|August 2007 · Vol. 19, No. 08
PELVIC SURGERY CONTROVERSIES
Repair of a constricted or shortened vagina: What works?
Iatrogenic damage that does not yield to estrogen cream or dilators requires individualized surgery
Complete separation of tissue by cutting is necessary during takedown of vaginal constriction
Director of Urogynecology, Good Samaritan Hospital, and Professor of Obstetrics and Gynecology, University of Cincinnati School of Medicine, Cincinnati, Ohio
Director of Urogynecology, Assistant Professor of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minn
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To watch a demonstration of the surgical treatment of vaginal stenosis using bilateral groin flaps and a demonstration of the takedown of iatrogenic vaginal constriction, visit the Video Library.
Patients who want to be sexually active but suffer iatrogenic vaginal constriction or shortening, or both, are a surgical challenge. Their condition may require any of a variety of nonsurgical and surgical procedures to restore the ability to have gratifying sexual intercourse, and they may need considerable preoperative and postoperative counseling and management.
What is the basis of this problem?
The cause of vaginal shortening or constriction is most often surgical. Rarely is systemic disease or a localized condition, such as urogenital atrophy, responsible.
Prolapse procedures. Most procedures that result in vaginal shortening or constriction are ones performed to correct pelvic organ prolapse (POP), notably:
posterior colpoperineorrhaphy with levatorplasty
hysterectomy, whether abdominal or vaginal, during which too much of the upper vagina is taken with the cervix
anterior and posterior colporrhaphy in which vaginal plication and trimming are performed overzealously.
Surgical mesh. More recently, as a variety of mesh materials are used to augment repair of prolapse, mesh sometimes needs to be removed because of erosion, extrusion, infection, or pain. Under such circumstances, closing or covering raw surfaces without creating vaginal constriction or shortening is at times a challenge.
Radiation therapy to the pelvis can result in vaginal shortening, constriction, and obliteration.
How do you avoid creating these problems?
Techniques to avoid vaginal shortening and constriction during vaginal reconstructive surgery include appropriate use of levatorplasty during posterior colpoperineorrhaphy. Although levatorplasty is, at times, the only way to decrease the size of a large vaginal hiatus, it should be used only in the distal third of the vagina. Levatorplasty above this area often creates vaginal constriction that results in postoperative dyspareunia.
Also, avoid 1) overzealous trimming during anterior and posterior colporrhaphy and 2) removing too much vagina at vaginal or abdominal hysterectomy.
Last, it is important that a patient who has undergone vaginal reconstructive surgery have a vaginal exam within 2 weeks after surgery. This will ensure that the vaginal incisions do not fuse, thus creating vaginal scarring, closure, and constriction.
How is correction approached?
Various modifications of a McIndoe procedure have been described for vaginal agenesis, but surgical correction of iatrogenic vaginal shortening or constriction is not well described; few case series exist in the literature. Consensus is lacking on what the minimal length of a vagina must be to preserve normal sexual function, and no standard exists in regards to either normal vaginal caliber or the relationship of the perineum and perineal body to the distal posterior vagina.
That being said, we have recognized the following correlates of a successful return to sexual function after surgery for vaginal constriction or shortening:
The vagina should, at minimum, be 7 cm long to have the potential for normal function
The vaginal opening should easily admit two fingers during examination
The relationship of the posterior vagina and the perineum should be a perpendicular one, in which a built-up perineum attaches to the posterior vagina at the posterior fourchette at a 90° angle
There should be no buildup of perineal skin above and beyond the posterior fourchette.
Is surgery the first intervention?
No. The patient should first undergo an attempt at nonsurgical management. This usually involves:
For a dilator to be successful, it must be able to be advanced through a vaginal constriction. Dilation will, most likely, be unsuccessful if the dilator reaches but does not pass through the constriction. Furthermore, dilation of a shortened vagina is rarely successful unless you are able to use a bicycle seat-type dilator. In this situation, you must, first, have patience and, second, apply a significant amount of vaginal estrogen cream in the hope of elongating the vagina.
What are options for surgery?
If nonsurgical management of vaginal constriction or shortening is unsuccessful or unsatisfactory, next choose an operation based on the needs of the individual patient. Some procedures involve placement of a skin graft or, possibly, other biologic material in the vagina to close over defects after constriction has been taken down or the vagina has been appropriately opened up. (It is fortunate that the vagina heals well by secondary intention; often, simply taking down the constriction and allowing the vagina to heal by secondary intention is successful.)
How is constriction released?
It is important to cut through the constriction and completely separate the tissue during the takedown of vaginal constriction. At this point, you need to decide whether to allow the separated vagina to heal by secondary intention or to cover the defect with a skin graft or other biologic material.
Whichever course you choose, keep the vagina open during the immediate postoperative period. Doing so may require placement of a vaginal stent, numerous postoperative exams, use of a vaginal dilator, or a combination of these measures.
When constriction rings are present in the face of ample vaginal length, you can perform a Z-plasty, in which the lines of a letter Z are incised transversely or longitudinally across the constricted region and the two flaps that have been created from the Z are transposed. This maneuver releases constriction well.
When constriction extends distally, the procedure used is, basically, a reverse perineoplasty: Cut the constriction band longitudinally, undermine the vagina, and then sew it back transversely. This relieves the distal band.
In a severe case of vaginal constriction, thigh flaps that are left on their vascular pedicle can be brought into the vagina to fill the gap created by cutting through the constriction. Initial incisions are made laterally in the vagina (unilaterally or bilaterally, depending on the degree of constriction) and extended to the perineum/vulva. Measurements are made to determine the length and width of flap(s) needed. The flaps are then mobilized, rotated into the defect(s), and sutured into place. This technique significantly increases the diameter of the vagina and can add length, if needed.
What about correcting shortening?
An iatrogenically shortened vagina presents the most challenging of cases. The vagina must be opened up at the cuff; ideally, this produces adequate length without having to enter the peritoneum.
Dr. Karram is a course director and Dr. Gebhart is on the faculty of the 10th Annual Pelvic Anatomy and Gynecologic Surgery Symposium (PAGS), to be held December 6-8, 2007, in Las Vegas (www.pags-cme.org).
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