Obliterative surgical procedures have been classically used to reduce pelvic organ prolapse in elderly women with certain comorbidities who do not wish to preserve the vagina for sexual intercourse due to their lower surgical risk and recurrence of prolapse. 

The term colpocleisis comes from the Greek words colpos (hollow) and cleisis (closure). The first author to describe colpocleisis was Geradin, in 1823, suggesting stripping of anterior and posterior vagina at the introitus and suturing them. In 1867 Neugebauer described the dissection of anterior and posterior vaginal faces, suturing them to a higher level of it. Current surgical techniques come from LeFort’s description in 1877, which left some vaginal tissue unharmed creating lateral drainage channels in communication with the cervix for potential discharge and completed with a perineorrhaphy. In the last decades, many modifications have been introduced to classical techniques. 

Colpocleisis has proven to be a highly effective surgery to correct genital prolapse, leading to an improvement of symptoms and quality of life in most patients. These results are maintained over time, and the appearance of complications is rare. Overall patient satisfaction with these procedures is high, with low rates of regret (3-9%). However, preoperative counseling should focus on the fact that even if the prolapse will be corrected, subsequent coitus will not be possible, and that urinary incontinence might not improve.

We present a case of complete fusion of labia majora after an obliterative procedure, a complication rarely described in the literature.
An 80-year-old woman, presented with a history of progressive difficulty on voiding onset and sensation of incomplete bladder emptying, with continuous urinary incontinence and low urinary tract symptoms (LUTS) on the last 6 months. Genital itching and draining of purulent liquid were also reported. 

She had undergone pelvic surgery 10 years earlier in an external clinic, where a vaginal hysterectomy, anterior colpoplasty and a colpocleisis were performed as a therapeutic procedure for her pelvic organ prolapse (POP). Information on the surgical technique could not be obtained. 

Other morbidities recorded in her medical history were diabetes mellitus, arterial hypertension hypercholesterolemia, and a stroke with no sequelae.

On physical examination, a complete fusion of her labia majora impeded the identification of the urethral meatus. Only three infra-milimetric porus were observed in the mid-line, with drainage of scarce purulent liquid, the cultures of which were positive for E.coli, Actynomyces turicensi and Actinotignum schaaii.

Topical promestriene was offered to enhance genital trophism, and a perineal reconstructive surgery was proposed. Challenges and possible complications due to the lack of information on the anatomical structures affected by the previous surgery were explained.

A 20-minute surgery was performed without any complication, as seen in the video.

The patient was released 6 hours after-surgery with excellent general condition.

In the postoperative period, intensive application of vaseline to the genitals was recommended, followed by hydration with maintenance oils and Promestriene.

Intraoperative urine culture was positive for E.Coli and E.Faecalis. In the first postoperative visit the patient reported severe urinary incontinence, so treatment with oral ciprofloxacin was completed with total remission from the urinary clinic.

Follow-up was made on the 1st, 2nd and 4th week after surgery, with optimal re-epitelization of the genitalia. No relapse of the labia fusion or POP has been observed. Urinary incontinence and LUTS have disappeared.

Obliterative surgery may be an alternative for selected elderly woman with symptomatic organ prolapse but complications have to be taken into account when planning these surgical procedures. Reparation of the perineum can be challenging due to lack of anatomical references and unknown previous surgical procedures.