Site Visit Nyatende Hospital (referral hospital for Kalagane Health Center)

We spoke with the senior surgeon, Dr. Vincent Cibavunya.

He has been there for 10 years. He has 6 MDs working with him at Nyatende now.

This is a Catholic hospital, beautifully constructed and impeccably maintained with a stately, separate maternity building.

When Dr. Cibavunya arrived, almost all deliveries happened at home with high infant mortality and stillborn rate and many fistulas.
He did a study to determine that the major factors were cultural bias against hospital birth, ignorance of the benefits of obstetric care, and financial barriers (all over Congo, women pay on average 7 USD for vaginal birth and 15 USD for Cesarean Section).

He instituted an outreach program with his doctors and nurses and local churches and pastors going village to  village and house to house, to explain the benefits of obstetric care and hospital birth. This continues with monthly staff meetings with the regional health center clinicians.

He also worked with some group to create a sort of health care credit union that allowed a reduction in all OB fees.

Today, 85% of births in the Nyatende cachement area occur in Nyatende, infant mortality is very low and fistulas are a rare occurrence. Another MD who has been there 3 months states he has yet to see a fistula. When they do have a fistula, he states they always refer to Panzi Hospital www.panzihospitalbukavu.org.

Prolapse is more common, with about 10 cases per month at Nyatende.

Incontinence is also reportedly rare.

Most surgeries performed at Nyatende Hospital currently are partial thyroidectomy for goiter, and lots of ENT, nasal polyps etc.

Kiel Bonhomme, Dr. Tina Amisi, Dr. Cibavunya, Dr. Tchango, Dr. Romanzi

WHO, UNFPA, USAID and any number of fashionable Stateside and European fundraisers are throwing millions of dollars with the attendant beauracracy and fanfare at the seemingly unstoppable tragedy of fistula caused by lack of basic obstetric management in third world settings around the globe. Seems Dr. Cibavunya forgot to read these myriad reports, having singlehandedly recognized and dealt with this exact problem in his cachement area with a few dollars, a few local institutions, and a lot of common sense. Hmmm.

Within 40 years of the advent of general anesthesia in the mid-1800’s, the world’s first fistula hospital, founded in New York City by Dr. J. Marion Sims, was rendered obsolete, razed, and replaced by the current Waldorf Astoria Hotel in 1893.

Well into the 21^st century, it is time, and as demonstrated by Dr. Cibavunya, it is well within possibility, to implement the rudiments of modern obstetric care that will preclude the need for expensive, stigmatizing, tragic, single-focus fistula centers – we need only apply the obstetrical practices and standards of care available in North America and Europe at the end of the 19^th century.

Hats off to Dr. Vincent Cibavunya and Nyatende Medical Center, South Kivu, Democratic Republic of Congo.

(C) Lauri Romanzi, 2010

If you need transfer to hospital, this S Kivu clinic will carry you 4 km to the nearest hospital in this exact chair, the "Ambulance Chair"

Today we travelled to a regional health clinic to find out what services and deficits exist for pregnant women at risk for maternal death or vaginal fistula. We found a hard working, well trained, and devoted “Titular Nurse”. In this facility with no electricity, no lights except a kerosene lamp, dicey plumbing and a pharmacy stocked with one medication (Ampicillin), they do indeed deliver babies, but only the “easy” ones with no complications of labor, like obstructed labor, or infection, or prolapse of the umbilical cord, or fetal distress, or heavy bleeding. If a woman has a complication during labor (or for that manner any man, woman, child or infant whose care is beyond the capacity of this facility), and you can’t get to the hospital on your own, they literally put you in this chair and carry you 4 kilometers over incredibly rough terrain (even the goats stumble) to the regional hospital. It seems the ambulance broke about a year ago, and with no funding to fix it, emergency transport is carried out by “Ambulance Chair”.

In an infrastructure and cash-strapped country, where corruption rules and chaos is not a choice, what’s more important? Funding more “fixing of Problem X” or funding ways to prevent Problem X while maintaining current methods by which Problem X gets fixed?  From what I gleaned at the hospital today, the doctors and other powers-that-be choose option #2.  To sum up, “retention and prevention” are the keys to fistula eradication in South Kivu, DRC- find ways to retain the talented local fistula surgeons who leave to find the “beyond fistula” training they cannot get at Panzi Hospital, and develop ways to improve obstetric care so that fistulas don’t occur in the first place.  When money is scarce, common sense pays bigger dividends.

The internet is slllloooow as cold molasses on a winter day here. It took me 45 minutes to post this post- (bad news)

It’s the dry season, hasn’t rained in 6 weeks, and without a single paved road in Bukavu, it’s a veritable dust bowl. So I promised our driver “I’ll make sure it rains tonight.” At 9 pm it POURED BUCKETS for about an hour. By now, this man must think I’m a witch – (good news)

More tomorrow, Mouseketeers.

What’s with my brain’s insistence on using Frank Sinatra’s “New York” as the default song-stuck-in-your-head soundtrack whenever I’m working in Democratic Republic of Congo?

Freshly arrived in the southern Kivu region of the Democratic Republic of Congo after 18 hours flight time and 5 hours drive from Kigali, Rwanda, I am pleased to report that Rwanda seems content in the wake of the recent “transparent” election on August 9th that allows President Paul Kagame to continue his program of healing and reunification (one version) or subversive neo-dictatorship, take your pick. On the way I read all manner of editorial and article on this election, leaving me pining for Camu’s imaginary political party for (forgive any misquote here) “people who are not sure they are correct”. The legacy of Belgian-mandated tribalism in this region is beyond the capacity of this well fed, safely raised American to pass judgement on, so I’ll stick with prayer that Kagame can heal his people. I will say this, despite USAID signs all over the country, the Chinese are all over Rwanda, laying electrical cable, engineering mountainside roads, investing in agribusiness…

Today’s drive from Kigali to the bordertown of Cyangugu was painless except for the usual money headache. Everyone here wants brand new USD, no tears, no wrinkles, 2006 mint. In Congo, the cash (and you can only use cash) needs to be small, and apparently, now in Rwanda, the USD cash needs to be big. I was ready for small – did not bring any big – inducing a polite, understated, sotto-voce full on caniption from the Rwandan driver about his tiny-tender, brand new USD $5’s fee. Thank goodness the Congolese relay driver had Benjamin in his wallet or I would have been driving halfway back to Kigali to wait for a bank to open on Monday.

Now on my 3rd return to Panzi Hospital www.panzihospitalbukavu.org, this time I am here to facilitate the regional needs assessment for a newly minted joint venture between Harvard Humanitarian Initiative www.hhi.harvard.edu and the Engender Health division of USAID www.engenderhealth.org designed to improve fistula care in this difficult and lately recognized disaster zone.

I’ll leave you with this quote from a 2007 treatise published by Dr. K. Ramsey of the United Nations Population Fund in the international journal of Gynecology and Obstetrics:

“Women in most developing countries still risk their lives and their health in childbirth despite the existence of life-saving interventions (the most obvious being cesarean section). In regions such as Africa and Asia, where approximately 95% of annual (worldwide) deaths occur, at least 20 women experience an obstetric morbidity (injurious complication of pregnancy that does not cause the mother to die) for every woman who dies…. The most devastating of these injuries is probably obstetric fistula, a condition that was virtually eliminated in industrialized countries nearly a century (A CENTURY) ago.”

International Journal of Gynecology and Obstetrics (2007) 99, 5130-5136.

Doesn’t that make you sad and furious and wanting to make it stop? Does me.

Content courtesy Alan Fogel

Pelvic floor disorders include problems with urinary incontinence, pelvic organ prolapse, fecal incontinence, fistula, urinary tract infections, and mechanical sexual dysfunction. Who wants to think about this stuff?  Well, for starters, women who suffer these disastrous conditions.

Pelvic organ prolapse, on which I’ve written aplenty, can sometimes induce a rather nasty condition called overactive bladder. Overactive bladder happens when your bladder muscle (yes, the bladder is a muscle, an automatic muscle, like the muscles in your intestines or your heart) decides to EVACUATE, any time it wants to, whether you’re on the toilet or riding the bus. Women with overactive bladder often report a compelling, sometimes sudden urge to void (urinate) that is difficult or impossible to defer. She may find her bladder waking her from deep sleep many times at night with this same horrible urgency. When this urgency control is “difficult”, she’s Kegeling her legs off, squeezing her thighs together and sweating bullets trying to make that horrible urge feeling stop so she can uncross her legs and dash to the nearest powder room. When the urge to void is “impossible” to defer, she wets her pants. It’s messy, horrifying, and terribly unsexy.

Urge Incontinence from Overactive Bladder

While most cases of overactive  bladder are idiopathic (medicalese for “no apparent cause”), some cases are caused by prolapse.  When the bladder or uterus (or both) prolapse, the urethra can be kinked or compressed, obstructing urine outflow and making it difficult for the bladder to empty completely. Obstructed bladders are cranky bladders, often becoming overactive in response to this interference with emptying.

A recent multicenter European study published in Neurourology and Urodynamics showed a distinct correlation between severe pelvic organ prolapse, bladder outlet obstuction, and overactive bladder. Prolapse can obstruct bladder outflow and if it does, the bladder tends to become overactive, reminiscent of that vaudeville song, “The head bone’s connected to the … neck bone…”.  In this timely review, they also found that successful prolapse surgery often, but not always, calmed down bladder overactivity by un-blocking the urethra and normalizing bladder outflow. The connection between prolapse, bladder outlet obstruction and overactive bladder

Women with prolapse and bladder problems often want to know if surgery will fix both. This study helps us understand that it indeed may help fix both the prolapse and the obstructed/overactive bladder disorders in a large portion of women with this unhappy combination. For years, I’ve used pessaries (vaginal widgets that comfortably hold prolapse in place) to help predict whether or not prolapse surgery might also stop obstructed voiding and overactive bladder, and most of the time it correlates well to surgical outcome. And sometimes, the patient is so pleased with the pessary that she cancels the operation.

For a detailed case report on women with prolapse, obstructed voiding and overactive bladder, click on this MedScape review:

Dr R for MedScape- prolapse, overactive bladder, stress incontinence, obstructed bladder

http://cme.medscape.com/viewarticle/700135

One last note for women with prolapse and bladder problems – there is another urinary incontinence condition, called stress incontinence, that may actually increase with pessary use or prolapse surgery, because a stress – incontinent urethra may actually seal better with the kinking and compression caused by prolapse, and may therefore increase when the prolapse and kinking are mechanically corrected. Stress incontinence is caused by poor urethral closure that allows urine to leak out with strenuous physical exertion, like sneezing or coughing or opening a window or lifting heavy grocery bags. No urgency, just “exert and squirt”.

Stress Urinary Incontinence = "Exert and Squirt"

If you have prolapse and stress incontinence, your problems require therapies for prolapse and therapies for stress incontinence. Prolapse therapy options usually involve pessary use or reconstructive surgery. Stress incontinence options include Kegel exercises with pelvic floor physical therapy, medications, or procedures such as urethral bulking injections or minimally invasive sling operations. You can do prolapse reconstruction and urethral sling in one operation, for instance, taking care of both your plumbing and your renovation problems at the same time (on Plumbing and Renovations).

Prolapse or no prolapse, urge incontinence from overactive bladder and stress incontinence from a weak urethral seal can plague any woman at any age. About 13% of women with overactive bladder are under the age of 35, and up to 30% college female athletes report regular urinary incontinence of one sort or another during training and competition. It comes with the territory, and it increases in prevalence as women age.

1/3 of incontinent women suffer only stress incontinence, 1/3 only urge (overactive bladder) incontinence and 1/3 suffer a mixture of both overactive bladder / urge incontinence AND stress incontinence.

If you have incontinence, or prolapse and bladder problems, make sure you don’t undertake any therapeutic measures without first understanding if you have overactive bladder, bladder outlet obstruction, and/or stress urinary incontinence. It is absolutely possible, and not at all uncommon, to have all three conditions if you suffer severe prolapse. Take the time to sort it all out, make sure it’s clear in your mind, then work with your doctor to set a common-sense course of action to restore your core to normal anatomic and physiologic function.

Pelvic organ prolapse, the medical term for vaginal bulges caused by damage to the connective tissues supporting the organs above and around the vagina (the uterus, bladder, rectum and vaginal opening), is a silent epidemic affecting women worldwide. Common terms include dropped bladder, dropped uterus, rectocele and vaginal laxity. Recent estimates using US Census population projections anticipate a 46 percent increase in pelvic organ prolapse among American women over the next 40 years, from 3.3 million in 2010 to 4.9 million. According to a recent study from Duke University, it is possible that the number of women with prolapse will be even greater than this, up to 9.2 million. Prolapse may occur to varying degrees in up to 50 percent of women who’ve given birth. Prolapse can even cause depression.

Childbirth contributes to most prolapse conditions, however genetics, medical disorders such as connective tissue disease, diabetes and obesity, and lifestyle habits have all been shown to contribute to pelvic organ prolapse risk. I’ve had many young women in their 30’s with prolapse who’ve never been pregnant, or found themselves suffering a dropped bladder after an easy and quick delivery of their first normal (or even low) weight baby. Even cesarean section is no guarantee against pelvic organ prolapse, with 5% of women in one recent study suffering severe, palpable and visible prolapse even though they delivered by cesarean section before going into labor. The role of Kegel fitness and Kegel exercise in the prevention of treatment of pelvic organ prolapse is just recently getting the research attention it deserves, and Kegel exercise may well play a role in prevention and treatment of prolapse. But for certain, if you suffer prolapse that looks like the image below, no amount of pelvic floor Kegel exercise, or any other kind of exercise, will pull your parts back into place.

Prolapse surgery often comes with a recommendation for hysterectomy, but the latest trends highlight new techniques that fix the prolapse just as well without removing the uterus. When the uterus prolapses it can be resuspended by one of several techniques, and the surgery holds up just as well as when a hysterectomy is included in prolapse repair surgery. This uterine resuspension concept is an exciting new option that allows many women to undergo prolapse repair surgery without removing any organs.

While many women with prolapse believe just one single body part is out of postion, most commonly, prolapse involves hernia-type displacement of several organs. When the bladder drops, formally called a cystocele (siss-toe-seal), it is often accompanied by a rectal bulge, called a rectocele (wreck-toe-seal).  Laxity at the vaginal opening, called a perineocele (pear-in-ee-oh-seal) results when the perineum loses connective tissue bulk as a result of childbirth.  Uterine prolapse is called, well, uterine prolapse. But behind a prolapsed uterus, it is common to find an internal small intestine hernia called an enterocele (en-tare-oh-seal).

When you put all these prolapse possibilities together at their absolute worst, it looks like this:

Courtesy WomensVoicesForChange.org

My role as guest blogger gives me the opportunity to demystify this deeply troubling malady.  For more information, check out this first of 2 posts on pelvic organ prolapse done for my friends at Sweet Talk on The Spot:

Dr R covers Prolapse, Part 1 for Sweet Talk on The Spot

To review Dr R’s book on prolapse, see www.plumbingandrenovations.com

If you have any questions, send in your comments on this post or post your own question to Ask Dr R.

(C) Lauri Romanzi, 2010

Betty, a woman with uterine prolapse, recently wrote in to this blog, asking advice after her doctor told her she would need a hysterectomy to fix her prolapse. We now understand that the mechanics of prolapse are all about those ligaments, and that the uterus, literally, contributes nothing to prolapse other than it’s change in position from “up there” to “out there”.  Dr. Pat Allen, Gynecologist extraordinaire and founder of Women’s Voices for Change, called me in to pinch hit on this one, and with bases full, Dr. R goes to bat:

Dear Betty,

You’ve done a great job of describing a condition that many women are intimately familiar with and, like you, embarrassed to talk about. I asked WVFC Medical Advisory Board member Lauri Romanzi, M.D., a specialist in reconstructive pelvic surgery and urogynecology, to respond. Which she did, pulling out a drawerful of medical illustrations to help explain what’s going on in your body, and why a hysterectomy isn’t the answer. —Dr. Pat

Betty\’s Prolapse Problem

Vaginal rejuvention, a mystical term with many facets, new darling of cosmetic surgery and battle cry of the “anti-medicalization of female sexuality” crusade, is a marketing term with no formal medical definition, this despite the American College of Obstetrics and Gynecology 2007 Clinical Practices Bulletin on the topic that was rife with both admonishments against some, and guarded approval of other, procedures advertised under this “VR” label. Some 3 years after the ACOG bulletin, concern and confusion reign on as the definition of vaginal rejuvenation continues to mutate.  

As a reconstructive pelvic surgeon and urogynecologist, I’ve been dealing with “Vaginal Rejuvenation” requests of all types since the term went public. As far as I can tell, the public’s interpretation of vaginal rejuvenation falls into three groups, listed here in order of increasing controversy and decreasing volume of safety & efficacy data:

Procedures to correct prolapse and incontinence

Procedures to alter the appearance of vulvar structures

Procedures alleged to enhance female sexual gratification

For a perspective-setting preview, consider reading this 2009 review of vaginal rejuvenation by Dr. R, and an excellent piece on birth plans written by Sharon Bond, PhD, Certified Nurse Midwife, here:

NAFC Quarterly Update Vaginal Rejuvenation & Childbirth Planning

These 2 articles, written for the National Association for Continence quarterly newsletter, dovetail nicely. As it turns out, much of what patients consider “vaginal rejuvenation” has a lot to do with childbirth-related changes in pelvic floor anatomy and function. As a contributor and member of NAFC (National Association For Continence, www.nafc.org), I share this fantastic online resource for information on pelvic floor disorders.  While the NAFC focus is on bladder and bowel control (as evidenced in the name), they do a great job of bringing up-to-date information on sex and well being to the public.

THE INSIDE SCOOP ON VAGINAL REJUVENATION

UPDATE 2010

Vaginal rejuvenation is a tenaciously fashionable concept, still with no strict medical definition. Yes that’s right, things vaginal continue to be fashionable. And, as with fashion, much is left to creative interpretation.

For many women, the childbearing, peri- and post- menopausal years come with pelvic, sexual, urinary, rectal or vaginal problems. Vaginal laxity, pelvic prolapse, poor bladder control, vaginal dryness, sexual pain, or waning sexual response can truly affect how you feel about yourself and your ability to enjoy your life. In medicine, we use “quality of life” questionnaires to measure the affect of such symptoms on health‐ mental health, ability to work, play, travel, enjoy sex, and feel normal and intact as a woman. If things aren’t right, you have options. These options, under the newly minted term “vaginal rejuvenation”, continue to spark controversy, raising concerns about safety, efficacy, and medical ethics.

With those options come obligations. Your obligation includes examining your motivations, taking stock of the overall impact of the condition(s) on your quality of life, and obtaining several medical or surgical opinions before you start any therapy or sign up for any surgery.  The doctor’s obligations include sorting out whether your condition(s) warrant physical, medical or surgical therapies or some combination thereof, and to help you understand what the risks, benefits and alternatives are for your personal mix of issues and symptoms.

Vaginal rejuvenation skipped onto the medical stage a few years ago, with no formal medical definition, in response to increased demand for  cosmetic alteration of gynecologic structures, most commonly the labia minora (inner vaginal lips). It has since come to mean any variety of procedures and treatments, many with an established record of use for generations, and others with no established history, little to no safety or efficacy data, and no predictable result.

“Vaginal Rejuvenation” for pelvic organ prolapse, vaginal laxity, and incontinence

Women with vaginal laxity, prolapse or  incontinence  might not know what “prolapse” or “incontinence” truly mean, but all women instinctively understand the notion of vaginal rejuvenation.

For a new mother, vaginal rejuvenation may mean improving pelvic muscle tone, and vaginal snugness with Kegel muscle exercises in a formal postpartum rehabilitation program of biofeedback (think “vaginal video games”) and pelvic floor electrical stimulation. For a 43 year old tennis‐playing mother of 3, it could mean minimally invasive surgery for “exert and squirt” type urinary incontinence (stress incontinence), with “perineoplasty” to restore the perineum (connective tissue between vagina and anus) back to normal, “rejuvenating” bladder control and vaginal snugness to pre‐baby condition. Or uterine resuspension, bladder lift, rectum reinforcement (rectocele repair), perineoplasty and a minimally invasive sling for combined prolapse and stress incontinence – what I call “the blue plate special.”

Vaginal Rejuvenation Traditional Medical Terminology

Vaginal muscle fitness = Pelvic Floor Rehabilitation a.k.a. Kegel Exercise

Lift a dropped bladder = Anterior Colporrhaphy*

Tighten a vagina permanently widened by childbirth= Perineoplasty

**Fix a bulging rectum = Posterior Colporrhaphy

Repair a leaky bladder = Urethral Sling or Urethral Bulking Injections

Restore anal control = Anal Sphincteroplasty

Lift a dropped uterus = Uterine Resuspension, aka Hysteropexy

***”Vaginoplasty” = creation of a vagina (often using  loop of intestine) in a woman born with congenital absence of the vagina, or creation of a vagina in a woman whose vagina is scarred shut from disease (fistula, radiation effect, infection, radical pelvic cancer surgery). More recently, under the marketing concept of vaginal rejuvenation, it has come to mean any combination of procedures from any of the basic three categories (prolapse/incontinence, cosmetic, sexual enhancement) for women without congenital or acquired obliteration defects of the vagina.

*Also referred to as “anterior repair”

** Also referred to as “posterior repair”

***On “vaginoplasty”, in the realm of “vaginal rejuvention” for women born with normal vaginal anatomy, this procedure, commonly attached to the word laser, as in “Laser Vaginoplasty” or “Laser Vaginal Rejuvenation”, carries no description in any medical or surgical textbook or peer review journal.  As of June, 2010, neither “laser vaginoplasty” nor “laser vaginal rejuvenation” are now or ever have been taught in any surgical or gynecological residency training program, nor in any urogynecology, female urology, plastic surgery, or other reconstructive surgical subspecialty fellowship training program. If you want to know about laser vaginoplasty, patient choice is restricted to consultation with a doctor who paid to be trained by the founder of the laser vaginal rejuvenation procedure. These doctors pay a fee to spend several days learning the procedure(s). The fee includes the franchise purchase, after which purchasing physician participates in an exclusive, robust webmarketing network restricted to purchasers of the franchise, the only doctors who may perform the laser vaginal rejuvenation procedures. These franchise-purchasing physicians are under contractual obligation that forbids discussing or otherwise disclosing the actual technique to anyone who has not purchased the franchise, including colleagues or the press. As such, and despite patient satisfaction testimonials on the franchise physician websites, there is no scientific, peer reviewed data in any peer reviewed medical journal documenting the actual technique, efficacy or safety of laser-based vaginal rejuvenation procedures

For some women, “rejuvenate” = “relubricate” (see When rejuvenate = relubricate). Vaginal dryness, poor lubrication and reduced clitoral sensitivity, common symptoms after menopause, are easily remedied with low‐dose vaginal estrogen therapy, treating the target areas without giving your body a full dose of estrogen.

With “vaginal rejuvenation” in the public lexicon, many women with prolapse or menopause-related vaginal dryness or problematic urinary incontinence eagerly seek out a little rejuvenating, often the same women who reject the unsexy but medically accurate labels of “pelvic organ prolapse” , “vaginal atrophy” or “incontinence.” For women over 50, the risk of severe pelvic organ prolapse or urinary incontinence are about 5%, and this increases in women who are overweight, or who have birthed children, particularly large babies and long pushing stage of labor.  A recent study of over 3000 women ages 50‐61 showed 6% with symptomatic, high‐grade prolapse.  Some estimates show 50% of women who’ve born children will have variable degrees of pelvic organ prolapse, from asymptomatic to gravely symptomatic.  By 2050, the number of women with urinary incontinence is expected to increase by 46%, and those with pelvic organ prolapse by 55%, with the number of American women with at least one pelvic floor disorder increasing from 28.1 million in 2010 to 43.8 million in 2050.

Whether you call it prolapse repair, incontinence therapy, or vaginal rejuvenation, pelvic floor disorders condition and related treatments (with “laser vaginal rejuvenation” the exception) come with generations of experience documented in medical and surgical texts and reams of data in myriad peer-reviewed medical journals.

“Vaginal Rejuvenation” to alter the appearance of the vulva and vaginal opening

Reduce and remodel inner labia = labiaplasty

Restore the hymen to a virginal state = hymenoplasty or “revirgination”

Reduce wrinking of outer labia = labial filler injections (of fat, collagen or other filler)

Labiaplasty reduces and remodels large inner labia (labial hypertrophy), or restores symmetry to unbalanced labia (labial asymmetry). Women requesting labiaplasty reduction and recontouring of the inner labia minora is often  report physical discomfort from labial catching, chafing, rubbing and folding in clothing or with sexual or other vigorous activities like tennis, yoga, running and biking. Women’s current propensity to depilitate all vulvar hair and wear thongs, the ad infinitum wearing of jeans formerly reserved for the under-30 set, intertwine with inevitable yet subtle changes in inner-outer labial consistency and relative size and natural age related vulvar wrinkling, resulting in unprecedented complaints of physical discomfort from this artificially increased labial exposure. I find many such patients adamantly unwilling to restore Mother Nature’s natural labial cushion that comes from full-growth pubic hair, full crotch underwear, and pants that aren’t painted on. I tell every labiaplasty patient every time, and 9 times out of 10, this (self-selected and therefore biased) group opts for the labiaplasty operation over nature’s blueprint.

The role of enculturation cannot be underestimated. On the other end of the labial alteration spectrum, from a region of the world more famous for rite-of-passage female genital mutilation than female sexual gratification, comes the regionally popular central African practice of labial elongation, believed to enhance female orgasm, female ejaculation, and sexual satisfaction for both male and female sides of the coital equation: Rwandan women enhance gratification with \”labial elongation\”

Hymen restoration involves careful reconnection of the hymen remnants to recreate a pseudo-virginal state, most commonly requested by women from cultures requiring virginity at the altar, but gaining popularity here in the States from women seeking “revirgination”. This procedure meets with much scrutiny, given the inherent cross-cultural and socio-ethical issues involved.

Labial bulking of the outer labia reduces age-related wrinkling as the body’s youthful fat pads diminish not only in the vulva, but also in the cheeks, hips, extremities and around the joints. These fat pads are well understood by cosmetic surgeons, who commonly plump up  facial cheeks made hollow by age-related loss of facial fat, often using liposuctioned fat from the patient’s own buttocks, abdomen or thighs. Popularized by these same cosmetic surgeons, women with age-related fat pad volume loss in the labia majora reportedly undergo similar bulking filler injections into the labia majora in cosmetic surgery offices.

As with rhinoplasties, lip enhancements, cheek and buttock implants, liposuction and all other cosmetic procedures, these “not medically necessary” labial alteration procedures are not covered by insurance. The physician is obligated to evaluate patient motivations, and to do their professional best to avoid performing them on women addicted to cosmetic procedures or suffering from body dysmorphia, both contraindications to cosmetic procedures.

A woman seeking labiaplasty for severe congenital asymmetry or labia that routinely catch, tear or chafe with sporting or sexual activities are not the same as patients responding to cruel comments from an unworthy sexual partner or insecure because they “don’t look like the women in porn movies”. Labiaplasty procedures are included in surgical texts, with techniques and data published in peer reviewed medical and surgical journals. Much controversy surrounds labial and hymenal procedures, taken as yet another sign of the increased medicalization of female sexuality, with “female sexuality as a newly minted profit center for unethical surgeons and greedy pharmaceutical corporations” as the banner-head under which such protests march. (see Professor Leonore Tiefer)

The controversy rages on, hitting fever pitch with the next category of rejuvenation procedures:

“Vaginal Rejuvenation” to enhance sexual gratification

Clitoral unhooding

G-Spot amplification (a.k.a. the G-shot)

Sub-clitoral bulking injections

This category of VR procedures carry significant risks, with sparse to no efficacy data published in peer reviewed medical or surgical journals.

Clitoral unhooding reduces or removes the skin folds over the clitoris. As an anatomy instructor at Weill Cornell Medical College, I consider clitoral unhooding an inherently risky procedure, given its proximity to the clitoral nerves and the small and vulnerable clitoris.

G‐spot amplification, another “sexual enhancement” procedure involves an injection of collagen or other bulking agent (same fillers used for facial wrinkles) into the front vaginal wall. The theory behind such an injection is to create a temporary (as collagen always absorbs and disappears) bump beneath the Grafenberg’s spot to enhance sexual response.

Sub-clitoral injections underneath the clitoris using filler bulking agents such as collagen or hyaluronic acid are purported to “lift” the clitoris, increasing exposure of the sensitive clitoral glans, allegedly to enhance sexual sensitivity.  This poorly documented procedure continues to flirt around the Upper East Side of Manhattan, offered primarily in cosmetic surgical offices.

Each of these sexual enhancement procedures carries the risk of scarring, pain, infection and numbness. Benefits are unclear, as the miniscule amount of peer-review data currently available used non-validated patient questionnaires administered by the surgeons themselves as opposed to blinded reviewers, and did not include objective measures of nerve function and other measures of genital function and sensitivity.

What say the gynecologists?

In 2007, The American College of Obstetrics and Gynecology issued a warning about all of these vaginal rejuvenation cosmetic and sexual enhancement procedures in Bulletin #378,  finding labiaplasty and perineoplasty “may be warranted in properly selected patients,” while reserving endorsement of G‐spot enhancement, the ill‐defined “vaginoplasty,” the mystery-shrouded, copiously marketed laser vaginal procedures, and clitoral unhooding, until each procedure garners the necessary peer review safety, efficacy, and technique disclosure warranted by medico-ethical standards of clinical acceptability.

For synopsis ACOG bulletin: ACOG committee opinion #378 on cosmetic gynecology

What say the plastic surgeons?

Nothing, really.

from American Society of Plastic Surgeons: ASPS weighs in on vaginal rejuvenation, sort of

There are a number of different vaginal rejuvenation procedures that can be performed by board-certified plastic surgeons. Here, an ASPS Members Surgeon explains the reasons why women may seek out procedures such as this. Learn more about cosmetic procedures.

Note: Some of the procedures and technologies presented in the following videos may be under investigation and presented for research and educational purposes. More scientific study may be needed to determine efficacy and success rate. The American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Educational Foundation (PSEF) do not endorse the procedures or technologies presented nor do the statements of the individual physicians represent the opinions, positions, or recommendations of the ASPS or PSEF.

From The American College of Surgeons, The American Society of Aesthetic Plastic Surgeons and the American Academy of Cosmetic Surgeons: Zero.

Except for ASPS saying “we can do it”, these non-gynecologic surgical societies, whose vaginal rejuvenating members aggressively online advertise cosmetic gynecologic procedures, provide no medico-ethical professional statements for us to consider, despite the widespread adoption of things gynecologic into the plastic surgeon’s arena. This “plastic/cosmetic surgeon as vaginal rejuvenator” phenomenon spawned a competitive explosion in the marketing of “vaginal rejuvenation”, replete with page after page of graphic, genital BEFORE AND AFTER images, something gynecologic surgeons had never previously adopted into office, online or related marketing practice. Given the robust vaginal and vulvar enthusiasm demonstrated by many plastic and cosmetic surgeons, you’d expect their professional societies to weigh in on the ongoing vaginal rejuvenation debate with something more than “we can fix your vagina and we have the images to prove it”  regarding this controversial corner of medicine.

If you’re interested in cosmetic “vaginal rejuvenation”, begin a conversation with yourself about your motivations and perspective: Cosmetic Gynecology Personal Perspective Litmus Test

While doctors, medical societies and health advocates rage on in the debate about what is and what is not acceptable vaginal rejuvenation, each patient is fairly clear about her individual rejuvenation goals. Vaginal rejuvenation is whatever you need it to be‐ Kegel exercise to improve vaginal muscle tone, bladder control and orgasm; vaginal estrogen for lubrication and clitoral sensitivity; prolapse operations to resuspend the dropped uterus, bladder and rectum; perineoplasty to restore vaginal snugness after childbirth; minimally invasive incontinence procedures or medications for bladders not controlled by Kegel exercise alone, each available as needed to get your pelvic life back on track. The cosmetic procedures to alter the labia or hymen, and to a greater extent, the operations promising sexual ehancement, carry relatively escalated levels of scrutiny due to concerns about the medicalization of female sexuality, and the variable dearth of data regarding both safety and efficacy.

REFERENCES OF INTEREST

Medicalization of Sexuality:

Professor Leonore Tiefer Home Page

Forecasting pelvic floor disorders:

Pelvic floor disorders 2010 – 2050

Labiaplasty technique:

Labiaplasty overview and link to technique monograph

Labiaplasty technique

Clitoral unhooding and mixed genital plastic surgery:

Female cosmetic genital surgery

Multicenter study of female genital plastic surgery

Hymen restoration:

Should doctors do virginal reconstruction for adolescent girls? Cultural considerations cannot be ignored,

Reconstructing the hymen: mutilation or restoration?

Hymen reconstruction:ethical and legal issues

Perineoplasty:

Vaginal laxity and post-perineoplasty images

Perineoplasty in women with sensation of a wide vagina

Combined anal sphincteroplasty and perineal reconstruction for fecal incontinence in women.

Kegel muscles and sex:

female orgasm: role of pubococcygeus muscle

vaginal contractions in female orgasm

The Science of Sex circa 1982

Orgasm mechanics the same in women and men