Designer Genitalia: Fad, Benefit, or Mutilation?

An Expert Interview With Cheryl B. Iglesia, MD

Janet Kim, MPH; Cheryl B. Iglesia, MD


January 28, 2013

In This Article

Advising Patients

Medscape: What should clinicians know about female genital cosmetic procedures?

Dr. Iglesia: Gynecologists and other clinicians who treat women and girls need to know that these procedures are marketed and that we do not have sufficient data to support them. Although some procedures may be indicated for functional reasons, possible problems that can occur include development of pain, pain with intercourse, scarring, nonhealing, and sexual dysfunction.

They also need to know that the sexual response is complex and that body dysmorphic disorders may coexist in the population of patients seeking cosmetic surgery. Taking a good history, asking your patients about what their expectations are and why they're interested in doing this, and trying to rule out an underlying pelvic support disorder or sexual disorder are very important. We need to address a lot of the emotional components as well.

A thorough history and physical examination are necessary in order to develop a treatment plan that is going to be acceptable to both the clinician and the patient. But what needs to happen first is that women need to be educated on the anatomy of the vulva and the vagina, and about the wide range of normal anatomy -- in particular, labial variation.

Medscape: How should clinicians advise patients who consult them about these cosmetic procedures?

Dr. Iglesia: They need to ask open-ended questions about the patient's concerns and understand the reasons why she wants surgery. Find out whether she is in a relationship, and ask whether there are any issues with her partner or whether any domestic violence or sexual abuse is present.

Also, some women might not feel anything during sex because of laxity of connective tissue and weak pelvic floor muscles. We need to figure out whether there is real prolapse and medical indications for reconstructive surgery. A woman may not have to pay the $4500 for the procedure if it's covered by insurance and performed by a good reconstructive pelvic surgeon, general gynecologist, or urologist.

There are also concerns about other specialists, such as plastic surgeons, doing these types of procedures because they may not have adequate training in reconstructive pelvic surgery.

Medscape: If, after evaluation and counseling, the patient still decides to go forward with one of these procedures, how should the gynecologist or other primary clinician manage the care of this patient?

Dr. Iglesia: We need to do all of the work-up for sexual dysfunction and conduct a thorough medical examination, both in the sitting and standing positions, to find out whether there's a bona fide prolapse or any functional issues with the bladder or bowel (urinary or fecal incontinence). If the woman is menopausal, she may need vaginal estrogen or lubricant.

I always like to advocate for exercise. We also need to evaluate the pelvic floor muscles or connective tissues and ask whether the woman is doing Kegel exercises.

Women who have increased body mass index can have more problems with the pelvic floor, particularly bladder control. Weight loss can significantly improve some of those issues.

If a patient decides to have this procedure, I would refer her to a reconstructive pelvic surgeon or someone who definitely knows the anatomy down there. And I'd be very wary of physicians who just take weekend courses and then call themselves cosmetic gynecologists. I'd check their credentials.