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Current Uses of Surgery in the Treatment of Genital Pain Michelle King, Rachel Rubin & Andrew T. Goldstein

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Current Uses of Surgery in the Treatment of Genital Pain Michelle King, Rachel Rubin & Andrew T. Goldstein Current Uses of Surgery in the Treatment of Genital Pain Michelle King, Rachel Rubin & Andrew T. Goldstein Current Sexual Health Reports ISSN 1548-3584 Curr Sex Health Rep DOI 10.1007/s11930-014-0032-8 1 23 Your article is protected by copyright and all rights are held exclusively by Springer Science+Business Media, LLC. This e-offprint is for personal use only and shall not be self- archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy Curr Sex Health Rep DOI 10.1007/s11930-014-0032-8 FEMALE SEXUAL DYSFUNCTION AND DISORDERS (A GIRALDI AND L BROTTO, SECTION EDITORS) Current Uses of Surgery in the Treatment of Genital Pain Michelle King & Rachel Rubin & Andrew T. Goldstein # Springer Science+Business Media, LLC 2014 Abstract Genital pain frequently causes sexual dysfunction during sexual intercourse, vary greatly. However, it has and psychological distress that can impact every aspect of a been suggested that as many as 17–19 % of women woman’s life. When conservative medical treatments do not have a lifetime prevalence of dyspareunia [1]. Due to adequately treat the genital pain, surgical procedures have the the fact that the mechanisms behind these sexual pain potential to significantly decrease the pain. The following disorders have only recently been explored through review examines surgical procedures currently being used to evidence-based research, few medical providers have treat pudendal neuralgia, scarring from lichen sclerosus, and adequate training on the evaluation and management of provoked vestibulodynia. In addition, a diagnostic algorithm dyspareunia [2]. Women experiencing sexual pain disor- is included that can be used to identify specific causes of ders frequently visit multiple health care providers and genital pain and to determining when surgery is an appropriate undergo multiple treatments prior to learning the true treatment option. cause of their symptoms and identifying appropriate treatment [3]. As the different etiologies of dyspareunia Keywords Pudendal neuromodulation . Pudendal neuralgia . are further clarified, diagnostic and treatment algorithms Lysis of vulvar adhesions . Vestibulodynia . Vulvar are being developed. vestibulectomy .Perineoplasty .Genitalsurgery .Dyspareunia This review will examine a diagnostic algorithm for the evaluation of vulvodynia and vesitibulodynia and the cur- rent surgical treatments being utilized in the treatment of genital pain of multiple etiologies, including pudendal Introduction neuralgia, complications of lichen sclerosus, and neuroproliferativevestibulodynia. The vulvar vestibule is Millions of women around the world are afflicted with defined as the tissue between Hart’slineandthehymen. sexual pain disorders that interfere with their daily lives Hart’s line is the lateral borders of the vestibule and marks and frequently result in sexual dysfunction that has the the transition between the non-keratinized squamous en- ability to cause significant psychological, physiological, dothelium of the vestibule to the keratinized epithelium of and marital distress. The results of studies examining the labia minora. The vulvar vestibule extends from the the prevalence of dyspareunia, or pain that occurs frenulum of the clitoris anteriorly to the posterior fourchette. Vulvodynia is defined as pain that of the ana- This article is part of the Topical Collection on Female Sexual tomical structures of the vulva, including the labia majora, Dysfunction and Disorders labia minora, clitoris, prepuce, vestibule, mons pubis, and urethra. Vestibulodynia is pain specifically localized to the M. King (*) : A. T. Goldstein The Center for Vulvovaginal Disorders, 3 Washington Circle NW, vestibule of the vulva. Suite 205, Washington, DC 20037, USA The aim of this review is to provide health care profes- e-mail: [email protected] sionals and patients diagnosed with sexual pain disorders with a general overview of the surgical approaches utilized in these R. Rubin Department of Urology, Georgetown University Hospital, procedures and examples of their success rates as published in Washington, DC, USA the literature. Author's personal copy Curr Sex Health Rep Diagnostic Algorithm of the vestibule, a vulvar vestibulectomy with vaginal ad- vancement, to remove the affected abnormal endoderm. One algorithm for the evaluation of vulvar pain was devel- oped at The Center for Vulvovaginal Disorders in Washing- ton, DC, USA (Fig. 1). This diagnostic algorithm has been Surgery for Genital Pain Caused by Pudendal Neuralgia derived from research conducted in the last 15 years that has helped to identify the underlying pathophysiology of different The term pudendal neuralgia refers to a neuropathic pain causes of vulvovaginal pain (vulvodynia). Specifically, this disorder involving the pudendal nerve dermatome [13]. Orig- research has help to recognize myofascial, hormonal, inating from the S2-4 sacral nerve roots, the pudendal nerve neuroproliferative, inflammatory, and neuropathic causes of carries sensory, motor, and autonomic fibers in both efferent vulvar pain [4–8]. This algorithm helps practitioners to differ- and afferent pathways [14]. The nerve travels inferiorly and entiate between different causes of vulvodynia/provoked posteriorly in a fixed space between the sacrospinous and vestibulodynia and, in so doing, allows them to select appro- sacrotuberous ligaments. It then exits the pelvis through the priate treatments. This has helped to improve the success of obturatorinternus muscle membrane termed Alcock’scanal conservative treatments and to limit unnecessary surgical in- [15]. There are classically three terminal branches described tervention. For example, a woman who is found to have the in the literature including the dorsal nerve of the clitoris/penis, combination of provoked vestibulodynia confined to only the the perineal nerve, and the inferior rectal nerve [15, 16]. posterior vestibule and hypertonic pelvic floor muscles will be Damage or entrapment of the nerve causes refractory pain in offered treatments to correct the hypertonus. The patient will the pudendal dermatome that is worsened by sitting and often be offered treatments such as pelvic floor physical therapy, progressive throughout the day. The neuropathic pain is usu- intravaginal diazepam suppositories, and levator ani botuli- ally described as burning, tingling, and numbing and can num toxin injections, but she would not be offered a surgical affect the clitoris, vulva, vagina, or rectum in a unilateral or intervention such as vulvar vestibulectomy because she does bilateral fashion [17]. not have an intrinsic pathology within the vestibular endothe- Patients who fail initial treatment with medications (such as lium [9–11]. Conversely, a woman who has the combination pregabalin and gabapentin) and pelvic floor physical therapy of provoked vestibulodynia throughout the entire vulvar ves- can be offered a number of procedural and surgical options. tibule and umbilical hypersensitivity (which is evidence of a Initial therapy routinely begins with pudendal nerve congenital neuronal hyperplasia within the tissue derived from blocks. These injections are classically used for both diagnosis the urogenital sinus) would be diagnosed with congenital and therapeutic relief. Various techniques have been described neuroproliferative provoked vestibulodynia (CNPVD) [12]. in the literature including transvaginal [17], transperineal [18], This patient would be offered surgical removal of the tissue and transgluteal. The transgluteal approach is often used Fig. 1 Algorithm for diagnosis and management of vulvar pain Author's personal copy Curr Sex Health Rep becauseitallowsforablockadeattheischialspineand system have their leads removed [18]. While initial outcomes directly in Alcock’s canal [8]. Various imaging techniques of neurostimulation used to treat pudendal neuropathy and are used to ensure accuracy of the injection. Hibner de- other chronic pelvic pain conditions are promising, small scribes his technique of injecting a series of three unilat- sample sizes and lack of randomized control trials make it eral or bilateral CT-guided injections into Alcock’s canal difficult to make broad conclusions [24, 25]. done 3 weeks apart. Injections consist of 10 cc of 0.5 % bupivicaine and triamcinolone [8]. Robert and colleagues conducted a randomized control trial Surgery for Genital Pain Caused by Complications that showed a reduction in pain in two thirds of patients with of Vulvar Lichen Sclerosus two to three blocks each over a period of 6 months [19]. Patients who do not find sustained relief despite serial Lichen sclerosus is a chronic inflammatory disease of the nerve blocks can be offered surgical decompression of the anogenitalepithelium that causes symptoms of vulvar itching, nerve. There are four described operations, including irritation, and burning [26, 27]. It has been reported that vulvar transichiorectal [20], perianal [15], laparoscopic, and lichen sclerosus affects
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