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Gynatresia

Presented by Dr Ikobho E. H
Senior registrar
Dept. of O & G UPTH
Introduction
Common problem among women
Occur world-wide
More in developing countries
Not life threatening
Mortality is very rare
Profound psychological distress
Dyspareunia, apareunia, and infertility
Definition
Lawson and stewart(1967)
Narrowing of the female genital tract
May involve part or whole of the vagina
Stenosis may only involve vulval orifice
Congenital or acquired
Congenital gynatresia occur world-wide
Acquired lesions –in developing countries
Incidence
5 in 1,000 of major gynaecological
admissions in UCH Ibadan (okunola 2001)
Congenital causes of gynatresia
Usually result from incomplete
canalization of mullerian duct
Vaginal atresia (partial or total)
Transverse & longitudinal vaginal septum
Cervical atresia
Imperforate hymen
Causes of acquired gynatresia
Labial agglutination
Scaring from female genital mutilation
Prolonged obstructed labour
Post radiotherapy for genital cancer
Post operative complications- VVF repair,
colporrhaphy, and radical pelvic operations
Chemical vaginitis
Infections-lymphogranuloma venereum
Labial Adhesions
Usually follow adhesive vulvitis due to post
delivery hypo-oestrogenic state
Never seen at birth
Usually noticed 3 and 18 months
Labial minora stick together in the midline
Begins posteriorly forwards until only a
small opening is left for urine to pass
Spontaneous resolution usually occur
when ovarian activity begins
Female Genital Mutilation
Practiced world-wide, more in Africa, and affects
about 85-114million Africans (WHO 1995)
Affects about 50-60% of Nigerian females (Sule
S. T. 1997)
Age and extent of procedure vary widely
range from type one to type four
May lead to severe vulval scaring
Causes dyspareunia, apareunia, dribbling of
urine, incontinence, UTI and dystocia.
Chemical vaginitis
Results from insertion of corrosive chemicals,
herbs, pessaries and creams
Rock salts to tighten the vagina (Arabia)
Caustic pessaries for abortion (S. Nigeria)
Herbal pessaries to treat amenorrhoea infertility &
vaginal discharge (W. Nigeria)
Vaginal deodorants
Irritation leads to damage to the vaginal
epithelium from chemical burns
Clinical presentation-congenital
Incidental discovery (labial adhesions)
Amenorrhoea (primary)
Cryptomenorrhoea, haematocolpos,
haematometra, and dysmenorrhoea or
cyclical abdominal pain
Abdominal tumor which may be painful
and tender at monthly intervals
Devastating and profound psychological
problems ( vaginal atresia)
Clinical presentation-acquired
Coital symptoms – dyspareunia, apareunia
Menstrual disturbance- dysmenorrhoea,
amenorrhoea, Cryptomenorrhoea,
haematocolpos and haematometra
Urinary symptoms- difficulty in micturition,
acute urinary retention and incontinence
Infertility – abandonment of intercourse
Dystocia
Investigations
PCV, Urinalysis/MCS, E&U/Creatinine
Grouping and cross matching
Abdomino-pelvic USS- presence of genital
structures, testes in abdomen/groins
Karyotype (XY females)
Hormone profile-17 OH-progesterone,
androgenes, serum cortisol
Laparoscopy and EUA
Treatment
Depends on the type of gynatresia
Medical and surgical
Counseling
Labial agglutination – expectant
management, oestrogen cream, surgical
separation using a probe, post operative
barrier cream
Treatment
Imperforate hymen – cruciate incision,
drainage, broad spectrum antibiotics
Vaginal septum – septotomy for
symptomatic ones and those obstructing
labour.
Thin septum close to the introitus may be
incised or excised
Cervical atresia
Rarely exist with functioning uterus
First establish pelvic anatomy
Aim to reduce risk of endometriosis,
haematosalpingiosis, and adenomyosis
Create a uterovaginal fistula through
hysterotomy and anastomose opening to
vaginal vault
Congenital absence of vagina
Pre-operative counseling and
psychological support
Surgery is better delayed until patient is
to resume intercourse
Use of graduated vaginal dilators
Vagina is a potential space/loose tissues
Patient to apply pressure for 10-20 min.
for 8 weeks. Most patient will require
surgery
Surgery for Vaginal Atresia-
Mc-Indoe Jayes Operation
A cavity is created at site of vagina by blunt
dissection
Line cavity to prevent closure with graft- split-
skin, amnion, peritoneum, or bowel
Advantages – good functional and cosmetic
result
Disadvantages- post-op pain/dyspareunia,
leucorrhoea (granulation tissue), contraction
(regular dilatation), fistula
Surgery for Vaginal Atresia
William's vulvovaginoplasty
Involves apposition of the labia in front
of the neo-vagina to create a pouch
Advantages – simple, comfortable,
rapid result, safe, contraction does not
occur, excellent clitoridal stimulation
Disadvantages- unusual angle of
vagina, perineum looks abnormal,
psychological inhibition of sexual
advances
Treatment of Acquired Gynatresia
Mainly surgical
Reconstruction is more difficult than
congenital, because of dense fibrosis and
distortion of normal anatomy
Adequate pre-op assessment & decision
Contraindications (relative) – post
menopausal women, massive stenosis,
previous repair of extensive VVF
Hysterectomy remains an option
Surgery for Acquired Gynatresia
Dissection and Reconstruction

May be difficult if tissue necrosis is severe


It may be necessary to keep a probe in the
bladder and a finger in the vagina
Where the canal is difficult to identify, operation
during menses is advised
If the correct plane is difficult to find, the uterus
can be entered abdominally and a probe passed
through the cervix
First drain haematocolpos before reconstruction
Reconstruction procedures
End-to-end anastomose of upper and
lower ends of vagina
Split skin graft on a mould
Pedicle graft from the labia
Post operatively, resumption of coitus is
advised as soon as possible
Alternatively, graduated glass dilators
could be used once every night
Other Surgical Methods
Division of stricture and simple suture-only
effective when a short segment of the
vagina is stenosed
Wharton’s operation- dissection of a cavity
between vagina and rectum, and insert an
obturator as biological stimulant
Baldwin's operation – involves bringing
down a loop of ileum through the pouch of
Douglas as neo-vagina
Conclusion
THANK YOU

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