(035) Rescue Excision of Periurethral Glans (PUG) Vestibular Tissue in Patients With Post-Vestibulectomy Pain: Initial Studies on the Importance of Managing the PUG

Abstract Introduction After complete vestibulectomy with vaginal advancement flap for neuroproliferative vestibulodynia (NPV), some patients continue to have bothersome pain in the tissue that immediately surrounds the urethral meatus, referred to by Levin in 1991 as the periurethral glans (PUG). Anteriorly, the PUG extends from the superior border of the urethral meatus to the anterior vestibule below the clitoris and frenulum. Posteriorly, the PUG extends from the inferior border of the urethral meatus to the junction of the endodermal/mesodermal vagina. Laterally, the PUG extends to Hart’s line. Objective The aim of this study was to assess outcome of a rescue surgical excision procedure of persistent bothersome painful PUG vestibular tissue in patients post-vestibulectomy and to compare immunohistochemical staining of excised PUG tissue to posterior vestibular tissue from their original vestibulectomy. Methods Charts from patients who underwent rescue excision of anterior and posterior PUG between 11/15/24-10/31/25 were reviewed. Surgical outcome of the rescue surgery was assessed by post-operative Patient Global Impression of Improvement (PGI-I) scores. For each patient, anterior and/or posterior PUG vestibular tissue was immunohistochemically stained for CD117 (consistent with mast cells) and PGP 9.5 (consistent with nerves). Slides were digitally photographed using a LCD35 CMOS color camera and an Olympus CX43 microscope at 100× magnification. For each tissue section, at least 2 photomicrographs were taken of representative regions of the epithelium and adjacent sub-epithelium. Density (% cross-sectional area) of nerves and mast cells were assessed in each field using Fiji version 1.54. For each patient, immunostaining data for PUG tissue (irrespective of anatomic location) was combined and mean densities were compared to those of tissues from the previous vestibulectomy. Comparisons were performed using paired T-test. Results A total of 8 patients, mean age 32.6 (range 22-61 years) met inclusion criteria. Cotton-tipped swab testing of the PUG pre-operatively revealed mean scores of 6.8/10 (range 5/10-10/10); post-operative results were 2.5/10 (range 0/10-10/10). Time from original vestibulectomy to rescue surgery was 22.3 months (range 6-73). Based on most recent PGI I scores at ≥3 months post-op (Fig. 1), 62.5% experienced improvement compared to their initial vestibulectomy while 37.5% experienced no change. There were no surgical complications based on the Clavien-Dindo classification system. The mean density of CD117 immunostaining was significantly higher (p = 0.026) in newly excised PUG tissue (1.51%) compared to original vestibular tissue (0.72%) (Fig. 2). Likewise, the mean density of PGP9.5 immunostaining was also significantly higher (p = 0.019) in newly excised PUG tissue (1.37%) compared to the original vestibular tissue (0.49%). Conclusions Excised PUG vestibular tissue was enriched in mast cells and nerves. Based on post-operative PGI-I data, rescue surgical excision of affected PUG tissue resulted in meaningful improvement in NPV symptoms in patients with periurethral pain after vestibulectomy. Patients with a history consistent with NPV should be assessed with cotton-tipped swab testing of PUG tissue and surgical excision should be considered for all affected regions during vestibulectomy. Our findings suggest that similar pathological processes may impact the PUG in NPV patients due to its endodermal origin and contiguous anatomy with the vestibule. Disclosure No.