This chapter should be cited as follows:
Faraj PE, Louis L, Glob Libr Women's Med
ISSN: 1756-2228; DOI 10.3843/GLOWM.418563
The Continuous Textbook of Women’s Medicine Series – Gynecology Module
Volume 4
Benign gynecology
Volume Editor: Professor Shilpa Nambiar, Prince Court Medical Centre, Kuala Lumpur, Malaysia
Chapter
Simple Operations of the Vulva
First published: January 2025
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TERMINOLOGY
We recognize that patients have diverse gender identities. In this chapter, we use the word ‘women’ to describe patients or individuals whose sex assigned at birth was female.
INTRODUCTION
Simple operations of the vulva are commonly performed in the day-to-day practice of gynecologists. Having a good understanding of the diverse presentations of benign vulvar disease is key to determining the best management plan and surgical technique needed. When the diagnosis is unclear and challenging, using the correct biopsy technique is essential to confirm the diagnosis and assist in the choice of the best surgical approach. It is imperative for the gynecologist to have a good understanding of the various surgical techniques used in the management of cysts, infections, lesions and benign conditions of the vulva, and also that they are able to differentiate those that look suspicious in terms of malignancy, and to refer these to the gynecological oncological team for further management.
VULVAR BIOPSY
Vulvar biopsies are a useful diagnostic tool, and, in some cases, are an effective method for treating benign conditions. A vulvar biopsy includes excision of both the skin and underlying dermis with the intent of completely removing a small lesion or sampling a large lesion. Vulvar biopsies should be performed in the case of concerning clinical features or symptoms, and can be easily performed under local anesthetic in the outpatient setting. When taking a biopsy, it is important that normal tissue alongside the lesion is included to aid in the histological diagnosis.
Indications to perform a vulvar biopsy include a lesion that cannot be clinically diagnosed, an ulcer or lesion that does not heal and persists, suspicion of vulvar dermatosis, or a symptomatic growth. Any lesions that undergo change in size, color or shape (raising the suspicion of melanoma) should be evaluated using the ABCDE warning sign tool: asymmetry, irregular border, variated color, diameter greater than 6 mm, evolving (growing or changing).1 There are generally no contraindications for performing a vulvar biopsy. Women with coagulopathy or on anticoagulants can still have a biopsy performed if it is limited and not extensive. However, it is best to delay performing biopsy in immunocompromised patients where possible.1
The equipment necessary to perform the vulvar biopsy includes a syringe for local anesthetic with a 25- or 27-gauge needle, sterile gauze, antiseptic solution, local anesthetic, biopsy instruments, sterile scissors and forceps, silver nitrate or Monsel’s solution, a container for the specimen, and antibiotic ointment. In some cases, a needle driver, suture and scalpel may be needed.
Biopsying subcutaneous lesions and those that are cystic in nature may benefit from use of ultrasound or MRI to guide management and the surgical approach.2
Procedure
Prior to starting the biopsy procedure, confirm that the supplies and equipment listed above are present in the room. Having an assistant in the room may be useful to help retract and pass equipment. Proceed to examine the vulva and decide on the most appropriate biopsy site and method of biopsy (Keyes punch, shave or excisional biopsy). Use aseptic wash to clean the area, and administer local anesthetic subcutaneously (Table 1). Obtain the biopsy by removing the epidermis and dermis. Hemostasis may be achieved through either direct applied pressure, hemostatic agents, silver nitrate or use of absorbable sutures if necessary. Finally, consider applying antibiotic ointment and gauze over the biopsy site.
1
Local anesthetic limits.3
Local anesthetic agent | Dose | Onset of action | Duration of effect |
Lidocaine 1% without epinephrine | 4 mg/kg (maximum 300 mg) | 2–5 min | Approximately 2 h |
Lidocaine 1% with epinephrine | 7 mg/kg (maximum 500 mg) | Approximately 3 h | |
Bupivacaine 0.25% without epinephrine | 2 mg/kg (maximum 175 mg) | 5–10 min | Approximately 6 h |
Bupivacaine 0.25% with epinephrine | 3 mg/kg (maximum 225 mg) | Approximately 6 h |
Techniques
Punch biopsy is used for most lesions, including inflammatory lesions, except for suspected melanoma. A disposable or reusable Keyes punch biopsy may be used, and these are available in varying tip sizes ranging from 1.5 to 8 mm in diameter. The biopsy is performed by keeping the skin taut using the non-dominant hand, placing the punch over the area to be biopsied, and then applying gentle pressure while twisting the Keyes punch. A biopsy depth of 1–2 mm, including both epidermis and dermis, is considered appropriate. Deeper biopsies are at higher risk of bleeding and potential nerve damage in the presence of vulvar atrophy. The tissue may then be lifted with forceps and excised.
A shave biopsy is mainly used for raised lesions that do not require full thickness for diagnosis. Such biopsies may be obtained by using either a scalpel, scissors or colposcopy biopsy forceps. It is important to get a good sample with appropriate depth while not cutting too deep. In contrast to punch biopsy, the skin should be pinched to create a better platform. It is key to obtain a sample of the lesion with some surrounding tissue, but taking large samples should be avoided to reduce the risk of bleeding and need for suturing.
Excisional biopsies are used for melanomas and treatment of vulvar intraepithelial neoplasia. For polypoid lesions, the tissue should be grasped with the forceps and excised at the bottom of the pedicle using a scalpel or scissors. Bleeding and a need for sutures are unlikely with such lesions. In cases in which the sample should be excised rather than sampled, an ovoid cut should be performed around the lesion, with a good clearance margin of at least 1 cm, and the cut should be closed with sutures. Subcutaneous sutures are best for reduced irritation and the best cosmetic results.
In cases in which suture closure is not required, applying gentle pressure with sterile gauze at the site of the biopsy can help to achieve hemostasis. When deeper biopsies are needed, applying either hemostatic agents or silver nitrate may help to maintain hemostasis in the absence of electrocautery. Placing sterile gauze over the hemostatic agent or using silver nitrate can help to prevent irritation to surrounding tissue, and may be removed by the patient themselves following first voiding. For larger biopsies, topical antibiotics and analgesics may be applied to prevent irritation after urination. Patients should be advised to keep the area clean and protected from fecal contamination to reduce the risk of infection.
Complications
Complications rarely occur following vulvar biopsies, but may include ongoing bleeding, infections and scarring. The occurrence of complications may be reduced by avoiding unnecessarily deep biopsies. Bleeding may be managed using suturing, hemostatic agents (physical or biologically active) or cautery. In cases in which an infection occurs, local wound care measures may be used. In some cases, systemic antibiotics as well as an antiseptic wash solution may be required, particularly in immunocompromised patients and poorly controlled diabetic patients. Pain tends to resolve quickly in the vast majority of patients, with minimal tenderness at the site of biopsy. Patients who complain of increasing persistent pain should be reassessed.4 Patients should be encouraged to soak in warm tub baths or sitz baths twice daily. Patients should be advised to refrain from sexual intercourse.
SURGERY FOR BARTHOLIN GLAND ABSCESS/CYST
The Bartholin glands are located bilaterally on the posterior margins of the introitus, with openings found between the hymen and labia minora at the 4 and 8 o’clock positions. They are overlaid by fascia and drain straight into the vestibule. Blockage to the ducts that drain the Bartholin gland leads to formation of cysts ranging from 1 to 5 cm in size. Small cysts are frequently asymptomatic but larger cysts may lead to vaginal pressure or dyspareunia, requiring surgical management.5
A Bartholin gland abscess occurs following obstruction of the ductal opening by accumulated pus. Patients with such an abscess usually report a rapid unilateral enlargement that tends to be painful, and may be accompanied by a fever, flu-like symptoms and drainage of pus. Typically, a fluctuating mass is found at the Bartholin gland projection. Bartholin abscesses are polymicrobial infections, with Escherichia coli, the aerobic rod bacteria, being the commonest organism isolated. Other common organisms are anaerobic Bacteroides species, aerobic Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus, Streptococcus species and Enterococcus fecalis.6,7 Chlamydia trachomatis and Neisseria gonorrhea8 are isolated more frequently in the adolescent population, and require treatment with appropriate antibiotics. Incision and drainage provide relief of symptoms, but have a higher recurrence rate compared with procedures that form a permanent outflow tract. The introduced foreign body (i.e. Word catheter or Jacobi ring) prevents wound closure, resulting in a new epithelialized fistula. The surgical goal is incision, drainage and creation of a new duct ostium. Therefore, for many patients, placement of a Word catheter, or performing a marsupialization, results in permanent resolution of the Bartholin cyst or abscess. Reported abscess formation recurrence rates range from 5 to 10%.9,10
Carcinomas of the Bartholin gland are responsible for approximately 5% of vulvar cancers. Postmenopausal women and women of African descent are at higher risk. In the presence of Bartholin gland enlargement in women over 40 years of age, or when a solid mass is present within the Bartholin gland, malignancy should be ruled out by tissue biopsy.11
Incision and drainage using Word catheter
Bartholin gland abscesses and large symptomatic cysts should be treated with incision and drainage. Identification of a drainable mass that is fluctuant on examination is imperative prior to incision and drainage. In some cases, there may be cellulitis with swelling, which may require alternative management. An ultrasound scan may be used in difficult cases to identify the presence of a collection of fluid for drainage. Incision and drainage may be inappropriate, and excision should be considered in patients with solid lesions, recurrence in patients over 40 years old, or for recurrent abscesses in general.10,12
Instruments
Supplies required for placement of a Word catheter include a protective pad to place under the patient, gauze sponges, a culture container, antiseptic solution, anesthetic agent, a syringe with a needle for local anesthetic, scalpel, small hemostats, toothed forceps, sterile fluid, and a Word catheter pack, which includes a Word catheter, a 22-gauge needle and a 3-ml syringe. The Word catheter is a 3-cm long latex or silicone tube stem with an inflatable balloon. It is important to test the catheter’s bulb with fluid to check for any leaks. The presence of a latex allergy must be excluded based on currently available kits.
Analgesia and patient positioning
Most procedures are performed in the outpatient clinic or emergency department. In rare situations (e.g. due to the large abscess size or when adequate analgesia is not achieved with local anesthetic), incision and drainage in the operating theater may be required. After examination and obtaining informed consent, it should be confirmed that all supplies needed are present in the room. The patient may benefit from taking simple analgesia prior to the procedure.
To perform the procedure, place the patient in the lithotomy position with a protective pad underneath them. Carefully examine the vulva and identify the drainable mass, ensuring that it is fluctuant. Identify an area proximal to the hymeneal ring for the incision site. Clean with antiseptic solution (povidone-iodine solution or another suitable agent), and inject local anesthetic subcutaneously in the area overlying and adjacent to the planned site of incision, allowing time for it to take effect. A 1% lidocaine solution, with or without epinephrine (ideally without), is recommended.
Incision and drainage
Perform a 1-cm incision using a scalpel with a number 11 blade to pierce the skin and underlying Bartholin cyst or abscess wall to allow the contents to start draining (Figure 1). The incision should be made on the bulge just outside and parallel to the hymeneal ring, and medial to Hart’s line. A culture may be obtained at this point by collecting the drained material or passing a swab across the incision site. Hemostats may now be used to explore and breakdown any adhesions and drain all potential loculations, followed by application of external pressure.
1
Incision and drainage of Bartholin abscess/cyst.
Word catheter placement
After all contents have been drained, insert the deflated Word catheter into the cavity while holding the cyst wall and skin edge with the forceps. Fill the Word catheter with 2–3 ml of sterile fluid (Figure 2), confirm it remains in place by a gentle tug, and tuck the hub end of the catheter into the vagina (Figure 3). This prevents the catheter from being dislodged by perineal movement. The Word catheter may be left in situ for 4–6 weeks to achieve fistulation and reduce the risk of recurrence.
2 Insertion and inflation of Word catheter. |
3 Tucked hub of Word catheter into vagina. |
Postoperative care
Bartholin cyst drainage does not require antibiotic treatment. However, antibiotics should be prescribed after drainage of abscesses that are typically surrounded by significant cellulitis. Appropriate choices include broad-spectrum antibiotics such as trimethoprim/sulfamethoxazole, amoxicillin/clavulanate or clindamycin, cefixime or cefalexin for 7 days. Patients should be encouraged to soak in warm tub baths or sitz baths twice daily. Patients should be advised to refrain from sexual intercourse to avoid discomfort and Word catheter displacement. If the catheter is displaced, there is no need to attempt replacement, because of the very likely closure of the cavity.
Complications
The main complications encountered are failure to develop a fistula track or premature closure of the formed track. This is more likely to occur in cases in which the Word catheter has fallen out without immediate re-siting, or failure to place the catheter appropriately into the cavity initially. The recurrence rate is between 3 and 18%.9,12,13 Other common complications include moderate pain and dyspareunia.14 Hematoma formation and bleeding are less common unless the scalpel was used to cut too deep or there was no mass to be drained to start with.
Marsupialization
Marsupialization is used in cases of recurrent cysts or abscesses after initial treatment. Marsupialization may be performed in the office under local anesthetic on patients with an uninfected cyst and good pain tolerance. Alternatively, the procedure can be performed in the operating room with either local anesthetic and sedation or a regional block. Marsupialization is less likely to be successful in the presence of infection due to inflammation and a high likelihood of premature fistula closure, with a recurrence rate of up to 15%.9,15
The equipment and steps needed for marsupialization are similar to those for the incision and drainage procedure described above but without the Word catheter to drain the mass, but the incision is extended to approximately 3 cm (Figure 4) and the cyst wall is identified and sutured to the overlying fascia and skin in a circumferential manner to create a permanent opening (Figure 5).
4 Line showing site of 3-cm incision. |
5 Suturing of cyst wall to overlying fascia and skin in circumferential manner to create permanent opening. |
Due to the increased risk of malignancy in postmenopausal patients, a biopsy should be obtained from the cyst wall. It takes up to 2 weeks for the wound to heal, and patients are usually reviewed after 1 week. The area should be kept clean and dry by the patient, and antibiotics should be given to those who are immunocompromised or pregnant. The risk of infection, bleeding, hematoma formation, dyspareunia and scarring are higher with marsupialization compared with use of a Word catheter.
Excision of Bartholin gland
Bartholin gland excision is rarely performed, and is indicated in cases in which the diagnosis is uncertain, there is evidence of an inflammatory reaction, in the presence of irregular or unusual pigmentation, ulceration, induration or bleeding, or a viral lesion such as a wart that is refractory to medical therapy or is flat, if there is rapid growth of the lesion, and in postmenopausal women or women in an immunocompromised state.10,14
Gland excision is performed under regional or general anesthesia. Due to the risk of bleeding, patients who are taking anticoagulants should stop their medication prior to the procedure. Immunocompromised patients may be offered a course of prophylactic antibiotics.
Procedure
Position the patient in the lithotomy position, and clean and drape the patient while maintaining a sterile field. Re-examine the gland to be excised, and confirm size and outline; a digital rectal examination may be needed. Make a 3-cm incision through the skin and fascia on the medial aspect of the gland, not through the gland itself. Gently dissect the gland from its surrounding fascia, and stop any active bleeding. Close the deep space that forms after removal of the gland in layers to prevent any collection of blood or serous fluid, and close the skin subcutaneously. Place a drain if there are concerns regarding depth or ongoing bleeding.
The patient should regularly clean the perineum and keep the area dry. It is important to follow up patients within 2 weeks to assess healing and determine the need for further management or follow-up. Simple analgesia is usually sufficient to manage the postoperative pain.
It is crucial to obtain good hemostasis during the procedure, as bleeding is the most common complication intra- and postoperatively. It is necessary to obtained informed consent from the patient and to discuss the risks of infection, bleeding, scarring, chronic pain, vaginal dryness and disfigurement. Cyst remnants may lead to recurrent cyst formation and are less amenable to repeat surgery, due to distortion of the anatomy caused by the initial surgery.
ABLATIVE PROCEDURES
Ablative procedures are mostly used for condylomata acuminata, together with other conditions such as skin tags, actinic and seborrheic keratosis, and molluscum contagiosum. Ablation may also be used in cases of vulvar intraepithelial neoplasia in which no invasive disease has been found. Ablative therapy should not be performed in the presence of infection or on lesions in the presence of diagnostic uncertainty, as this would destroy tissue that may be used for diagnostic evaluation. Immunocompromised patients are at higher risk of delayed healing and developing infection following ablation.
In cases of limited disease, ablative procedures may be performed in the outpatient setting if patients can tolerate local anesthetic administration and are able to sit still for the procedures. Due to the risk of damaging healthy tissue, extensive lesions are managed in theater under general anesthetic.
Cryotherapy
Cryotherapy aims to create very low temperatures of −50°C using liquid nitrogen. Various spray tips are available, and are used with freeze and thaw cycles. To perform ablation with cryotherapy, start by cleaning the area with water, removing any debris. Apply local anesthetic under the lesion to elevate it. Apply the probe directly on the lesion in closed systems, or approximately 1 cm above the lesion when using the spray. Aim for a 2-mm rim of frost surrounding the lesion, and observe for thawing. Skin tags require a 5-s freeze time, while seborrheic keratosis and condyloma need up to 10 s, and actinic keratosis requires up to 20 s.16,17
Carbon dioxide laser ablation
Carbon dioxide laser ablation may be used for the treatment of vulvar lesions under direct vision or through a colposcope. Safety measures should be taken into consideration when dealing with viral lesions: both the patient and team members are advised to wear masks and eye protection, due to the theoretical risk of transmitting vaporized viral particles.8 Use of a smoke evacuator is advised where available. Ablation at depths greater than 3 mm may breech the dermis and increase the risk of complications. To perform carbon dioxide laser ablation, examine the lesion carefully using a colposcope, and apply acetic acid to demarcate the area. Use wet towels to absorb laser beams surrounding the lesion. Test the laser on a wet tongue depressor. The optimal power is 6 W for flat lesions and 10 W for most others. Set the laser spot size to diffuse; this can be achieved by controlling the distance from the lesion when using a free-hand laser. Aim for a 1-cm margin and 2–3-mm depth of ablation.18,19
Simple analgesia should be sufficient postoperatively. Antimicrobial use is associated with reduced risk of infection and prevention of labial fold adherence. Petroleum jelly is an alternative to ointments that are not tolerated.
LABIA MINORA REDUCTION (LABIAPLASTY)
The labia minora is known to vary in both size and shape, with no set criteria to define hypertrophy. Labia minora reduction is requested by some women with asymmetrical and large labia minora who suffer from dyspareunia, difficulty exercising, irritation when wearing certain types of clothing or esthetic dissatisfaction.20 Due to the risk associated with surgery, the American College of Obstetricians and Gynecologists recommends labia minora reduction surgery for medical indications only. Indications include labial hypertrophy and asymmetry caused by congenital conditions, female genital mutilation, asymmetry following traumatic vaginal delivery, hygiene issues and infections.21
As this is an elective procedure, caution should be exercised when performing labiaplasty surgery on patients with immunosuppression, bleeding disorders or an anticoagulated state, and those with multiple comorbidities.
The aim of labiaplasty surgery is size reduction and maintenance of normal anatomy. Traditional techniques involving excision of the labia at the base have the drawbacks of stiffening and color contrast at the suture line, decreased labial sensation, sexual dysfunction and chronic pain. Techniques to address these drawbacks, including the S-, V-, W- and Z-plasty incisions, have been developed by specialist gynecologists and plastic surgeons.22 There are no definitive guidelines on which incision should be used as there is no clear advantage of one technique over another.
The two techniques described below, edge and wedge resection, are straightforward and should be easily performed by the general gynecologist.23
Procedure
For both edge and wedge resection, the patient is placed in the lithotomy position, and cleaned and draped in an aseptic fashion. It is key to identify and mark the area to be resected correctly, aiming for a symmetrical appearance. Local anesthetic (comprising lidocaine and epinephrine) may be injected subcutaneously along the marked area, avoiding distortion of the labia.
Edge resection
For edge resection of the labia, the excess labial tissue is marked (Figure 6), infiltrated with local anesthetic and excised using a scalpel or Metzenbaum scissors. Extra care should be taken while excising to achieve smooth edges. A layer of interrupted subcutaneous sutures is placed to reduce tension from the edges using 4‑0 Vicryl sutures (Figure 7), which may then be used to close the edges with running subcuticular sutures. In cases in which a large amount of tissue is removed, ‘dog ears’ may form, and should be excised immediately prior to completion of suturing. This technique is effective in cases in which the excision is performed following trauma and irregular edges are to be repaired. The uninjured labia will also need to be excised to achieve symmetry. Sensory innervation to the labia is higher at the periphery, and patients are at risk of developing paresthesia following an edge resection.
6 Marking of excess labial tissue. |
7 Layer of interrupted subcutaneous sutures is placed to reduce tension from edge. |
Wedge resection
For wedge resection of the labia, the area is marked in a wedge shape from the center and posterior aspect of the labia (Figure 8) and then infiltrated with local anesthetic. The marked area is then excised, and the edges are closed in two layers (Figure 9). Tension is reduced by means of a first layer of subcutaneous interrupted sutures using 4‑0 Vicryl. The skin is then closed by a second layer of subcuticular or interrupted sutures using 5‑0 Monocryl. This technique creates a natural border to the labia, and is best used in patients with labia protruding more than 2 cm beyond the fourchette.
8 Wedge-shaped markings from the center of the labia. |
9 Excised marked edge and closure. |
Postoperative management
Simple analgesia may be advised for pain relief. Alternatively, an anesthetic containing topical antibiotic may be used. Usage of ice packs within the first 48 h or sitz baths in the first 24 h can also provide pain relief. Safety netting advice should be given to the patient regarding signs of infection, and they should be advised to seek advice in cases of erythema, purulent material, increased pain or fever. A 2-week follow-up may be arranged to assess for any signs of complications. Patients should be advised to delay intercourse until the wound is healed. Swelling is common, and may take up to 4 weeks to completely resolve. In case of hematoma formation, this should be drained to allow healing and to reduce pain. Dehiscence, bleeding and infection are uncommon.24
EXCISION FOR VESTIBULE DISORDER (VESTIBULECTOMY)
The vestibule is defined as the area between the hymen and Hart’s line, extending to the fourchette posteriorly and the frenulum of the clitoris anteriorly. Surgery on the vestibule is reserved for patients who are unable to engage in sexual intercourse due to pain and who have not responded to pelvic floor rehabilitation and medical treatment alone.
All treatable causes of pain must be excluded prior to the diagnosis of vulvodynia.25 Vulvodynia may be easily mistaken for vaginismus, which does not resolve with surgical management. Surgery has been shown to be successful at resolving the pain in up to 60–90% of cases of vulvodynia, prompting the suggestion that surgery should be more readily offered to patients.26 Patients should be medically optimized preoperatively, and should not have any signs of infection or inflammation. Caution should be taken in those who are immunocompromised or anticoagulated due to the increased risk of complications.
Vestibulectomy may be performed in the outpatient setting for those with pain in smaller areas, while those with pain across larger areas require sedation or general anesthetic.27
Procedure
Initially, the patient is placed in the lithotomy position. A cotton swab is used to map the area of pain, and a marker is used to outline the area to be excised (Figure 10). The vulva is then cleaned and draped using an aseptic technique. Local anesthetic containing both lidocaine and epinephrine is recommended to help reduce postoperative pain and bleeding during the procedure. Using a scalpel blade, the marked area is excised at a depth of 2–5 mm starting from the lateral border. Precautions should be taken when dissecting around the urethra to avoid unwanted damage. The skin under the vagina should be undermined to create a flap and to facilitate closure without tension. After creation of the flap, deep interrupted sutures should be placed using 3‑0 Vicryl to close the deep space and reduce the risk of dimpling and collections. The overlying mucosa should then be closed using 4‑0 Vicryl in an interrupted or running fashion (Figure 11).
10 Marked vestibule area to be excised. |
11 Approximation and closure of the created vaginal flap. |
Postoperative care consists of application of ice packs to the perineum for 2 days. Sitz baths may be used after 24 h for pain relief. Insertion of foreign objects such as tampons and intercourse should be avoided for up to 6 weeks or until healing is achieved and both surgeon and patient are happy with the results. Rigorous activity and friction should be avoided for 14 days. There is no role for prophylactic antibiotics in this procedure. Follow-up should be arranged to assess the operation site in 4–6 weeks.28
Complications following a vestibulectomy may include bleeding, collection of blood or serous fluid, infection, wound separation needing repair in some cases, scarring and formation of Bartholin cysts. Poor cosmetic results may be an issue following vestibulectomy, and this should be discussed with the patient in the preoperative period.29
PERINEOPLASTY
The perineum refers to the area below the pelvic muscles and fascia that make up the pelvic outlet. Within the perineum, there is a specific section called the perineal body, which is located between the anus and the vagina. There are various perineoplasty techniques that are used to address various perineal issues such as incontinence, prolapse and obstetric lacerations, but this chapter focuses specifically on revision perineoplasty for individuals who are experiencing dyspareunia related to the vaginal introitus.
Revision perineoplasty is typically recommended for those who have undergone non-surgical treatments, such as pelvic floor muscular therapy, but continue to experience significant dyspareunia. It may also be necessary for individuals who have scarring or skin damage at the introitus due to prior obstetric injuries, other trauma, or treatment of vulvar lesions. However, it is not advisable to perform this surgery too soon after vaginal delivery, in the presence of inadequately repaired third- or fourth-degree perineal lacerations, or if there is ongoing significant rectal incontinence. Additionally, this surgery is not designed to address other issues such as cystoceles or rectoceles. Patients should also not have any medical conditions that would make surgery or the use of anesthesia unsafe.30,31,32
Procedure
The surgery is performed as a day surgery, with the patient placed in the dorsolithotomy position, and the area prepped and draped. A triangular incision is made on the perineal skin, extending from each side of the introitus towards the anus and meeting at a point in the midline (although some surgeons use a diamond-shaped incision extending into the vagina). The vagina is then undermined to allow it to be pulled out without any tension. Once the triangular piece of skin and vaginal tissue are removed, the edges of the vaginal tissue are sewn to the perineal skin using interrupted sutures, typically with 3‑0 to 4‑0 Vicryl. The underlying tissue may also be approximated to reduce tension, but care is taken not to create any extra tension in the midline that may lead to dyspareunia.
Pain following the procedure may be managed with simple analgesia and sitz baths. Healing generally takes around 6–8 weeks, during which time patients should avoid intercourse and tampon use. A follow-up appointment is best arranged 4–6 weeks after the procedure to monitor healing. Possible complications include bleeding, dehiscence, dyspareunia and infection, but these are rare.
PRACTICE RECOMMENDATIONS
- Having a good understanding of the diverse presentations of benign vulvar disease is key to determining the best management plan and surgical technique needed. When the diagnosis is unclear and/or challenging, using the correct biopsy technique is essential to confirm the diagnosis and assist with the choice of the best surgical approach.
- Vulvar biopsy is a useful diagnostic tool, and, in some cases, an effective method for treating benign conditions. A vulvar biopsy includes excision of both the skin and underlying dermis, with the intention of completely removing a small lesion or sampling a large lesion.
- Vulvar biopsy can be easily performed under local anesthetic in the outpatient setting, and should be performed in the case of concerning clinical features or symptoms. Techniques include shave, punch and excisional biopsy.
- A Bartholin gland abscess occurs following obstruction of the ductal opening by accumulated pus.
- Bartholin abscesses are polymicrobial infections, with Escherichia coli, aerobic rod bacteria, being the commonest organism isolated.
- Incision and drainage of Bartholin gland abscesses provides symptom relief but has a higher recurrence rate compared with procedures that form a permanent outflow tract, such as created by introducing a foreign body (i.e. a Word catheter or Jacobi ring) to prevent wound closure, resulting in a new epithelialized fistula.
- Bartholin gland excision is rarely performed, but is indicated in cases in which the diagnosis is uncertain, there is evidence of an inflammatory reaction, the presence of irregular or unusual pigmentation, ulceration, induration, bleeding, the presence of a viral lesion such as a wart, that is refractory to medical therapy or is flat, if there is rapid growth of the lesion, and in postmenopausal women or those in an immunocompromised state.
- Ablative procedures, such as cryotherapy and carbon dioxide laser vaporization, are most commonly used for condylomata acuminata, together with other conditions such as skin tags, actinic and seborrheic keratosis or molluscum contagiosum, and vulvar intraepithelial neoplasia in which no invasive disease has been found.
- Ablative therapy should not be performed in the presence of infection and on lesions in the presence of diagnostic uncertainty, as this would destroy tissue that can be used for diagnostic evaluation.
- Due to the risk associated with surgery, the American College of Obstetricians and Gynecologists recommends labia minora reduction surgery for medical indications only, such as labial hypertrophy and asymmetry caused by congenital conditions, female genital mutilation, asymmetry following traumatic vaginal delivery, hygiene issues and infection.
- The aim of labiaplasty surgery is size reduction and maintenance of normal anatomy. There are no definitive guidelines on which incision is to be used, as no clear advantage for one technique over the other has been described in the literature.
- Surgery on the vestibule is reserved for patients who are unable to engage in sexual intercourse due to pain and have not responded to pelvic floor rehabilitation and medical treatment alone.
- Revision perineoplasty is typically recommended for those who have undergone non-surgical treatments, such as pelvic floor muscular therapy, but continue to experience significant dyspareunia, and for individuals who have scarring or skin damage at the introitus due to prior obstetric injury, other trauma or treatment of vulvar lesions.
CONFLICTS OF INTEREST
The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.
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REFERENCES
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