Gynatresia Gynatresia

Presented by Dr Ikobho E. HPresented by Dr Ikobho E. H

Senior registrarSenior registrar

Dept. of O & G UPTH Dept. of O & G UPTH

Introduction Introduction

Common problem among womenCommon problem among women

Occur world-wide Occur world-wide

More in developing countriesMore in developing countries

Not life threateningNot life threatening

Mortality is very rareMortality is very rare

Profound psychological distressProfound psychological distress

Dyspareunia, apareunia, and infertility Dyspareunia, apareunia, and infertility

Definition Definition

Lawson and stewart(1967)Lawson and stewart(1967)

Narrowing of the female genital tractNarrowing of the female genital tract

May involve part or whole of the vaginaMay involve part or whole of the vagina

Stenosis may only involve vulval orificeStenosis may only involve vulval orifice

Congenital or acquiredCongenital or acquired

Congenital gynatresia occur world-wideCongenital gynatresia occur world-wide

Acquired lesions –in developing countries Acquired lesions –in developing countries

Incidence Incidence

5 in 1,000 of major gynaecological 5 in 1,000 of major gynaecological admissions in UCH Ibadan (okunola 2001)admissions in UCH Ibadan (okunola 2001)

Congenital causes of gynatresiaCongenital causes of gynatresia

Usually result from incomplete Usually result from incomplete canalization of mullerian ductcanalization of mullerian duct

Vaginal atresia (partial or total)Vaginal atresia (partial or total)

Transverse & longitudinal vaginal septumTransverse & longitudinal vaginal septum

Cervical atresiaCervical atresia

Imperforate hymenImperforate hymen

Causes of acquired gynatresiaCauses of acquired gynatresia

Labial agglutinationLabial agglutination

Scaring from female genital mutilationScaring from female genital mutilation

Prolonged obstructed labourProlonged obstructed labour

Post radiotherapy for genital cancerPost radiotherapy for genital cancer

Post operative complications- VVF repair, Post operative complications- VVF repair, colporrhaphy, and radical pelvic operationscolporrhaphy, and radical pelvic operations

Chemical vaginitisChemical vaginitis

Infections-lymphogranuloma venereumInfections-lymphogranuloma venereum

Labial Adhesions Labial Adhesions

Usually follow adhesive vulvitis due to post Usually follow adhesive vulvitis due to post delivery hypo-oestrogenic statedelivery hypo-oestrogenic stateNever seen at birthNever seen at birthUsually noticed 3 and 18 monthsUsually noticed 3 and 18 monthsLabial minora stick together in the midlineLabial minora stick together in the midlineBegins posteriorly forwards until only a Begins posteriorly forwards until only a small opening is left for urine to passsmall opening is left for urine to passSpontaneous resolution usually occur Spontaneous resolution usually occur when ovarian activity begins when ovarian activity begins

Female Genital Mutilation Female Genital Mutilation

Practiced world-wide, more in Africa, and affects Practiced world-wide, more in Africa, and affects about 85-114million Africans (WHO 1995)about 85-114million Africans (WHO 1995)

Affects about 50-60% of Nigerian females (Sule Affects about 50-60% of Nigerian females (Sule S. T. 1997)S. T. 1997)Age and extent of procedure vary widelyAge and extent of procedure vary widely range from type one to type fourrange from type one to type fourMay lead to severe vulval scaringMay lead to severe vulval scaringCauses dyspareunia, apareunia, dribbling of Causes dyspareunia, apareunia, dribbling of urine, incontinence, UTI and dystocia. urine, incontinence, UTI and dystocia.

Chemical vaginitis Chemical vaginitis

Results from insertion of corrosive chemicals, Results from insertion of corrosive chemicals, herbs, pessaries and creamsherbs, pessaries and creamsRock salts to tighten the vagina (Arabia)Rock salts to tighten the vagina (Arabia)Caustic pessaries for abortion (S. Nigeria)Caustic pessaries for abortion (S. Nigeria)Herbal pessaries to treat amenorrhoea infertility & Herbal pessaries to treat amenorrhoea infertility & vaginal discharge (W. Nigeria)vaginal discharge (W. Nigeria)Vaginal deodorants Vaginal deodorants Irritation leads to damage to the vaginal Irritation leads to damage to the vaginal epithelium from chemical burnsepithelium from chemical burns

Clinical presentation-congenital Clinical presentation-congenital

Incidental discovery (labial adhesions)Incidental discovery (labial adhesions)Amenorrhoea (primary)Amenorrhoea (primary)Cryptomenorrhoea, haematocolpos, Cryptomenorrhoea, haematocolpos, haematometra, and dysmenorrhoea or haematometra, and dysmenorrhoea or cyclical abdominal pain cyclical abdominal pain Abdominal tumor which may be painful Abdominal tumor which may be painful and tender at monthly intervalsand tender at monthly intervalsDevastating and profound psychological Devastating and profound psychological problems ( vaginal atresia) problems ( vaginal atresia)

Clinical presentation-acquired Clinical presentation-acquired

Coital symptoms – dyspareunia, apareuniaCoital symptoms – dyspareunia, apareunia

Menstrual disturbance- dysmenorrhoea, Menstrual disturbance- dysmenorrhoea, amenorrhoea, Cryptomenorrhoea, amenorrhoea, Cryptomenorrhoea, haematocolpos and haematometrahaematocolpos and haematometra

Urinary symptoms- difficulty in micturition, acute Urinary symptoms- difficulty in micturition, acute urinary retention and incontinenceurinary retention and incontinence

Infertility – abandonment of intercourseInfertility – abandonment of intercourse

Dystocia Dystocia

Investigations Investigations

PCV, Urinalysis/MCS, E&U/CreatininePCV, Urinalysis/MCS, E&U/Creatinine

Grouping and cross matchingGrouping and cross matching

Abdomino-pelvic USS- presence of genital Abdomino-pelvic USS- presence of genital structures, testes in abdomen/groinsstructures, testes in abdomen/groins

Karyotype (XY females)Karyotype (XY females)

Hormone profile-17 OH-progesterone, Hormone profile-17 OH-progesterone, androgenes, serum cortisolandrogenes, serum cortisol

Laparoscopy and EUALaparoscopy and EUA

Treatment Treatment

Depends on the type of gynatresiaDepends on the type of gynatresia

Medical and surgicalMedical and surgical

CounselingCounseling

Labial agglutination – expectant Labial agglutination – expectant management, oestrogen cream, surgical management, oestrogen cream, surgical separation using a probe, post operative separation using a probe, post operative barrier cream barrier cream

Treatment Treatment

Imperforate hymen – cruciate incision, Imperforate hymen – cruciate incision, drainage, broad spectrum antibioticsdrainage, broad spectrum antibiotics

Vaginal septum – septotomy for Vaginal septum – septotomy for symptomatic ones and those obstructing symptomatic ones and those obstructing labour. labour.

Thin septum close to the introitus may be Thin septum close to the introitus may be incised or excised incised or excised

Cervical atresia Cervical atresia

Rarely exist with functioning uterusRarely exist with functioning uterus

First establish pelvic anatomyFirst establish pelvic anatomy

Aim to reduce risk of endometriosis, Aim to reduce risk of endometriosis, haematosalpingiosis, and adenomyosishaematosalpingiosis, and adenomyosis

Create a uterovaginal fistula through Create a uterovaginal fistula through hysterotomy and anastomose opening to hysterotomy and anastomose opening to vaginal vaultvaginal vault

Congenital absence of vaginaCongenital absence of vagina

Pre-operative counseling and Pre-operative counseling and psychological supportpsychological support

Surgery is better delayed until patient is to Surgery is better delayed until patient is to resume intercourseresume intercourse

Use of graduated vaginal dilators Use of graduated vaginal dilators

Vagina is a potential space/loose tissuesVagina is a potential space/loose tissues

Patient to apply pressure for 10-20 min. for Patient to apply pressure for 10-20 min. for 8 weeks. Most patient will require surgery8 weeks. Most patient will require surgery

Surgery for Vaginal Atresia- Surgery for Vaginal Atresia- Mc-Indoe Jayes Operation Mc-Indoe Jayes Operation

A cavity is created at site of vagina by blunt A cavity is created at site of vagina by blunt dissectiondissectionLine cavity to prevent closure with graft- split-Line cavity to prevent closure with graft- split-skin, amnion, peritoneum, or bowelskin, amnion, peritoneum, or bowelAdvantages – good functional and cosmetic Advantages – good functional and cosmetic resultresultDisadvantages- post-op pain/dyspareunia, Disadvantages- post-op pain/dyspareunia, leucorrhoea (granulation tissue), contraction leucorrhoea (granulation tissue), contraction (regular dilatation), fistula (regular dilatation), fistula

Surgery for Vaginal AtresiaSurgery for Vaginal AtresiaWilliam's vulvovaginoplasty William's vulvovaginoplasty

Involves apposition of the labia in front Involves apposition of the labia in front of the neo-vagina to create a pouchof the neo-vagina to create a pouch

Advantages – simple, comfortable, rapid Advantages – simple, comfortable, rapid result, safe, contraction does not occur, result, safe, contraction does not occur, excellent clitoridal stimulationexcellent clitoridal stimulation

Disadvantages- unusual angle of Disadvantages- unusual angle of vagina, perineum looks abnormal, vagina, perineum looks abnormal, psychological inhibition of sexual psychological inhibition of sexual advancesadvances

Treatment of Acquired Gynatresia Treatment of Acquired Gynatresia

Mainly surgicalMainly surgicalReconstruction is more difficult than Reconstruction is more difficult than congenital, because of dense fibrosis and congenital, because of dense fibrosis and distortion of normal anatomydistortion of normal anatomyAdequate pre-op assessment & decision Adequate pre-op assessment & decision Contraindications (relative) – post Contraindications (relative) – post menopausal women, massive stenosis, menopausal women, massive stenosis, previous repair of extensive VVFprevious repair of extensive VVFHysterectomy remains an option Hysterectomy remains an option

Surgery for Acquired GynatresiaSurgery for Acquired GynatresiaDissection and Reconstruction Dissection and Reconstruction

May be difficult if tissue necrosis is severeMay be difficult if tissue necrosis is severeIt may be necessary to keep a probe in the It may be necessary to keep a probe in the bladder and a finger in the vaginabladder and a finger in the vaginaWhere the canal is difficult to identify, operation Where the canal is difficult to identify, operation during menses is advisedduring menses is advisedIf the correct plane is difficult to find, the uterus If the correct plane is difficult to find, the uterus can be entered abdominally and a probe passed can be entered abdominally and a probe passed through the cervix through the cervix First drain haematocolpos before reconstruction First drain haematocolpos before reconstruction

Reconstruction procedures Reconstruction procedures

End-to-end anastomose of upper and End-to-end anastomose of upper and lower ends of vaginalower ends of vagina

Split skin graft on a mouldSplit skin graft on a mould

Pedicle graft from the labiaPedicle graft from the labia

Post operatively, resumption of coitus is Post operatively, resumption of coitus is advised as soon as possibleadvised as soon as possible

Alternatively, graduated glass dilators Alternatively, graduated glass dilators could be used once every night could be used once every night

Other Surgical Methods Other Surgical Methods

Division of stricture and simple suture-only Division of stricture and simple suture-only effective when a short segment of the effective when a short segment of the vagina is stenosedvagina is stenosedWharton’s operation- dissection of a cavity Wharton’s operation- dissection of a cavity between vagina and rectum, and insert an between vagina and rectum, and insert an obturator as biological stimulantobturator as biological stimulantBaldwin's operation – involves bringing Baldwin's operation – involves bringing down a loop of ileum through the pouch of down a loop of ileum through the pouch of Douglas as neo-vaginaDouglas as neo-vagina

Conclusion Conclusion

THANK THANK YOUYOU