Surgical resection. If a skin bridge is clearly observed at the introitus, or if the introitus has been overly narrowed by perineorrhaphy but the remainder of the vagina has adequate length and caliber, surgical resection of the skin bridge might relieve symptoms of difficult penetration. In the case of obstructive perineorrhaphy, an attempt at reversal can be made by incising the perineum vertically but then reapproximating the edges transversely—sometimes referred to as reverse perineorrhaphy.
If scar tissue found elsewhere in the vagina might obstruct penetration, this condition might also be amenable to resection. When scarring is annular, relaxing incisions can be made bilaterally to relieve tension on that tissue; alternatively, it might be necessary to perform a Z-plasty. Nearly always, severe scarring is accompanied by levator myalgia, and a combined approach of surgery and physical therapy is necessary.
Neovagina. It is possible to find vaginal stenosis or shortening, to a varying degree, after surgical prolapse repair, with or without mesh or graft. As discussed, vaginal dilation should be offered but, if this is ineffective, the patient might be a candidate for surgical creation of a neovagina. Numerous techniques have been described for patients with congenital vaginal agenesis, with a few reports of similar techniques used to treat iatrogenic vaginal stenosis or obliteration.
The general principle of all neovagina procedures is to create a space between bladder and rectum of adequate caliber and length for desired sexual function. Reported techniques include a thigh or buttock skin graft, use of bowel or peritoneum, and, recently, a buccal mucosa graft.20,21
Resection or excision of mesh. In patients who develop sexual dysfunction after mesh placement, the problem can be caused by exposure of the mesh in the vagina or erosion into another organ, but can also arise in the absence of exposure or erosion. Patients might have tenderness to palpation at points where the mesh is palpable through the mucosa but not exposed.
Again, complete investigation is necessary to look for mesh involvement in the vagina and, depending on the type of implant, other adjacent organs. Assessing partner symptoms, such as pain and scratches, also can be telling.
If there is palpable tenderness on vaginal examination of the mesh, resection of the vaginal portion might be an option.17 Complete excision of mesh implants can be morbid, however, and might not provide a better outcome than partial excision. The risk of morbidity from complete mesh excision must be weighed against the likelihood that partial excision will not resolve pain and that the patient will require further excision subsequently.17,22 Excising fragmented mesh can be difficult; making every attempt to understand the contribution of mesh to sexual dysfunction is therefore critical to determining how, and how much of, the mesh comes out at the first attempt.
Last, for any woman who opts for surgical intervention to treat pain, you should engage in a discussion to emphasize the multidimensional nature of sexual function and the fact that any surgical intervention might not completely resolve her dysfunction.
Continue to: CASE Discussing options...