VVS and Surgery: Part I
For many women with VVS, the word "surgery" is an anxiety-inducing one; I’ve always found this to be the case mostly because, although it is touted to be the only “cure” for VVS, scholarly articles on the subject are awfully hard to come by (this has become much less so over the past several years though, thank goodness). Add anxiety-inducing questions like “Does it actually work?”, “What happens during the surgery?”, and “What happens afterward?” (and so on) to the mix and it's a pretty potent combination!
So, I've decided to address many of these issues head on in yet another several part email series. This one will differ, however, in that I’d like to send out the parts consecutively because I know that this is a topic that is of great interest to a lot of you.
In this Part I, the questions that will be addressed will be:
a) What is the surgery for VVS? What happens during surgery? b) When we talk about "success rates", what does it really mean to have a "success"? and c) What are the success rates?
What Happens During Surgery? A Description.
As in turns out, there are actually several different procedures (6 to be precise) that doctors perform for the treatment of VVS, each with varied degrees of invasiveness and, consequently, implications on the success rates.
PS: I'm going to leave in a couple "medical terms" in the descriptions because, chances are, the doctors that you will talk to about VVS surgery will throw around these words. I've defined most of them but I didn't want to take them out entirely because being aware of them makes the conversations go much more smoothly.
1) Woodruff Procedure:
This is the oldest technique out there and one of the most invasive. In this procedure, a semi circular portion--from about 3 o’clock to 9 o’clock--of the perineal skin (region between the posterior--back--vulva junction and the anus) and the posterior portion of both the vestibule and hymen ring are removed. To put in simple terms, it's the removal of a triangular portion of skin starting from 3 and 9 o'clock and going down several inches, towards the anus. While it's known for it's effectiveness in removing painful tissue, it's criticized for its' relatively high complication rate dues to new problems such as decreased skin elasticity and the implications of removing functioning glands.
2) Vulvar Vestibulectomy:
This is the removal of the skin starting from around the urethra and including the posterior fourchette (the fold of skin that forms the back margin of the vulva); the procedure doesn’t include the excision (removal) of the perineal skin. The skin that surrounds the removed area is advanced (as in: pulled up) and sutured. This one is less invasive than the Woodurff procedure so while it has a lot of the same concerns, they are often less severe in nature.
3) Modified Vulvar Vestibulectomy:
The difference between this one and the version above is the amount of skin that is advanced; while the vulvar vestibulectomy involves the area around the urethra, the modified version focuses on removing the skin in the posterior of the vestibule (around 6 o'clock, where women with VVS often have pain). Again, less cutting means fewer complications. This one is "most popular" (for lack of a better term!) because it stikes a fairly good balance between removing enough tissue that painful areas are removed but it doesn't require major reconstruction of the surrounding tissues.
This is where only the most painful areas of the vestibule are excised (no skin advancement). This one is the least invasive so far because it usually only requires local anesthetic. This one works best for mild cases of VVS where the pain is very localized and distinct. The key to a "successful" surgery is making sure that the patient is indeed an appropriate candidate which means things like lack of pelvic floor dysfunction as well as other factors that difuse the pain to other regions of the pelvic floor.
5) Carbon Dioxide Laser:
This is the removal of the vestibular tissues and can include up to 1 cm of tissues. I’m mentioning this one for completeness although this procedure has one of the lowest success rates. Instead, a different type of laser surgery has climbed in popularity among physicians which is:
6) Flashlamp Excited Dye Laser:
This type of surgery usually includes the removal of painful glands/localized areas and does not include any skin advancement. It has also been used to "kill off" (non-clinically speaking) tiny blood vessels around painful areas in the vestibule which decreased symptoms of inflammation. Because this procedure uses a different type of laser than the procedure above, it has proven to have less complications and higher success rates. If you're interested in reading more about this, there's a really great article on the topic (and on VVS in general).
Note: While I found this information from many different sources, the best complete resource I found so far has been the book Women’s Sexual Function and Dysfunction: Study, Diagnosis, and Treatment by Irwin Goldstein and Susan R. Davis. It reads a lot like a textbook but it's still very good if you're really interested in delving into the nitty gritty details.
Note number 2: There are differing opinions on a lot of the information I included. The way I decided what to include here is by trying to find the most reputable resources (like the one I mentioned above). In any case, if you do your own searching, you're bound to find information contrary to what I have here; in dealing with this, I personally recommend actively seeking out multiple opinions on the information you find to verify not only the validity of the information (this includes what I wrote as well!) but also how it applies specifically to you.
So What Constitues a "Success"?
When reading about surgery for VVS, it’s sometime hard to tell what is classified as “a successful surgery”. For the most part, unless stated otherwise, it means that the patient can resume a normal, pain-free sex life. To be honest, this is a loaded question that I'll address down the road but I wanted to include this little bit here so that the next thing I say makes more sense:
What are the Success Rates?
According to the often-sited Dr. Andrew Goldstein, the most common type of surgery that he performs is the modified vulvar vestibulectomy on patients who have localized vulvar vestibulitis (it’s important to note that this type of surgery is rarely performed on patients with generalized vulvodynia...another gargantuan topic that will be covered next) and the break down of the "success rates" goes as follows:
1) There is a close to 100% success rate for the removal of pain from activities such as sitting, wearing tight pants, and physical contact.
2) Over 50% of the women experienced completely pain-free sex after the surgery.
3) About 40% of the women had slight discomfort during sex (but could still have sex).
4) And around 10% of the patient could not have sex due to high pain levels. There are several reasons for why this may be the case and I'll be discussing that in the consequent emails as well.
As you can see, the term "success rates" is used very loosely in the literature; when we put these numbers with the definition of a successful surgery, we would be able to say that a modified vulvar vestibulectomy has over a 50% success rate. That's not to say that other women's lives haven't been positively effected by the surgeries, of course, but we're simply talking labels here for the sake of knowing what to look for when reading literature.
Ok, so that's that for Part I but there's lots more to come! What to expect from Part II of the series on VVS and Surgery:
a) Why do some women still have pain after surgery? What's going on? b) What to do after the surgery to ensure better results (and why doing those things is really important). c) Answers to questions like: what is the recovery time? how will my normal functioning (like lubrication) be affected?