Baylor University Medical Center Proceedings July 2017 - 291

Management of pelvic floor disorder in a diethylstilbestrol
daughter
Christopher P. Chung, MD, Suzanne Cao, DO, Grace Wakabayashi, and Ernest S. Han, MD, PhD

Between 1947 and 1971, the synthetic estrogen diethylstilbestrol (DES)
was prescribed to pregnant women to prevent spontaneous abortions.
Many studies have demonstrated adverse consequences of prenatal
DES exposure. This report describes a DES daughter treated for uterine cancer who presented with a foreshortened vagina of 4 cm and
stage III pelvic organ prolapse. She underwent successful vaginal native
tissue reconstructive surgery with uterosacral colpopexy and anterior
and posterior repair to lengthen her vagina and treat her prolapse. She
then developed stress incontinence and underwent periurethral bulking
5 months later. She has been followed for 2 years with no recurrence of
prolapse or incontinence.

ere we describe a case of pelvic ﬂoor disorder in a woman
exposed to diethylstilbestrol (DES) in utero who also
had a history of treated gynecologic cancer. Due to the
side eﬀects of radiation on vaginal epithelium, special
consideration should be taken when performing pelvic ﬂoor
reconstructive surgery.
CASE DESCRIPTION
A 64-year-old nulliparous known DES daughter had a
history of stage III, grade 2 endometrioid adenocarcinoma
of the uterus treated by total abdominal hysterectomy and
bilateral salpingo-oophorectomy and staging. She received
pelvic radiation, brachytherapy, and six cycles of paclitaxel
and carboplatin in 2003 (at age 51). She then presented to
our service with stage III vaginal vault prolapse (vaginal cuﬀ
prolapsing 2 cm outside of hymen) and a foreshortened vagina of 4 cm. She was sexually active and wished to proceed
with deﬁnitive surgical management for her prolapse. Bladder
stress test with prolapse reduction did not demonstrate stress
incontinence.
With transvaginal anterior and posterior repair, we were able
to lengthen her vagina to 9 cm with high uterosacral colpopexy.
Postoperatively, she was instructed to use a vaginal dilator to
prevent vaginal stenosis. Five months after her prolapse surgery,
she complained of having bothersome stress urinary incontinence, which was conﬁrmed by urodynamic testing. She then
underwent periurethral bulking injection with good result. She
has been followed for 2 years with no recurrence of prolapse or

Proc (Bayl Univ Med Cent) 2017;30(3):291-292

incontinence. Her vaginal length decreased to 8 cm, and she
has continued use of a vaginal dilator.
DISCUSSION
Pelvic organ prolapse in the general population is common.
The prevalence of pelvic organ prolapse is estimated to be as
high as 30% to 40%. In the United States, it is estimated that
women have an 11% lifetime risk of surgery for pelvic organ
prolapse or incontinence (1). However, pelvic ﬂoor disorder
among DES daughters has not been well described. It is unknown if DES exposure has any impact on a patient's risk of
pelvic organ prolapse. DES is a potent teratogen, and prenatal
DES exposure can disrupt the diﬀerentiation of estrogen target organs, mainly the reproductive organs (2). DES is known
to have adverse consequences including clear cell adenocarcinoma of the vagina or cervix and genital tract abnormalities
such as transverse cervical and vaginal ridges, vaginal adenosis,
and hypoplastic and "T-shaped" uterus (3). Many studies have
demonstrated that DES daughters also have poor reproductive histories and commonly experience infertility, premature
delivery, and recurrent abortions.
Careful and extensive consideration was given in approaching this patient's prolapse surgery due to her foreshortened
vagina (4 cm) and history of uterine cancer and pelvic radiation. Abdominal sacral-colpopexy with mesh was discussed with
her. Due to the risk of mesh-related complications including
erosion and ﬁstula formation, the patient elected to proceed
with vaginal native tissue reconstructive surgery. We elected to
proceed with high uterosacral ligament colpopexy due to the
ability to preserve and lengthen her vagina.
Radiation is a common treatment modality for gynecologic cancers. Treatment with radiation has been associated
with adverse side eﬀects including shortening and stenosis of
the vagina, decreased lubrication, and atrophy. There was an
extensive discussion with the patient about the possibility of the
recurrence of a short vagina as well as vaginal stenosis. Therefore,
our patient was instructed to use a vaginal dilator and resume
From the Division of Gynecologic Oncology, Department of Surgery, City of Hope
Medical Center, Duarte, California.
Corresponding author: Christopher Chung, MD, 1500 E. Duarte Road, Duarte,
CA 91010 (e-mail: chchung@coh.org).
291

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