Exuberant Granulation Complicating an Episiotomy Wound: Case Report on the Treatment Using Surgical Excision and Estrogen Vaginal Cream

Abstract

Nnabuike Chibuoke Ngene1,2 1Department of Obstetrics and Gynaecology, Rahima Moosa Hospital, Johannesburg, Gauteng, South Africa; 2Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South AfricaCorrespondence: Nnabuike Chibuoke Ngene, Email nnabuike.ngene@wits.ac.zaBackground: Poor wound healing may limit body functionality and is an indication for clinical intervention. Excessive formation of granulation tissue above the edge of the skin surrounding a wound without re-epithelization is termed exuberant granulation, or proud flesh. It is uncommonly reported as a complication of an episiotomy wound.Aim: This study aimed to report exuberant granulation that complicates an episiotomy wound with a friable vaginal epithelium and to describe the successful treatment of the lesion with surgical excision and topical conjugated equine estrogen vaginal cream.Case Report: A 24-year-old para 1 had spontaneous vaginal birth of a normal baby at term in a district hospital. Five months later, she presented to a regional hospital with complaints of pain and incomplete wound healing at the episiotomy site. She had used topical povidone-iodine ointment with no success. Following a physical examination, an exuberant granulation at the episiotomy wound was diagnosed. The lesions were located mostly at 5 to 7 o’clock position in the vagina which had a thin and friable mucosa. The patient was treated with surgical excision and postoperative topical conjugated equine estrogen vaginal cream 0.625 mg per 1 g at a dose of 0.5 g per intravaginal application twice weekly for two weeks, and thereafter once weekly for one week. A review after 6 weeks, 12 weeks, and 6 months confirmed complete wound healing and normal function of the genitalia.Conclusion: Exuberant granulation that complicates an episiotomy wound with friable vaginal mucosa is amenable to surgical excision and postoperative intermittent intermediate doses of topical conjugated equine estrogen vaginal cream.Keywords: episiotomy, estrogen vaginal cream, exuberant granulation, proud flesh, surgical excision, wound healing