Acquired Complete Obliteration of the Vaginal Canal: Surgical Techniques for Management

INTRODUCTION: Vaginal agglutination is a condition where the walls of the vagina are fused above the hymen. Vaginal agglutination may be associated with inflammatory skin conditions such as lichen planus or lichen sclerosis, trauma, or iatrogenic causes such as post-radiation or post-laser therapies. Standard management for vaginal agglutination depends on the etiology. Typically, particularly in the case for postmenopausal women, management starts with vaginal estrogen and dilation therapy. In cases refractory to conservative management, surgery may be required to restore the vagina for vaginal length and sexual function. OBJECTIVE: In this video, we present a 60-year-old patient with a history of lichen sclerosis presenting with complete vaginal agglutination with loss of the vaginal canal and obliteration of the vaginal opening. We will present the surgical steps for excision of the iatrogenic vaginal septum and techniques to restore vaginal length in a methodical and safe manner. METHODS: General techniques for vaginal reconstruction include the use of free flaps and rotation grafts. In instances where the vaginal epithelium is present but adherent, as in the case of vaginal agglutination, the surgical principle is focused on separating the planes of the anterior and posterior vaginal epithelium without injuring the bladder, rectum, and other surrounding organs. In this video, we present one treatment option for a patient with vaginal agglutination thought to be from an inflammatory skin disorder or iatrogenic from post-laser therapy. The first step is to identify the urethra and bladder with a transurethral catheter and a finger in the rectum to delineate the rectum. Visually, there is typically a plane between the anterior and posterior vaginal epithelium that could be visualized, and if it is not obvious, it can be determined with upward traction of the anterior vaginal wall or posterior vaginal wall. Once this plane is identified, careful adhesiolysis begins with electrocautery and with sharp dissection. This is continued proximally along the vagina until the vaginal apex, or cervix, can be visualized. RESULTS: Preoperatively, the patient presented with a vaginal length of 1 cm and a genital hiatus size of 1 cm. With our technique, we were able to restore the vaginal length to 9 cm and a genital hiatus of 4 cm. There were no postoperative complications. For post-procedural management, the patient was discharged with a vaginal packing and catheter for 48 hours. Upon removal of the vaginal packing and catheter, the patient was instructed to start daily vaginal dilation as well as a post-procedural vaginal estrogen and corticosteroid therapies. The postoperative results of the surgery were an increase in patient’s genital hiatus to 4 cm, increase in vaginal length to 9 cm, release of the midline fusion of the labia minora with visualization of urethra, and release of pus from the vagina. A vaginal swab and 4 skin/vaginal punch biopsies were also successfully collected. CONCLUSIONS: Management of vaginal agglutination depends on the etiology and goals of care. This requires an individualized treatment approach, and this video illustrates one methodical technique in restoring vaginal length and function.