Application of transrectal bi-plane high-frequency ultrasonography combined with vaginal saline injection in a postpartum woman with vaginal stenosis
Introduction
In this article, we explore the clinical efficacy of the transrectal bi-plane high-frequency ultrasonography (TBHU) probe combined with vaginal saline injection (VSI) for diagnosing vaginal stenosis. To the best of our knowledge, no prior cases with similar characteristics have been documented.
Vaginal stenosis may be congenital or acquired, with the latter primarily observed in postmenopausal women, or as a consequence of radiotherapy for cervical cancer (1). Conversely, acquired vaginal stenosis is a rare complication of vaginal delivery. The incidence of vaginal stenosis is rare globally, and comprehensive statistics are lacking. Factors such as vaginal length, mucosal changes, and vaginal volume alterations influence the diagnosis of vaginal stenosis. Further, the clinical assessment of vaginal stenosis, defined by Nunns et al. (2) as the inability to insert two fingers into the vagina, often relies on evaluating vaginal volume.
Case presentation
A 29-year-old woman (gravida 1, para 1) experienced severe vaginal tears during vaginal birth. At her routine postpartum rehabilitation examination 45 days later, she was diagnosed with vaginal stenosis. Conventional vaginal ultrasound could not be performed normally, and transrectal ultrasound also failed to visualize the vagina. Even enhanced magnetic resonance imaging (MRI) did not lead to a diagnosis of vaginal stenosis. However, using the TBHU technique, we successfully detected the condition.
In this case, structural damage to the vaginal layer was observed using the high-frequency linear array mode of TBHU (Figure 1A). When the mode was changed to the biplanar convex array mode, a 0.33-cm gas echo manifested at the left margin of the middle vagina (Figure 1B). To improve the assessment of the lesion degree and location, VSI was immediately administered. Injecting normal saline into the vagina during TBHU facilitated the clear observation of the extent and severity of the vaginal stenosis.
The widest diameter of the upper and lower portions of the stenosis was approximately 1.27 cm on the right lateral wall of the lower and middle vaginal segments (Figure 1C), while the narrowest diameter was 0.56 cm near the left lateral wall (Figure 1D), with the left and right diameters measuring 1.0 cm. The fissure on the left edge of the vagina measured approximately 0.39 cm (Figure 1E). The distance between the lower margin of the closed segment and the outer margin of the perineum was approximately 1.6 cm.
During the surgical procedure, a close examination of the hymen margin revealed dense adhesions between the anterior and posterior walls of the vagina, along with a fissure at the three o’clock position of the vagina (Figure 1F). The gap was probed with a No. 5 expanding rod, and the process was smooth. Next, a hysteroscopy was performed to assess any structural abnormalities. The upper vagina appeared intact, and the cervix was visible before removing the hysteroscope. The vaginal scar tissue was excised, and the wound was sutured with 3-0 absorbable sutures. Following the surgery, two fingers were able to be comfortably inserted into the vagina (Figure 1G). Vaseline gauze was then inserted to prevent the formation of new adhesions. Figure 1H shows the coronal section of the vaginal stenosis.
All the procedures in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this article and the accompanying images. A copy of the written consent form is available for review by the editorial office of this journal.
Discussion
The preoperative diagnosis of vaginal stenosis primarily relies on clinical examination, MRI, and ultrasound. Clinical examination cannot reveal the internal structure of the vagina, and MRI cannot accurately diagnose the vaginal stenosis due to the anatomical complexity of the vagina. Transabdominal ultrasound frequently produces low-quality images, limiting its diagnostic utility. Transrectal ultrasound, which emits an acoustic beam from the top, does not allow for a comprehensive evaluation of the vagina because the beam is not perpendicular to vaginal entirety.
TBHU has emerged as an appropriate, non-invasive, and easily operable technology. The combination of the convex and linear array is advantageous for comprehensive lesion scanning, and effectively circumvents artifact interference. TBHU has not been previously used in the diagnosis of vaginal stenosis, but its combination with VSI shows promise in enhancing diagnostic accuracy.
Conclusions
TBHUS combined with VSI is effective in the diagnosis of vaginal stenosis. Further, this combination method enables the evaluation of vaginal stenosis from multiple angles in both sagittal and transverse positions. It also enables the visualization of vaginal lesions, and the accurate and efficient determination of the extent and scope of any such lesions. The identification of normal gas lines in the vagina and the injection of saline to dilate the vagina are highly beneficial in making a definitive diagnosis.
Acknowledgments
Funding: This work was supported by
Footnote
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-23-1706/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for the publication of this article and the accompanying images. A copy of the written consent form is available for review by the editorial office of this journal.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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