Mohit R Saraogi*, Usha Kiran**
(* Assistant Professor, ** Associate Professor **, Department of Obstetrics & Gynaecology, Cama & Albless Hospital, JJ Group of Hospitals,
.) Mumbai, India
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.
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. 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. 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.
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.
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. Chemical vaginitis following insertion of caustic vaginal pessaries is the major cause of acquired gynaetresia. 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.
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.
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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