(108) Initial Cases of Complete Vestibulectomy for Treatment of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia

Abstract Introduction There are at least 50 recognized triggers of persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) that may lead to intense spontaneous activation of the paracentral lobule in the somatosensory cortex of the brain. These multiple triggers may originate in one or more of 5 regions in a patient with PGAD/GPD: (1) end organ; (2) pelvis/perineum; (3) cauda equina; (4) spinal cord; and/or (5) brain. Neuroproliferative vestibulodynia (NPV) has emerged as a potential Region 1 etiology of PGAD/GPD. Unfortunately, treatment by complete vestibulectomy has not been reliably successful in the past due, in part, to the inability to gauge the extent to which the anterior and posterior vestibule should be excised. Recent developments offering an expanded and more detailed physical examination during cotton-tipped swab testing has allowed for more accurate surgical excision borders. Objective To report on a case series of patients with PGAD/GPD triggered by NPV for whom symptoms have been ameliorated following complete vestibulectomy. Methods Charts from January 2022 through April 2025 were reviewed to identify patients presenting with PGAD/GPD and NPV. Only patients with no PGAD/GPD 3 months post-operatively were included in this case series. Patients were examined by vulvoscopy with cotton-tipped swab testing to identify locations of vestibular pain using an updated detailed pain mapping system for better accuracy. Pain scores (0-10) of the 1:00-11:00 locations were summed for vestibular total pain scores (range 0-70). Vestibular anesthesia testing (VAT) occurred by applying local benzocaine (20%), lidocaine (8%), tetracaine (6%) to the painful regions to determine if local numbing suppressed both vestibular pain and PGAD/GPD symptoms, confirming the vestibule as the Region 1 source of the PGAD/GPD. Patients then underwent complete vestibulectomy with vaginal advancement flap reconstruction, excising the tissue of the anterior and posterior vestibule including the peri-urethral glans vestibular tissue identified as painful during the detailed mapping (Fig. 1). Results Two patients, ages 21 and 28, diagnosed with PGAD/GPD and NPV met inclusion criteria. Baseline PGAD/GPD symptom severity was rated 6–7/10 and 5/10. Cotton-tipped swab testing of the entire posterior vestibule (from 1:00–11:00) demonstrated total pain scores of 70 and 56, respectively. Both the anterior and posterior peri-urethral glans vestibular tissue revealed significant pain 6-10/10. During VAT, both patients experienced temporary resolution of PGAD/GPD symptoms. At follow-up visits at 10 and 4 months respectively, each patient maintained significant resolution of PGAD/GPD symptoms. Vulvoscopy revealed that cotton-tipped swab testing ranged from to 0-2/10 including the region surrounding the anterior and posterior peri-urethral glans vestibular tissue. Conclusions Complete vestibulectomy in two patients with NPV resulted in amelioration of PGAD/GPD symptoms from Region 1. Based on previous experience with vestibulectomy for PGAD/GPD from NPV, it is important to note that relief is only possible when all symptomatic vestibular tissue is excised. A detailed pre-operative examination that includes the anterior vestibule and peri-urethral glans vestibule is needed. Leaving behind any vestibular tissue with excess nerves and mast cells may result in a lack of resolution of the PGAD/GPD. Disclosure No.