(Note: The term vaginectomy should be reserved for gynecologic oncology procedures performed to remove vaginal cancer. Vaginectomy entails full-thickness excision of the vaginal walls, including the fibromuscular layer, as opposed to excision of the epithelial layer only, as in colpocleisis. In this article, we present the LeFort method, a partial colpocleisis technique, because we believe it is more easily adapted by the general gynecologist.8)
CASE 1 RESOLVED
After detailed counseling, which includes family members, the patient opts to undergo colpocleisis. The procedure takes 45 minutes. She is discharged on postoperative Day 1, and reports substantially improved quality of life.
CASE 2: Recurrent prolapse and problems with a pessary
A 72-year-old multiparous, widowed woman experiences recurrent stage-III isolated apical prolapse. She has already undergone two reconstructive procedures, and was discouraged from undergoing a third because of her chronic obstructive lung disease. She tried to use a Gellhorn-type pessary, which required a doctor’s intervention to insert and remove. Frustrated by the many office visits involved in having the pessary checked, she now demands surgical therapy. Another gynecologist has offered to repair the prolapse using mesh, but the patient has concerns about the safety and efficacy of the procedure because it is a relatively new approach.
In addition to the recurrent prolapse, she loses urine with stress and urge. She often has a postvoid residual volume >100 cc; urodynamic assessment confirms mixed urinary incontinence. The patient does not foresee any change in her social status (unmarried, sexually inactive).
Is colpocleisis a reasonable option?
Although the pessary is a helpful conservative alternative for women who are either unable or unwilling to undergo complex surgical pelvic repair and is considered first-line treatment by a majority of urogynecologists, it sometimes becomes more difficult to maintain than the patient is willing to tolerate.9 When a woman cannot remove and reinsert the device herself, the pessary requires a lifelong commitment to doctor’s visits every 2 or 3 months. This commitment is especially problematic for patients who become unable to drive or who lack social support.
Maintenance of the pessary becomes more frustrating as the patient becomes more dependent. Many gynecologists have seen a patient who developed a serious complication such as vesicovaginal or rectovaginal fistula because of a neglected pessary.10
In Case 2, the patient appears to be a potential candidate for colpocleisis, given her age and single status. Although pelvic floor repair appears to be safe in older women, any perioperative complication in a patient 70 years of age or older doubles the risk of discharge to a care facility.11,12 Women who have already undergone several surgeries or who have advanced medical problems such as coronary artery disease or cancer should be counseled thoroughly about the safety and efficacy of colpocleisis.
As for self-image, colpocleisis eliminates prolapse and reduces the genital hiatus. If the patient understands that colpocleisis is obliterative for the vagina but may improve the external appearance of the genital area, she may be more accepting of the procedure. One recent prospective, multicenter study found that only 2% of women thought their body looked worse 1 year after colpocleisis; 60% thought their body looked better.5
When reviewing treatment options, inform the patient that the pessary is a palliative option, whereas surgical therapy aims to be definitive.
CASE 2 RESOLVED
After comprehensive counseling, the patient elects to undergo colpocleisis, along with placement of a midurethral sling. She is discharged 1 day after surgery, and reports substantially improved urinary function, including bladder emptying, and quality of life. She says she would recommend the procedure to any woman who has a similar condition.
CASE 3: Pessary-related complications, incontinence, and underlying medical conditions
A 92-year-old multiparous widow, whose stage-IV uterovaginal prolapse has been managed by a pessary, develops vaginal ulcers in both anterior and posterior walls. After removal of the pessary and 4 weeks of treatment with vaginal estrogen, a smaller pessary is inserted, but she again develops ulcers and bleeding.
The patient’s medical condition is complicated by hypertension and generalized arthritis. She has urodynamically confirmed mixed urinary incontinence. She lives with her daughter and does not want to be placed in a nursing home.
What treatment options should you offer to her?
Because of this patient’s advanced age, poor health, and pessary-related problems, she is an ideal candidate for colpocleisis, provided she consents to the procedure after thorough counseling about its benefits and limitations.
Preoperative concerns
A thorough history, physical examination, and normal Pap test are necessary. If a suspicious pelvic mass or uterine bleeding is present, transvaginal ultrasonography (US) is crucial. In-office endometrial sampling also is necessary in any woman who has unexplained vaginal bleeding. More invasive procedures such as dilatation and curettage and hysteroscopy are needed only when the biopsy is inadequate or endometrial thickness exceeds 4 mm on transvaginal US.13