What you will read is a story of a war veteran who lost his leg at southeast area of our country and his wife… A true story.
I met with lady Füsun in front of the gynecology department after a surgery on a humid, so humid that you move like you are swimming, a typical sticky, very hot July day at Istanbul. She was a rather small woman. She had quite the serenity which one would respect. She called me many times but, due to intensity of surgeries, we didn’t have a time to talk. Then, she decided to come to me.
Even though I noticed that she wore a long sleeved dress and she had her right hand bandaged, I didn’t dwell upon that. One of my dearest friend whom I did my obligatory service with sent her to me. She had beautiful green eyes with brown halos, which are seen on Circassian people very often.
“I know you are tired…” she began talking, she had been waiting me for a long time but while she was telling me her problem, one of my assistants came to me telling one of the patients who had a surgery that morning had a serious problem and he dragged me to the patient. While we were running to the patient, I told her to come to clinic with her husband at 9 am next day.
I have to admit, I forgot the appointment I gave to lady Füsun due to the incidents emerged later on. I reminded the appointment when sir Mustafa notified me there were people waiting just after I walked into the clinics at 08.30.
They were sitting in front of the clinic door. They got up. Mr. Cemal, husband of lady Füsun, was a 1.90m tall men using crutches to stand. He was a war veteran of the southeast area of our country. His right leg was amputated due to the landmine he pressed on. His left leg had problem that couldn’t be fixed even though he had 3 surgeries about it. Even after these, he was standing there with crutches, highly staid, very upright, challenging what he faced, and stating “these are just a scratch”. Even his handshaking was strong.
We sat down. After asking lady Füsun the classic questions, I wanted them to explain their problems. They looked each other and Mr. Cemal began first, “I am concerned about my wife, these are not easy things to talk…”
He said that his wife wasn’t taking any pleasure while intercourse and this was affecting him while he was peeking to his wife. It was like he was feeling guilty.
It is best to talk separately for these kind of delicate subjects. However, it is hard to achieve this considering clinic terms.
Hence, we developed different tactics. For example, talking to patient while taking ultrasonography since ultrasound machine is in another room. These are the most efficacious solutions to talk to patients while respecting their privacy, especially for young girls who come with their mothers. Also, for this group patient…
As to lady Füsun, she told me that she was feeling a small pain during the intercourse and this was distracting her which was causing her not to concentrate on the intercourse. After directing basic questions to lady Füsun about this pain, I told a nurse to prep the patient for ultrasound and examination.
After his wife left the room, Mr. Cemal told me “I feel awful during the intercourse, she doesn’t feel any pleasure and it feels like I am forcing her for that. Sometimes she cramps like she was feeling pain. I am very grieved.”
I told him I will try to figure this out. After asking him “Did this problem occur while having intercourse before?” he became nervous. “Are you asking me this is about my leg?” he asked.
He actually asked me the real question he was concerned very deeply: “Does she really want me or she do it just because she pities me?”
I told him that I had to ask this in order to understand the question, not because I thought that and we should talk about this after the examination. The sentences I made did not satisfy him, I could tell that looking in his eyes.
The problem was not only sexual, it was also the questions he couldn’t answer and feel sorry when he sometimes figured an answer by himself, creating not ceasing, relentless hurricanes in his soul.
Nurse Sevcan prepped lady Füsun for examination and I asked her to sit down. I asked the same question to her this time. She told me that she was feeling this pain at the beginning of the intercourse and it occurred after Mr. Cemal came from his duty. She had too many fungal infection and discharges. After that this pain started to occur.
This pain which was not very much at the beginning increased rapidly in time. She told me that she feels this pain when she wears tight pants or sometimes when she sit down. When I remind her that she described this as a slight pain she replied “I don’t want him to know doctor, but the pain is too much. I don’t want him to think I am refusing him.”
After that, she slowly removed the sleeves of her dress which nearly cover her entire hand. There were healing wounds on her hand and wrist. She showed me old scar marks which if you don’t look closely, you could easily mistake them for simple bruises or color change. Those marks were like teeth marks.
When I looked at her I noticed her eyes were filled with tears. ”I don’t want him to know. I am feeling so much pain during the intercourse for the past 3-4 months, I squeeze or bite my hand in order not to show it” she said with tears in her eyes. Then she looked at me with her eyes filled, “He is my valiant, veteran, hero. I’d rather die than him to think I refuse him”.
When I examined her, I noticed that there were a severe sensibility at vaginal entrance, beginning from urethra and surrounding vaginal entrance, which we call vestibulum, causing very severe pain just by touching.
The region we call pelvic floor is a muscle group filling the space between hipbones. These muscles are stronger in women than men. They can bear 1.5 tons of force! This way, a woman can bear children and give birth.
Anywhere on a human body, in case of pain, for example when abdomen is cut during surgery, surrounding muscle tissues are contracted in order to stabilize the wound region. This way, pain sensation is not awaken. A typical example is women who had a cesarean. If you pay attention, you will see they get up holding their abdomen. Pelvic floor and vaginal entrance are no different than the other parts of a body.
In case of a pain like this, that muscles which can bear 1.5 tons of force contract and the intercourse become terribly painful or impossible. In western countries, this is called “burning and sharp pain”. This situation is called “Vulvar Vestibulitis Syndrome”.
In the case of lady Füsun, this was rather worse. There were an incredible contraction at the pelvic floor of the patient who feels tremendous pain even with a simple touch. In these kinds of situations, patients usually come to me complaining they cannot have intercourse. However, lady Füsun had intercourse even though she felt too much pain (although she ripped her hands doing so). She’d rather shred her hands than left her husband…
I guess any action between two people called “intercourse” with the spouse or lover should base on a strong foundation. This story I am telling describe this very good.
While lady Füsun having a serious illness, feeling too much pain, she forced herself into intercourse in order not to make his husband sorry and refuse him. Sir Cemal, on the other hand, interpreted these “symptoms” she was having as the other way around and felt sorry.
Before applying the different steps of the treatment, solving this communication problem was necessary. Having both in front of me, firstly, I explained the problem lady Füsun having and the hard situation she was in to Mr. Cemal. Then I told what Mr. Cemal told me earlier to lady Füsun. They held each other’s hands. I left the room and leave them alone for some time while lady Füsun was crying. I didn’t want to ruin that moment…
The story above is a story of vulvar vestibulitis syndrome (VVS). Even recognizing VVS is a problem. Not just in our country, anywhere on the world it is hard to get a new idea through leaders. Especially if it is about medicine.
In 2008, after a speech I gave about this subject in a symposium, one of our “great” doctors who were the session leader made fun of me in his own way by saying “You are such an outstanding man Süleyman Bey, only you encounter such patients!” After I simply smiled and said “Please ask and listen to patients. After then you can make a VVS diagnosis”.
Even though the same doctor said “There is such thing” when he and I encountered after 3 years, it is hard to change the settled ideas and tear down prejudices.
VVS is actually a newly defined syndrome. For some reason which we still not know what it is, number of mast cells at vestibulum increase. This increase triggers the construction of a molecule called “nerve growth factor”. Then, this factor causes number of nerve terminals at vaginal entrance to increase.
In result, a healthy woman feels “touch” if you touch the vaginal entrance of that woman, but a woman with VVS feels incredible amount of pain when touched. Then, this causes the contraction I explained above. Hence, the intercourse becomes impossible with this pain and contractions.
If you ask about the treatment, I would like to mention some information on the internet which are ABSOLUTELY wrong. In some websites, surgery is suggested and it is said that this surgery can be done by local anesthesia in 5 minutes and you can go to work the next day. I am sorry but this is completely wrong. If your pain can go after this simple procedure, you don’t even need a surgery!
In reality, surgery is important, but caring after the surgery is very important and it includes a 3 week period. You can obtain the right information about this topic from foreign sources. There is an example below which is a publication of Dr. Goldstein.
Another problem is that this is fairly new for us gynecologists and we don’t recognize and diagnose it very well. Hence, patients visit doctor to doctor, use ointments and antibiotics without solving any problem and the pain does not go. It is a problem such that sometimes patients walk by me with their spouses saying “thank you doctor, I wasn’t crazy, there really was a problem”.
However, it is also hard for my colleagues. This topic was first mentioned at conferences at 2005 and it is not included in the syllabus unfortunately. Also, there are doctors who make fun of you when you give a speech about the problem.
Lastly, a group of these patients try to go to psychiatrists or psychologist to get a treatment with a vaginismus pre-diagnosis. This is why cooperating with other disciplines is important.
So, what should be done?
Every patient should be evaluated according to their own expectations. First, conservative treatments and medications should be tried and sometimes you can directly suggest surgery according to severity of VVS. It is possible for you to see the algorithms about this subject. (Though they are rather old, there are new options, website needs a renewal
The story of Mr. Cemal and lady Füsun still goes on. There are ups and downs in their life just like any other, but they are happy. Lady Füsun had an operation and got pregnant 7 months after that. Now, she has a beautiful daughter. Life somehow goes on and the important thing is to increase the quality of life, and having the courage to apply some changes in order to do that.
The weather is spectacular at Istanbul, I hope you are having a beautiful Sunday that this weather deserves.
With love and respect.
Glad to have you…