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Procedures

Perineoplasty for Perineum Repair

 en.wikipedia.org/wiki/Perineoplasty

Perineum repair is the most common use of perineoplasty. A woman may experience damage to her perineum and vaginal flatus as a result of:

  • Child birth--it may be torn or cut
  • Weight gain may stretch the perineum or lead to muscle separation
  • Inadequate innervation (lack of nerves)
  • No known cause

Women report a loose, sagging feeling in the vaginal area that may or may not be accompanied by lower sexual satisfaction than before perineal damage. Perineal damage may also be accompanied by anal sphincter detachment and rectum prolapse (rectocele). Perineoplasty for perineum repair is closely associated with posterior colporrhaphy.

Perineoplasty involves first a V- or U-shaped incision in the posterior wall of the vagina, depending on the amount of correction required. Incisions at the top of the V may be flat, curved, or angled upward, depending on the amount of vaginal tightening to be achieved. 

Once the incision is made, any existing scar tissue and abnormal tissue fixations as a result of previous surgery or injury are removed. Depending on the amount of damage present, repair may be made to:

  • Pubococcygeus muscles
  • Bulbospongiosus muscles that may have become detached from the perineal body
  • Separation of other muscles from their attachments in the perineum

Stitching of the muscles in perineoplasty must be performed very carefully to avoid transverse ridges that can create a "washboard" or "stair-step" effect in the vagina. 
Recovery from perineoplasty takes 4-6 weeks.

Perineoplasty for Dyspareunia

Women who experience dyspareunia (painful intercourse) or vaginismus (involuntary contraction of the puboccygeus muscles) can often be treated with a variation of perineoplasty. In this procedure, the goal is to loosen a tight vaginal introitus (entry). Some surgeons use a simple surface incision at the fourchette for this purpose, but such superficial treatment is not generally effective. 

To perform loosening perineoplasty, a triangle of skin is excised from below the vulvar vestibule with its base near the vestibule and its apex near the anus. This allows the removal of genital warts and the adjustment of musculature necessary to increase the size of the vagina. In this procedure, it is desirable to maintain the vaginal mucosa as much as possible. Recovery typically requires 4-6 weeks.

Perineoplasty is generally considered effective for treatment of dyspareunia 16, including that caused by lichen sclerosus 17, and vaginismus.18 It is also considered an effective treatment for vulvar vestibulitis, although it is generally recommended following the failure of nonsurgical methods. 19, 20 ,21

Perineoplasty for Treatment of Sexual Dysfunction

Some surgeons caution against over-use of perineoplasty for the treatment of sexual dysfunction. In its 2007 statement on "cosmetic vaginal procedures," the American College of Obstetricians and Gynecologists (ACOG) recommended that "Women who want to improve their sexual response should be evaluated for sexual dysfunction, and nonsurgical interventions, including counseling, should be considered."

In his description of perineoplasty, David Nichols noted, "The extent to which reconstruction of a very loose vaginal outlet contributes to coital satisfaction has undoubtedly been overemphasized." He recommended against perineoplasty for the improvement of a relationship, a recommendation echoed in a more recent study of labiaplasty patients that noted, "Not all women experienced an improved sex life postoperatively, and those hoping for an improved relationship were disappointed." Nichols further cautions against unnecessary procedures that may result in fibrosis or rigidity of the vagina. Nichols also noted that there were generally insufficient standards in terms of procedures or outcomes for vaginal surgery, making procedures variable from doctor to doctor a statement echoed by Michael Goodman in a recent commentary