Surgery for vulval pain
Removing areas of vulval tenderness from women with vulval pain syndromes has been practised by surgeons over many years. In the 1980s there were many publications in medical literature outlining the benefits of surgery for the treatment of vulval pain. The operations performed are carried out by gynaecologists who have the greatest experience. Obviously if you see a dermatologist or genitourinary medicine physician then these procedures will not be offered to you unless you are referred.
What procedures are carried out?
The main procedure that is recommended for managing vulval pain syndromes is the vestibulectomy. This is a procedure which removes the tender areas of the skin within the vestibule (the area between the lower vagina and just within the vulva). The amount of tissue removed is variable and depends on your symptoms and the surgeon in charge of your care. Sometimes only isolated areas of skin are removed from the lower part of the vestibule and in other women with extensive symptoms, larger areas of the vestibule can be removed up to the front of the vagina near the urethra, where you pass urine. Other procedures are less commonly performed and these include removal of the labial skin and the skin near the back passage. The procedures are usually carried out in hospital under general anaesthetic and take around 10 to 40 minutes, depending on the surgeon. Dissolvable stitches are usually used to cover the defects where the tender areas of skin were removed. After the operation you might be sent home either the same day or a day or so later. Obviously you need time to recover from this and this is variable — anything from 6 to 12 weeks. Your doctor may advise use of other treatments following surgery and this might include the use of creams (steroid creams, emollients), the use of vaginal dilators (to prevent scar tissue reforming) and a review by a pain management team or possibly a psychosexual counsellor.
Who is suitable?
The vulval pain syndromes describe two conditions — vestibulodynia (vulval vestibulitis) and dysaesthetic vulvodynia. It is generally believed that surgery may be appropriate for women with vestibulodynia: that is, women who have pain localised to the vestibule when the area is touched. This is the classic feature of vestibulodynia and removal of this tender area of skin will make sense for some women and will be successful. However, on the whole, vestibulodynia is managed medically and very few choose to go for surgery. Surgery is rarely carried out for this condition, but is effective in well selected patients.
Dysaesthetic vulvodynia gives more continuous pain and the findings of tenderness to touch in the vestibule area are variable. If pain is continuous then surgery is often unsuccessful. For dysaesthetic vulvodynia or when there is continuous burning pain in the vulva, tricyclic antidepressants, such as amitriptyline, may be of benefit to some women to alter pain perception.
Complications vary amongst different women and with different procedures. Clearly the surgeon offering you treatment will discuss these with you. Sometimes the pain that you originally experienced may persist and the surgery will have failed. It will be up to you and your doctor to discuss further surgery or alternative treatments to manage this.
The success rates of surgery reported in medical literature are extremely variable and are very difficult to interpret. There is no figure to be quoted in general, as some success rates are very low — around 20 - 30% — and others are much higher — in excess of 90%. Obviously once you have had surgery there are many other factors that can be responsible for your symptoms. Some women who undergo surgery use other treatments in addition to surgery such as creams and local anaesthetic gels. Other women can develop complications and the original symptoms can become worse. The problem with many of the studies is that they fail to follow women up for adequate periods of time to know exactly what the long-term success rate is.
Other complications that might occur from surgery include scar tissue formation, areas of granulation (or healing) tissue which can cause delayed healing, and post-operative infections.
What if I am offered surgery?
This is a difficult area for us to advise on as clearly the decision to undergo surgery should be made by yourself in discussion with your own doctor. We do not wish to influence your decision in this article, as the choice is a personal one. The choice of surgery does not appeal at all to many of our members. However, some of our members have taken up and have had surgical procedures and found this to be of benefit. If your doctor, however, does suggest surgery to you it would be wise when you see him/her to ask:
- What areas of skin will be removed?
- What will the recovery period be?
- How many women has he/she performed this procedure on before, and if so what the success rates are?
- What if the treatment fails?
Hopefully these questions will enable you and the surgeon to develop a clearer picture prior to deciding whether surgery is appropriate for you.