His and Her Health

I posted this in another board but have not received any replies. So, I'm trying this board in hopes I will have better success.

I have a tear or fissure in the posterior fourchette which makes intercourse just about impossible. Every time I do have intercourse, it splits and the pain is severe. It was not diagnosed by several run of the mill gyns, so I went to a specialist at a major university medical center (I don't know if I can name it here so I won't) who made the diagnosis and has been treating it for about 6 months with Estrace both inserted vaginally (1/2 applicatorful 2 times a week) and applied to the area every night. No luck. She has told me that I will need to have it repaired and suggested a Z-plasty procedure. However, she noted that the down side is that it might not work - in which case I will need to have it redone by a plastic surgeon who will do a graft. She suggested that I have a consultation with him, which I have not done yet as I am awaiting insurance approval. At any rate, my question is whether I should have her do the procedure or the plastic surgeon do it. My thinking is that why take a chance on having to have surgery twice - just let the plastics guy do it and be done with it. It is very difficult to find a plastic surgeon who does this kind of work and I couldn't find any on my insurance plan, so it's going to cost me a whole lot more for a plastic surgeon to do it. The up side, though, is that if a plastics guy does it, it shouldn't have to be done again. I should also add that I'm 58 years old and have been on premarin for about 14 years since a total hysterectomy. I would really appreciate some feedback as I haven't been able to get much information.
Thanks.

A recuurent fissure at the posterior fourchette that will not heal with topical estrogen (and testosterone) can be treated successfully with surgery in 85-90% of the pateints. However, the only appropriate surgery is a perineoplasty with vaginal advancement. In my opinion this should only be done by a vulvar specialist who has done many of these procedures. If done incorrectly, it can make the vagina too tight.

<small>[ 03-13-2006, 09:18 AM: Message edited by: Moderator ]</small>

Thank you so much for your reply Dr. Goldstein. Can you tell me how to go about finding such a specialist in the Los Angeles area? I'm guessing my GYN may be one since she is at a major university medical center and only deals with special cases. However, she recommended a plastic surgeon. What do you think of that? And how do I find one of those?

I think that a plastic surgeon is not a very good idea. It is very unlikely that a plastic surgeon has done many, if any of these procedures. Again, if done incorrectly, it can do much more harm than good. Unfortunately, I am unable to recommend physicians in this forum.

I have had a recurring fissure at the 6:00 position for over 15 years and, although it is very small, it is excruciatingly painful. I have been prescribed more treatments than I can count or remember. After doing some research recently, I decided to ask my Gyn if it would be worthwhile to try 0.5% Clobetasol Pripionate, which, of course, has its own set of issues. I don't have any real symptoms of lichen schlerosis, for which this steroid is a known treatment, but I'm desperate. After no luck with anything else after all these years, it seems to be working after about 3 weeks of twice daily topical application.
Phyllis, obviously I'm no doctor, but I wonder if it would be worth asking about before you resort to surgical treatment.
Dr. Goldstein, any thoughts?

One should only use clobetasol if there is a dermatologic condition. A vulvar specialist should be able to make that determination.

I also have a fissure in the 6 o'clock position. My Gyno prescribed me clobetasol as well, which helped, but did not heal the fissure. He had mentioned performing an apisiotomy as a last resort. It sounds like I should not have this done???? How do I go about finding a Vulvar Specialist? I have tricare

Kelly-get in touch with NVA (national vulvodynia association)

i actually did just before I saw your message! thanks...By the way, Im also a MPT

To Niva,
Have you treated patients with a recurrent posterior fourchette fissure?

I have vetibulitis and a small tear at the 6' oclock position as well. I don't know if it's recurring because my gynecologists kept missing it. I went to a specialist at a university in Los ANgeles that noticed it.

Dr Goldstein and others,

First, do estrogen testosterone creams sometimes heal the tear if you go off BCP? That's what I'm using now for the vestibulitis in general.

Second, if I do find that it's recurring after it heals, or if it won't heal, would a vestibulectomy remedy the situation or just a perineoplasty with vaginal advancement?

Also Phyllis if you are still around I would love to know how things turned out for you. I think we may have the same doctor. WHich procedure did you end up having? I tried to pm you but I wasn't able to. THanks!

Kelly, I definitely have seen patients whom have had fissures in their history, but I can't remember off the top of my head if recurrent....

<small>[ 05-08-2009, 12:24 PM: Message edited by: Moderator ]</small>