Deformities of the vagina
Author: khurram akhtar
which may be felt above the symphysis pubis. If the uterus is not distended, it may be felt as a hard structure perched on top of the cystic swelling. Retention of urine may occur owing to the bladder being pushed upwards with the uterus, thus elongating the urethra. Enquiry will often show that the patient has had abdominal discomfort each month, although no external loss has occurred. Later, if the uterus or tubes are becoming dis- tended, or if there is peritonitis, pain may b~ severe. The diagnosis is obvious on inspection of the vulva, when the bulging occluding membrane is seen, with a purple colour if it is thin. Rectal examination reveals a large, 'I tense, cylindrical swelling filling the pelvis. ,;
In newborn infants similar distension of the vagina, and sometimes of I the uterus and tubes, occurs with mucoid fluid secreted by the cervix (hydrocolpos). A large abdominal mass is found, with a bulging membrane and urinary retention. Careful examination of the anal canal and urinary tract is most important, as there may be other congenital abnormalities.
In the rarer cases in which the atresia is at a higher level, the diagnosis is
not so obvious. There is less distension of the vagina, and attac abdominal pain may be the most prominent feature.
Obstruction may affect one-half of a double uterus and vagina and rise to a tumour which may cause considerable difficulty in diagn since the patient menstruates regularly from the other half of the ge tract. Laparotomy may be needed to reveal the complete picture.
The treatment of haematocolpos or hydrocolpos is simple. All that necessary is to establish drainage. This is best done by excising the m brane; although simple incision will suffice immediately, stenosis occur later and dyspareunia result. The risk of infection is considera and surgical technique must be meticulous. A vaginal examination sho not be made when the membrane is excised. The contents may be aspira with a vacuum extractor but should not be 'mopped out' with sw which could easily introduce infection. Antibiotic treatment should started 24 hours before the operation and continued for 5 days afterw
If the stenosis is at the level of the cervix, it may be possible to open the canal by dissection from below. If the vagina is absent, an artifi vagina may be constructed (see below).
The remote prognosis in cases of haematocolpos is satisfactory if distension is confmed to the vagina. If the uterus and tubes are disten some patients become sterile as a result of sealing of the fimbrial en the tubes.
Absent vagina In cases with complete absence of the vagina it is unusual to find a func ing uterus. There is often a shallow depression at the site of the no vaginal orifice. If the patient wishes to marry, or if the abnormality is discovered after attempts at intercourse, then an operation to fo cavity in the position of the vagina may be performed.
Williams' operation is a simple procedure in which the edges of posterior parts of the labia majora are sutured together in the midI form a perineal pouch. The artificial pouch runs in a more horiz direction than the normal vagina, but results of the operation are 0
A more extensive operation is that of McIndoe, in which a sp dissected in the fascial space between the rectum behind and the bl and urethra in front. This cavity must be lined with skin or it will contract down. A split skin graft (Thiersch graft) is cut from the thigh wrapped round a mould of compressed plastic foam. The graft is ap . to the mould so that the basal active surface of the skin graft is dir outwards to come into close contact with the walls of the cavity. mould is held in place with a few stitches at the introitus, and fiU worn until the whole surface of the cavity is covered with living skin. foam expands to give gentle pressure until the graft has taken.
Yet another operation that is occasionally performed is that of Bald '
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