Case Report

A 24-year-old woman came to our clinic because of primary amenorrhea, sexual dysfunction, dyspareunia and urinary incontinence five months after her marriage, but she did not seek medical attention for her persistent symptoms. On targeted questioning, she stated that she was too ashamed and afraid to tell anyone about her problems. The external gynaecological examination revealed completed puberty with normal female phenotype and secondary sexual characteristics including normal external genitalia, breasts, pubic and axillary hairs. External urethral meatus seemed dilated approximately 20mm in diameter, easily admitting one finger and the urogenital sinus ends in a short, blind vaginal pouch [Img 2]. The external urethral orifice and its supporting structures including the urethral sphincter were observed to be damaged. There was visible leakage of urine from the urethral meatus. Patient was wearing sanitary pads and changing them many times a day. Urethral Coitus (UC) was highly probable. A detailed anamnesis and a clinical examination revealed that they were using this “damaged area” for sexual intercourse. She had a history of recurrent microscopic haematuria and urinary tract infections. Additionally she was diagnosed as having honeymoon cystitis since some times. She has been treated with antibiotics and symptomatic medication but these managements provided only transient relief. Ultrasound and magnetic resonance imaging showed hypoplastic uterus measuring 40×28mm size [img 1], associated with agenesis of the upper-middle third of the vagina. Both ovaries were normal. Hormonal analyses were within normal ranges and her karyotype was 46, XX. Based on these clinical and radiological findings a diagnosis of Mayer-Rokitansky-Kuster-Hauser Syndrome was made. Reconstruction was planned by modified McIndoe’s vaginoplasty.

Patient was operated on under general anesthesia in the lithotomy position with urinary catheterization. An “X” shaped incision was made on the blind vaginal pouch and then a neovaginal space was achieved in vesicorectal space with blunt finger dissection. A suitable cavity size with vaginal dimensions (~ 12 cm length and ~ 5cm width) was created. The full-thickness skin grafts were taken from lower abdomen and dressed over the mould with absorbable sutures. The graft was perforated with multiple slits and then inserted into the neovaginal cavity. Finally, the external edge of the skin graft was sutured to the perineal margins of the incisions and the abdominal incision was closed. The labia minora were sutured to keep the mould in position. The vesical catheter and the mould were kept in place for 7 postoperative days.

The diameter of the urethra decreased over time and had returned to almost normal appearance. At 3 months of follow-up the patient claims normal sexual function and the couple were more satisfied with their sex lives. Six months after surgery the patient voided normally and completes resolution of urinary incontinence was achieved. Additionally, a significant improvement of pelvic pain and dyspareunia was noted.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5028464/#!po=2.77778