Vulvar-Vaginal Reconstruction Treatment & Management

Management of a patient who has sustained perineal trauma must address the following objectives:

• Minimization of blood loss
• Minimization of risk for infection
• Detection and correction of injury to pelvic organs and support structures
• Restoration of function
• Relief of pain

Cosmetic restoration, while an important goal, must be considered a secondary objective.

 

The following discussion is limited to management of perineal, vulvar, and vaginal injuries. As noted previously, the possibility of intraperitoneal pathology must be considered. If present, such pathology must be corrected; however, such a discussion is beyond the scope of this article.

Ensure that tetanus prophylaxis is current. 

Superficial perineal trauma, in the absence of significant bleeding, generally resolves with conservative management. Address injuries associated with hemorrhage or disruption of deep structures with surgery. In the case of soft tissue trauma, palliative therapy, such as ice packs applied to the site for the first 24 hours, is useful.

Should operative reconstruction be indicated, site preparation, adequate anesthesia, and unfettered access to the surgical field are of paramount importance. Note the following considerations:

• Positioning: For most procedures involving the female perineum, the dorsal lithotomy position, with legs abducted and slightly hyperextended, is preferable. Take care to avoid applying undue pressure against the soft tissues of the upper legs or lower abdomen in order to prevent subsequent neuropathy.

• Site of surgery: Except for superficial lacerations, surgical therapy for most perineal trauma is of sufficient complexity that an operating room with sufficient light, technical assistance, and equipment is recommended.

• Anesthesia: For superficial lacerations of the vulva, local anesthesia may be sufficient. However, if extensive dissection, prolonged operating time, or manipulation of normally tender tissues is anticipated, administration of regional or general anesthesia is warranted. Maintain a very low threshold for regional or general anesthesia for pediatric patients.

• Preoperative medications: Consider antibiotic prophylaxis, especially in the case of a patient with trauma involving the urinary tract. A first- or second-generation cephalosporin administered in the preoperative holding area is appropriate. In patients at elevated risk for thromboembolic phenomena, perioperative antithrombosis prophylaxis is advisable.

• Site preparation: Standard surgical preparation should be performed on the operative site.

Intraoperative details depend on the location of the injury.

Straddle injury - perineum

This injury results from blunt impact trauma to the perineum. The classic example is that of a young child who falls straddling a bar of a jungle gym. The impact results in such rapid distention of the perineal epithelium that the elastic limit is exceeded and the epithelium tears. Commonly, only superficial tissues are involved. Examine the perineum, proximal vagina, and anus to ensure that deeper structures are not involved. Examination under anesthesia may be appropriate for very young children in order to avoid additional psychological trauma. ^{[11, 12]}

If only superficial epithelium is involved and bleeding is minimal, thorough cleansing and oral analgesia are often all that is required because the forces acting on the perineal skin keep the edges of such lacerations apposed. If bleeding is a concern, 1 or 2 simple subcutaneous sutures of fine delayed absorbable braided suture are generally sufficient.

The patient should be observed for perineal hematoma formation. As noted, the perineal tissues are quite elastic and provide minimal resistance to hematoma expansion. Nonetheless, as most vulvar hematomata are of venous origin, conservative management with rest, external pressure, and ice packs is usually sufficient. Should serial observation reveal continued expansion of the hematoma despite such measures, or if the patient develops hemodynamic instability, surgical management should be instituted. This would involve incision and drainage of the hematoma and exploration of the cavity to identify a bleeding arterial source. Care should be taken to minimize further venous trauma, especially in the area of the vestibular bulb. Antibiotic prophylaxis should be considered. ^[3]

Following initial therapy, advise the patient to avoid activities involving abduction of the thighs for several days. 

Deep perineal laceration - perineum

This section is devoted to management of deep perineal lacerations. Management of other vaginal sites is discussed in other sections.

Repair of perineal trauma in the non-pregnant patient is very similar to that required for a parturient who has sustained obstetrical trauma. As noted in the discussion of perineal anatomy, the perineum is richly perfused. The venous network, both because of the absence of valves to reduce backflow from the proximal system, and (in the case of the post-partum patient) of increased pressure during the second stage of labor, can undergo extensive distention. Laceration of the perineum can thus be associated with impressive blood loss.

Achieving temporary hemostasis must therefore be a principal initial objective. Fortunately, venous bleeding generally is easily controlled with appropriately applied pressure. One simple, rapid, and minimally uncomfortable technique is to grasp the region around the bleeding vessel with a ring forceps, which is then closed only to the first ratchet setting. This provides an opportunity to conduct a complete assessment of the extent of damage.

In an attempt to minimize repetition, the remainder of this discussion describes a single effective technique for repair of a complete perineal laceration (one that extends cephalad of the hymen and the anal verge, disrupting the entire perineal body and anal sphincter complex). The principles discussed are also generally applicable to less extensive tissue disruption. Note that the intent of the following description is to illustrate only one of several methods of achieving the goals of repair, especially the ultimate objective of restoring tissue integrity and function.

Remember that repair of a perineal laceration, especially an extensive one, is a true surgical endeavor. Generally accepted surgical principles are thus very much in order. Essential to a successful outcome are appropriate surgical setting, sufficient lighting, appropriate assistance, and adequate anesthesia. Unfortunately, in many instances, these requirements are not met, increasing the risk of poor results.

The steps involved in this procedure are the same as for any surgical procedure: to identify, restore, and repair anatomy. Meticulous attention to hemostasis is essential, and every attempt should be made to minimize tension. Techniques relying on bulk closure of a perineal defect are inferior to site-specific methods in which care is taken to restore the original anatomic tissue relationships. This observation is especially true of postmenopausal women, in whom the perineum is less resilient.

The initial step in the repair is identification of the proximal extent of both vaginal epithelial and rectal epithelial laceration. Unfortunately, although rectal lacerations are usually linear, vaginal tears are frequently branched, often extending along both posterolateral gutters. In addition to the anterior and posterior apices, identifying the medial ends of the posterior portion of the hymeneal ring is useful. These surface features, as discussed previously, overlie the medial borders of the levator ani muscles.

Once the extent of the laceration has been determined, the repair proceeds in a stepwise fashion, as follows:

1. Repair of the rectal mucosa and submucosa

2. Repair of internal and external anal sphincter

3. Repair of the rectovaginal fascia and proximal perineal body

4. Repair of the vaginal epithelium and subepithelial tissue

5. Repair of the distal perineal body

6. Repair of the epithelium of the perineum and fourchette

Repair of the rectal mucosa and submucosa is best accomplished in 2 layers to satisfy the objective of minimizing tension across the wound. One means of achieving a watertight epithelial closure is to place an initial submucosal running course of fine delayed absorbable braided suture, reinforced with a second imbricating layer closed with simple interrupted sutures of the same suture. Successful anatomic reconstruction requires good delineation of the anal canal, which is best accomplished by placing the middle finger of the nondominant hand in the anal canal and advancing the fingertip above the superior apex of the anal mucosa laceration. It is important to ensure that the most superior loop of the first suture layer is proximal to the upper apex of the laceration to minimize nonunion of the epithelium and subsequent rectovaginal fistula formation. The internal layer extends from the apex to the level of the anal verge.  The imbricating layer extends from the apex to the levator borders. This technique effectively reapposes the rectovaginal fascia to the superior aspect of the puborectalis raphe, reconstituting the proximal aspect of the perineal body.

The next step is repair of the internal and external sphincter. As noted in the discussion of perineal anatomy, the internal anal sphincter is a physiologic thickening of the circular muscle layer of the distal rectum and proximal anus, extending approximately 3 cm along the anal axis. The external anal sphincter overlaps (for approximately 1.5 cm) the distal internal anal sphincter. Restoration of these relationships improves the probability of restored function.

 The internal sphincter is smooth muscle, which has no fascia capsule. However, this layer is surrounded by the structures of the perineal body, which are partially comprised of connective tissue. Using the finger as a guide, it is possible to reapproximate the internal sphincter layer, together with surrounding connective tissue, anterior to the anal canal with a series of moderate-gauge (eg, 2-0) delayed absorbable polyfilament sutures from the upper extent of the rectal laceration distally to the capsule of the external anal sphincter.

Although end-to-end reapproximation of the external anal sphincter capsule is the technique typically described in obstetric and gynecology textbooks, this closure method is associated with a lower long-term success rate than the overlapping closure technique favored in the colorectal surgery literature. ^[13] In the latter method, a far-near/near-far, full-thickness suture placement scheme is used from the superior aspect of the external sphincter to its inferior border, thereby overlapping the separated ends of the disrupted sphincter and its capsule. Generally, placing as many as 4 such sutures in the sphincter is possible. Note that the external sphincter, by its nature, is under tension. Given this constraint, using multiple simple loops of larger caliber absorbable suture for this aspect of the repair to permit sufficient time for tissue healing is prudent.

Repair of the vaginal epithelium and subepithelial tissues is next. The vaginal epithelium is generally very resilient, and heals rapidly; therefore, this portion of the procedure can be accomplished successfully with a single-layer closure. Specific attention to the paired midline arterial supply of the posterior vaginal wall is prudent. The initial pass of the needle must be superior to the apex of the laceration in order to achieve hemostasis of these arteries. Care must also be taken to avoid incorporating the rectal mucosa into this vaginal suture. As noted previously, the medial ends of the disrupted hymen serve as the inferior landmarks for this portion of the procedure. This layer can be closed effectively with a single, running, moderate-gauge, polyfilament delayed absorbable suture that incorporates both the epithelial and subepithelial tissues from the initial pass distally to the hymeneal ring. 

At this juncture, it is convenient to continue this layer as a running subcuticular closure from the level of the puborectalis raphe, as marked by the hymeneal ring, out to the distal end of the fourchette, thereby closing the epithelium of the fourchette.

Accomplish repair of the distal perineal body in layers with simple interrupted sutures of moderate-gauge delayed absorbable suture.

For repair of the perineal epithelium, the suture penetration of the skin increases postprocedure pain. As noted earlier, adduction of the legs results in compression of the perineum, enhancing closure. A running subcutaneous suture of fine delayed absorbable polyfilament suture is therefore appropriate for this layer.

Ensure good hemostasis at each step of this repair.

Blunt trauma or foreign body injury - urethra

Lacerations of the tissues surrounding the external urethral meatus are generally limited to epithelium or superficial subepithelial tissue. This is also true of shallow lacerations of the distal urethra itself. In the absence of bleeding, adequate healing can occur with only conservative management. If a superficial bleeding source does not respond to brief pressure, 1 or 2 simple sutures of fine delayed absorbable suture generally suffice. Management of lacerations extending deeper into the urethral canal or penetrating into the urogenital diaphragm is discussed below.

Penetrating injury - urethra

As discussed previously, support of the distal urethra is provided by the relatively dense and nondistendible tissue of the urogenital diaphragm. Significant shear force is required to disrupt this tissue layer. The urethral wall, on the other hand, has much less strength, so that injuries resulting in disruption of the urogenital diaphragm frequently also involve the full thickness of the adjacent urethral wall. ^[14] If such an injury is detected, complete evaluation of the urethra and bladder, as discussed in the section on evaluation, is appropriate.

Repair of injuries of the distal urethral and urogenital urethral supports is accomplished by a layered approach. After the proximal urethra and bladder have been evaluated, the vaginal epithelium is carefully and sharply dissected off the underlying tissue to mobilize the lacerated tissue. The urethral mucosa is closed with a running suture of fine delayed absorbable polyfilament suture. A second imbricating layer of interrupted fine delayed absorbable polyfilament sutures is placed to reapproximate the submucosal layer. Another layer of simple interrupted sutures of the same material is then placed to repair the tissues of the perineal diaphragm. The epithelium can be closed with simple interrupted subcutaneous sutures.

Foreign body penetrating injury - vagina

Any patient who has sustained foreign body penetrating injury of the proximal vagina must be evaluated for associated broad ligament and intraperitoneal damage, as described earlier. Once these possibilities have been reliably excluded, planning the surgical approach to repair must include consideration of the close approximation of the ureters to the anterolateral vaginal fornices. If damage to the vaginal epithelium is detected in this vicinity, undertake measures to evaluate the possibility of ureteral compromise and consider the option of cystoscopic placement of ureteral stents to minimize the risk of ureteral incorporation into the repair.

When closing a vaginal wall laceration, remember that the blood vessels of the vagina are located between the outer muscular layer of the vaginal wall and the surrounding loose connective tissue; therefore, ensure that the full thickness of the vaginal wall, including the connective tissue layer, is incorporated in the closure sutures in order to obtain hemostasis. Also, remember that the layer between the lateral aspect of the super-levator vagina and the levator ani is a potential space, easily distended by an expanding hematoma. If hemostasis is questionable following vaginal wall repair, consider placement of a closed suction drain in the paravaginal space.

Distention laceration - proximal vagina (including obstetric injury)

For treatment of a lateral fornix (sulcus tear), see the earlier discussion regarding repair of penetrating injuries to the vagina.

For posterolateral tears, when closing a vaginal wall laceration, remember that the blood vessels of the vagina are located between the outer muscular layer of the vaginal wall and the surrounding loose connective tissue. Therefore, ensure that the full thickness of the vaginal wall, including the connective tissue layer, is incorporated in the closure sutures to obtain hemostasis. Remember that the separation between the lateral aspect of the vagina and the levator ani is a potential space, easily distended by an expanding hematoma. If hemostasis is questionable following vaginal wall repair, consider placement of a closed suction drain in the paravaginal space.

A 2016 ACOG Practice Bulletin on the Prevention and Management of Obstetric Lacerations at Vaginal Delivery estimated that 53% to 79% of women will experience some type of laceration during vaginal delivery, most commonly in the perineal body, however most lacerations do not result in adverse functional outcomes. The bulletin also stated that the more severe third- and fourth-degree lacerations that result in obstetric anal sphincter injuries (OASIS) may occur in up to 11% of women giving birth vaginally. The bulletin recommended that perineal massage, either antepartum or during the second stage of labor, can decrease muscular resistance and reduce the likelihood of laceration and the use of warm compresses on the perineum during pushing can reduce third-degree and fourth-degree lacerations. ^{[15, 16]}

Hematoma - vulva

As noted in the discussion of pelvic anatomy, the superficial compartment of the anterior perineal triangle communicates with the subfascial space of the lower abdomen below the inguinal ligament. Little tissue is available to tamponade bleeding into this space, even from the low-pressure venous system; thus, a hematoma can extend from the posterior margin of the anterior triangle (at the level of the transverse perineal muscle), anteriorly over the mons to the fusion of fascia at the inguinal ligament.

A hematoma resulting from venous bleeding, although it can form rapidly, stabilizes at the above margins because of the low-pressure nature of the bleeding, and therefore may be managed expectantly. On the other hand, a rapidly expanding hematoma that does not stabilize is more likely to be the result of arterial bleeding. In such an instance, an incision medial to the labium majus permits evacuation of the hematoma. If possible, identify and ligate the source of bleeding.

Laceration - vulva

A superficial laceration of the vulva can be managed in a fashion similar to any other skin laceration. If the laceration extends into the superficial triangle and involves the vestibular bulb, it can be associated with significant blood loss. As noted previously, blood supply to this region is derived from both lateral and medial sources. Additionally, the tissue involved is erectile tissue, which is quite friable. Hemostasis in this region is best achieved by wide lateral and medial sutures that incorporate both the superficial and deep fascial borders of the space, thereby sandwiching the erectile tissue between 2 dense connective tissue layers.

Appropriate post-operative analgesia is important to minimize inhibition of patient ambulation. A multi-agent regimen is preferred. Narcotic therapy should be kept to a minimum to avoid constipation. Stool softeners and increased oral fluids should be considered. Ice packs to the perineum for the first 24 hours are useful analgesia supplements.

Meticulous perineal hygiene is essential to minimize infection. Sitz baths in clear warm water two or three times/day are useful adjunctive therapy. Although preoperative antibiotic prophylaxis may, in selected instances, be considered, continuing such measures postoperatively in the absence of overt preexisting infection is of no value.

Adequate bladder drainage must be confirmed. Vulvar trauma can result in periurethral soft tissue edema or pain sufficient to prohibit normal micturition. Although indwelling transurethral catheters are associated with increased risk of urinary tract infections, urinary obstruction or urethral surgery may require indwelling transurethral or suprapubic bladder drainage.

Question all patients who sustain nonobstetric perineal trauma about the status of tetanus immunization.

Maintain appropriate anti-thrombotic measures.

 

Patients who require significant surgical therapy for perineal trauma are at significant risk for infection. Encourage the patient to maintain good hygiene of the area. This can be problematic, given the discomfort that commonly accompanies perineal trauma and its repair.

Instruct the patient regarding early signs of infection, and see her often enough in the immediate postoperative period to ensure early detection of incipient infection.

Encourage the patient to increase progressively her level of ambulation and resumption of normal activites. Prolonged sitting or standing should be avoided. Advise against sexual activity until healing is completed. 

Patients who require surgical therapy for perineal trauma are at risk of complications from both the trauma and its management.

Infection, as noted earlier, must be watched for closely. The patient must be instructed regarding signs of early infection and must be monitored often enough during the immediate postoperative period to permit early identification.

Repair dehiscence

Patients with traumatized tissues have suffered, to a greater or lesser extent, devascularization and initiation of tissue necrosis and are at risk of postrepair wound disruption. This is especially true of patients whose tissues were repaired under tension.

Cosmesis

Other sequelae of tissue trauma, devascularization, and necrosis are poor tissue healing and scar retraction, which may result in altered cosmetic appearance. At some point early in the management process, the patient should be counseled regarding this possibility in order to minimize disappointment and recriminations.

Abscesses

Abscesses involving the greater vestibular gland complex result from occlusion of the common duct draining the complex, not the actual glands. Recurrent abscess formation occurs when previous drainage attempts have failed to establish a patent meatus and warrant more aggressive measures to disrupt internal loculations and to create a satisfactory sinus tract. The glands are embedded in the vascular complex of the vestibular bulb. Excision can be associated with significant bleeding because this tissue obtains its blood supply from both lateral and medial sources.

Pain

Chronic pain is not uncommon following perineal trauma, especially that of nonobstetric etiology. Adequate perioperative analgesia is of great importance.

Long-term counseling should be offered, especially for patients who have been victims of sexual assault.

In the absence of early infection and wound breakdown, perineal trauma generally responds favorably to surgical therapy. Posttraumatic chronic pain is possible.

Two sites are at increased risk of long-term functional deficit: the urethra and the rectal sphincter. A progressive decrement in function of both of these structures occurs with aging. Many women experience additional decrement associated with sphincter repair, especially of the external anal sphincter, even following appropriate vulvar reconstruction.

As noted, the ultimate cosmetic result following acute management of perineal trauma may be suboptimal. Plastic revision may be considered after completion of the healing process but generally should be delayed 3-6 months.