Narrow Vagina Research Articles

Type of Mutation and Surgical Procedure Affect Long-Term Quality of Life for Women with Congenital Adrenal Hyperplasia

In congenital adrenal hyperplasia (CAH) caused by different mutations, feminizing surgery is mostly performed in childhood, and many patients are lost to follow-up. A follow-up study on 62 CAH women aged 18-63 yr and 62 age-matched controls to correlate findings of both operative method and mutation was performed. Semistructured interviews were performed in cases and controls, as well as a gynecological examination in the cases. The results were correlated with disease-causing mutations and earlier surgical procedures if performed. The study was conducted at university hospital referral clinics. Gynecological examination in all cases correlated to previous surgery (n = 49), type of mutation, and questionnaire responses. Half of the CAH women claimed that the disease affected their sex life. The women were less satisfied with their genitals, whether operated or not. Clitoris size and functions were affected by the surgical method. Five women had a clinically evident vaginal stenosis on examination. However, almost half of patients experienced a narrow vagina. The overall psychosexual aspects of life were affected in these patients with later sexual debut, fewer pregnancies and children, and an increased incidence of homosexuality. These quality of life factors were correlated to the severity of the mutations. The overall quality of life in adult women with CAH is affected both by the type of mutation and operative procedure. Indications for clitoroplasty should be restrictive. Medical, surgical, and psychological treatment should be centralized.

Vaginal reconstruction with a greater omentum–pedicled graft combined with a vicryl mesh after anterior pelvic exenteration. Surgical approach with long-term follow-up

Resection of anterior vaginal wall that occurs with some cases of anterior pelvic exenteration leaves the patient with a small and narrow vagina. This affects their sexual life leading to major psychologic problems, especially in young women. The aim of this study is to evaluate a new technique of vaginal reconstruction following anterior pelvic exenteration with clinical and cytohistologic follow-up. Between March 2002 and November 2004, ten sexually active female patients underwent vaginal reconstruction after radical cystectomy that required en bloc removal of the anterior vaginal wall, with a pedicle graft of greater omentum combined with a vicryl mesh. The mean age of the patients was 38 years. The mean operative time of the reconstructive procedure was 50 min. There were no complications regarding the reconstructive procedure. On follow-up, the neovagina accepted two fingers easily and showed a pink-colored smooth lining. Seven patients reported successful attempts of sexual intercourse. It was concluded that reconstruction of vagina after anterior pelvic exenteration in sexually active women can be done safely with the use of vicryl mesh combined with a pedicled omental graft. It is a simple, reliable, and not time-consuming technique. The long-term follow-up was very beneficial in detection of complete healing, postoperative infections, and hormonal activity of the graft and recurrence of malignancy.

Facteurs du choix de la voie d’abord des hystérectomies pour lésions utérines bénignes (prolapsus et indications obstétricales exclus)

We searched for the factors determining the type of hysterectomy (vaginal, laparoscopy or laparotomy) performed in women with supposedly benign uterine disease.We conducted a retrospective study of 101 consecutive hysterectomies performed on voluminous uteruses, prolapsus and obstetrical indications excluded. The following factors likely to have influenced the decisions were examined: patient age, nulliparity, menopausal status, history of laparotomy, uterus weight, narrow vagina, nature of uterus lesions, associated unilateral or bilateral annexectomy, complications.The frequencies were: vaginal route 58.4% (average uterine weight 249.4 g, range 93-1149 g), laparoscopic preparation 37.6% (average uterine weight 348 g, range 92-818 g), and laparotomy 4% (average uterine weight 586.2 g, range 112-1216 g). Factors determining type of hysterectomy were uterine weight (and therefore volume) (p < 0.05), nulliparity (p < 0.04), narrow vagina probed by compulsory Schuchardt incision (p < 0.02), associated annexectomy (p < 0.01). No other factors were significantly determinant. The vaginal route appears to be highly preferred.Vaginal hysterectomy is clearly the most preferred and practiced. Laparoscopy may be helpful for vaginal hysterectomy and laparotomy is exceptional.

Wardium canarisi n. sp. (Cestoda: Hymenolepididae) parasite of Arenaria melanocephala (Aves: Charadrii) of Alaska.

The authors describe and illustrate Wardium canarisi n. sp. (Cestoda: Hymenolepididae), an intestinal parasite of Arenaria melanocephala (Aves: Charadrii) from Alaska, characterised by a strobila 20-40 mm long, 10 aploparaksoid hooks 19-21 microm long, a short cylindrical cirrus (40 microm) covered with very minute spines (0.2 microm), and a short (8-18 microm) and extremely narrow (1 microm) copulatory vagina. These characters have no equivalent, even approximate, among the 27 species of Wardium parasitic in the Charadrii which are reviewed. The genus Debrosia Spassky, 1987 appears to be justified.

The use of fluoroscopy to guide needle placement in interstitial gynecological brachytherapy

Interstitial brachytherapy is generally performed for gynecological malignancies with extensive parametrial involvement, by inserting the needles through a transperineal template. Often, the implanted needles are not parallel, and the multiple sources can be difficult to identify on localization radiographs, especially if obtained with a portable X-ray unit. We have used fluoroscopy to guide the needles for interstitial brachytherapy to treat various gynecological malignancies. Because the resultant needles are parallel, dosimetry can be performed based on the template hole positions used, rather than identifying individual sources. This report focuses on the technique; the outcome of patients implanted with this technique will be reported separately. Seventy-one patients were implanted transperineally with 192iridium using a Syed template under fluoroscopic guidance, from September 1989 to May 1995, for bulky parametrial disease, narrow vagina, extensive vaginal involvement, recurrent disease after previous course of pelvic radiation therapy, or in cases in which the patient had previously undergone hysterectomy. 137Cesium was added in a central tandem in cases with a cervical os. Thirty patients were treated for primary cervical or vaginal carcinoma; 41 patients were treated for recurrent disease from endometrial or cervical cancers. The brachytherapy dose (prescribed to the periphery of the implant) was 40 to 55 Gy when used alone (15 patients) and 22-40 Gy when used as a boost to 34.2 to 59.4 Gy of pelvic external-beam radiotherapy (56 patients). The patients were followed for 6 to 63 months. In all cases, some of the needles had to be repositioned to improve the alignment. Hence, the use of fluoroscopy aided in achieving parallel placement of the needles in all implants as seen on anterior-posterior radiographs. Because the 192iridium sources were ordered beforehand based on the preplan, and the dosimetry was based on idealized geometry of the template hole positions, all patients were loaded on the same day of implant. Fluoroscopically guided perineal interstitial brachytherapy is a feasible technique for use in various gynecological malignancies. The use of fluoroscopic guidance helped to achieve parallel needle placement in all of our implants, but it required repositioning of some of the needles in all cases. The parallel positioning allowed the use of preplanned dosimetry, minimizing the delay in loading of the patients. The outcome of the patients treated using this technique is currently undergoing analysis and will be reported separately.

Sex behavior following primary radiotherapy of cervix cancer

57 women with invasive cervical carcinoma treated by primary irradiation were asked by means of a questionnaire about their partnership, especially about their sexual life. 9 women (15.7%) had no more sexual intercourse. 50% of those 48 patients who were sexually active also after the treatment had marked discomfort during coitus due to lack of lubrication. They reported pain caused by a short or narrow vagina less often (20.8%). Only 33.3% had their first intercourse 3 months after the irradiation, frequency of cohabitation was reduced in 68.4% of the patients. The reason for this was fear of recurrence of the cancer, fear of pain and lack of libido: 57.9% of the women mentioned reduced libido. Before irradiation 14% had no orgasm during the coitus, but 52% had none after treatment. The sexual life was not disturbed in those women who had been well informed about the consequences of the irradiation and who had their first intercourse soon after the therapy.

Abdominal Repair of Vaginal Prolapse and the Postoperative Outcome as Judged by a Scoring System and X-Ray Colpography

Three abdominal procedures were combined to suspend the prolapsed vagina in patients with post-hysterectomy vault prolapse and a narrow vagina and uterine prolapse with pelvic diseases (such as fibroids) necessitating laparotomy. We used Moschcowitz's method (obliteration of the cul-de-sac by purse-string sutures) Burch's method (fixation of the anterior vaginal wall to Cooper's ligament) and Williams and Richardson's method (suspension of the vaginal stump using fascial strips from the external oblique aponeurosis. The postoperative outcome of 8 operations was judged by a scoring system and by X-ray colpography with superimposition of films obtained at rest and during straining (subtraction technic). The scoring system indicated that the anterior vaginal wall and the vaginal vault were well supported by this combination procedures. However, the prolapse of the lower posterior vaginal wall needed an additional vaginal repair. The X-ray colpogram showed that the axis of the repaired vagina was slightly more vertical than normal. But displacement of the vagina on straining was within the normal range. Neither dyspareunia nor stress urinary incontinence were seen as complications of our procedures.

Abdominal repair of vaginal prolapse and the postoperative outcome as judged by a scoring system and X-ray colpography.

Three abdominal procedures were combined to suspend the prolapsed vagina in patients with post-hysterectomy vault prolapse and a narrow vagina and uterine prolapse with pelvic diseases (such as fibroids) necessitating laparotomy. We used Moschcowitz's method (obliteration of the cul-de-sac by purse-string sutures) Burch's method (fixation of the anterior vaginal wall to Cooper's ligament) and Williams and Richardson's method (suspension of the vaginal stump using fascial strips from the external oblique aponeurosis. The postoperative outcome of 8 operations was judged by a scoring system and by X-ray colpography with superimposition of films obtained at rest and during straining (subtraction technic). The scoring system indicated that the anterior vaginal wall and the vaginal vault were well supported by this combination procedures. However, the prolapse of the lower posterior vaginal wall needed an additional vaginal repair. The X-ray colpogram showed that the axis of the repaired vagina was slightly more vertical than normal. But displacement of the vagina on straining was within the normal range. Neither dyspareunia nor stress urinary incontinence were seen as complications of our procedures.

The narrow vagina, the antecedent for irradiation injury

The narrow vagina may result in an overirradiation of the normal pelvic organs. This inadequate spatial relationship cannot be avoided by packing or choosing another applicator. Since this problem often occurs in the elderly patient, surgery is not seriously considered as an alternative. The prediction of radionecrotic complications is important for both the radiation therapist and the gynecologic oncologist. The narrow vagina can be defined in terms of the ratio of Point A dose to that of the bladder and/or rectum. It is important that a poor therapeutic ratio be recognized in order to prevent excessive radiation to the normal structures. Alternates to the “routine” intracavity Curie therapy will be presented. The role of the colpostats, the protruding source, and the tandem will be discussed in a manner which will yield better communication between the radiation therapist and the gynecologic oncologist. The deliverance of overtolerance radiation in order to gain cancer cure in select patients must be a combined radiotherapeutic surgical decision. Guidelines for management will be presented.

Extradural Analgesia for Culdoscopy

150 women (aged 18 to 43) receiving culdoscopy at Pittsburghs Magee-Womens Hospital from May 1967 to April 1968 were observed and interviewed to determine the efficacy of extradural analgesia. 120 patients received lumbar epidural blocks and continuous technique was used in 23 cases 12 of which had intraabdominal surgery following culdoscopic examination. 30 caudal blocks were performed including 2 continuous techniques. Supplemental analgesia was required in 18 out of 150 cases. Lumbar epidural technique elicited 1 paresthesia but the patient displayed no postoperative neurologic sequelae. 6 patients displayed significant hypotension (25% decrease in blood pressure) which was readily corrected with fluids in 5 while 1 required an intravenous vasopressor. 1 patient experienced vomiting and 13 displayed shivering but no convulsions. Only 1 patient had a postdural headache and no treatment was required for 28 mild backaches at the epidural site. Common complaints of pain and discomfort of the shoulder upper chest or epigastric area was thought to reflect either retained free air subdiaphragmatic irritation or soreness from the shoulder braces. Retained air is usually eliminated by gas expulsion induced by manual pressure on the abdomen before withdrawal of the cannula. Contraindications to culdoscopy include vaginal infection acute pelvic inflammation a narrow senile vagina and fixed masses in the cul-de-sac. Pulmonary cardiac or orthopedic diseases may indicate inability to assume the knee-chest position. Culdoscopy was usually completed in 30 minutes which included training and demonstration time. A high degree of patient acceptance combined with low morbidity rates and zero mortality in the study suggest that extradural techniques approach the ideal analgesia for culdoscopy.