Outcome of Surgical Treatment for Superficial Dyspareunia from Vulvar Vestibulitis

Abstract & commentary

Synopsis: Approximately 80% of patients with vulvar vestibulitis are improved following surgery.

Source: Schneider D, et al. J Reprod Med. 2001;46(3):
227-231.

Between 1993 and 1997 schneider and colleagues performed 69 vestibulectomy procedures for women with dyspareunia. Although it is unclear from the text, it appears that almost all of these women would fit into the classification of chronic vulvar vestibulitis. Unfortunately, only 54 of the patients responded to the questionnaire that was mailed.

Schneider et al divided the patients into "primary" vestibulitis and "secondary" vestibulitis. Primary included those women who had always had painful intercourse, and secondary included those who developed it later. Four of 5 women had received medical therapy of some type prior to surgery.

There were no intraoperative problems, but 15% of the patients had postpartum complications. Except for 1 patient with heavy bleeding, the complications were mild. Nine patients required repeat surgery to excise a remaining piece of tissue that caused pain with intercourse. Thirty-four percent of the women who had surgery found it necessary to seek medical therapy for continuing dyspareunia of some degree.

Schneider et al noted that those women who had the most severe disease prior to surgery were most likely to benefit from it. That is, 96% of those women who were unable to have intercourse preoperatively reported moderate to excellent results, but only 70% of those who could occasionally have intercourse prior to surgery had a similar improvement.

Schneider et al conclude that surgery is probably the most effective method of therapy for vulvar vestibulitis, but that all women should have conservative methods attempted prior to resorting to surgical therapy.

Comment by Kenneth L. Noller, MD

The chronic vulvar vestibulitis saga continues. While medical therapies come and go, there is certainly no doubt that the single most effective therapy for this condition is vestibulectomy. However, it is also clear that vestibulectomy is not 100% successful. While different success rates have been reported in the literature (including 1 with no failures) it has been my observation that only 60-80% of women have marked benefit from the procedure.

I particularly like this paper. It has one main flaw (see next paragraph), but overall is a fair appraisal of the results of surgery for vulvar vestibulitis. The fact that Schneider et al emphasize that women with more severe problems that have not been helped by medical therapy respond better than women with more minor symptoms is an important fact for clinicians who treat this condition to note.

A shortcoming to this study is that it tells us nothing about the success of medical therapy. That is, it is a study only of those women who failed medical therapy and had surgery. While Schneider et al make this point clear in their paper, casual reading of the manuscript might lead some clinicians to assume medical therapy has no role in the treatment of vulvar vestibulitis. Indeed, it has been my experience that patients who are immediately offered surgical therapy have minimal relief of symptoms postoperatively far more commonly than women who have tried all medical measures first.