Necrotic Vaginal Pressure Ulcer Repaired Using Vulvar Flaps

The patient presented with a 1-month history of vaginal discharge, initially suspected to be a yeast infection. However, further evaluation by her local provider revealed extensive necrotic eschar involving the posterior fourchette, vestibule, and vaginal tissue up to the pubic bone while sparing the Labia majora. A CT scan ruled out necrotizing fasciitis. Necrotic tissue debridement and administration of broad-spectrum antibiotics were promptly initiated.

Surgical Intervention: Coordinated surgery involving pediatric and adolescent gynecology and plastic surgery was performed. Intraoperatively, the patient displayed an open circumferential wound encompassing the entire vestibule. Notably, the inferior labia minora and urethral meatus were surgically absent, with the vaginal introitus collapsing at the wound's base. The distal mucosal edge was detached from the underlying tissue, and a 3 × 4 cm area of the retropubic ligament was exposed.

The surgical repair involved multiple steps. The posterior portion of the vaginal wall was advanced and attached to healthy skin, repairing the collapsed vaginal introitus. Large vulvar flaps were transposed and secured overlappingly to resurface the lateral and anterior defects, covering the exposed retropubic ligaments and attaching to the lateral vaginal walls. Fasciocutaneous advancement flaps were utilized to close the vulvar defects, with wide undermining at the subfascial level. To maintain vaginal patency, a soft stent coated in estrogen cream was placed in the repaired vaginal canal.

This case highlights the challenging management of extensive vulvovaginal necrosis in a teenage paraplegic patient. Prompt diagnosis, necrotic tissue debridement, and broad-spectrum antibiotics were crucial in halting disease progression. The subsequent coordinated surgical intervention, involving pediatric and adolescent gynecology and plastic surgery, successfully reconstructed the vulvovaginal anatomy and addressed the extensive tissue loss.

Moon LM, Wheeler KN, Liew-Spilger A, et al. Necrotic Vaginal Pressure Ulcer Repaired Using Vulvar Flaps: a Case Report. Journal of Pediatric and Adolescent Gynecology. 2023;36(2): 222-223. https://doi.org/10.1016/j.jpag.2023.01.260.