Difficult Case: Recurrent Vault Dehiscence

Presentation and Clinical History:

• Multiparous, mid-30s
• Post total abdominal hysterectomy for abnormal uterine bleeding/bicornuate uterus
• Unremarkable postop course
• Vault dehiscence with intercourse at 2 months post-op
• Complains of vaginal bleeding and severe pain
• Seen in Emergency Department and repaired in an emergency surgery
• Advised no penetrative sex for three months

Patient was seen for follow-up at 3 months. Vault had healed and patient was given the go-ahead to partake in gentle sexual activity. Two weeks later, patient presented again with recurrent vault dehiscence, elevated white count, and severe pain. She was treated with IV antibiotics for three days, repaired with PDS, and referred to a urogynecologist.

Patient was examined by the urogynecologist 3 weeks after repair in the emergency department. PDS sutures were still in situ, there was no abnormal discharge, and cuff edges were apposed. Normal vaginal length (TVL-8) was recorded. Urogynecologist noted she did not push too hard because the patient was tender, and she worried she would dehisce again.

What would you do?

1. Leave her be and suggest she and her partner be more creative in terms of reducing the penetrative length.
2. Take her back to the operating room and re-repair transvaginally.
3. Take her back to the operating room and try to mobilize some peritoneum laparoscopically over the vault.
4. Perform laparoscopic sacrocolpopexy.

Expert Response

Post hysterectomy vault dehiscence is considered a surgical emergency. The presented case is very concerning as a recurrence of a dehiscence brings about concerns regarding causation. The initial dehiscence was managed properly.

The question now is what is normal at 3 weeks post-dehiscence repair. It appears the patient is healing well with sutures still present - as would be expected with PDS. The patient’s tenderness may be normal for this time during the healing process. She should remain at pelvic rest and limit physical activities for at least another 3-6 weeks to allow for further healing. No penetrative sexual activity should occur until the sutures are completely gone and complete healing is documented.

At this time, if there is a concern regarding infection, hematoma or abscess formation, a TV U/S can be performed to assess the area. Thus, neither of the 4 posted options are appropriate. The patient needs more time to heal and should be re-assessed in 3-4 weeks. If she is post-menopausal, estrogen cream should be initiated, and tissue health monitored for at least 6 months.

Expert Response

Collagen in any tissues can easily take 6-12 months to finish healing. The maturation phase (Mostafa et al) – where remodeling i.e., where a steady, gradual growth in wound tensile strength occurs, continues for 6 to 12 months although the process begins to plateau at 6 weeks. During this time, cross-links between collagen strands increases. Highly cross-linked collagen is stronger than the collagen produced earlier during the wound healing process but will always be weaker than native unscarred tissue (Bowden et al). I would hold off for 6 months before penetrative sex, then consider a change of position or device such as OhNut to control depth of penetration.

REFERENCES

Normal Wound Healing. In: Mostafa G., Cathey L., Greene F.L. (eds) Review of Surgery. Springer, New York, NY; 2006. https://doi-org.proxy.queensu.ca/10.1007/978-0-387-44952-4_7.

Bowden LG, Byrne HM, Maini PK, Moulton DE. A morphoelastic model for dermal wound closure. Biomech Model Mechanobiol. 2016 Jun;15(3):663-81.