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The Epidemiology and Management of Gynatresia in Lagos, Southwest Nigeria

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The Epidemiology and Management of Gynatresia in Lagos, Southwest Nigeria International Journal of Gynecology and Obstetrics 118 (2012) 231–235 Contents lists available at SciVerse ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo CLINICAL ARTICLE The epidemiology and management of gynatresia in Lagos, southwest Nigeria Andrew O. Ugburo a,⁎, Idowu O. Fadeyibi b, Ayodeji A. Oluwole c, Bolaji O. Mofikoya a, Abidoye Gbadegesin d, Omololu Adegbola c a Department of Surgery, Burns and Plastic Surgery Unit, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi-Araba, Nigeria b Department of Surgery, Burns and Plastic Surgery Unit, Lagos State University College of Medicine/Lagos State University Teaching Hospital, Ikeja-Lagos, Nigeria c Department of Obstetrics and Gynecology, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi-Araba, Nigeria d Department of Obstetrics and Gynecology, Lagos State University College of Medicine/Lagos State University Teaching Hospital, Ikeja-Lagos, Nigeria article info abstract Article history: Objective: To document data from patients presenting with gynatresia at 2 tertiary health centers in Lagos, Received 4 December 2011 southwest Nigeria. Methods: In a prospective, descriptive study, clinical history and physical examination Received in revised form 30 March 2012 data were collected for women who presented with gynatresia between January 2004 and January 2011. Ul- Accepted 18 May 2012 trasonography results and abnormality at surgery were also documented. Where possible, the severity of ste- nosis and surgical outcome were assessed by published scales. Results: Forty-seven patients were included in Keywords: the study. Eight patients (17.0%) presented with congenital gynatresia, the commonest cause of which was Acquired gynatresia Mayer–Rokitansky–Küster–Hauser syndrome (4 patients, 50%). Thirty-nine patients (83.0%) presented Intersex syndrome Pudendal thigh flap with acquired gynatresia, the main cause of which was herbal pessaries (30 patients, 76.9%). Herbal pessaries Vaginoplasty were used to treat fibroids (23 patients, 76.7%), uterovaginal prolapse (3, 10.0%), and infertility (2, 6.7%); and to procure abortion (2, 6.7%). The ages of the patients who used herbal pessary ranged from 18 to 50 years (mean 36.10±1.24 years). Other causes of acquired gynatresia were birth injuries (6 patients, 15.4%), and fe- male genital mutilation (2, 5.1%). Conclusion: Acquired gynatresia was more common in Lagos than congenital gynatresia. The causes of acquired gynatresia are preventable and could be eliminated by health education. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction 2. Materials and methods In high-resource countries, the incidence of acquired gynatresia is A prospective study was carried out at 2 tertiary healthcare lower than that of the congenital type, and results from iatrogenic institutions—the Lagos University Teaching Hospital and the Lagos causes such as surgery and radiotherapy to the genital tract [1].In State University Teaching Hospital—in Lagos, southwest Nigeria. Be- low-income countries, however, acquired gynatresia is more com- tween January 20, 2004, and January 31, 2011, patients diagnosed mon because birth injuries and female genital mutilation (FGM) con- with congenital vaginal atresia or aplasia of the vagina, and patients tribute to the incidence of this type of gynatresia. with acquired gynatresia from all causes were enrolled in the study. Vaginitis resulting from herbal pessary is the most frequent cause of Approval for the study was obtained from the research and ethics gynatresia in southwest Nigeria [1–4], whereas FGM is reported to be committee of both health institutions, and consent was obtained the most common cause of acquired gynatresia in eastern Nigeria [5]. from the patients. By contrast, a study carried out in Benin in central-west Nigeria and The data collected were age, occupation, marital status, clinical Ibadan in southwest Nigeria found that herbal pessary is the commonest history, physical examination, abdominal and pelvic ultrasound find- cause of acquired gynatresia, followed by FGM [2]. Similarly, in a study in ings, and abnormalities found during examination under anesthesia Ibadan, Arowojolu et al. [3] reported that herbal pessary was the most and surgery. Data were presented as mean±SEM. frequent cause of acquired gynatresia, followed by birth injuries. The severity of the stenosis and the outcome of surgery were The aim of the present study was, first, to evaluate the causes of assessed via published scales [6]. The data were analyzed via SPSS gynatresia in Lagos in southwest Nigeria 20 years after the introduction version 17 (IBM, Armonk, NY, USA). of health education to discourage FGM and the use of herbal pessary, and after improvements in obstetric care; and, second, to compare the 3. Results treatment of and outcomes of gynatresia with previous data. Forty-seven patients presented with gynatresia during the study period. Eight patients (17.0%) presented with congenital gynatresia ⁎ Corresponding author at: Department of Surgery, College of Medicine, University of Lagos, Idi-Araba, PMB 12003, Lagos, Nigeria. Tel.: +234 8023124495. (Table 1). The most frequent cause of congenital gynatresia was E-mail address: [email protected] (A.O. Ugburo). Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome (4 patients). 0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2012.04.004 232 A.O. Ugburo et al. / International Journal of Gynecology and Obstetrics 118 (2012) 231–235 Table 1 Clinical information of patients presenting with congenital gynatresia. Age, y Etiology Other findings Surgery Outcome 14 MRKH Occluded atretic fallopian tubes Bilateral PTF Flap survival 24 MRKH Dysgenetic right ovary and tubes Gracilis myocutaneous flaps Flap survival 15 Intersex CAH hypoplastic uterus with hypertrophic clitoris Bilateral PTF Flap survival 14 Hermaphrodite Hypoplastic uterus, 1 ovotestis, hypertrophic clitoris Bilateral PTF; gluteal flap for labia Flap survival 15 MRKH Cystic ovaries Bilateral PTF Flap survival 3 Intersex Macrostomia Awaiting surgery Awaiting surgery 19 Intersex CAH, hypertrophic clitoris Awaiting surgery Awaiting surgery 35 MRKH Absent uterus Bilateral PTF Flap survival Abbreviations: CAH, congenital adrenal hyperplasia; PTF, pudendal thigh flap; MRKH, Mayer–Rokitansky–Küster–Hauser syndrome. Three patients had an intersex phenotype with ambiguous genitalia. Thirty-nine patients (83.0%) presented with acquired gynatresia. One patient was a true hermaphrodite (Table 1). The most common cause of acquired gynatresia was scarring from Three patients with MRKH syndrome had normal uterine develop- vaginal chemical burns (SVCBs), resulting from herbal pessary use ment with amenorrhea and hematometra. These 3 women presented (30 patients; 76.9%) (Table 2, Fig. 1). The ages of the patients with with cyclic monthly abdominal pain, but absence of menstruation. SVCBs ranged from 18 to 50 years (mean±SD, 36.10±1.24 years). Two of the 3 patients had vaginoplasty with bilateral pudendal Two patients, aged 18 years and 22 years, sustained SVCBs from use thigh flaps (BPTFs), whereas 1 patient had vaginoplasty with bilateral of herbal pessary to induce abortion (Table 2, Fig. 1). Most patients gracilis myocutaneous flaps. For all 3 patients, uterovaginal continuity with SVCBs had had gynatresia for 5 to 10 years before presentation was restored with normal menstrual outflow. One patient with MRKH at the clinic. Eight patients (26.7%) had undergone at least 1 or 2 pre- syndrome presented with absence of the uterus. This patient had vious unsuccessful vaginoplasty procedures, and 3 patients (10.0%) vaginoplasty with a BPTF (Table 1). had undergone 3 or 4 previous unsuccessful vaginoplasties. The Two of the patients with an intersex phenotype presented with vaginoplasty procedure in these patients was vertical division of the congenital adrenal hyperplasia with hypertrophy of the clitoris. One scar with or without transverse suturing with vaginal dilatations. of these patients had vaginoplasty with a BPTF and clitoridectomy; The 30 patients with SVCBs used the herbal pessary for the follow- the other was awaiting surgery at the time of publication. The true ing conditions: fibroids (23 patients, 76.7%), uterovaginal prolapse (3, hermaphrodite was a genetic female with ovotestes, ovaries, and hy- 10.0%), infertility (2, 6.7%), and abortion (2, 6.7%) (Fig. 1). Among the poplastic uterus. The patient had vaginoplasty and vulval reconstruc- 23 patients that used the pessary to treat fibroids, 14 (46.7%) had as- tion with a bilobed BPTF and gluteal fold flaps. sociated primary infertility, 8 (26.7%) had fibroids alone, and 1 (3.3%) Table 2 Clinical information of patients with acquired gynatresia resulting from pessary use. Age, y Education Occupation Source of Indication for Parity Severity Other No. of previous Surgery Outcome referral pessary use of stenosis findings vaginoplasty 34 Technical Community Radio Infertility/fibroids 2 2 – 3 EPTF (left)+PTF (right)+ Excellent education health worker myomectomy 39 Secondary Trader Friend Infertility/fibroids 0 3 – 4 Bilateral PTF Excellent 30 Post-secondary Civil servant Radio Infertility/fibroids 0 4 CS 4 Bilateral PTF+myomectomy Excellent 40 Secondary Housewife Radio Infertility/fibroids
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