(086) The Turtle: A Methodical Examination of the Anterior Vestibule to Better Inform Surgical Options for Neuroproliferative Vestibulodynia

Abstract Introduction The anterior (12:00) vestibule, typically 2.5 cm by 2.5 cm, can be associated with significant provoked or unprovoked pain in some patients with neuroproliferative vestibulodynia (NPV) negatively impacting sexual positions, activities such as bicycling, and choice of clothing such as underwear or tight pants. The superior border of the anterior vestibule is just below the clitoris and frenulum. The inferior border is the anterior aspect of the urethral meatus including the anterior peri-urethral glans vestibule. The lateral border extends to Hart’s line. Historically, surgical techniques for vestibulectomy have focused on excision of posterior vestibular tissue with vaginal advancement flap reconstruction. Leaving behind anterior vestibular tissue with excess mast cells and nerves may be associated with persistent pain post-vestibulectomy. To more precisely map out areas of pain in women with suspected NPV prior to vestibulectomy surgery, a tool known as “the turtle” was developed at a sexual medicine clinic in April 2025. The turtle offers a methodical assessment of the anterior vestibule by dividing this area into 14 locations for cotton-tipped swab testing (Fig. 1, Fig. 2). Patients considering vestibulectomy are advised that if their pain extends to the superior border of the anterior vestibule, they should consider having a buccal mucosal graft performed concurrently with posterior vestibulectomy. If their pain extends to only 1-2 cm above the inferior border of the anterior vestibule, they should consider having an anterior peri-urethral glans vestibule excision performed concurrently with vestibulectomy. If there is no pain in the anterior vestibule, they should consider focusing exclusively on excision of the posterior vestibule with vaginal advancement flap reconstruction. Objective The aim of this study was to determine the percentage of patients with suspected NPV who reported moderate to severe pain in the borders of the anterior vestibule, utilizing a new methodical assessment tool. Methods A retrospective chart review was performed of patients presenting to our clinic with suspected or confirmed NPV between April 22, 2025 and November 10, 2025 who underwent vulvoscopy and cotton-tipped swab testing and had anterior vestibule assessment using the turtle. Results The turtle was utilized on a total of 41 patients. 25 (60.9%) patients reported moderate to severe pain at A, B or C, indicating involvement of the entire anterior vestibule with a recommendation that a buccal mucosal graft be performed concomitantly with the posterior vestibulectomy. 36 (87.8%) patients reported moderate to severe pain only at 1-2 cm of the anterior peri-urethral glans vestibule, with the recommendation for peri-urethral glans vestibule excision during posterior vestibulectomy. 15 (36.6%) patients were unable to complete the full turtle due to severity of pain, highlighting the significance and intensity of the pain in this region. 5 (12.2%) had mild to no pain at the area examined with the turtle, and therefore needed only a complete posterior vestibulectomy with vaginal advancement flap reconstruction. Conclusions To determine the best surgical treatment options with greatest likelihood for success, the anterior vestibule must be fully evaluated in a methodical, systematic manner. Disclosure No.