(025) VULVAR GENITAL TISSUE APPEARANCE BEFORE AND AFTER COMPLETE VESTIBULECTOMY FOR NEUROPROLIFERATIVE VESTIBULODYNIA: FIRST-EVER OBJECTIVE ASSESSMENT
Authors: Ponce S , Goldstein S , Kim NN , Goldstein I 
Published: December 2024

Abstract

Introduction
Patients with neuroproliferative vestibulodynia (NPV), characterized by persistent entry dyspareunia, allodynia, and hyperalgesia, are often treated by complete vestibulectomy with vaginal advancement flap reconstruction. Vestibulectomy surgery involves subepithelial excision of the 1:00– 11:00 and, if appropriate, 12:00 endodermal vestibular regions, with ectodermal vulva anastomosed to mesodermal vagina. NPV patients considering surgery often express concerns pre-operatively regarding post-operative appearance of their genitalia. Counseling for this has been challenging as, to the best of our knowledge, there have been no reported objective assessments of post-operative changes in genital tissue appearance.

Objective
To objectively assess changes in vulvar genital tissue appearance in NPV patients who underwent complete vestibulectomy.

Methods
To assess for change in genital tissue appearance post-operatively, we reviewed charts of patients from a single site who i) underwent complete vestibulectomy between September 2022 and February 2024 and ii) returned to the clinic for a post-operative visit including vulvoscopy with photography at least 3 months after surgery. The primary outcome measure was the 8-item modified Vulvar Genital Tissue Appearance (mVGTA) scale. Vulvoscopic photographs were deidentified and blinded as to whether they were from pre-operative or post-operative visits and read by a trained research team member not involved in patient care. Each photograph was graded for appearance using the mVGTA scale. The 8 items assessed individually and as a total were appearance of: labia majora resorption, labia minora resorption, clitoral glans visualization, clitoral adhesions, introitus pallor, introitus erythema, loss of introital moisture, and posterior fourchette tightness; judged on a 0 to 3 ordinal scale (0 = none; 1 = mild; 2 = moderate; 3 = severe). After unblinding, data were analyzed using descriptive statistics and Wilcoxon matched-pairs signed rank tests. In addition, the vaginal advancement flap was examined for both color and scar tissue between the vagina and vulva using the unblinded post operative photographs.

Results
Eleven patients were included, age 29 years (range 22-35) who met inclusion criteria. The average time from surgery to post-operative vulvoscopy was 6 months (range 3-13). A total of 178 photographs were graded. (Fig. 1) There were statistically significant improvements from pre- to post-operative mVGTA scores for: clitoral glans visualization (p = 0.023), clitoral adhesions (p = 0.0078), introital pallor (p = 0.0078), introital erythema (p = 0.0117), and the total mVGTA score (p = 0.0029).(Figure 2) Of note, 8 patients underwent lysis of clitoral adhesions at the time of vestibulectomy surgery, all with improved scores in clitoral glans visualization and clitoral adhesions. In all 11 patients, the vaginal advancement flap was pink in color and with no scar tissue identified between the vagina and vulva. There were no statistically significant changes in appearance of the labia majora/minora resorption, labial moisture or posterior fourchette tightness (Fig. 2).

Conclusions
These findings suggest that complete vestibulectomy improves appearance of genital tissue color and clitoral visualization, and does not change the labia majora, labia minora or posterior fourchette tightness. This should reassure patients concerned about genital appearance considering complete vestibulectomy for NPV.

Disclosure
No.