The repair of post-traumatic vaginal stenosis using local thigh flaps

Abstract

Minor degrees of vaginal stenosis, especially lesions close to the vaginal introitus, can be dealt with safely and satisfactorily by local transposition flaps. The more extensive varieties of vaginal stenosis, sometimes amounting to virtual obliteration of the vagina by scar tissue, are a far greater surgical challenge. There are several causes of “post-traumatic” vaginal stenosis and the aetiological pattern in any reported series obviously reflect the geographical and social background of the patients and the surgical skills that are available locally. In the Western world, most cases of severe vaginal stenosis are likely to be the result of trauma to the pelvis and perineum following serious accidents, over-zealous repairs of rectocoele or cystocoele, particularly those repairs complicated by severe infection, and stenosis following treatment by radiotherapy and/or surgery for malignant disease involving the external genitalia, the rectum and the vagina, especially lesions extending into the pelvic floor. By contrast, the surgeon working in the tropics and in the under-developed parts of the world will see vaginal stenosis more often as a complication of vaginal damage due to prolonged obstructed labour and disastrous obstetrical management or the late effects of tropical infections such as lymphogranuloma. The efforts of native medicine men or so-called “healers” to cure infertility or punish infidelity may produce virtual obliteration of the vaginal cavity. A typical example of this severe stenosis is seen in some Middle Eastern countries following the deliberate insertion of crude rock salt into the vagina. Severe stenosis of this degree can be treated along the conventional lines advocated by McIndoe for congenital atresia of the vagina, but only on condition that the scar is completely excised before the insertion of a split skin graft. The amount of bleeding encountered often makes it prudent to do the operation in 2 stages, namely packing the vaginal cavity after the scar excision and grafting the defect some 7-10 days later at a second operation. Even under ideal conditions a complete “take” of the graft cannot be guaranteed and the post-operative co-operation demanded of the patient in keeping the grafted cavity dilated often results in a disappointing and inadequate reconstruction. Experience with 3 cases of vaginal stenosis suggests that the use of bilateral partially de-epithelialised thigh flaps could offer a solution to this problem.