(101) Resolution of Genito-Pelvic Dysesthesia and Dyspareunia Following Excision of a Vaginal Wall Nodule

Abstract Introduction This report presents a unique case of a posterolateral vaginal wall nodule whose excision led to resolution of chronic urinary, vestibular, anal, and sexual pain symptoms. This case broadens the current differential diagnosis for individuals assigned female at birth who present with genito-pelvic dysesthesia and sexual pain originating from Region 1: End Organ. Objective To describe the clinical presentation, diagnostic findings, surgical management, and postoperative outcomes of a 45-year-old cisgender female with a posterolateral vaginal wall nodule causing urinary, vestibular, anal, and sexual pain symptoms. Methods The patient presented in April 2025 with a 3-year history of worsening symptoms of unprovoked anterior vestibular pain, urinary urgency pain, both occurring daily, and intermittent left-sided anal tingling and itching. She also reported dyspareunia characterized by “burning and scratchy” pain felt at the anterior vaginal wall that became sharper with deeper penetration, resulting in symptom flares lasting several days. These symptoms led to avoidance of penetrative sexual activity. The patient scored a 16.8 on the Female Sexual Function Index (FSFI). Her medical history included left-sided PGAD/GPD with sciatic pain secondary to L4–L5 disc pathology treated surgically in 2017. Spinal surgery resolved her left PGAD symptoms and significantly improved her urinary symptoms and deep dyspareunia felt in her left posterolateral vagina. Despite long-term local vulvovaginal hormone therapy with estradiol 0.3%/testosterone 0.01% cream and intravaginal DHEA for GSM, her urinary symptoms recurred, with new and progressing symptoms of unprovoked anterior vestibule pain and dyspareunia felt at the anterior vaginal wall. Pelvic examination revealed normal pelvic floor muscle tension without myalgia; however, palpation of a firm nodule along the left posterolateral vaginal wall (4–5 o’clock position) reproduced her urinary and dyspareunic symptoms. Surgical excision was performed, revealing a subepithelial nodule overlying the medial edge of the puborectalis muscle but not embedded within the muscle fibers. (see photo of vaginal epithelium and nodule). Results Pathology confirmed a benign, fibrotic, calcified lesion. Postoperatively, the patient began pelvic floor therapy at four weeks. By ten weeks, she reported complete resolution of unprovoked anterior vestibular pain, absence of dyspareunia, and significant improvement in urinary symptoms and sexual function. At five months, she remained asymptomatic, noting feeling pleasure at the anterior vaginal wall, experiencing penetrative G-zone orgasms, and elimination of left anal tingling/itching. Her FSFI score increased to 31.5 Neuroanatomically, the nodule’s location in the distal one-third of the vagina suggests involvement of pudendal nerve branches-particularly the left deep and superficial perineal nerve and inferior rectal nerve-accounting for the left-sided urinary, vestibule, and anal symptoms. Possible cross-innervation with pelvic splanchnic nerve branches and secondary sensitization of the puborectalis muscle may also have contributed to symptoms. Conclusions Our findings reflect the importance of considering fibrotic calcified lesions of the posterolateral distal vagina on the differential of genito-pelvic dysesthesia and dyspareunia. Surgical excision of such nodules in select patients may result in substantial symptom relief and improved sexual function. Disclosure No.