis, including the use of small suture and delicate instruments.

Importantly, legitimate vulvar surgery does not include “vaginal rejuvenation,” “designer vaginoplasty,” “revirgination,” or “G-spot amplification.” Some practitioners are marketing these procedures heavily for the sole purpose of changing labial appearance or for enhancing sexual pleasure. No studies exist to demonstrate their efficacy, safety, or patient satisfaction, and they have the risk of significant complications, including infection, scarring, altered and/or diminished sexual response, and adhesion formation. Patients seeking these sorts of surgical procedures should be counseled about the normal variability of the appearance of their external genitalia and about normal sexual function not being dependent on labial appearance.11

Comprehension Questions

30.1 A 32-year-old woman is diagnosed with vulvar vestibulitis. She has searched the Internet and learned that surgery is an option for therapy. Under what circumstances should she consider surgical management?

A. If she has been unresponsive to other therapy

B. Only if she is older than 50 years of age

C. Only if a minimal amount of tissue can be removed

D. As a possible first line treatment

30.2 A 45-year-old woman is diagnosed on vulvar biopsy to have VIN II. The patient asks about risk factors. You explain that the VIN:

A. Has a relationship to HPV infection rates

B. Does not seem to be related to smoking

C. Is related to topical corticosteroid use

D. Is related to topical estrogen

30.3 Labioplasty

A. Is legitimate surgery for the proper indication

B. Has recently been noted to have scientific basis for therapy

C. Is relatively straightforward and is associated with few complications

D. Is an antiquated procedure and does not have a place in modern gynecology

ANSWERS

30.1 A. Surgery for vulvar vestibulitis provides better results than any other therapy for this disabling condition and is most effective in younger patients. Complete excision of all involved tissue provides the best functional result.

30.2 A. Vulvar dysplasia in recent years is associated primarily with HPV infection, and it is exacerbated by smoking. Alcohol intake is not known to be a contributing factor.

30.3 A. Valid indications for labial plastic surgery are well known and reasonable, but the combination of labioplasty with questionable and ill-defined therapeutic goals associated with some practitioners’ heavy marketing efforts place these efforts in a non-professional category.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Pretreat the area on the labia to be biopsied with a topical anesthetic cream to reduce the pain of injection and the biopsy itself (Level B).

➤ At the preoperative visit for the patient who is to have labioplasty, especially for reduction in the labia minora, use a marking pen and a mirror and be sure that the patient is in agreement with the amount of tissue to be removed (Level C).

REFERENCES

1. Jones RW, Rowan DM. Vulvar intraepithelial neoplasia III: a clinical study of the outcome in 113 cases with relation to the later development of invasive vulvar carcinoma. Obstet Gynecol. 1994;84:741-745. 

2. Baggish MS, Sze EHM, Adelson MD, Cohn G, Oates RP. Quantitative evaluation of the skin and accessory appendages in vulvar carcinoma in situ. Obstet Gynecol. 1989;74:169-174. 

3. 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. 

4. Traas MAF, Bekkers RLM, Dony JMJ, et al. Surgical treatment for the vulvar vestibulitis syndrome. Obstet Gynecol. 2006;107:256-262. A definitive treatise justifying surgery for this perplexing entity. 

5. Andersen PG, Christensen S, Detlefsen GU, Kern-Hansen P. Treatment of Bartholin’s abscess. Marsupialization versus incision, curettage and suture under antibiotic cover. A randomized study with 6 months’ follow-up. Acta Obstet Gynecol Scand. 1992;71:59-62. 

6. Haider Z, Condous G, Kirk E, Mukri F, Bourne T. The simple outpatient management of Bartholin’s abscesses using the Word catheter: a preliminary study. Aust N Z J Obstet Gynecol. 2007;47:137-140. 

7. Cardosi RJ, Speights A, Fiorica JV, Grendys EC Jr, Hakam A, Hoffman MS. Bartholin’s gland carcinoma: a 15-year experience. Gynecol Oncol. 2001;82:247-251. 

8. Pardo J, Sola V, Ricci P, Guilloff E. Laser labioplasty of labia minora. Int J Gynaecol Obstet. 2006;93:38-43. 

9. Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertrophy of labia minora: experience with 163 reductions. Am J Obstet Gynecol. 2000;182:35-40. 

10. Choi HY, Kim KT. A new method for aesthetic reduction of labia minora (the deepithelialized reduction of labioplasty). Plast Reconstr Surg. 2000;105:419-422. 

11. American College of Obstetricians and Gynecologists. Vaginal “rejuvenation” and cosmetic vaginal procedures. ACOG Committee Opinion No. 378. Obstet Gynecol. 2007;110:737-738.

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