Re: dyparunia after vaginal reconstruction
From: Charlie Chambers (cchamber@gorge.net)
Thu Oct 9 17:46:23 2003
Richard, at the very least, I would give a trial of vaginal dilators
prior to re-op. If a patient with vaginal agenesis can dilate to
sufficient caliber for intercourse in some circumstance then I would
think that your patient should as well. I'd be concerned that another
surgery, she might very well form more of a scar or granulation tissue.
On Thursday, October 9, 2003, at 02:10 PM, Richard Chudacoff, MD wrote:
> 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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************************************************************************
****
Charlie Chambers
Hood River, OR USA
cchamber@alumni.rice.edu
"...not because I regard fishing as being so terribly
important but because I suspect that so many of the other
concerns of men are equally unimportant-and not nearly
so much fun."
John Voelker
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