Colpocleisis is Not Only for the Frail and Elderly

Linguistically, colpocleisis is the closure of the vagina. In medical terms, colpocleisis refers to the approximation of anterior and posterior vaginal walls over a uterus left in situ (if present), resulting in correction of advanced pelvic organ prolapse (POP), and a 2-3 cm residual vaginal length.¹ This would render vaginal coitus impossible, similar to what is encountered following “constrictive” repair of pelvic organ prolapse, with or without hysterectomy.²

Evidence that recurrence of prolapse following colpocleisis is less than what is reported following alternative surgical procedures is overwhelming.^1,3 Compared to “suspensory procedures” (SP) where the vaginal length and caliber are maintained (sacrospinous, uterosacral, ileococcygeus suspensions, vaginal mesh, and sacrocolpopexy), colpocleisis and constrictive procedures offer a favorable profile regarding morbidity, operative time, and cost.³ Furthermore, vaginal constrictive procedures are more successfully integrated in residency programs, compared to SP where a subspecialty training is often necessary. Obviously, the advantages of constrictive procedures, including colpocleisis, come with a major drawback: eliminating the function of the vagina as a coital organ. The only actual “physical function” of the vagina, in addition to vaginal delivery, is vaginal coitus.

A legitimate concern when offering colpocleisis is the possibility of regret. This has been found to be rather uncommon (3-9%), and most importantly not related to the absence of the vagina as a coital organ, but rather to the development of urinary storage dysfunction.¹

Surveys have estimated that a sizeable proportion of women in the age range of patients with POP are not engaging in penetrative vaginal sex.³ Most representative is a study conducted in 29 countries on five continents, which concluded that 35% out of 13,882 women older than 40 (mean age 54–58) had not had intercourse during the last year.⁴

Most urogynecology literature focuses on “sexual function” without discerning vaginal coitus from other sexual activities. Sex and vaginal coitus are not synonymous; our patients tell us when asked. In an interesting study evaluating men and women older than 60 in the USA, 57–62% reported embracing/hugging or kissing as a “physical or sexual experience,” whereas intercourse was not experienced at all by 82% during the last year.⁵

In almost all studies evaluating sexual function after POP surgery, there is underrepresentation of women who exclusively have sex with women. The sexual practices of this population, after the age of 50, have been studied,⁶ and it is our duty to conduct proper counseling to individualize surgical treatment.

Admittedly, many non-coitally active women could continue to perceive the presence of a patent vagina as a gender identifier, similar to the preservation of the uterus for some. This stance must be recognized and respected. Recognition and respect of the patient’s wish cannot be overemphasized.

Despite all what preceded, it is unfortunate that colpocleisis is still perceived by many as a “palliative” procedure for the frail and elderly, or a procedure of choice only for the patient with significant medical morbidities.⁷ A 2016 survey revealed 62% of urologists and 31% of gynecologists in 17 Latin American countries do not even offer obliterative surgery to sexually inactive women.⁸

It is quite possible that skill development and technological advance in the last decades have overshadowed colpocleisis in favor of SP and put it in the forgotten drawer of “ancient procedures.”

Colpocleisis (as all constrictive procedures for POP) has its own merits. It should be offered to all women seeking surgical correction of POP, irrespective of age and medical status, after adequate counseling.

REFERENCES

1. Buchsbaum GM, Lee TG. Vaginal obliterative procedures for pelvic organ prolapse: a systematic review. Obstet Gynecol Surv. 2017;72:175–183.
2. Töz E, Özcan A, Apaydın N, Uyar İ, Kocakaya B, Okay G. Outcomes of vaginal hysterectomy and constricting colporrhaphy with concurrent levator myorrhaphy and high perineorrhaphy in women older than 75 years of age. Clin Interv Aging. 2015;10:1009–1015.
3. Bazi T. The underutilization of obliterative and constrictive surgery in the surgical treatment of pelvic organ prolapse. Int Urogynecol J. 2019;30:1221-1224.
4. Nicolosi A, Laumann EO, Glasser DB, Moreira ED Jr, Paik A, Gingell C, et al. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology. 2004;64:991–997.
5. Ginsberg TB, Pomerantz SC, Kramer-Feeley V. Sexuality in older adults: behaviours and preferences. Age Ageing. 2005;34:475–480.
6. Schick V, Rosenberger JG, Herbenick D, Reece M. Sexual behaviour and risk reduction strategies among a multinational sample of women who have sex with women. Sex Transm Infect. 2012;88:407–412.
7. Practice Bulletin No. 176: Pelvic Organ Prolapse. Obstet Gynecol. 2017 Apr;129(4):e56-e72.
8. Plata M, Bravo-Balado A, Robledo D, Castaño JC, Averbeck MA, Plata MA, et al. Trends in pelvic organ prolapse management in Latin America. Neurourol Urodyn. 2018;37:1039–1045.