Aptos unveil a minimally invasive thread technique for the perineum to tackle complaints of intracoital sensibility dysfunction, hiatus of vestibule, and a reduction of sexual satisfaction
In recent years, the increased interest for aesthetic gynaecology has been detected, in particular, for minimal invasion methods for the aesthetic correction of the vulva. A collaboration of gynaecologists, urogynaecologists, psychiatrist-sexologists, dermatologists, and plastic surgeons made a major contribution into the development of this sphere. Unfortunately, in Russia, we see a total absence of understanding between specialists, who are engaged in various aspects of ‘sexual medicine.’ Usually, surgical corrections of the vagina and vulva, under medical conditions, were performed by gynaecologists, but considering the increased demand on procedures, which improve the quality of sexual life, more and more specialists of aesthetic medicine express an interest to aesthetic gynaecology. According to the results of a consensus, adopted in 2007 by the American College of Obstetricians and Gynaecologists, medical conditions for an intimate surgery are the following:
- Necessity of vulva reconstruction after an ritual circumcision or iatrogenic damage
- Asymmetry and hypertrophy of labia minora (smaller lips)
- Scleroatrophical processes in the vulva
- Hypertrophy of clitoris in the result of androgens’ excess.
Currently, most surgical invasions in aesthetic gynaecology are performed under aesthetic conditions or for improvement of the woman’s sexual life. According to multi-center retrospective research, in the case of 76% of 258 women, a surgery was performed because of functional reasons; 35% underwent surgery because of cosmetic reasons and 33% — for the improvement of self-esteem. 54% of women, who underwent a vaginal/perineoplasty and 24% of those women who underwent a combined procedure, including vaginal/perineoplasty, labioplasty and surgery of clitoral hood, made it for the improvement of a partner’s sexual pleasure.
After a vaginal childbirth, some women complain of the feeling of vaginal relaxation because of perineum ruptures, incorrectly rehabilitated episiotomy or perineoplasty, but in the domestic literature, as of today, there is a lack of data on this phenomenon. Depending on the age, a sexual dysfunction, including a depression of libido, dryness of vagina, inability to reach orgasm and dyspareunia are found in more than 40% of women. Women with the feeling of vaginal relaxation can complain of the reduction of sensitivity during sexual intercourse and decrease of sexual satisfaction, and their partners (men) can complain of reduction of contact feeling during sexual intercourse. Although, several non-surgical and surgical methods for elimination of the above-mentioned complaints were described, there is not a single approach for the selection of a treatment method for these patients. For the patients of this group, a vaginoplasty is the most frequently performed procedure, which allows the practitioner to reduce the size of the vagina. Each surgeon chooses a specific method for this surgery, be it an anterior, posterior, lateral colporrhaphy, perineoplasty, colpoperineoplasty or their various combinations. Colpoperineoplasty or vaginoplasty have become routinely performed.
Perineoplasty can be an independent procedure or one of the series of surgical procedures, performed due to the prolapse of organs around a small pelvis. According to the theory of DeLencey, this allows for the restoration of the third level of support. This procedure can be performed under aesthetic conditions, when a patient complains of expressed cicatricial deformation of perineum in the result of ruptures or episiotomy or perineotomy, vulvodynia and stenosis of vagina vestibule because of Lichen sclerosus. Considering the change of attitude to the quality of sexual life, reduction of the tolerance level in relation to sexual dysfunctions, more and more often a perineoplasty is performed with the purpose of improvement of sexual life, an elimination of the feeling of vaginal relaxation and hiatus of vaginal vestibule. Despite the high frequency with which this procedure is performed, there are not unified surgical methods on how to perform it. Moreover, published recommendations about the criteria of selection of patients for this procedure are also absent.
The above-mentioned reasons, as well as the results of research, conducted by Pardo and Goodman, in which the percentage of complication is assessed from 3% to 19.7% respectively, make the necessity a development of new methods of sexual life’s rehabilitation and elimination of existing defects of architectonics of pelvic floor’s superficial layer of muscles by means of minimally invasive methods. Aptos threads are well known in the world of aesthetic medicine, although, these methods are a relative novelty in gynaecology. Since 2014, the school of professor Lutskovskaya has collaborated with the Aptos company in the development of advanced methods of thread correction of urogenital area for men and women. In our practice, for patient women, who want to improve the appearance of the vulva and quality of sexual life, we perform a minimally invasive correction by means of Aptos threads, without using posterior colporrhaphy, assuming that the real reason of all complaints is a weakened pelvic support and abnormality of architectonics of pelvic floor’s superficial layer of muscles, and not overstretching of vaginal mucous membrane. The goal of this article is to describe an application of method of thread correction for the perineum and vulva, using Aptos threads for treatment of this condition and to examine its efficiency, safety and results. Minimal percentage of traumas, safety and short period of rehabilitation are important aspects of thread correction, because this allows the patient to retain the possibility of natural childbirth after this procedure, without the additional risk of ruptures and lesion of childbirth activity. This circumstance, along with three above-mentioned points, are the main criteria, because of which patients and doctors decide to go ahead with minimally invasive thread correction of the vulva and perineum.
Materials and methods
In this prospective, observational research, which was approved by the local ethical committee, established in the clinic by professor Lutskovskaya, we presented the results of treatment to the patients, who had complaints of intracoital sensibility dysfunction, hiatus of vestibule, a reduction of sexual satisfaction, and who underwent the procedure of minimally invasive thread correction of perineum by means of the Aptos method, during the period September 2014–November 2017. Fourteen patients of reproductive age were included in the research, all of them were volunteers and were reminded of the possibility to abstain from participation in the research. Criteria for inclusion were at least one vaginal childbirth, complaints of vaginal vestibule relaxation and reduction of intracoital sensibility, absent of previously performed vaginal/perineoplasty in the anamnesis, general somatic contraindications for performing a procedure and/or anaesthesia. All patients were examined by the gynaecologist, in the range of gynaecology examination, assessment of pelvic floor condition under the POP-Q system, visual-analogous scale of assessment of satisfaction with the results of aesthetic procedures GAIS and sexological examination by means of FSFI questionnaire. Patients with a prolapse of organs due to a small pelvis, extending a POP-Q ≥ 1 stage, rectocele, cystocele, presence of perineoplasty or vaginoplasty in the anamnesis, dyspareunia, incontinence of urine, defecation difficulty, sexually transmitted diseases and cervical diseases, and patients who were pregnant or had a childbirth during the previous 12 months were excluded from the research. All patients underwent examination after one week following the procedure, for the evaluation of early post-surgical unwanted developments, and after 6 months for the evaluation of possible late unwanted developments. Control visits for the evaluation of correction results were appointed on 1st, 3rd, 6th and 12th months after the procedures.
Thread correction of the perineum was performed under local anaesthesia using an Ubistesin solution, in ambulatory conditions, without sedation. Intrasurgical antibiotic prophylaxis was not performed. The patient, during the procedure was lying in lithotomy condition on the gynaecological chair or surgical table. Marking were made by means of sterile marker in the supine position. 10% solution of povidone-iodine was applied to the skin of the perineum and outer third of the vagina.
The volume of anaesthetic for infiltration anaesthesia varied in the range of 6–10 ml. In this procedure, Aptos Light Lift Needle 2G thread was used. A thread made from L-lactic acid and Σ-hexanoic acid, with divergent barbs, located along the whole length of thread from the centre toward edges, makes it possible to reliably fixate and move muscle compartment, and trigger biostimulation with further formation of dense carcass made from connective tissue, in the area of the perineum. Double-sharp needles can freely change the trajectory of thread route, depending on the necessity and anatomical characteristics of the patient. An outer layer of pelvis diaphragm muscles was navigated in a tactile way. Threads were introduced through the skin, up to the distal edge of the bulbospongiosus muscle, along a direct trajectory.
The tension vector and transposition of this bundle was formed in the direction of the perineal body. Multiple bilateral repetition of this manoeuvre allowed the practitioner to match bulbospongiosus muscles in the projection of posterior commissure of the large lips. The detailed scheme of the procedure performed is presented in (Figure 1). Intra- and post-operational complications were not detected, all patients were able to return to normal social life after two hours following the procedure. In the earlier post-operational period, the patients were forced to restrict vaginal coitus, sport exercises, thermal procedures — for the period of 2–3 weeks.
Average age of patients was 42.7 year (37–48), average value of BMI was 22.7 (18.4–26.2). Detailed characteristics of patients, participating in the research, are given in Table 1. Collection of sexological anamnesis showed that most prevalent reason for applying to this procedure was the lack of satisfaction with sexual activity (86% of patients, n=12), aesthetic problems, especially because of cicatrices after the episiotomy (65%, n=9), and hiatus of vestibule (65%, n=9). According to the assessment of the results of an FSFI questionnaire, an average value was 24.9 ± 2.4 points, and in 65% of patients (n=9) there were apparent sexual dysfunction. After the surgery, the amount of patients with apparent sexual dysfunction was reduced to 21% (n=3, p = 0.001, Table 2). The detailed analysis of FSFI results showed that a statistically significant improvement was detected after the procedure, in relation to such domains of sexual functions, libido, excitement, lubrication, orgasm, and sexual satisfaction (p <0.05). In relation to painful sexual dysfunctions, no statistically significant improvement was detected (p <0.149).
Overall points in the FSFI after an operation was 28.1 ± 1.6 (p <0.05). Each patient and one independent medical observer (a physician from the personnel of professor Lutskovskaya’s clinic) were assessing aesthetic results on the scale of Global Aesthetic Improvement Scale (GAIS), in the range from 1 (no change) to 10 (significant improvement), at initial level (preoperative condition) and after 12 months following the procedure. During the last visit, a patient and medical observer were assessing improvement on GAIS, comparing it with the preoperative picture. To ensure an objective evaluation, each patient was identified according to a serial number. The name of patient had been anonymous during the evaluation performed by an independent observer. The patients were asked to write their points on the blank, which was similarly identified by a serial number. After the completion of all evaluations, the blanks were collected and analyzed. Preoperative and postoperative results were studied by means of T-test for pair samples. All patients returned for a planned 12-month visit. A significant improvement was detected (p<.0001) on the scale of GAIS, as in values obtained by the patients as well as in case of the doctor (Table 3). GAIS indicator was improved from an average value of 5.26 (evaluation of the patients, range 2–9) and 5.98 (evaluation of the doctor, range 2–9), to 8.7 (evaluation of patients, range 6–10) and 5.98 (evaluation of the doctor, range 6–10). It is interesting that the t-test showed that the points, assigned by the doctor, were significantly higher, than the points from patients in the preoperative period (p<0,0001) and significantly lower, than points in postoperative period (p<.011).
Discussion The results of our study showed that a procedure of minimally invasive perineoplasty using the Aptos method has a significant impact on the improvement of sexual function of women. So, the preoperative and postoperative differences in the results of aesthetical satisfaction and index of woman’s sexual function point to the fact that an operation of minimally invasive perineoplasty is effective for the improvement of sexual function and quality of life in patients, who delivered through natural childbirth. Considering the fact that a majority of patients apply for this procedure to improve the quality of sexual life and eliminate symptoms of hiatus of vaginal vestibule, our recommendation for doctors is to discuss, prior to the operation, the expectations of patients with them, and inform them about the efficiency of this procedure and its possible complications. In our study, we gave the necessary information to the patients about potential complications, such as a formation of hematomas, a risk of contagion and trauma of straight intestine, as well as about long-term postoperative painful syndrome. During conducting the control examinations of the patients after 1, 3, 6 and 12 months following the operation, we did not detect cases of formation of cicatrices or granulating tissues. Vaginal examinations after 6 months following the operation did not show changes in conditions of pelvis floor according to the POP-Q system.
We detected the significant increase of ISFI values after the procedure. In the statistical analysis, which covered all patients, we noticed the significant improvement of libido, excitement, lubrication, orgasm, and sexual satisfaction after surgery. Despite the absence of a significant difference in relation to dyspareunia, the overall FSFI points were significantly higher after the procedure. It is possible that the existence of a hiatus of vestibule, vaginismus and feeling of a ‘broad vagina’ in patients with a perineal defect after a natural childbirth causes a disruption of psychosexual perception of themselves and sexual perception of a partner. An elimination of a perineum defect can improve the confidence of patients in their abilities, which can have a positive impact on sexual function.
Moreover, an improvement of satisfaction with partners, in relation to the rehabilitation of vaginal cuff, facilitates a harmonization of relations and improvement of partner’s sexual function, Maybe, the most serious problem, which was encountered during this study, is associated with the control visits of the patients, because for many of them, it was problematic to arrive at the clinic only to fill the questionnaire and take the control photos. Therefore, we think that it is necessary to establish a system of remote access to patients, by means of modern communication and protocols. Finally, this research points to the fact that a procedure of minimally invasive thread perineoplasty allows us to improve the conditions of women, who suffer from a sexual dysfunction from the result natural childbirth. Further studies should investigate a sustainability of improvement over time and an impact on physiological, medical, and psychosocial factors of sexual function.
About the Author
Plastic surgeon in the clinic of Professor Yutskovskaya. Member of ESSAM (European Society for the Study of Aging Men). Member of the RSU (Russian Society of Urology). Member of the society “Men’s Health”. Member of PARU (Professional Association of Russia Urologists). Member of the ESSM (European Society of Sexual Medicine). Member of ISIAAM (International Society of Interdisciplinary Anti Aging Medicine).