In women, the urethral meatus is surrounded by fleshy tissue called the peri-urethral glans. This observation regarding vestibular anatomy is relatively new. It is theorized that this fleshy tissue surrounding the urethral meatus protects the urethral meatus during penetrative sexual activity, similar to the protection provided men where the urethral meatus is surrounded by the glans penis.
Why is this new observation important? In women suffering with significant, unrelenting entrance dyspareunia from neuroproliferative vestibulodynia, the pathology of excess mast cells and nerve endings may also involve the peri-urethral glans. In such cases, excision of these peri-urethral glans along with all other vestibular tissue infiltrated with excess mast cells and nerves would be critical to provide the most effective surgical solution.
To identify if the peri-urethral glans is involved as a pain source in patients with neuroproliferative vestibulodynia, it is essential to undergo pre-op cotton-tipped (Q-tip) swab testing and then focal peri-urethral glans anesthesia testing with topical benzocaine, lidocaine, and tetracaine (BLT). Only if the pain is temporarily resolved fully would excision of the peri-urethral glans be considered. To excise the peri-urethral glans during surgery, the inferior aspect of the urethral meatus would be anastomosed to the mesodermal aspect of the vagina. Biopsies of peri-urethral glans specimens that have been removed during surgery have all had immunohistochemical staining consistent with excess mast cells and nerves, confirming the need to remove this tissue in some individuals.