Narrowing of the Vagina After Childbirth: A Case of Successful Yet Challenging Treatment
Introduction
A physician from the district polyclinic sought assistance for a patient with a non-healing vaginal tear after childbirth. The patient is a 24-year-old woman.
Complaints
The woman complained of constant scanty bloody discharge from the genital tract and an unpleasant odor from the vagina. The bloody discharge intensified during defecation and attempts at sexual intercourse.
History
During childbirth, which occurred 9 months ago, a vaginal tear occurred. It was sutured twice (immediately after childbirth and the next day), but the bloody discharge persisted. Due to vaginal bleeding and pain, intimate contact was impossible. The woman became irritable and tearful.
These were her first childbirth, which occurred at term. There have been no surgeries throughout her life. Only the involvement of the vessels of the left leg in the form of arteriovenous transformation is noted.
Examination
During the examination on the chair, adhesions (scarring) of the vulva and narrowing of the vagina to 7 mm were observed. Attempts to dilate the vaginal entrance were accompanied by profuse bleeding, making further examination impossible.
Examination using mirrors was also unsuccessful due to severe pain, so an examination under intravenous anesthesia was performed. Adhesions of the vulva, narrowing of the vagina from the hymen (site of the vaginal membrane) to the middle of the vagina were found. Marked granulation tissue (connective tissue formed during healing), tissue infiltration, including the levator ani muscles (pelvic floor muscles), were observed. The vagina was narrowed to 5 mm.
The woman underwent:
Colonoscopy – the intestinal mucosa was not damaged.
Ultrasound of the pelvic organs – no pathologies were detected.
During the examination for flora in vaginal smears, abundant cocci flora was found, indicating inflammation.
Diagnosis
Post-traumatic stenosis (narrowing) of the vulva and vagina. Non-healing vaginal erosions. Granulomas of the perineal muscles. Depression.
Treatment
At the first stage, inflammation of the vagina was treated with Terzhinan suppositories – one suppository nightly for 10 days. Then, the vulva and vaginal walls were lubricated with Oflomelide ointment in the morning and evening for 7 days. This treatment helped reduce pain and discharge.
After that, surgery was performed. The mucous membrane of the vulva, posterior vaginal wall, granulomas were excised, and adhesions in the vaginal wall were removed. Coarse adhesions of the vagina with the rectum were eliminated, thus restoring the volume of the vagina.
The lesion of the posterior vaginal wall was quite pronounced, and after excision, there was no mucous membrane left to close the defect. The edges of the vaginal wound were 4 cm apart, and suturing would have led to vaginal narrowing again. It was decided to restore the posterior vaginal wall with the mucous membrane of the labia minora (flap on the pedicle). The necessary flaps were allocated from both sides, wrapped and fixed to the edges of the preserved vagina. Monocryl 4/0 suture material was used during the operation. Labioplasty was then performed (changing the shape and size of the labia minora).
Standard antibiotic therapy was conducted for 5 days after the operation:
Ceftriaxone 2 g per day;
Metronidazole tablets 500 mg twice a day.
For 10 days, the perineum and labia minora were treated with 3% hydrogen peroxide solution, followed by 0.05% chlorhexidine solution.
After 2 weeks, vaginal discharge ceased, and the unpleasant odor disappeared. The pain also subsided.
During the treatment, it was possible to restore the normal volume and diameter of the vaginal entrance, allowing the patient to engage in sexual activity, which was previously impossible.
Conclusion
Vaginal surgery remains complex to this day. The reason is that gynecological surgeons (obstetricians) do not receive sufficient training to suture vaginal tears, and there is not a complete understanding of anatomy during such procedures. All this can lead to complications that significantly worsen the quality of life for patients, as in this case.