Concerns about the use of graft material, particularly Prolene mesh, continue to mount after the most recent FDA warning on mesh in vaginal surgery.  These diligent authors from Michigan, Texas, Massachussetts, Washington State, New Mexico and Israel combed the international medical literature in all languages from 1950 to present, looking for data on adverse events when graft material is used at the time of vaginal prolapse repair. Three common problems, erosion (graft eroding through the vaginal skin so that it is palpable to touch and/or visible to the examining eye), granulation tissue (“proud flesh” commonly found in wounds as they heal inside and outside of the body), and dyspareunia (painful sex) were the key factors under review.

Granulation, Erosion, Dyspareunia and Prolapse Organ Prolapse Surgery with Graft Materials

What they found is that rates of each of the three complications did not differ between synthetic (such as non-absorbable Prolene or absorbable  Vicryl mesh) vs non-synthetic (such as porcine [Surgisis] or bovine [Xenform] or human cadaver-based) graft material, and that reportage with regard to sexual problems was so spotty and incomplete that it was difficult to figure out if women with sexual pain after surgery had sexual pain before surgery with the problem persisting after reconstruction, or whether it was clear that the surgery definitely caused the dyspareunia (sexual pain).

Of the more than 2000 mauscripts considered, less than 200 were included and most did not report on all three of these possible complications. In more recent years, the reportage tended to be consistent with our modern-day concerns, as one might expect the case to be.

Bottom line: there are no guarantees. Grafts reduce prolapse recurrence rates, but come with their own set of headaches.

To mesh or not to mesh?

Synopsis for the Journal of Sexual Medicine from original manscript published in the July 2011 issue of the International Urogynecology Journal:

Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Roberts RG

Incidence and management of graft eriosion, wound granulation and dyspareunia following vagianl prolapse repair with graft maeriasl: a stematic review.

Int Urogynecol J (2011) 22:789-98.

This metanalysis reviewed global data published from 1950-2010 from papers  reporting adverse events after vaginal prolapse repairs using graft materials. 2260 citations were identified using Medline search terms including vaginal or uterine prolapse, rectocele, surgical mesh, cystocele, and similar pelvic  floor terms. After review of each, data from 196 manuscripts was included in this analysis. Graft erosion was reported in 110 studies (10.3%) with similar rates for synthetic and biologic grafts.  Diagnosis of erosion occurred between 6 weeks and 12 months. The most common risk factor for erosion was concomitant hysterectomy, as well as patient age, smoking and diabetes, surgeon experience, and use of T incision of vaginal skin during dissection. Granulation tissue as reported in 7.8% of the 16 papers reporting on this outcome in series using a single type of graft material. While not statistically significant, the reported rate of granulation was higher with biologic graft material than with synthetic/permanent graft material (9.1% and 6.8%, respectively). Spontaneous resolution of granulation tissue and resolution with suture removal and silver nitrate treatment were reported treatment options.

Dyspareunia was reported in 71 papers with overall incidence of 9.1%, rates similar between synthetic and biologic grafts, with risk factors including posterior repair and mesh erosion. Listed treatments included vaginal estrogen cream and excision of eroded mesh. The authors point out that many of these studies did not limit reportage to sexually active women, nor make clear whether the painful sex was persistent or de novo. They also remind the readers that dyspareunia is known to occur with native tissue repairs also, operations where no graft material of any sort is used. The authors go on to report that most of the studies did not including what proportion of women sere sexually active, how may had pre-existing sexual dysfunction and how many benefited from improved sexual function. They state that as more studies use the validated quality of life Pelvic Organ Prolapse / Urinary Incontinence Sexual Questionnaire, the quality of  data on the impact of pelvic floor surgery on sexual function will improve in accuracy and clinical relevance.

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

This is another manuscript I reviewed for the Journal of Sexual Medicine, published by colleagues from The Mayo Clinic in the International Urogynecology Journal July 2011 issue. These authors looked carefully at the possibility of change in vaginal contour resulting from pelvic organ prolapse surgery with regards to female sexual function. They measured vaginal length and width before, immediately after (patient still in the operating room under anesthesia, case finished), and 6 months after surgery. The women completed a validated questionnaire for prolapse, incontinence and sexual function in women called the PISQ-12 before and 6 months after surgery. In summary, vaginas were a bit shorter and a bit narrower after surgery, and sexual function quality of life questionnaire scores did not change, nor did sexual satisfaction or lack thereof correlate to vaginal measurements either before or after surgery.  This helpful study will no doubt be repeated in various fashion as we in the field of urogynecology do our best to adhere to the mandate of “primum non nocere” (first, do no harm).

Once you’ve done this:

Childbirth - good thing they're so cute

You might need this:

Cutting & Sewing - 2 darts and a dash of facing, voila!

To get back to this:

Anatomy in 3-D - the vagina in relation to the rest of you

Journal summary:

Ochhino JA, Trabuco EC, Heisler CA, Klingele CJ, Gebhart JB.

Changes in vaginal anatomy and sexual function after vaginal surgery.

Int Urogynecol J (2011) 22:799-804

The authors enrolled 92 women undergoing vaginal reconstruction prolapse surgery in study including pre- and post-surgery completion of a validated sexual function questionnaire (PISQ-12) and in measurement of vaginal contour before, immediately after, and 6 months after surgery in order to determine whether changes in vaginal length and caliber correlate to changes in sexual function. All but one of the women was white. 72.8% were menopausal and 16.3% had undergone one prior prolapse operation. 47.8% were sexually active before surgery with a preoperation PISQ-12 score of 33.5. Pre-operation vaginal length was 10.4 cm on average with mean caliber 3.2 cm. Some women had intentional coning (narrowing) of the top of the vagina to correct excessive laxity and some did not – those undergoing coning (N=14) were evaluated separately from those who did not (N=78) for post-op vaginal contour measurements.

Immediately after surgery while still anesthetized, vaginal length of women with no coning was reduced to 7.9 cm with caliber 3.0 cm while coned patients measured 6. 8 cm length with caliber 2.8 cm. At 6 months postop, the no-cone women measured 8.7 cm length with 2.8 cm caliber while coned women continued to measure 6.8 cm length with .2 cm caliber.

74 women completed the PISQ-12 prolapse-incontinence-sexual function questionnaire at 6 months post-surgery, with 52.6% sexually active. Only 34 sexually active women completed the questionnaire before and after surgery, and in this group no change in score was demonstrated (33.4 vs 34.7). Further, no correlation was found between pre0operation score and vaginal length or caliber or between post operation score and vaginal length or caliber. The authors did not comment on the drop-out rate for questionnaire completion. They point out that, according to this data in this first study to look at changes in vaginal contour as correlates to sexual function, changes in vaginal dimensions does not seem to affect sexual function in women who were sexually active before and after the pelvic organ prolapse operation.

Level of evidence: III Count: 325 words

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Hello Dr. R,

I am a 51 year old that has pain upon entry, visited my doctor and he is suggesting a perineoplasty, is that the same procedure as a Fenton’s?  Is there anything else that wouldn’t be as invasive? I do not want to take hormones and I am not ready for my sexual life to be over.  Once the opening is loosened up a bit it doesn’t hurt as long as I use a lubricant. Would this be a senario for a perineoplasty?  Thank you so much!

Painful sex (dyspareunia) after menopause is best treated with a dose of creativity - rush not to the knife!

Dyspareunia: perspective from a urogynecologist

Hello L,

Without examining you, it is impossible to know if a perineoplasty is your only treatment option for painful sex (dyspareunia). I strongly suggest you seek second opinions from urogynecology specialists in your area, which you may locate through American Urogynecologic Society. Therapies may include vaginal estrogen, dilators, pelvic floor physical therapy, pelvic floor electrical stimulation, valium vaginal suppositories, or some combination there-of.  You may consider perineoplasty and Fenton’s to be synonymous for this indication. Keep us posted…

Dr R

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Vulvar anatomy circa 1798. Some things never change. Thank goodness...

Every two months I report for on scientific manuscripts in the recent medical literature for the Journal of Sexual Medicine that pertain to female sexual function. In an anatomic study of vulvar anatomy published in the journal of the American Urogynecologic Society, scientists took a close look at the microscopic goings on of labia minora. The controversy over labiaplasty and other forms of cosmetic gynecologic surgery rages on, with proponents on both sides claiming “fair” and “foul” in equal measure.

The clitoris has erectile function

Unless you believe in the G-Spot orgasm and are of the opinion that there is a difference between “internal/vaginal” and “external/clitoral” orgasms for women, you’re probably in agreement with most physiologists and anatomists that the female orgasm emanates from the clitoris, the organ in the body with the highest density of sensory nerves and an intense erectile response to sexual stimulation. That’s right, ladies. Your clitoris gets a woody every time you have an orgasm, or even get aroused.  The role of labia majora and labia minora in this erectile and orgasmic function is so poorly understood it’s almost criminal. Seriously – do you know how much is understood about male sexual function and role of erectile tissue in a man’s sexual pleasure? They’ve written books about it. An entire pharmaceutical industry is making $$bajillions catering to it. Courses are taught, books are written, Medicare PAYS FOR IT (all of it) right down to the fancy shmancy-est of prosthetic penile implants.

Labia minora: high density of nerve function and blood flow

So this study took a look at the micro-anatomy of labia minora. Few studies have reported any meaningful data on labiaplasty’s (surgical reduction of labia minora) impact on sexual function. There is one study by a renowned cosmetic genital surgeon who reported that out of 166 women undergoing combined labiaplasty and clitoral hood reduction, 38 reported better sexual pleasure and 9 reported a worse, or a negative impact on sexual function, from the procedure. This raises the question that it may be possible for genital cosmetic operations done to improve sexual function may actually have the opposite effect…

Being that the subjects in this particular study were all cadavers, evaluating sexual function was not possible. But the researchers did find a high density of nerve fibers on both the outer and inner surfaces of labia minora in all specimens, in addition to a high density of blood vessels, in excess of that needed to maintain the skin of the labia, indicating a high likelihood that the blood vessels of the labia minora play some role in the sexual response and possibly in the engorgement and erectile function of the clitoris, although these points remain to be proved in studies on live women.

Remember, one study does not an absolute fact make. This area of gynecologic surgery is in evolution, and this anatomy study is one important contribution to that body of literature that will permit, over time, for meaningful conclusions to be made.

Here’s the summary to appear in the Journal of Sexual Medicine sometime this fall:

Ginger VAT, Cold CJ, Yang CC.

Structure and innervation of the labia minora: more than minor skin folds.

2011 Female Pelvic Medicine & Reconstructive Surgery  17:4, 180-3.

Eight fresh cadaveric vulvar specimens were fixed and stained to report the histologic features of the labia minora with regard to female sexual function.

Labia were highly variable in appearance. Labia minora were thin in relation to majora, and in some cases fused. No labia minora contained fatty component, as do the labia majora. After fixation and histologic staining, the inner labum minus were found to be  covered by a basket-weave keratin type dermis.. The substance included numerous vascular structures surrounded by connective collagen and no smooth muscle, thereby making the labia minora vascular tissue non-erectile.  Elastin was abundant, as were neural elements with no difference in distribution of neural elements between the lateral and medial sides of the labia minora. There was a central core of neural elements long the length of the labia, traveling alongside vascular structures to form the neuro-anatomic substrate where sexual arousal results in labial engorgement. Neural elements were sparse with in the labia majora.  Histologic images are included to illustrate these findings. The authors go on to comment on genital labioplasty done for aesthetic or functional reasons, reiterating that reports of diminished sexual responsiveness are documented in at least one series of 166 women undergoing labiaplasty and clitoral hood reduction, where 9 reported negative effect on sexual sensation in contrast to 38 reporting improved sexual sensations.  They note that among reports on labia minora structure, very little mention is made of possible function. They comment that the specimens obtained for hits study were likely, but not know for certain, to be from menopausal women in which degenerative changes would have been present and that despite this, a high density of neural and vascular elements were found in the labia minora of the specimens evaluated.  They finish by stating that “Biochemical and molecular studies may further elucidate (the labia minora’s) role in the female sexual response,… which are specialized vascular structures with densely distributed neural elements providing anatomic substrate for changes observed during sexual arousal”.

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

If you have a vagina and you’re old enough to vote, then Kegel Exercise belongs in your feminine fitness daily routine. Before you dive into pelvic fitness, it’s important to know what Kegel muscles actually DO. Kegels—or the levator ani muscles—wrap around a woman’s most important parts: her bladder, vagina, and rectum.

Research shows that toned levator ani muscles can reduce urinary incontinence, prevent problems with vaginal laxity and help a woman achieve a stronger orgasm. Clinicians and researchers in urogynecology also suspect, but have yet to prove, that these muscles help prevent pelvic organ prolapse, a condition in which  a woman’s bladder, rectum, or uterus falls into her vagina.

For women looking to live their best lives, strengthening your Kegel muscles—or pelvic floor fitness—just makes sense!

HOW TO CHECK YOUR KEGEL EXERCISE ACCURACY:

To get started, sit in bed relaxed against pillows, knees up and separated, using a hand mirror to look at your perineum,which is the skin between your anus and vagina.

Pull in using the muscles you use to urinate, as if you’re trying to stop urine midstream.

If you’re Kegeling correctly, you’ll see your perineum retract into your body.

You should feel the pull in your urethra and anus, NOT your butt or abs.

If you have trouble with proper Kegeling, talk to your gynecologist about pelvic floor physical therapy.

Pelvic floor physical therapy involves working with a Kegel coach, using biofeedback, and/or pelvic muscle electrical stimulation, each designed to “train” your pelvic muscles to perform correctly.

Once you’ve got the art of Kegeling down, get in the habit of doing tKegels daily.

Here’s Dr. Romanzi’s “Starter Set for Kegel Beginners”:

For the first set, perform 10 controlled, sustained contractions, holding each for five seconds, relaxing out of each slowly, and contracting into the next one without taking a break in between. Don’t forget to BREATH. If you find yourself holding your  breath, count softly or sing while contracting the levator muscles.

For the second set, perform 30 quick contractions, holding for just one second each.

There’s no need for a break between the two sets. Simply move from one right on to the next.

Do 2-3 of each set per day. Be creative! There are many ways and settings in which one can Kegel – no one will know if you’re Kegeling on the bus or in a meeting or while driving your car (at a stop sign, preferably).

In terms of where you should do your Kegel exercises, there’s only one rule: NEVER do them on the toilet!

Not only is 8 seconds of urination too short to really benefit your muscles, but it’s also distracting to your bladder, which has an important job of its own to do!

Other than that, you can fit in a Kegel routine whenever—and wherever—you prefer!

For more information, check out this  video \”Kegel Exercise: The Facts\”, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

For the latest on vaginal dryness in your 40’s and beyond,  enjoy this guest-blogger interview with PHIT’s medical director from  Sweet Talk on the Spot. I’m talking user-friendly vaginal estrogens, over-the-counter lubricants, kitchen myths and the latest from Europe.

WD-40

Dr. Romanzi Talks Lubrication After 40Wednesday, April 21, 2010 by SweetTalk on the Spot

Our resident Vaginal Phitness expert, Dr. Lauri Romanzi, educates the SweetTalk community with answers to your most pressing, personal questions.

Q: Dear Dr. Romanzi, Why do women experience pronounced vaginal dryness after 40, and what lubricants do you recommend for women over 40?

A: Aaaah, the Magic of Estrogen.

First, a little background: Before puberty, estrogen levels in girls circulate at a tiny fraction of normal adult levels. At puberty, the ovaries start cranking out estrogen to full – range, grown woman levels, and stay that way til about age 35, when the slippery slope toward menopause goes gently into first gear.

By age 40-45, fertility, skin integrity, bone density, cardiovascular resilience and even memory can be affected as the reduction in estrogen production accelerates into third gear.  For many women this “Change before the Change” is confusing, because they continue to menstruate, and may even become pregnant, as these menopausal symptoms cavort erratically around the edges of their lives. One month is “normal”, the next nutty with late menses, heavy flow or light spotting, hot flashes, night sweats, aches and pains, insomnia and mood swings in a rollercoaster of unpredictability that heralds the life cycle book-end mate to the process of puberty. My New York City colleague, Dr. Laura Corio, coined this phrase, “The Change Before The Change”, and used it as the title of her book on health in the decade before menopause.

Regarding vaginal dryness and lubrication: The vulva, vagina, clitoris and lower urinary tract skin surfaces contain a high density of estrogen receptors, and as these receptors undergo peri-menopausal deprivation in the early to mid-40’s, many women report uro-genital symptoms.  In the vagina, these may include dryness, poor spontaneous sexual lubrication, reduced clitoral sensitivity, difficulty achieving orgasm, and muted orgasm intensity. And here’s the ironic truth – overweight women tend to fare better because body fat makes its own estrogen, called estrone, that, when present in high levels, minimizes the impact of reduced ovarian estrogen production, called estradiol. Skinny women make very little estrone, overweight women make a lot of estrone. Both skinny and overweight women’s ovaries run out of estradiol between age 35-ish and menopause.

A woman who is sensitive to reduced estrogen production in the 40’s and beyond, sex may be plagued by painful dryness that is often frustrating and confusing, both for her and her sexual partner. With reduced estrogen production, the exquisitely estrogen- sensitive skin of the vulva, vagina, and clitoris literally becomes thin, dry, and brittle. As a doctor, I’ve taken care of many women over the years in stable, happy, sexually active relationships who come in to the office utterly mystified by these symptoms, with partners convinced that the women don’t love them any more or accuse them of having an affair. so abrupt and intense can be the sexual impact of estrogen deprivation.

My favorite treatment option for hormone-related vaginal dryness is … hormones: Recoil not, as this does not mean total-body-dose (a.k.a. systemic) hormones. You can use ultra-low-dose vaginal estrogen therapy that rejuvenates the vaginal skin to youthful elasticity, sensitivity, and lubrication. It does this by making those poor, deprived estrogen receptors in the vagina, vulva and clitoris happy.  There is not enough estrogen in these local estrogen treatments to increase estrogen blood levels, and there is no evidence that they increase cancer risks, as some total-body hormone regimens might. Ultra-low-dose vaginal estrogen therapies come in cream (fingertip application), suppository (vaginal insertion) and ring (vaginal insertion 4 times per year) form.  I shared this low dose vaginal estrogen information on the Dr. Oz show a few weeks ago.

Lubricants help with dryness, but will not improve elasticity or sensitivity. The best lubricants are water soluble and paraben free. Glycerin-free lubricants are best for women who cannot tolerate this additive, and silicone based lubricants require less re-application. Lubricants contain no hormones.

Oils and herbs are purported to reduce vaginal dryness, however clinical trials thus far fail to demonstrate efficacy, and oils may throw off vaginal pH or turn rancid, ultimately causing vaginal irritation and possible increased risk of vaginitis.

Several of my European patients are using hyaluronic acid vaginal suppositories, which are not available in the U.S.  These novel vaginal ovules help maintain cellular hydration, and are marketed both for post-operation healing and menopausal dryness.  Given that these ovules contain no hormones, it is likely that this product will not improve sensitivity, but would restore lubrication and thereby improve elasticity.  Catch the red-eye to Paris and let us know if it works for you!

Back to lubricants before I finish: The shop shelves buckle under the voluminous assortment of 21^st century sexy lubricants with additives designed to improve blood flow, enhance sensitivity and super-charge orgasm intensity.  Marketing trials are not the same as scientific, clinical trials published in peer-reviewed medical journals, and it is not clear that the robust marketing claims are born out in the bedroom. That said, if these pumped-up lubricants rock your world, are paraben free and water soluble, have at it!

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: The Z-Plasty Technique Monograph

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