(005) The Forgotten Region of the Vestibule: The 12:00 Location
Authors: Uloko M , Minton J , Gagnon C , Stearns H , Goldstein I 
Published: June 2023

Abstract

Introduction
The vestibule, consisting of the urethral meatus and minor and major vestibular glands, is a unique surface of endodermal tissue between Hart’s line, at the inner aspect of the labia minora, and the hymen, just at the vaginal opening. The vestibule releases mucinous lubrication during sexual arousal, achieved, in part, by robust vestibular innervation. Although not well studied, this likely consists of both somatic (perineal nerve), and autonomic (pelvic and hypogastric) nerves. The vestibule is commonly involved in entrance dyspareunia pathology related to infectious, dermatologic, hormonal, neurologic, pelvic floor, neuro-proliferative and other factors. Examination of the vestibule in symptomatic patients is best performed by vulvoscopy, and usually involves cotton swab testing of the 1:00, 3:00, 5:00, 6:00, 7:00, 9:00, and 11:00 locations, assessing for intensity of pain and degree of erythema. However, this examination does not assess the entire vestibule. The vestibule actually extends superiorly from just above the urethral meatus to just below the clitoris/right and left frenulum and laterally to Hart’s line. This may be considered as the “12:00” region of the vestibule; few providers examine there, and few surgeons excise the 12:00 region during vestibulectomy.

Objectives
The primary goal was to assess the relationship of the pathology of the 12:00 region to pathology in the usual vestibular locations. A secondary goal was to assess for presence of ostia of minor vestibular glands in the 12:00 region of the vestibule.

Methods
Women presenting to our clinic for sexual dysfunction were consented and underwent vulvoscopy with photography and cotton swab testing using a vulvoscope (Wallach Zoomscope) with attached camera (Cannon). Figure 1 shows cotton swab testing for pain and erythema at 12:00. Pain intensity was rated 0 – 10, with pain &gt;3/10 considered clinically significant. Erythema was rated absent, mild, moderate or severe with any erythema considered clinically significant.

Results
Of 88 patients (mean age 42 +/− 19, range 13-83 years) with various sexual dysfunctions who underwent vulvoscopy with photography and cotton swab testing, 19 (22%) had absent pain and absent erythema throughout the usual vestibular locations as well as at the 12:00 location. Of 54 (61%) patients with positive findings of significant pain and erythema in at least 4 of the usual locations, 38 (70%) also had significant pain and erythema at 12:00. 26% of photographs examined revealed obvious single or multiple ostia of minor vestibular glands in the 12:00 region of the vestibule. Figure 2 shows 2 minor vestibular glands at 12:00.

Conclusions
While the vestibule extends from Hart’s line to the hymen including the usual 1:00, 3:00, 5:00, 6:00, 7:00, 9:00, and 11:00 locations, it also includes the region superiorly from just above the urethral meatus to just below the clitoris/right and left frenulum and laterally to Hart’s line. There are minor vestibular glands in this 12:00 region of the vestibule that can contain significant pathology. Providers are encouraged to consider the entire vestibule during diagnosis and treatment of women with sexual dysfunction.

Disclosure
No.