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Table of Contents
CASE REPORT
Year : 2023  |  Volume : 28  |  Issue : 1  |  Page : 73-76

Successful pregnancies after vaginal reconstruction following acquired gynatresia with pudendal thigh (Singapore) flaps


1 Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Nigeria
2 Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu, College of Medicine, University of Nigeria, Enugu, Enugu State, Nigeria

Date of Submission12-Jun-2022
Date of Decision09-Aug-2022
Date of Acceptance22-Sep-2022
Date of Web Publication13-Dec-2022

Correspondence Address:
Obinna R Okwesili
Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_57_22

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  Abstract 

Acquired gynatresia resulting from traumatic vaginal delivery is rare. The use of bilateral pudendal flaps for reconstruction provides sensate tissue for a functional neovagina. Reconstruction of the vagina after complete stenosis from birth trauma has not widely been reported. We present a 29-year-old woman who developed vaginal stenosis within 2 months after vaginal delivery of a stillbirth baby. There was a failure of coitus for approximately 5 months before presentation. She had successful vaginal reconstruction with pudendal flaps and became pregnant twice through coitus after surgery. Her baby was delivered via Caesarean section. We have reported a case where the vagina was successfully reconstructed with bilateral pudendal thigh flaps which resulted in subsequent spontaneous (unassisted) pregnancies.

Keywords: Acquired gynatresia, pudendal flaps, vaginal reconstruction


How to cite this article:
Achebe JU, Okwesili OR, Adiri CO, Asimadu EE. Successful pregnancies after vaginal reconstruction following acquired gynatresia with pudendal thigh (Singapore) flaps. Int J Med Health Dev 2023;28:73-6

How to cite this URL:
Achebe JU, Okwesili OR, Adiri CO, Asimadu EE. Successful pregnancies after vaginal reconstruction following acquired gynatresia with pudendal thigh (Singapore) flaps. Int J Med Health Dev [serial online] 2023 [cited 2023 Jan 28];28:73-6. Available from: https://www.ijmhdev.com/text.asp?2023/28/1/73/363257




  Introduction Top


Traumatic vaginal delivery is a rare cause of acquired gynatresia[1],[2] and secondary infertility. Chemical vaginitis resulting from the use of herbal pessaries in the treatment of fibroids, uterovaginal prolapse, or induction of abortion is the most common cause of gynatresia in many parts of Nigeria.[3],[4],[5],[6],[7] The use of bilateral pudendal thigh flaps for reconstruction provides sensate tissue for a functional neovagina.[3] Management of patients with acquired gynatresia usually requires a multidisciplinary team that includes plastic surgeons, urogynecologist, psychologists, and sometimes general surgeons.


  Case Report Top


Ethical approval for this case report was obtained from the Ethics Committee of University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu (UNTH/CSA/329/OL.5: NHREC/05/01/2008B-FWA00002458-1RB00002323). All the guidelines outlined in the Declaration of Helsinki were met. We present the case of a 29-year-old woman who was referred to the plastic and reconstructive surgery clinic by gynecologists. She had complete stenosis of the vaginal canal that had lasted for 7 months before presentation. Her first and only delivery before her presentation was traumatic, and it resulted in a stillbirth. It was a vertex delivery following prolonged labor and she sustained a deep vaginal laceration. The vaginal laceration sustained during this delivery was repaired by an auxiliary nurse. Two months after delivery, the patient noticed a progressive narrowing of her vagina, and it closed completely a few weeks after. She also complained of having progressively worsening dyspareunia during that period which ultimately resulted in apareunia. Her menstrual flow ceased and there was no more vaginal discharge. Lower abdominal pain was another symptom she experienced and this was most pronounced in the suprapubic region. The pain was continuous and did not radiate to any other part of the body. These disturbing symptoms necessitated her seeking medical treatment at a nearby hospital before presenting to our hospital. Her husband was 39 years old at the time of her presentation. She presented to the gynecologists at our hospital, the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu. On examination, the vagina was observed to be shallow with a depth of 2 cm, and the proximal part was stenosed. Diagnosis of acquired gynatresia was made and she was sent for some investigations. Transvaginal and transrectal ultrasounds were done and a markedly shortened vagina with reduced thickness was noted. The vagina was also inhomogeneous, hypoechoic stringy in appearance. It measured 2 cm in length. The cervix showed features of atrophy. The uterine fundus was bulky, anteverted, and had a normal endometrial echo but had an accumulation of fluid in the lumen. An impression of vaginal stenosis with marked atrophy of the vagina and uterine cervix was made by the radiologists.

She was booked for surgery which was carried out with the patient in the lithotomy position. The stenosed part of the vagina was carefully dissected to recreate a lumen at the proximal part of the vagina. This was done with the guidance of a lubricated Hegar’s dilator in the rectum and a urethral catheter in the urethra to avoid creating an opening into the rectum or urethra respectively. A copious amount of brownish fluid (accumulated menstrual fluid) flowed out of the uterus. The cervix was palpable and was examined with the aid of a vaginal speculum. Bilateral pudendal (Singapore) flaps of 13 cm by 5 cm were designed and raised leaving skin bridges between the introitus and the secondary defects. Both flaps were islanded as shown in the first picture of [Figure 1] and passed under the skin bridge and into the vagina through a lateral vaginotomy on either side. The flaps were used to form a tube [Figure 1] that was anchored to the proximal part of the vagina. Active wound drains were inserted and the vagina was packed. Vaginal dilatation was started while the patient was still on admission and she was counseled together with her husband to continue the dilatation for a few more days after she was discharged from the hospital. She was followed up for months and she became pregnant 4 months after surgery. She was referred back to the obstetricians for antenatal care. She started antenatal care at 23 weeks of gestational age. An elective caesarian section was done at a gestational age of 38 weeks and she was delivered of a live baby boy.
Figure 1: Islanded pudendal flaps used in forming tube for the vagina

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She presented again 2 years after delivery due to a reoccurrence of dyspareunia without cessation of menstrual flow. Examination under anesthesia (EUA) was done and the vagina was observed to be narrow. Serial dilatation with lubricated Hegar’s dilator was done under anesthesia and dilatation was continued after surgery using a plastic vaginal dilator. She became pregnant a second time about 4 months after the EUA and vaginal dilatation. She delivered her second live baby boy at GA of 39 weeks + 6 days. She is being followed up.


  Discussion Top


Postpartum vaginal stenosis is rare even in developing countries like ours.[8] The postpartum gynatresia that occurred in this patient was due to traumatic injuries sustained during her first delivery. Physical birth trauma, even when severe, is not a common cause gynatresia.[1] Chemical vaginitis has also been reported as a cause of postpartum gynatresia.[9] Majority of patients that had postpartum gynatresia were treated successfully with serial dilatation of the vagina[8] unlike the present case where it was no longer possible at the time the patient presented to us. Umar et al.[1] also reported a case of successful pregnancy after reconstruction of postpartum gynatresia but the method of reconstruction was not stated.

Restoration of function is the most important outcome of vaginal reconstruction but cosmesis should be considered as well.[10] Reconstruction with bilateral pudendal thigh flaps is a good technique for effective treatment of acquired gynatresia[3] that provides satisfactory cosmesis and good function. There are options for using bilateral flaps for reconstructing the vagina. In our practice, we prefer the formation of a tube for the neovagina using the two flaps before anchoring it to the fornix due to the difficulty in anchoring the two flaps separately and adding more side stitches within the depth of the vagina. The vulva and other parts of the external genitalia may appear to have been distorted in the immediate postop but it gradually returns to its normal appearance after some weeks as is shown in [Figure 2].
Figure 2: Appearance of the genitalia immediate postop and 9 months later, respectively

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The neovagina created by the use of pudendal flaps does not require long periods of dilatation. We encouraged the patient to use a plastic dilator [Figure 3] for dilation in the first few days after surgery to minimize the possibility of dyspareunia in the early stages. We also encouraged the patient to use lubricants like K-Y jelly to aid coitus. There was also a need for intermittent dilatation or coitus to avoid the challenges our patient had after a prolonged period of abstinence during the period of the pregnancy after surgery. This was however sorted out by one episode of dilatation done under anesthesia, and she was able to conceive again subsequently. Umar et al.[1] also applied postoperative dilatation to their patient after vaginal reconstruction.
Figure 3: Plastic dilator used in the early postop period

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  Conclusion Top


Postpartum-acquired gynatresia can result from birth injuries if appropriate management is not instituted early. We have reported a case where the vagina was successfully reconstructed with bilateral pudendal thigh flaps and the patient was able to conceive twice through sexual intercourse. The use of pudendal thigh flaps in vaginal reconstruction is a reliable technique that provides good structure and function for the neovagina.

Ethical consideration

Ethical approval for this case report was obtained from the Ethics Committee of University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu (UNTH/CSA/329/OL.5:NHREC/05/01/2008B-FWA00002458-1RB00002323). All the guidelines outlined in the Declaration of Helsinki were met.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Umar AG, Ahmed Y, Garba JA, Adoke AU, Saidu AD, Hassan M Successful pregnancy following acquired gynatresia. Ann Afr Med 2019;18:108-10.  Back to cited text no. 1
    
2.
Kunwar S, Khan T, Gupta H Acquired gynatresia. BMJ Case Rep 2014;28:bcr2014203529.  Back to cited text no. 2
    
3.
Ugburo AO, Mofikoya BO, Oluwole AA, Fadeyibi IO, Abidoye G Pudendal thigh flap in the treatment of acquired gynatresia from caustic pessaries. Int J Gynaecol Obstet 2011;115:44-8.  Back to cited text no. 3
    
4.
Ugburo AO, Fadeyibi IO, Oluwole AA, Mofikoya BO, Gbadegesin A, Adegbola O The epidemiology and management of gynatresia in Lagos, Southwest Nigeria. Int J Gynaecol Obstet 2012;118:231-5.  Back to cited text no. 4
    
5.
Ozumba BC Acquired gynetresia in Eastern Nigeria. Int J Gynaecol Obstet 1992;37:105-9.  Back to cited text no. 5
    
6.
Omale AE, Ibrahim SA, Anor F Acquired gyaetresia with cryptomenorrhea secondary to induced abortion: A case report. Ibom Medical Journal 2008;3:64-7.  Back to cited text no. 6
    
7.
Okunlola MA, Adekunle AO, Arowojolu AO Management outcome in patients with acquired gynatresia in Ibadan. Trop J Obstet Gynecol 2001;18:12-5.  Back to cited text no. 7
    
8.
Krimou Y, Guennoun A, Mamouni N, Erraghay S, Bouchikhi C, Banani A [Acquired vaginal stenosis: About a case and literature review]. Pan Afr Med J 2019;34:175.  Back to cited text no. 8
    
9.
Kaur G, Thomas S, Jindal M, Bhatti SM Visual function and ocular status in children with disabilities in special schools of Northern India. J Clin Diagn Res 2016;10:NC01-4.  Back to cited text no. 9
    
10.
Slaoui A, Bagayogo TK, Karmouni T, Elkhader K, Koutani A, Attaya AI Secondary reconstruction of vaginal stenosis using a posterior labial perforator based Falandry flap. Pan Afr Med J 2015;21:185.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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