CLINICAL ARTICLE Pudendal thigh flap in the treatment of acquired gynatresia from caustic pessaries Andrew O. Ugburo a, ⁎, Bolaji O. Mofikoya a , Ayodeji A. Oluwole b , Idowu O. Fadeyibi c , Gbadegesin Abidoye d a Burns and Plastic Surgery Unit, Department of Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria b Experimental and Maternal Medicine Unit, Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria c Burns and Plastic Surgery Unit, Department of Surgery, Lagos State University College of Medicine/Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria d Department of Obstetrics and Gynaecology, Lagos State University College of Medicine/Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria abstract article info Article history: Received 7 December 2010 Received in revised form 14 April 2011 Accepted 24 June 2011 Keywords: Acquired gynatresia Myomectomy Pudendal thigh flap Vaginoplasty Objectives: To evaluate the use of vaginoplasty with the pudendal thigh flap in patients with gynatresia caused by herbal pessaries in a multidisciplinary context. Methods: The study included patients with herbal-pessary- induced vaginitis and gynatresia. Surgical treatment consisted of vaginoplasty with the pudendal thigh flap; patients with associated fibroids had a myomectomy during the same setting. The severity of the stenosis and the outcome after surgery were assessed with rating scales devised for the present study. Results: The study included 21 patients (mean age 36.05 ± 1.69 years, range 18–50 years). The most common reason for herbal pessary use was fibroids with infertility. Prior to presentation, most patients had already undergone a median of 2 procedures involving vaginal adhesiolysis and dilatations without improvement. In total, 17 (80.9%) patients underwent surgery. Of these, 6 (35.3%) presented with both fibroids and gynatresia. Before surgery, all patients had poor sexual function with apareunia. Postoperatively, 11 (64.7%) patients reported painless sexual intercourse. Conclusion: Joint management by plastic surgeons and gynecologists using the pudendal thigh flap for vaginoplasty in caustic gynatresia resulted in a functional vagina. Simultaneous myomectomy and vaginoplasty in patients with fibroids and gynatresia was safe. © 2011 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. 1. Introduction In high-income countries, acquired gynatresia is less common than congenital gynatresia and usually results from iatrogenic causes [1]. These causes include surgery and radiotherapy on the female genital tract [1]. However, in low-income countries, acquired gynatresia predomi- nates. The reason is that all causes of acquired gynatresia found in high- income countries are also present in low-income countries. In addition, female genital mutilation and birth injury from poor obstetric care contribute to the higher incidence of acquired gynatresia. In Nigeria, chemical burns resulting from the use of herbal pessaries are the most common cause of acquired gynatresia [1–5]. These pessaries are prescribed and prepared by herbalists, purport- edly for the treatment of conditions such as fibroids and uterovaginal prolapse and for the induction of abortion [1]. The aim of the present study was to describe the surgical management of patients with gynatresia resulting from the insertion of these herbal pessaries. 2. Materials and methods The study was conducted at 2 tertiary health facilities (Lagos University Teaching Hospital in Idi-Araba and Lagos State University Teaching Hospital in Ikeja) in Lagos State in southwestern Nigeria from January 20, 2004, to December 15, 2009. All patients who presented with vaginitis or gynatresia after using herbal pessaries were included. Management consisted of vaginoplasty using pudendal thigh flaps. Exclusion criteria were any other causes of congenital or acquired gynatresia. Ethical approval was obtained from the Research and Ethics Committees of the 2 study institutions. The following information was collected: demographic data, presenting symptoms, parity, reason for herbal pessary use, abnor- malities found on general and perineal examination, pelvic ultraso- nography report, and abnormalities found on examination under anesthesia and at surgery. The severity of the vaginal stenosis was rated during examination under anesthesia by the operating plastic surgeon and the gynecologist, who used a severity scale that had been designed for the present study (Table 1). Postoperative assessments included vaginal speculum examinations at 21 and 180 days after surgery. The patients commenced sexual intercourse 6 weeks after surgery, and genital penetration, pain, and sexual satisfaction after surgery were assessed via patient interview using another scale developed for the purpose of the present study at 180 days after surgery (Table 2). International Journal of Gynecology and Obstetrics 115 (2011) 44–48 ⁎ Corresponding author at: Burns and Plastic Surgery Unit, Department of Surgery, College of Medicine, University of Lagos, Idi-Araba PMB 12003, Lagos, Nigeria. Tel.: + 234 8023124495; fax: + 234 1837630. E-mail address: andyugburo@yahoo.com (A.O. Ugburo). 0020-7292/$ – see front matter © 2011 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. doi:10.1016/j.ijgo.2011.04.010 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo