Author Information
Mohit R Saraogi*, Usha Kiran**
(* Assistant
Professor, ** Associate Professor **, Department of Obstetrics &
Gynaecology, Cama & Albless Hospital, JJ Group of Hospitals, Mumbai , India
Abstract
Colpocleisis or obliteration of the vagina is a rare
clinical entity with most cases being acquired in the form of Le Forts repair.
Sponataneous Colpocleisis following a normal vaginal delivery is an
unknown phenomenon in medical history.
Here we present to you a case report of a young woman who presented to us with
spontaneous colpocleisis following a normal vaginal delivery at home with no
precipitating or predisposing factors.
Introduction
Colpocleisis or obliteration of the vagina is derived from
the greek term "kolpos" which refers to a fold in the greek tunic and
"cleisis" which stands for occlusion or closure.[1] Therapeutic
colpocleisis in the form of Le Forts repair, has long been accepted as a
treatment modality for prolapse in elderly women who are unfit for major surgery
or general anaesthesia.[2] However
spontaneous colpocleisis following a vaginal delivery is an unknown clinical
entity with no documented literature available on its occurrence and
management. The condition can be traumatizing for a young women in the
reproductive age group as it can present with apareunia, dyspareunia, menstrual
irregularities, hematometra, pyometra and endometriosis. We present the case
report of a young woman who presented to us with spontaneous colpocleisis
following a normal vaginal delivery at home.
Case Report
A 25 year old para 2 living 2 woman presented to our Out
Patient Department (OPD) with complaints of apareunia following a vaginal
delivery 1 year ago. The patient had undergone an uneventful cesarean section
in her first pregnancy 5 years ago in view of non progress of labor. In her
second pregnancy, the patient went into spontaneous labor 1 year ago and had a
home delivery under the supervision of a dai (traditional midwife).
On direct questioning the duration of labor in the patient
was approximately 12 hours. The delivery was uneventful and the patient was
examined in a nearby municipal hospital immediately postpartum and later
discharged without any intervention. There was no history of vaginal
lacerations, postpartum hemorrhage or need for intervention in the patient
after delivery. The patient gave history sexual abstinence for six weeks
following delivery. On attempting to resume coitus, she had apareunia which had
persisted till date. On direct questioning she also gave history of
hypomenorrhea since 8 months with minimal soakage of 1 pad per day for 5 days.
Her prior menstrual history was normal. There was no history of any other
medical or surgical illness in the patient.
On examining the patient, her vital parameters were stable and
her general and systemic examination were normal. On abdominal examination, her
abdomen was soft. Local examination
showed no signs of chronic perineal tear. Per vaginal or per speculum
examination was tried unsuccessfully as there was complete obliteration of the
vaginal cavity with thick mucosal adhesive band across. A decision for
examination under anesthesia with vaginal refashioning was taken for the
patient.
The patient was
examined under spinal anesthesia in the operation theatre and the OPD findings
were confirmed. A decision to proceed with vaginal refashioning was taken. A
Foley’s catheter was introduced into the bladder so as to minimize the risk of
bladder or urethral injury. A per rectal examination revealed that the uterus
and the cervix could be felt above the level of the adhesions through the
posterior vaginal wall. A small pin point dimpling was seen in the center of
the vagina with a thin mucosal aperture of 1 mm, when the fleshy adhesive band
was stretched using the finger in the rectum. The aperture would not admit a
uterine sound. A tuboplasty probe was
passed through the aperture followed by a uterine sound. Then a series of
progressively increasing Hegar’s dilators (No. 3 onwards) were passed through
the vaginal opening to enlarge the lumen until a one finger digital examination
could be performed. The digital examination showed that there were thick fleshy
mucosal adhesions across the anterior, posterior and lateral vaginal walls in
the lower end of the vagina. However the upper two thirds of the vagina was
free of adhesions and the uterus and cervix could be digitally palpated and
also visualized using a small sized speculum by stretching the adhesions
slightly. This fleshy band of adhesions were lysed with a transverse incision
and dissected fully using sharp scissors, taking care not to injure the
bladder, urethra or the rectum. At the end of the surgery, the vagina admitted
two fingers and a speculum examination could be done easily. Raw vaginal mucosa
was sutured perpendicular to the line of incision and a vaginal Foley’s
catheter was placed in the middle and lower one third of the vagina
and inflated with 50 ml normal saline, so as to prevent contractures. This
catheter was deflated and reinflated once a day. The patient was given broad
spectrum antibiotics (cefotaxime and metronidazole) for 5 days and kept
catheterized (bladder) for 24 hours. The patient was given Seitz bath 3-4 times
a day and encouraged to maintain genital hygiene. A speculum and digital
examination was repeated 72 hours after the surgery and the wound was found to
be healing well. The vaginal Foley’s catheter was changed after 72 hours and
removed after 1 week. The patient was discharged on day 7 of surgery and asked
to follow up weekly on an OPD basis.
On her
first post operative visit, a digital examination was done. The vagina could
admit two fingers and a speculum examination revealed a healthy cervix and
vagina. Her second post operative visit confirmed the same findings, however
there was an inflammatory ridge on the posterior vaginal wall made prominent by
the contraction of the levator ani as a reflex action to pain. The patient was anxious and complained of
pain. Stronger pain killers were prescribed
to the patient along with lignocaine jelly for local application. As the wound
had healed well she was asked to use vaginal dilators to prevent recurrence of
adhesions and to enlarge the lumen. On her third postoperative visit, she was
comfortable using dilators and the pain had reduced considerably. She was asked
to resume sexual intercourse gently using vaginal lubrication. She had resumed
her menses postoperatively. In her first period postoperatively, the patient
bled for 5 days soaking 2-3 pads for the first 2 days.
Figure 1. Obliterated vaginal
cavity at the start of the procedure.
Figure 2. Uterine sound cannot
be passed though the vagina.
Figure 3. Vaginal adhesions
being dissected.
Figure 4. One finger being
passed through the vagina.
Figure 5. Vagina admitting 2
fingers.
Figure 6. Patient on post
operative follow up visit.
Discussion
Spontaneous colpocleisis following vaginal delivery is an
unheard of phenomenon in medical literature. Rock Salt induced vaginal stenosis
was fairly common in Arabic women in the 70’s, who were known to pack their
vaginas with salt in the first postpartum week. This was supposed to restore
the vagina to its nulliparous state and improve the husband’s sexual pleasure.[3]
Chemical vaginitis following insertion of caustic vaginal pessaries is the
major cause of acquired gynaetresia.[4] This can lead to not only coital problems but
also to symptoms similar to vaginal atresia (haematocolpos).
But both of these are rare phenomena in today’s time. Our
case had spontaneous colpocleisis without any external intervention, which was
resolved by a vaginal refashioning operation. It helped restore sexual activity
in her and improved her marital life and restored her menstrual function.
Conclusion
Spontaneous colpocleisis is a rare but serious complication
which can occur following vaginal delivery.
The condition is however correctable by a simple reconstructive vaginal
surgery. Obstetricians should be aware of this rare complication of normal
delivery and its management and outcomes.
References
1.
Lior Lowenstein and Shay Erisson -
Colpocleisis - Current Practice and Complication; Complications of female
incontinence and pelvic reconstructive surgery. Current clinical urology, 2013.
pp 69-70.
2.
N. Kohli, E.Sze, M Karram. Pyometra
following Le Fort Colpocleisis – International Urogynaecology Journal 1996;7:264-266.
3.
Betty ML, Underbill MB. Salt induced
vaginal stenosis of Arabia BJOG 1964;71:293-298.
4.
Arowojolu A O, Okunlola MA, Adekunle AO, Ilesanmi AO. Three
decades of acquired gynaetresia in Ibadan
: Clinical presentation and management J Obstet and
Gynaecol 2001;21:375-8.
Citation
Saraogi MR, Kiran U. Focal Spontaneous Colpocleisis Leading To Apareunia. JPGO 2014 Volume 1 Number 8 Available from: http://www.jpgo.org/2014/08/focal-spontaneous-colpocleisis-leading.html