Most patients pain free after surgical removal of Bartholin's glands. (Vulvar Vestibulitis).
"It's my belief that this problem, which I am now seeing in almost epidemic proportions in the United States, stems from dysfunctional mucous glands in the vulva. You can pinpoint this in virtually every case of vestibulitis, and the Bartholin's glands seem to be the most frequently affected," Dr. Baggish noted during an interview.
Other vulvar glands that are less often involved include Skene's, as well as the paraurethral glands, he said at an ob.gyn. meeting sponsored by the University of Chicago.
A more commonly used surgery involves the simple excision of the hymen and perihymenal tissues or photocoagulation of the vestibular dermis and epidermis.
The problem with simple excision is that it simply excises the glandular ducts, leaving the glands themselves still in place.
About 45% of patients report good results with the simple vestibular excision technique, said Dr. Baggish, who is professor of ob.gyn. at the University of Cincinnati.
"Results are objectively better with removing the gland, rather than just excising the skin. It's not a skin-deep problem. If you're going to take the duct of the gland, what happens to the gland? In some cases it will atrophy," he said at the meeting.
In a variation of the more common technique, Dr. Baggish performs an excision of the vestibule and excision of the Bartholin's glands and sometimes other glands, as well as advancement of the vagina.
This treatment provides the most consistent and long-lasting relief, compared with any other treatments for vulvar vestibulitis.
In a series of 250 patients with vulvar vestibulitis whom Dr. Baggish has treated, a total of 95%-97% have had complete relief of pain with intercourse, he said.
Patients with vulvar vestibulitis are typically nulliparous (66%), almost exclusively white (96.5%), and invariably have a long history of recurrent vaginal fungal infections.
The fungal etiology is seldom documented by culture evidence.
Vulvar vestibulitis usually presents abruptly with burning pain that is limited to the vestibule and is instigated by such things as sexual intercourse, tampon insertion, wearing constricting pants, and bicycle or horseback riding.
"Gynecologists need to be aware this is the typical way this syndrome starts--they shouldn't just dismiss this as recurrent fungal infections. The simplest thing is to examine the patient," said Dr. Baggish, who is also chair of obstetrics and gynecology at Good Samaritan Hospital in Cincinnati.
The condition is easily recognized. "The patient is red over the Bartholin's ducts, and where the gland is located, a light cotton swab touch will elicit an unusual response, pain way out of proportion to te touch. In addition, even slight pressure such as spreading the labia will cause discomfort, and since the skin remains chronically inflamed, many of the patients will have skin that splits and tears very easily," he said.
The etiology of vulvar vestibulitis remains unknown, but Dr. Baggish said that he believes it is caused by a chemical sensitivity that may be induced by a variety of agents, including contact with topical anrifungals, iodine preparatory solutions, topical or laser treatments for human papillomavirus, lubricating agents, or chlorine agents that are present in feminine hygiene products or swimming pools.
He performs surgery only on those patients who have undergone a 3- to 4-month trial of conservative therapy, although he noted that only 15% of his patients have had relief of symptoms with this treatment.
Conservative treatment involves no topical applications, abstention from intercourse for a total of 6 weeks, postvoid irrigation with distilled water to negate the possible irritation of high urinary oxylate, and low-dose Elavil to interrupt pain signals.
Dr. Baggish cautioned that excision of the Bartholin's glands is a surgically challenging procedure that can take more than an hour per gland and requires intraoperative visualization with a microscope to ensure accuracy.
He suggests that physicians who are not familiar with this technique should consider referring their patients to a specialist to avoid potential serious complications, such as significant blood loss, wound infection, entry into the urethra or rectum, or scar formation.
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|Publication:||OB GYN News|
|Date:||Nov 1, 2001|
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