Excision of Vestibular Adenitis Nonspecific inflammation in the glands in the vestibule of the vulva, termed vulvodynia by the International Society for the Study of Vulva Disease, has been broken down into three categories: (1) vestibulitis, (2) squamous papillomatosis (vulvar dermatoses, cyclic candidiasis, squamous papillomatosis), and (3) essential vulvodynia. All too often these patients have a 6-month or greater history of being treated with anti-inflammatory, antifungal, and antibacterial agents prescribed by numerous physicians. All to often these patients undergo laser vaporization that results in more constriction and dyspareunia to the vaginal outlet. Excision of the hymen along with the adjacent inflamed glands has produced relief of symptoms in about 75-90% of cases. Where there is diagnostic uncertainty, every effort should be made to treat these patients with conservative therapy prior to surgical resection. Once surgical resection has been chosen, it is important that the entire vestibular glandular area involved in the process be surgically removed. Physiologic Changes. The predominate physiologic change in resection of vestibular adenitis is removal of the inflamed vestibular glands that cause sever pain and dyspareunia. The absence of this tissue produces little change in the physiology of the functioning vagina and vulva. Points of Caution. The involved area of the vestibule should be carefully marked out under superior light and, if possible, with optical magnification to ensure that an adequate excision of the vestibular adenitis is made. Thorough mobilization and advancement of the posterior and lateral vaginal wall sufficient to come out on the posterior fourchette without tension should be performed. If the posterior vaginal wall is brought out under tension, it will retract, and contracture of the vaginal outlet with its sequela will occur. Technique The involved vestibule of the vulva and vagina is shown. The punctated area needs to be carefully marked off, and the incision should encompass the entire lesion. Crosscutting will result in recurrences of the problem. The vestibule is removed along the marked off lines. One of the most important aspects of the operation is thorough mobilization of the posterior vaginal wall from the posterior fourchette to the top of the vagina. All to often, insufficient mobilization is made. This is performed by elevating the posterior vaginal wall and dissecting under the vaginal mucosa with scissors. The posterior vaginal wall is gently pulled out onto the posterior fourchette. It should lie in place without retraction. The purpose of sutures is not to retract the posterior wall out of the vagina but to hold it adjacent to the skin of the vulva for proper wound healing. The edges of the vaginal mucosa are sutured to the edge of the skin. The new rapid synthetic absorbable suture is superior for this purpose if adequate mobilization has occurred. If inadequate mobilization occurs, a longer acting suture is needed that may require removal of the suture in the office in 2 weeks.

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Excision of Vestibular Adenitis

Nonspecific inflammation in the glands in the vestibule of the vulva, termed vulvodynia by the International Society for the Study of Vulva Disease, has been broken down into three categories: (1) vestibulitis, (2) squamous papillomatosis (vulvar dermatoses, cyclic candidiasis, squamous papillomatosis), and (3) essential vulvodynia. All too often these patients have a 6-month or greater history of being treated with anti-inflammatory, antifungal, and antibacterial agents prescribed by numerous physicians. All to often these patients undergo laser vaporization that results in more constriction and dyspareunia to the vaginal outlet.

Excision of the hymen along with the adjacent inflamed glands has produced relief of symptoms in about 75-90% of cases. Where there is diagnostic uncertainty, every effort should be made to treat these patients with conservative therapy prior to surgical resection.

Once surgical resection has been chosen, it is important that the entire vestibular glandular area involved in the process be surgically removed.

Physiologic Changes. The predominate physiologic change in resection of vestibular adenitis is removal of the inflamed vestibular glands that cause severe pain and dyspareunia. The absence of this tissue produces little change in the physiology of the functioning vagina and vulva.

Points of Caution. The involved area of the vestibule should be carefully marked out under superior light and, if possible, with optical magnification to ensure that an adequate excision of the vestibular adenitis is made.

Thorough mobilization and advancement of the posterior and lateral vaginal wall sufficient to come out on the posterior fourchette without tension should be performed. If the posterior vaginal wall is brought out under tension, it will retract, and contracture of the vaginal outlet with its sequela will occur.

Technique

The involved vestibule of the vulva and vagina is shown. The punctated area needs to be carefully marked off, and the incision should encompass the entire lesion. Crosscutting will result in recurrences of the problem.

The vestibule is removed along the marked off lines.

One of the most important aspects of the operation is thorough mobilization of the posterior vaginal wall from the posterior fourchette to the top of the vagina. All to often, insufficient mobilization is made. This is performed by elevating the posterior vaginal wall and dissecting under the vaginal mucosa with scissors.

The posterior vaginal wall is gently pulled out onto the posterior fourchette. It should lie in place without retraction. The purpose of sutures is not to retract the posterior wall out of the vagina but to hold it adjacent to the skin of the vulva for proper wound healing.

The edges of the vaginal mucosa are sutured to the edge of the skin. The new rapid synthetic absorbable suture is superior for this purpose if adequate mobilization has occurred. If inadequate mobilization occurs, a longer acting suture is needed that may require removal of the suture in the office in 2 weeks.