Acquired gynaetresia is increasingly becoming a major concern in gynaecological practice. This manifests as the reduction in the depth and capacity of the vagina, this can present as either a complete occlusion where the vaginal canal is totally obliterated or partial occlusion. The adhesions that occur could also vary from flimsy adhesions to being dense fibrotic, this will ultimately affect the type of surgical intervention, the ease of the treatment, complications and prognosis thereafter [1][2]. It is a unique, complex and difficult clinical condition in Nigeria or anywhere it occurs because of the anatomic distortion it creates, the disruption of normal physiologic functions such as cryptomenorrhea, apareunia, and in some cases infertility, and genital tract fistulas. These all contribute negatively to the affected women’s quality of life. This condition is rare in high-income countries and follows therapeutic procedures such as extensive pelvic surgery or radiotherapy, however in developing nations especially Nigeria, acquired gynaetresia is frequently a tragic consequence of poverty, poor healthcare choices, limited access to quality healthcare, harmful trado-medical practices [3]. This difference in the aetiology will also require a different and more pragmatic approach in addressing this challenge such as public enlightenment campaign, training and targeted interventions to address the menace and infrastructure provision. Other identified causes are birth related conditions such as obstructed labour, caesarean hysterectomy, vaginal hysterectomy and total abdominal hysterectomy. The aim of this study is to review the cases seen with this condition and treated over a period of 72 months at a federal teaching hospital in southwest Nigeria [3].

Many case reports and series exist about this disturbing problem; we have decided to highlight our findings to provide more insight to the disturbing figures that exist regarding this gynaecological condition.

Data of 44 patients who had acquired gynaetresia with surgical repair was retrieved between January 2019 and December 202 During this period a total of 935 women with various gynaecological conditions were seen at the gynecological outpatient clinic, with a prevalence of 4.7%. The data was inputted and analyzed. The mean age was 37.5 ± 6.8 years. 40 were still married at the time of the presentation. 2 were widowed and 2 separated from their spouse at the time of presentation.

Table 1.Patient’s demographics and diagnostic information.

All the patients involved had primary and secondary school education, with 15 having tertiary education and 2 were educated up to master’s degrees as shown in Table 1.

Eleven women (11) developed gynaetresia on account of obstructed labour and complications during caesarean delivery for obstructed labour, this accounted for 25%.

There was a single case of gynaetresia following dilation and curettage for an unwanted pregnancy as shown in Figure 1.

Figure 1. Aetiology of Acquired gynaetresia.

Figure 2. Indications for use of corrosive pessary.

We had 42 of the women presenting with difficulty or inability to achieve peno-vaginal sexual intercourse due to the extent of vaginal stenosis, this accounted for 95.5%. All the cases of vesico-vaginal fistula and one of the women with rectovaginal fistula occurred as a result of obstructed labour, the second case of rectovaginal fistula developed as a result of insertion of corrosive pessary as shown in Table 2. Majority of the women (71.4%) who inserted corrosive substance did so to cure their infertility while two (10.7%) of the cases of vesicovaginal fistula also used the corrosive pessaries, hoping to achieve a cure in the process (Figure 2). In 2 cases, 4.54% gynaetresia was an incidental finding, they had presented with vesicovaginal fistula, they were widowed and not sexually active.

Table 2. Diagnosis and associated complications.

All had surgical intervention for the treatment of the gynaetresia. A single stage vaginoplasty was done. This was followed up with subsequent vaginal dilation with a mould, while 10 had Singapore flap utilized in the repair accounting for 22.7%. The women who were sexually active were asked to commence sexual activity once they returned home, this was to be done alongside with the use of vaginal mould to preserve the patency of the vaginal canal created for them, while those who had vesicovaginal fistula repair were advised to abstain from sexual intercourse for 3 months and also did not have vaginal dilation done with the use of moulds. Thirty three (33) reported an improved ability to achieve peno-vaginal intercourse following the procedure at 6 weeks clinic visit and at 3 months clinic visit. 2 were rescheduled for repeat vaginoplasty with Singapore flap, this was sequel to the reocclusion which occurred following the initial procedure. They were followed up at 6weeks, 3months and 6 months interval and they also reported satisfactory outcomes with peno-vaginal intercourse. The women with secondary infertility were referred for evaluation and management at the infertility unit. Those who had associated vesicovaginal fistula had the fistula repair done at the same surgery.

The patients who had concomitant vesicovaginal fistula and rectovaginal fistula were advised to abstain from sexual intercourse following the surgery for a period of 3 months, they were advised to resume coitus after this and it was discovered that the vagina was still patent in 4 of the cases. The other three (3) women had repeat adhesiolysis after 6months to correct the gynaetresia as shown in Table 3.

Table 3. Clinical outcomes following surgical intervention.

Table 4 shows the factors are associated with successful outcomes of surgical repairs of patients with gynaetresia. There was a significant association previous vaginoplasty (Fisher’s P = 0.0187), co-existing genital tract fistula (Fisher’s P = 0.017), severe gynaetresia (Fisher’s P = 0.015), the use of grafts or flaps (Fisher’s P = 0.005) and successful primary outcome. The higher the number of previous attempts at vaginoplasty the lower the chances successful primary outcome. Also, fistular-associated gynaetresia and severe form of gynaetresia have poorer outcome of surgery. The use of inter-positional grafts and flaps improve the outcome of surgery.

Table 4. Factors associated with successful surgical repair of acquired gynaetresia.

Acquired gynaetresia is a still a significant reproductive health concern in southwest Nigeria, with obstetric trauma and insertion of corrosive pessaries being the leading cause of the problem in this region. The commonest cause identified was insertion of corrosive pessaries which accounted for 56.8% of the cases seen, the reasons for the use of this was mainly because of infertility which was secondary infertility in all the women seen. This accounted for 71.4%, the other reasons were uterine fibroids, in three women, vesicovaginal fistula in 3 women and 2 used the pessaries for menstrual irregularities, these accounted for 10.7%,10.7% and 7.2% respectively similar to the previous report [4] The use of corrosive vaginal pessaries have been documented in literature almost fifty years ago [5], but preceding that time, obstretric trauma, female genital mutilation were the leading causes of acquired gynetrsia [5][6]. The trend has however changed, with corrosive pessaries being the major risk factor. Despite of the increase in knowledge, improved socioeconomic conditions and better access to healthcare and specialist medical doctors, the use of corrosive vaginal pessaries has continued to sincrease, and has become the leading cause of acquired gynaetresia as attested to in some publications within the country [3]. The use of corrosive pessaries is not limited to women without formal education as shown in this study, rather well-educated women also patronize quacks who introduce the pessaries to them. The pessaries have been documented to contain potash and herbs which cause chemical vaginitis [3][7][8]. However, there are some present and marketed as “tumorex” the chemical component of this is however yet to be known. The use of these substances’ highlights, the desperation of these women to seek care from the alternative sources rather than orthodox medicine. Some of the reasons given were aversion to surgery and treatment for infertility.

Some of the women who presented, 15 women, accounting for 34.1% had surgical intervention done before by orthodox medical practitioners, however, the procedures were not successful. The reasons for these were not known, with some reporting no improvement right after the surgery. All the women who presented at our center had surgery done. Some others developed the condition as a consequence of traumatic vaginal delivery with accompanying vesicovaginal fistula. The treatment offered was a modification of the McIndoe vaginoplasty [9], which involves careful dissection in the area of where the anterior and posterior vaginal walls were bound together. In many cases, there is moderate to severe scarring with complete or partial loss of the vaginal epithelium and the cervix would no longer be visible, having sloughed off, when the corrosive substance was inserted. we usually create a reasonable depth and width of approximately 10 cm and 4 cm respectively. In situations with hematometra, a combined abdominal and vaginal approach is done, where a probe is inserted abdominally via an incision on the uterus and it exits through the cervical canal. Cases which result from obstructed labour, difficult deliveries, previous hysterectomies are far less mutilating compared with those that result from the insertion of corrosive pessaries. The use of the Singapore flap, is easier, cosmetically better and has been reported to have better outcomes [10]. This was applied in those with extensive scarring, otherwise adhesiolysis, with use of vaginal moulds was sufficient to keep the vagina patent for coitus. This mutilating condition severely affects the quality of life of these women; concerted efforts need to be put in place to help the society and eradicate this from the community

This study highlights the need for improved maternal healthcare, prevention, and multidisciplinary approaches to diagnosis and treatment to stem the rising tide of acquired gynaetresia which is still common in our environment, especially with the use of corrosive pessaries.

This study adds to knowledge about this condition and serves as a reminder to everyone involved in the practice of women’s health to be more dedicated in eradication of the problem.