Vulvectomy - A Patient's Guide

Your Physician has recommended that you have a vulvectomy. Before recommending this type of surgery, your physician has considered your age, physical condition, test results and physical examination. A vulvectomy is a surgery to remove the cancer of the vulva or other abnormal skin. You probably have many questions about the surgery and about what will happen to you.

This guide is to help you and your family learn about the surgery and how to care for yourself after the surgery. It cannot answer all of your questions.

Write any down any questions you may have and ask your physician or nurse, at your next visit or by phone.

The vulva is the outside part of a woman's genital organs. It includes the labia minora, labia majora, clitoris and vaginal opening. Another name for the vulva is the perineum.

A vulvectomy is the recommended type of treatment for cancer of the vulva and other abnormal skin growth such as condyloma (warts/HPV, ask your nurse for this booklet). Vulvar cancer is usually cured with surgery. This is because it is visible and grows quite slowly.

Cancer is the uncontrolled growth of cells. Cancer of the vulva is a type of cancer that starts in the skin of the vulva. Symptoms may include: itchiness, lumps or sores on the vulva. Smoking also increase the chance of having this type of cancer.

If this type of cancer spreads, it usually goes to the lymph nodes in the groin. The normal role of the lymph nodes is to drain fluid from your body.

A vulvectomy is a surgery to remove the vulva or parts of the vulva. The type of vulvectomy depends on the size and location of the cancer or other abnormal skin growth. The types of vulvectomy can be spread into two categories:

1. To see a physician, he or she will ask you questions about your general health and examine you. Bring your medication for this appointment.
2. To prepare you for surgery, the following tests may be done:
   
   • Blood and urine tests
   • Chest X-ray
   • Electrocardiogram if you are over 50

• The hospital admitting office will call you with the time to arrive at the hospital. You will have to wait about 2 to 2 1/2 hour before your surgery.
• After midnight, you must have nothing to eat or drink.
• During your pre-admission visit, the physician will have told you if you need to take any of your regular medication.
• The physician or Gynecologic/Oncology nurse will give you special instructions on how to clean out your bowels.

• Go to your hospital admission's office.
• Once in the hospital, you will need to change into a hospital gown. The nurse may start an intravenous in your arm. You may receive intravenous antibiotics to prevent an infection.

Rest and activity:

• Your physician may request that you remain in bed for a few days after surgery to let your incision start to heal. Move your legs to prevent blood clots in your legs. Turn often to prevent a lung infection (pneumonia). Changes in body position may be difficult at first. Moving and turning decreases complications.
• Early walking helps to improve blood circulation, muscle strength, energy level, breathing and bowel movement. The nurse will help you increase your activity. The nurse will show you how to get out of bed. Pain medication before walking helps.

Area of surgery:

• A large dressing over your perineal area, for the first day or two after a radical vulvectomy.
• A Foley catheter to drain the urine from your bladder and to keep the incision area dry. This will be in place for a few days after surgery.
• One or two drains in your incisions that will drain away extra fluid, after a radical vulvectomy.
• You must keep the incision area clean and dry. The nurses will teach you how to do perineal care and sitz bath to prevent infection. You should try to keep your legs spread when you are in bed, to keep the surgery are dry.
• Because of the location of your incisions, the wound may open. If this happens, your nurse will clean the are and apply a dressing to your wound until it heals.

• You may have pain and tightness around the surgery area. Ask the nurses for medication to decrease the pain. The pain should decrease after 24 hours and you may need less pain medication.

• You will start by drinking clear fluids, after surgery. You can start regular food when you can pass gas by your anus. You may have gas pain on the second or third day after surgery. This is simply a sign that your bowels are returning to normal. Walking helps to decrease gas pain.

• The Gynecologic/Oncology Liaison nurse (if one is available at you centre), the social worker or the ward nurse are available to talk to you about the changes in your body and in your sexuality.

After your vulvectomy, you may develop some side effects while you are in the hospital. Below you will find tips on how to prevent these side effects. If you have any of these side effects, they may be treated as follows:

• You are at risk for infection at the surgery area or opening of the incision, because of the moisture in that area. To prevent infection it is important to keep this area clean and dry by taking sitz baths and keeping your legs apart. The nurses and physicians will look at your surgery area every day for signs of infection. The signs of infection are: redness, bad odor, more tenderness or fever. If you have an infection, the nurse will change the dressing more often. You may have to take antibiotics.
• You are also at risk of a urine infection because of the catheter in your bladder after surgery. Signs of a urine infection are: urinating often or burning when urinating. To prevent a urine infection, drink about 8-10 glasses of liquid per day. If you develop a urine infection, you will receive antibiotics by pills or in intravenous (in your veins).
• Since you will not be moving and walking after your surgery, you may develop pneumonia. People who smoke are more at risk of pneumonia. Pneumonia is an infection in your lungs: do deep breathing and coughing exercises (ask your nurse for the booklet on breathing exercises). If you smoke, you should try to stop smoking (decrease) a week before your surgery. If you have pneumonia: you may receive antibiotics by intravenous or by pills.
• Another side effect is a Thrombosis. Thrombosis is a blood clot in your leg, often caused by not moving your legs or walking. To prevent a thrombosis, move your legs while you are in bed. The nurse will give you a needle of heparin under the skin. Heparin is a medication to thin your blood; it prevents blood clots. Your nurse will tell you when you should start walking. Signs of thrombosis are: sharp pain, redness, swelling and /or hot skin on your legs. The physicians and nurses will look at your legs regularly.
• After any type of surgery, there is a small risk of bleeding at the surgery area. If you bleed, the nurse will apply more dressing to the surgery area. The nurses and the physician will observe you carefully.

The clerk at the desk will give you the date and time of your next visit with the physician. Visits from a nurse can be arranged if you need dressing changes and cleaning of your incisions at home.

• After a bowel movement or urinating, wipe yourself from front to back, away from the vulva. In hospital, the nurses will give you spray bottle to facilitate cleaning.
• Daily cleaning of your incision is necessary at home. Bring your sitz bath at home. You will need to continue doing sitz bath (or take baths) three times a day and after each bowel movement, until the incision is healed.
• Keep the vulvar area as dry as possible. Dry carefully after your bath and after each sitz bath. Use a hair dryer on a low setting.
• Use clean towels and wash cloths each time.

• Wear loose clothing, cotton underwear.
• Try to limit the amount of time your wear pantyhose or panty girdles. They decrease air circulation which may increase the chance of infections.
• Do not wear underwear overnight.
• Use natural soaps (glycerin) or just warm water when cleaning the vulva area. Avoid soaps with perfume or bubble baths.
• After sexual intercourse, always empty your bladder and dry your perineal area.

After your vulvectomy, you may develop some side effects that may last for many months. If you have any of these side effects, please notify your nurse or physician at your next visit.

The types and degree of side effects depend on the type of surgery and the amount of skin removed. Your nurse and physician can help you understand why your changes may have occurred.

Sexual activity can resume 6 to 8 weeks after the surgery, when the incision is healed, unless otherwise specified by your physician. The outside of your vulva has changed but the inside of your vagina is the same.

Keep in mind that we love with our minds as well as our bodies. Remember that the ability for you and your partner to feel pleasure from touching is very important. It is also important to keep an open mind as to what gives pleasure i.e. cuddling, touching and stroking can give you great pleasure

The type of sexual difficulties depend on the type of surgery and the amount of skin removed. Sexual difficulties occur less frequently after a simple vulvectomy. The length of time for this recovery varies but is possible with patience and care.

It can take 1 to 3 months, but it is not unusual for it to take longer. Both you and your partner have to adjust to these changes. Good communication with your partner is important. Remember that your physician, nurses and other team members are there to help you.

If the cancer has spread to the lymph nodes, radiation therapy may be necessary to control further spreading of the cancer. Please discuss any questions or concerns with your nurse or physician.

• Cancer Information Service: Call toll free 1-888-939-3333.
• Cancer Connection: 1-800-263-6750 to speak with someone who has had a similar situation.
• Booklet: Sexuality & Cancer, for the women who has cancer and her partner. (American Cancer Society). This booklet can be obtained from the Canadian Cancer Society.