dyparunia after vaginal reconstruction

From: Richard Chudacoff, MD (rchudacoff@mylinuxisp.com)
Thu Oct 9 16:08:54 2003

4 months ago I performed a vaginal reconstruction on a 38 yo. with uterovaginal prolapse. Prior to the surgery I asked and was told her husband was extremely large and intercourse was important to them. With this in mind, the introital and luminal diameter of the vagina was >2.5 fingers (around 6 cm) after the reconstruction, as it remains today. She returns today with significant posterior dyspareunia. Dyspareunia is worse if she is on top or in knee-chest, and only slightly less if she is supine. She denies pain with bowel movements. There is no deep thrust pain.

Evaluation notes that there is minimal pain with downward traction of the perineal body. (For discussion sake proximal is referred to as closer to the cuff, distal is closer to the perineal body.) Pain increases just proximal to the perineal body, at about the level of the hymeneal ring, and extends three cm proximal. There is no pain of the most proximal half of the vaginal. There is excellent suspension of the vaginal cuff, no granulation tissue, and no pain with palpation. There is neither adnexal pain nor masses. Anteriorly there is an absence of pain as well. Of note, the uterosacral ligaments were used for vaginal suspension

Rectovaginal exam notes a supported, but thin rectovaginal septum. No palpable suture, granuloma nor retention of the septum. The pararectal space is free of scar, contraction or involvement of levator ani muscles. It feels very pliable. The sulci also seem to be without tension. There is also no pain with ventral movement of the rectovaginal septum.

The only option I can think of is to make a window in the rectovaginal fascia and put a pliant mesh.

Does anyone have any other suggestions? 

--
Richard Chudacoff, MD, FACOG
Chudacoff Obstetrics & Gynecology, PLLC
15200 Southwest Freeway, #270
Sugar Land, TX 77478


Tel: 281-277-3900
Fax: 281-277-3901


rchudacoff@mylinuxisp.com
Richard.Chudacoff@obgyn.net


http://www.mdhub.com/281-277-3900
http://www.chudacoffobgyn.yourmd.com


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