Vaginal outlet

Vaginal outlet stenosis is sometimes seen in virgins, but it appears most often in a woman who has undergone repair of an episiotomy or posterior repair. In relieving this condition, which is obviously associated with extreme dyspareunia, the surgeon opens the posterior outlet and pulls the mobilized vaginal mucosa onto the posterior fourchette and the perineal body. Postoperatively, the vaginal mucosa is treated with estrogen so that it becomes well cornified.

Physiologic Changes. The vaginal outlet is opened sufficiently to allow pain-free sexual intercourse.
Points of Caution. Adequate mobilization of the posterior vaginal wall is extremely important in order that it may be pulled over the perineal body.

Technique

In a standard case of vaginal outlet stenosis, Allis clamps are applied at the 7 and 5 o'clock positions, respectively, and an incision is made at the posterior fourchette.

Dissection is carried up under the posterior vaginal wall for a distance of approximately 7-8 cm. A triangle of skin is removed from the perineal body, from the posterior fourchette down toward the anus.

The superficial transverse perineal (STP) muscle is exposed. Small incisions are made into this muscle in order to relax the vaginal outlet. An Allis clamp is used to keep the posterior vaginal wall on traction.

The posterior vaginal mucosa is pulled over the denuded superficial transverse perineal muscle onto the perineal body.

If sufficient posterior vaginal wall mucosa is not available to cover the perineal defect, the vaginal mucosa can be split in the midline, thereby enlarging the flap to allow adequate coverage.

The posterior vaginal mucosa is sutured to the skin of the perineal body with interrupted 4-0 synthetic absorbable sutures.