Treatment of malformations of the vagina and uterus

The purpose of treating vaginal and uterine malformations is the creation of an artificial vagina in patients with vaginal and uterine aplasia or outflow of menstrual blood in patients with delay.

Indications for hospitalization - the patient's consent to a conservative or surgical correction of the development of the uterus and vagina.

Medicamentous treatment for malformations of the uterus and vagina is not used.

Non-pharmacological treatment of malformations of the vagina and uterus

The so-called bloodless colpopoiesis is used only in patients with aplasia of the vagina and uterus by using colpelotongators. When carrying out colpelongation according to Sherstnev, the artificial vagina is formed by stretching the mucous vestibule of the vagina and deepening the existing or formed "fossa" in the vulva with the help of a tread (colpoelonator). The degree of pressure of the apparatus on the tissue of the patient is regulated by a special screw taking into account its own sensations. The patient conducts the procedure independently under the supervision of medical personnel.

To improve the extensibility of the tissues of the vestibule vestibule, colpelongation is performed with the simultaneous use of Ovestin cream and Kontraktubeks gel. The undeniable advantages of the method are conservatism, the lack of the need to start a sexual life immediately after its termination.

The duration of the first procedure - an average of 20 minutes, in the future it increases to 30-40 minutes. One course of colpelongongation is about 15-20 procedures, starting from one procedure per day with transfer 1-2 days to two procedures. Usually, one to three courses of colpelongongation are carried out with an interval of about 2 months.

In the vast majority of patients with aplasia of the vagina and uterus in the colposlation, it is possible to achieve the formation of a well-extensible neovagin that passes two transverse fingers to a depth of at least 10 cm. If the conservative treatment is ineffective, an operation is indicated.

Surgical treatment of malformations of the vagina and uterus

In patients with vaginal and uterine aplasia, surgical colpopoiesis is used.

The first reports of attempts to conduct this operation date back to the beginning of the 19th century, when G. Dupuitren in 1817 tried to create a canal in rectovesical fiber in a sharp and blunt way. Before the introduction of endoscopic technologies, colpopoiesis was accompanied by an exceptionally high risk of intra- and postoperative complications.

To prevent overgrowth of the created recto-urethral orifice, attempts were made to apply its long tamponade and dilatation, introduction into the tunnel created between the bladder and rectum of prostheses (dilators of Gagar from silver and stainless steel, a phantom with kbbutec-2 and kolatsinom etc.). However, the implementation of these procedures is extremely painful for patients and is not effective enough. Later, there were numerous variants of colpopoiesis with skin flap transplantation into the created tunnel. After carrying out such operations, scarring of the neovaginalis, necrosis of implanted skin grafts was often formed.

V.F. Snegirev in 1892 performed colpopoiesis from the rectum, which was not widely used due to the great technical complexity, high incidence of intra- and postoperative complications (the formation of rectovaginal and pararectal fistula, stricture of the rectum). Later, methods of colpopoiesis from the small and large intestine were suggested.

Until now, some surgeons have been using sigmoidal colpopoiesis, which, to advantages, include the possibility of performing this operation long before sexual intercourse when this type of malformation is detected in childhood. Negative features of this type of colpopoiesis are its extreme traumatism (the need for performing the abdominal cavity, extraction and lowering of the segment of the sigmoid colon), the emergence of a large number of operated patients with loss of neovaginal walls, complications of an inflammatory nature, including peritonitis, abscesses and intestinal obstruction, cicatricial narrowing of the vaginal opening , as a result of this, renunciation of sexual life. Psychotraumatic situation for patients - allocation from the genital tract with a characteristic intestinal smell and frequent loss of the vagina during sexual intercourse. When examining the external genitalia clearly visualize the demarcation border of red color at the entrance level of the vagina. It is impossible not to agree with the opinion of L.V. Adamyan et al. (1998) that this method of correction, performed not for vital indications, is traumatic, is accompanied by a high risk of complications both during the operation and in the postoperative period, and is at present only of historical interest.

In modern conditions, the "gold standard" of surgical colpopoiesis in patients with vaginal and uterine aplasia is colpopoiesis from the pelvic peritoneum with laparoscopic assisting. In 1984, N.D. Selezneva et al. They first proposed colpopoiesis from the pelvic peritoneum with laparoscopic assist. Using the "glowing window" principle, the technique of which was refined in 1992. L.V. Adamyan et al.

This surgical intervention is performed by two teams of surgeons: one performs endoscopic stages, the second - perineal.

Under endotracheal anesthesia, a diagnostic laparoscopy is performed, during which the pelvic organs are assessed, the peritoneal peritoneum of the vesicoureteral cavity is assessed, the number and location of the muscular ridges are revealed. The manipulator marks this part of the peritoneum and feeds it down, constantly holding it.

The second brigade of surgeons proceeds to the crotch stage of the operation. The crotch of the crotch is dissected along the lower edge of the labia minora at a distance of 3-3.5 cm in the transverse direction between the rectum and the bladder at the level of the posterior adhesion. Sharp and mostly blunt way to create a channel in a strictly horizontal direction, without changing the angle. This is the most crucial stage of the operation in connection with the possibility of injuring the bladder and rectum. The canal is created up to the pelvic peritoneum.

The next crucial stage of the operation is the identification of the peritoneum, which is performed with the help of a laparoscope by illuminating (diaphanoscopy) the parietal peritoneum from the side of the abdominal cavity and applying it with soft forceps or a manipulator. The peritoneum is grasped in a tunnel by clamps and cut with scissors. The edges of the cut of the peritoneum are reduced and hemmed with separate vikril sutures to the edges of the cutaneous incision, forming the entrance to the vagina.

The last stage of the operation is the formation of the neovaginal dome, which is carried out through the laparoscope. They impose sutures on the peritoneum of the bladder, muscular ridges (rudiments of the uterus) and peritoneum of the lateral walls of the small pelvis and sigmoid colon. The dome of the neovaginal is created at a distance of 10-12 cm from the cutaneous cut of the perineum.

For 1-2 days in the neovaginal gauze swab with vaseline oil or levomelem is administered. The onset of sexual activity is possible 3-4 weeks after the operation, and regular sexual intercourse or artificial bougie to preserve the lumen of the neovaginal is an indispensable condition for preventing the fusion of its walls.

Studies of long-term results have shown that almost all patients are satisfied with sex life. With gynecological examination, the visible border between the vaginal vestibule and the created neovaginal is absent, the length is 11-12 cm, the extensibility and capacity of the vagina are quite sufficient. There is a moderate folding and a slight mucosal vaginal discharge.

With an inadequate vestigial but functioning uterus and pain syndrome caused, as a rule, by endometriosis (according to MRI and subsequent histological examination), simultaneously with colpopoiesis from the pelvic peritoneal perform their removal. Removal of functioning muscle strands / strands is possible with a pronounced pain syndrome in patients of young age without carrying out colpopoiesis. Colpopoiesis is carried out at the second stage of treatment: surgical (from the pelvic peritoneum before the onset of sexual activity) or conservative (colposology according to Sherstnev).

A similar tactic of treatment is the only valid method for correcting vaginal aplasia in patients with a vestigial functioning uterus. To select the method of surgical correction, it is necessary to have a clear idea of the anatomical and functional fullness of the uterus. The functioning uterus with aplasia of the cervix or cervical canal is a rudimentary, underdeveloped organ, unable to fully exercise its reproductive function, and there is no need at all costs to maintain an inferior uterus. All attempts to save the organ and create an anastomosis between the uterus and vestibule with the help of sigmoid or peritoneal colpopoiesis were unsuccessful due to the development of severe postoperative infectious complications requiring repeated operations. In modern conditions, extirpation of the functioning rudimentary uterus during vaginal aplasia can be performed with laparoscopic access.

Stages of extirpation of the functioning rudimentary uterus by laparoscopic access:

• diagnostic laparoscopy (revision of small pelvis, hysterotomy, opening and emptying of hematomas, retrograde hysteroscopy, confirming the absence of continuation of the uterine cavity into the lumen of the cervical canal);
• creation of a canal to the functioning rudimentary uterus and pelvic peritoneum by crotch access:
• extirpation of the functioning rudimentary uterus by laparoscopic access (intersection of the uterine ligaments, fallopian tubes, ovary's own ligaments, opening of the vesicle-uterine fold, crossing of the uterine vessels, uterine clipping);
• colpopoiesis from pelvic peritoneum to patients ready for the onset of sexual activity; patients who do not plan to have sexual intercourse, after the operation and the healing of the sutures, it is possible to conduct colpoelongation.

In a certain number of operated patients with vaginal aplasia and a rudimentary uterus, a dysfunctional endometrium is found in the histological examination of the removed preparation and adenomyosis and numerous endometrioid heterotopias are revealed in the thickness of the rudimentary uterus, which, apparently, is the cause of the pronounced pain syndrome.

Unfortunately, girls with a vagina aplasia (partial or full) and a functioning uterus with symptoms of an "acute abdomen" are often diagnosed with an incorrect diagnosis (acute appendicitis, etc.). As a result, appendectomy, diagnostic laparotomy or laparoscopy, removal or resection of the uterine appendages, erroneous and harmful cutting of the apparent atreized hymen, etc. Are performed. Conducting surgical interventions in the volume of puncture and drainage of the hematocolpos, including with the subsequent buzhirovaniem aplazirovannoj parts of the vagina, is unacceptable. This not only does not eliminate the cause of the disease, but also makes it difficult in the future to carry out adequate correction in connection with the development of the infectious process in the abdominal cavity (pyokolpos, pyometra, etc.) and cicatricial deformity of the vagina.

Currently, the optimal method for correcting incomplete vaginal aplasia with a functioning uterus is vaginoplasty using the method of sliding grafts. In order to reduce the risk of surgery, an objective assessment of the condition of the uterus and appendages, if necessary, correcting the accompanying gynecological pathology, vaginoplasty should preferably be performed with laparoscopic assist. In addition, the creation of pneumoperitoneum promotes the displacement of the lower edge of the hematocolpos downward, which, even if its filling is insufficient, greatly facilitates the operation.

Stages of vaginoplasty using the method of sliding grafts.

• Crosswise dissection of the vulva with mobilization of the flaps for 2-3 cm.
• Creation of a tunnel in retrovaginal fiber to the lower pole of the hematocolpus. This stage of the operation is the most complex and responsible in connection with the risk of injuring the bladder and rectum, which are closely related to the aplastic part of the vagina.
• Mobilization of the lower pole of the hematocolpos for 2-3 cm from the underlying tissues.
• X-shaped section of the lower pole of the hematocolpus (at an angle of 45 "with respect to a straight cross-sectional incision).
• Puncture and emptying of the hematocolpos, washing the vagina with an antiseptic solution, visualization of the cervix.
• Connection of the edges of the vulva and the lower edge of the emptied hemato- cilpus as a wedge in the groove (the principle of the teeth of the gear).

After the operation, a loose wax impregnated with vaseline oil is injected, followed by a daily sanation of the vagina and repeated insertion of the tampon for 2-3 days.

With the functioning closed horn of the uterus, the rudimentary uterus and the hematosalpinx are removed through the laparoscope. To reduce the trauma of the main uterus in those situations where the rudimentary uterus is intimately associated with the main uterus, L.V. Adamyan and M.A. Strizhakova (2003) developed a method of surgical correction of a closed functioning horn located in the thickness of the main uterus. Perform laparoscopy, retrograde hysteroresectoscopy and resection of the endometrium of the closed functioning horn of the uterus.

Surgical treatment of doubled uterus and vagina with partial aplasia of one of them consists in dissection of the wall of the closed vagina and creating a communication between it and a functioning vagina measuring 2x2.5 cm under laparoscopic control.

• Vaginal stage:
  • opening of the hematocolpos;
  • emptying of hematocolpos;
  • washing the vagina with an antiseptic solution;
  • Excision of the closed vaginal wall (creating an "oval window").
• Laparoscopic stage:
  • clarification of the relative position of the queens, the condition of the ovaries, the fallopian tubes;
  • control of emptying of hematocolpos;
  • emptying of the hematosalpinx;
  • detection and coagulation of foci of endometriosis;
  • sanitation of the abdominal cavity.

In girls with atresia of the hymen, under local anesthesia, X-shaped dissection and emptying of the hemato- cilpus are performed.

Approximate terms of incapacity for work

The disease does not cause permanent disability. Possible periods of incapacity for work - 10-30 days are due to the rate of reconvalescence after surgery.

Further management

In patients with aplasia of the vagina and uterus, it is advisable to repeat the course of colpelotongation 2-3 times a year in the absence of a permanent sexual partner for the prevention of neovaginal stricture after surgical colpopoiesis.

In order to timely diagnose cicatricial changes in the vagina after surgical correction of the vagina and uterus, a dispensary observation is shown with a checkup every 6 months to 18 years.

Information for patients

The absence of independent menstruation at the age of 15 and older, the cyclical intensifying pains in the lower abdomen and menarche are testimony to the consultation of a gynecologist of children and adolescents for the timely detection of the developmental defect of the uterus and vagina. With severe painfulness of the first sexual intercourse or the impossibility of sexual activity, you should stop trying to have sexual intercourse to avoid penetrating maiming of the perineum and urethra in patients with vaginal aplasia.

Forecast

With timely access to a gynecologist in a qualified gynecological department, equipped with modern diagnostic and surgical equipment, the prognosis of the course of the disease is favorable. Patients with aplasia of the vagina and uterus in the conditions of development of methods of assisted reproduction have the opportunity to use the services of surrogate mothers under the program of in vitro fertilization and embryo transfer.