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CASE SNIPPET
Year : 2021  |  Volume : 67  |  Issue : 1  |  Page : 53-54

Ischiopubic rami excision for mechanical dyspareunia due to malunited pelvic fracture secondary to hyperparathyroidism


1 Department of Urology, MIOT International, Chennai, Tamil Nadu, India
2 Department of Plastic Surgery, MIOT International, Chennai, Tamil Nadu, India
3 Department of Orthopedics, MIOT International, Chennai, Tamil Nadu, India

Date of Submission02-May-2020
Date of Decision25-Jun-2020
Date of Acceptance23-Jul-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
S S Kumaran
Department of Plastic Surgery, MIOT International, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.JPGM_453_20

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How to cite this article:
Rajaian S, Pragatheeswarane M, Kumaran S S, Prasad J R. Ischiopubic rami excision for mechanical dyspareunia due to malunited pelvic fracture secondary to hyperparathyroidism. J Postgrad Med 2021;67:53-4

How to cite this URL:
Rajaian S, Pragatheeswarane M, Kumaran S S, Prasad J R. Ischiopubic rami excision for mechanical dyspareunia due to malunited pelvic fracture secondary to hyperparathyroidism. J Postgrad Med [serial online] 2021 [cited 2021 Oct 16];67:53-4. Available from: https://www.jpgmonline.com/text.asp?2021/67/1/53/304162




A 27-year-old female presented with difficulty in achieving consummation after marriage for 1 year duration, since June 2018. She denied history of any other lower urinary tract symptoms. Earlier during 2013, she had right femoral shaft fracture following an accidental fall and underwent open reduction and intramedullary nailing. Plain X-ray pelvis (dated 28.01.2013) done during surgery revealed normal architecture of pelvic inlet and outlet with osteoporosis [Figure 1]a. Five years later, she sustained fracture of neck of right femur and bilateral ischiopubic rami. Raised serum calcium and serum parathyroid hormone (PTH) values of 13.8 mg/dl and 1202 pg/ml, respectively, were noted. 99 Tc Sestamibi scan revealed right parathyroid adenoma. She underwent dynamic hip screw fixation with compression for fracture neck of femur with intramedullary nail removal. After right inferior parathyroidectomy, her serum calcium and serum PTH levels had reduced to 9.0 mg/dl and 103.3 pg/ml, respectively. Current examination showed normal external urethral meatus. Vagina could not be examined with speculum as the introitus was very narrow; allowing insertion of only an examining finger. Vaginal space was crowded by the medially displaced pubic bones secondary to malunited bilateral ischiopubic rami fracture. Plain X-ray of the pelvis – both the inlet and outlet views (dated 21.08.2019) revealed malunited fracture of the anterior pelvic ring [Figure 1]b and [Figure 1]c. She was counselled for excision of the bilateral inferior pubic and ischiopubic rami to achieve adequate space for intercourse. Under general anesthesia, in lithotomy position, after urethral catheterization, bilateral paralabial incisions were made [Figure 2]a. Malunited bony segments were exposed. The marked bony segments were excised on both sides [Figure 2]b and [Figure 2]c. After excision of the bony segments, a wide vaginal speculum could be placed [Figure 2]d. A lubricated pack was kept in the vagina after achieving hemostasis [Figure 2]e. The entire bilateral inferior pubic rami and part of the ischiopubic rami were excised [Figure 2]f to create adequate vaginal space. Bilateral suction drain was kept for 2 days. Subsequent postoperative period was uneventful. She had an uneventful recovery in terms of gait and posture. Her serum calcium levels were within normal limits. The postoperative X-ray of the pelvis (dated 23.09.2019) showed wide outlet pattern [Figure 1]d. The entire sequence of events has been tabulated [Table 1]. During follow up, she was able to perform normal penile-vaginal intercourse comfortably and she became pregnant 3 months later.
Figure 1: (a) Plain X-ray of the pelvis showing fracture neck of right femur (solid white arrows). (b) Inlet view of the pelvic X-ray showing the inward deviation of the malunited bilateral inferior pubic rami fracture (hollow white arrows). (c) Outlet view of pelvic X-ray showing narrowing of the outlet caused by medially displaced ischiopubic complex (hollow white arrows). (d) Postoperative X-ray pelvis showing widening of the pelvic outlet (hollow white arrows)

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Figure 2: (a) Bilateral labial incisions markings. (b) Exposure and excision of the left ischiopubic ramus (hollow black arrow). (c) Exposure and excision of the right ischiopubic ramus (hollow black arrow). (d) Post-excisional defect on both sides of labia majora (hollow black arrows). (e) Vaginal pack of about 6 cm girth kept in the vaginal space. (f) Excised bone fragments from bilateral ischiopubic rami

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Table 1: Sequence of events

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Osteitis fibrosa cystica (OFC) occurs in advanced undetected primary hyperparathyroidism (PHPT) and often secondary to a parathyroid adenoma in 85–90% cases. Excess of PTH overstimulates osteoclasts leading to an increase in bone resorption than bone formation. It leads to occurrence of cystic and fibrous nodule formations, called as “brown tumours”.[1] Although OFC is the classical presentation of PHPT, it is rare. Subclinical bone resorption occurs mainly in long cortical bones and less commonly in cancellous bones like vertebrae.[2] The prevalence of osteoporosis secondary to PHPT varies between 39 and 62.9%.[3] Pathological fractures happen with trivial force due to osteoporotic, deformed and fragile bones. Clinically silent fractures especially of vertebrae are a common feature of PHPT.[4] Malunion of silent fracture segments leads to number of complications. Malunited pelvic fracture causing mechanical obstruction for coitus is rare. Obstructive dyspareunia secondary to PHPT in deformed pelvis in the absence of trauma has been reported and can be resolved successfully by ischiopubic rami excision as shown by Khedr et al.[5]

Excision of the obstructive bony elements without compromising the pelvic support has been helpful in achieving sexual intercourse in our patient. Our case is unique where a trivial trauma has exaggerbated the pelvic crowding seen in PHPT and led to mechanical dyspareunia that precluded coitus. In selected patients, mechanical dyspareunia secondary to pelvic trauma in the backdrop of hyperparathyroidism can be successfully resolved by appropriately planned surgical excision of obstructive bony segments. This case also highlights the importance of having high index of suspicion to rule out a metabolic cause for pathological fractures, like PHPT. Early recognition of the condition helps in avoiding serious complications.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 :: References Top

1.
Lewis JL, Daly PA, Landsberg L. The Merck Manual of Medicine. 19th rev. ed. Whitehouse Station (NJ): Merck & Co., Inc.; 2011. p. 837-54.  Back to cited text no. 1
    
2.
Silverberg SJ, Shane E, de la Cruz L, Dempster DW, Feldman F, Seldin D, et al. Skeletal disease in primary hyperparathyroidism. J Bone Miner Res 1989;4:283-291.  Back to cited text no. 2
    
3.
Walker MD, Silverberg SJ. Primary hyperparathyroidism. Nat Rev Endocrinol 2018;14:115-25.  Back to cited text no. 3
    
4.
Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: Summary statement from the Fourth International Workshop. J Clin Endocrinol Metab 2014;99:3561-9.  Back to cited text no. 4
    
5.
Khedr A, Khaled AS. Ischiopubic rami excision for obstructive dyspareunia in hyperparathyroidism. Curr Orthop Pract 2016;27:E16-9.  Back to cited text no. 5
    


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