Stenoză vaginală la o femeie în postmenopauză

Introduction

Vaginal agglutination is an uncommon condition often associated with hypoestrogenic states, such as postmenopause, where reduced estrogen levels lead to thinning of the vaginal epithelium and subsequent adhesion⁽¹⁾. It can cause significant morbidity due to symptoms like vaginal discomfort, urinary issues and difficulties with sexual intercourse. Early diagnosis and treatment are crucial to prevent complications and improve the quality of life. Understanding the underlying pathophysiology and the available treatment options is essential for the effective management of this condition.

Vaginal agglutination primarily affects postmenopausal women due to the significant drop in estrogen levels that accompanies menopause. Estrogen plays a critical role in maintaining the health and integrity of the vaginal epithelium⁽²⁾. When estrogen levels fall, the vaginal epithelium becomes thinner, less elastic and more prone to minor injuries and infections. These changes can lead to the formation of adhesions between the vaginal walls, resulting in partial or complete vaginal occlusion.

Case report

A 65-year-old postmenopausal woman presented to the gynecology clinic with complaints of vaginal discomfort for the past six months. She also reported a recent onset of difficulty with urination and a feeling of incomplete bladder emptying. The patient had been postmenopausal for 15 years, and she had no significant medical history other than well-controlled hypertension. She denied any history of pelvic surgeries, radiation therapy, or trauma to the genital area. The patient’s gynecological history was otherwise unremarkable, with regular menstrual cycles until menopause at the age of 50. She had two uncomplicated vaginal deliveries and no history of sexually transmitted infections or chronic gynecological conditions. Her symptoms began gradually and progressively worsened over the past six months, prompting her to seek medical attention.

On examination, the external genitalia appeared normal. Speculum examination revealed adhesion of the vaginal walls approximately 3 cm from the introitus, with a pinhole opening allowing minimal passage. The vaginal epithelium was noted to be atrophic and pale, consistent with hypoestrogenism (Figure 1). The presence of vaginal adhesions was indicative of a hypoestrogenic state leading to epithelial atrophy and subsequent agglutination.

The physical examination findings were significant for the extent of the vaginal adhesions and the associated atrophic changes in the vaginal epithelium. The adhesions were firm and fibrous, suggesting a chronic process likely related to prolonged hypoestrogenism. The pinhole opening in the adhesions was barely sufficient to allow passage of the speculum, underscoring the severity of the agglutination. A transabdominal pelvic ultrasound was performed to rule out other potential causes of the patient’s symptoms, such as pelvic masses or prolapse, and confirmed normal uterine and ovarian structures. Laboratory tests, including complete blood count, fasting blood glucose and renal function tests, were within normal limits. The ultrasound findings were unremarkable, with no evidence of pelvic masses, cysts or other abnormalities. The laboratory results confirmed the absence of systemic disease or metabolic abnormalities, reinforcing the diagnosis of hypoestrogenism as the primary underlying condition. The clinical findings and investigative results led to the diagnosis of vaginal agglutination secondary to postmenopausal hypoestrogenism. This diagnosis was based on the patient’s clinical history, physical examination and laboratory findings, all of which pointed towards a hypoestrogenic state as the underlying cause of the vaginal adhesions. The diagnosis was supported by the characteristic appearance of the atrophic vaginal epithelium and the firm, fibrous nature of the adhesions.

Due to the extent of the adhesions and the patient’s symptoms, surgical correction was deemed necessary. Under general anesthesia, the adhesions were carefully separated using a scalpel, and the vaginal walls were mobilized. No suturing was needed. Care was taken to avoid injury to the underlying tissues (Figure 2). After the procedure, a vaginal dressing type of medicated wound dressing was kept per vaginum. It is a fine, soft gauze impregnated with an antibiotic ointment, typically containing framycetin sulfate, which is an aminoglycoside antibiotic. This dressing is used to prevent or treat bacterial infections in wounds, burns or ulcers. Skin grafts were placed to prevent re-adhesion, and the patient was started on a regimen of topical estrogen therapy to promote healing and epithelial regeneration. The use of topical estrogen was intended to restore the vaginal epithelium to a more normal state, reducing the risk of recurrence of adhesions. The surgical technique involved meticulous dissection of the adhesions to avoid damaging the underlying vaginal tissue. The adhesions were carefully excised, and the vaginal walls were gently mobilized to restore the normal anatomy of the vaginal canal. The placement of a vaginal dressing soaked in paraffin postoperatively helped maintain the patency of the vaginal canal and prevent reformation of adhesions. Topical estrogen therapy was initiated immediately after surgery to promote healing and enhance the regeneration of the vaginal epithelium.

At the four-week follow-up, the patient reported significant improvement in her symptoms. Speculum examination revealed well-healed vaginal walls with no signs of re-adhesion. The vaginal epithelium appeared more robust and well-vascularized. Continued use of local estrogen therapy was recommended, and the patient was advised to return for a follow-up visit in three months. The follow-up plan aimed to ensure the long-term success of the treatment by maintaining the integrity of the vaginal epithelium and preventing further adhesions.

The patient adhered to the prescribed regimen of topical estrogen therapy, reporting improved comfort and functionality of the vaginal canal. The absence of re-adhesion at the follow-up visit was a positive outcome, indicating the success of the surgical intervention and postoperative management. She could pass urine without difficulty, and there was no dribbling of urine. The patient expressed satisfaction with the improvement in her symptoms and quality of life.

Discussion

Vaginal agglutination is a rare but significant condition in postmenopausal women, primarily caused by hypoestrogenism⁽¹⁾. In cases where conservative management is insufficient, surgical correction can effectively separate the adhesions and restore vaginal patency. The postoperative management with local estrogen therapy and mechanical dilation is crucial to prevent recurrence. The pathophysiology of this condition involves estrogen deficiency, leading to atrophic changes in the vaginal epithelium, which can result in the fusion of the vaginal walls⁽³⁾. The hypoestrogenic state in postmenopausal women leads to a reduction in the thickness and elasticity of the vaginal epithelium. This atrophic epithelium is more prone to microtraumas and infections, which can cause inflammation and subsequent adhesion formation. The resultant agglutination can significantly impact a woman’s quality of life, causing symptoms such as dyspareunia, urinary difficulties and vaginal discomfort.

The vaginal epithelium relies on estrogen for maintaining its structure, elasticity and vascularity. When estrogen levels decline after menopause, the epithelium becomes thin, fragile and less lubricated. These changes increase the susceptibility to minor injuries, which can heal by forming fibrous adhesions between the vaginal walls^(3,4). The chronic inflammation and healing process can further exacerbate the formation of adhesions, leading to the condition known as vaginal agglutination. The diagnosis of vaginal agglutination is primarily clinical, supported by patient history and physical examination findings. Imaging studies such as pelvic ultrasound are useful in ruling out other potential causes of the symptoms. Hormonal assays can confirm the hypoestrogenic state. Differential diagnoses include other causes of vaginal stenosis or obstruction, such as radiation therapy, lichen sclerosus and congenital anomalies⁽⁵⁾. The clinical presentation of vaginal agglutination includes symptoms of vaginal discomfort, dyspareunia and urinary difficulties, often in the context of a hypoestrogenic state. Physical examination typically reveals adhesions within the vaginal canal, with associa­ted atrophic changes in the vaginal epithelium. Imaging studies help exclude other conditions that could cause similar symptoms, while hormonal assays confirm the low estrogen levels characteristic of postmenopausal women. Treatment options for vaginal agglutination include both conservative and surgical approaches. The conservative management involves the use of topical estrogen therapy and mechanical dilation with vaginal dilators^(6,7). However, in cases where the adhesions are extensive or symptomatic, surgical intervention is necessary. The goal of surgery is to separate the adhesions and restore the normal anatomy of the vagina. Postoperative care with local estrogen therapy and regular use of vaginal dilators is essential to prevent recurrence. Conservative management is often the first-line treatment for mild cases of vaginal agglutination. Topical estrogen therapy helps restore the health and elasticity of the vaginal epithelium, while vaginal dilators mechanically separate the adhesions and maintain vaginal patency. In more severe cases, surgical intervention is required to excise the adhesions and reconstruct the vaginal canal. The postoperative management with estrogen therapy and dilators is crucial to prevent the recurrence of adhesions and ensure long-term success. The surgical technique involves careful dissection of the adhesions under anesthesia. It is important to avoid injury to the underlying tissues during the procedure. The use of a vaginal mold postoperatively helps maintain the patency of the vaginal canal. Local estrogen therapy is started immediately after surgery to promote healing and epithelial regeneration. During surgery, the adhesions are carefully dissected and excised to restore the normal anatomy of the vaginal canal. The use of a vaginal mold postoperatively helps maintain the separation of the vaginal walls and prevent reformation of adhesions⁽⁸⁾. Topical estrogen therapy is initiated to enhance the healing process and promote the regeneration of a healthy, robust vaginal epithelium. The combination of surgical intervention and postoperative management is essential for achieving a successful outcome. Postoperative management is critical in preventing the recurrence of vaginal adhesions. The use of local estrogen therapy helps in the regeneration of the vaginal epithelium, while mechanical dilation with vaginal dilators ensures that the vaginal canal remains patent. Regular follow-up visits are necessary to monitor the patient’s progress and make any necessary adjustments to the treatment plan^(6,7). The postoperative management plan includes the continued use of topical estrogen therapy to maintain the health and elasticity of the vaginal epithelium. The patient is also instructed to use vaginal dilators regularly to prevent the reformation of adhesions and maintain vaginal patency. Follow-up visits are scheduled to monitor the healing process, assess the patient’s symptoms and adjust the treatment plan as needed. The combination of estrogen therapy and mechanical dilation is crucial for preventing recurrence and ensuring the long-term success. Vaginal agglu­tination can significantly impact a woman’s quality of life, causing symptoms that affect both physical and emotional well-being. Early diagnosis and appropriate management are essential in alleviating symptoms and improving the quality of life. Surgical intervention, when necessary, can provide significant relief from symptoms and restore normal vaginal function. Continued use of estrogen therapy and vaginal dilators helps maintain the benefits of the treatment and prevent recurrence. The impact of vaginal agglutination on a woman’s quality of life can be profound, affecting her ability to engage in sexual activity, causing urinary difficulties and leading to chronic discomfort. Early recognition and appropriate management of the condition are crucial for alleviating these symptoms and improving the patient’s overall quality of life. Surgical intervention can provide significant relief from symptoms, while the continued use of estrogen therapy and vaginal dilators helps maintain the benefits of the treatment and prevent recurrence. Regular follow-up visits ensure that any recurrence of adhesions is promptly identified and managed. A review of the literature indicates that vaginal agglutination is a rare condition, with few reported cases in the medical literature. Most cases are associated with hypoestrogenic states, such as menopause or conditions causing ovarian failure. The use of estrogen therapy, both systemic and local, has been shown to be effective in preventing and treating vaginal agglutination. Surgical intervention is typically reserved for severe cases where conservative management is insufficient. The literature on vaginal agglutination is limited, reflecting the rarity of the condition. Most reported cases occur in postmenopausal women, where the decline in estrogen levels leads to atrophic changes in the vaginal epithelium and subsequent adhesion formation^(9,10). Estrogen therapy is a cornerstone of both prevention and treatment, helping restore the health and elasticity of the vaginal epithelium. Surgical intervention is reserved for severe cases, where adhesions significantly impact the patient’s quality of life and conservative measures are insufficient.

Conclusions

This case highlights the importance of considering vaginal agglutination in postmenopausal women presenting with vaginal and urinary symptoms. When conservative treatments fail, surgical intervention combined with postoperative estrogen therapy and mechanical dilation can effectively manage this condition, significantly improving the patient’s quality of life. Early recognition and appropriate management are crucial in preventing complications and in ensuring a successful outcome. The case underscores the need for clinicians to be aware of vaginal agglutination as a potential diagnosis in postmenopausal women with vaginal and urinary symptoms. Early recognition and appropriate management, including surgical intervention, when necessary, can provide significant relief from symptoms and improve the quality of life. Postoperative estrogen therapy and mechanical dilation are essential components of the treatment plan to prevent recurrence and ensure the long-term success.

Autor corespondent:  Smit Bharat Solanki E-mail: drsmitbharat@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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