AMBULATORY GYNECOLOGIC SURGERY ^143 ^163 ^225 ^680

Many invasive procedures that were once routinely performed by the obstetrician-gynecologist in the inpatient setting now can be performed safely, efficiently, and cost-effectively in an appropriately equipped ambu­latory setting.

Ambulatory surgical procedures should be limited to those for which there is a reasonable expectation of discharge within a short time, with traditional recovery occurring at home; that can be performed safely; that are consistent with staff expertise, facilities, and equipment; and that are appropriate relative to the intrinsic risk of the procedure, the patient’s con­dition, and the need for anesthesia.

Regulations

Clinicians should be aware of any federal, state, and local regulations governing surgical procedures, including ambulatory surgical procedures that require anesthesia or conscious sedation. Clinicians should be aware of payers’ regulations regarding sites for which professional and facility charges will be paid because they have a bearing on where procedures may be performed.

When the office setting is chosen for the performance of ambulatory sur­gery, policies, procedures, and practices should be developed to facilitate a safe and effective environment.

Box 4-13. Office Set-Up Checklist for Surgical Procedures

Documentation and Systems

• Create a policy and procedure manual (updated with the American College of Obstetricians and Gynecologists’ current Guidelines for Women's Health Care)

• Create a patients’ rights handout

• Create informed consent materials

• Arrange for a transfer agreement with nearby hospital

• Ensure compliance with local building codes, fire codes, and Occupational Safety and Health Administration regulations

• Ensure compliance with state board of pharmacy and Drug Enforcement Administration regulations

• Ensure compliance with state and professional guidelines

• Create an office-based surgery procedure record

• Ensure a procedure outcome reporting system is in place

• Create an adverse-event reporting system

Equipment and Supplies

• Ensure adequate equipment for level of anesthesia and analgesia, ³ ncluding

— monitors for blood pressure and pulse and heart rate

— pulse oximeter

— exhaled carbon dioxide monitor for deep sedation

— reliable oxygen source

Box 4-13. Office Set-Up Checklist for Surgical Procedures (continued)

— suction

— cardiac monitor

— resuscitation equipment, including defibrillator

— auxiliary electrical power source

— emergency medications

• Maintain, test, and inspect all equipment per manufacturers’ recommen­dations

• Ensure ability to monitor level of sedation

• Ensure ability to rescue patients from excessive sedation

Staff

• Ensure that a physician or other health care provider certified in advanced cardiac life support, pediatric advanced life support, or basic life support is immediately available to provide emergency resuscitation.

• Institute a quarterly mock drill

• Ensure credentialing and privileging of all participating physicians

Patient Selection

Create a checklist that meets the following requirements:

• Meets ASA Physical Status #1 criteria or medically controlled ASA Physical Status #2 criteria

• Contains prescreening verification that the patient is a candidate for an office-based procedure. Contraindications include, but are not limited to, the following:

— Personal or family history of adverse reaction to local anesthetic

— History of previous failure with local anesthesia or low pain threshold

— Need for maximal relaxation

— Poor tolerance of pelvic examinations

— An acute respiratory process

— High-risk airway assessment

— Abnormal blood sugars

— Extreme obesity

— Pregnancy (unless procedure is pregnancy related)

Box 4-13. Office Set-Up Checklist for Surgical Procedures (continued)

— Failure to understand or cooperate with the procedure (eg, unable to comply with preoperative dietary restrictions)

— Substance abuse

• Documents appropriate workup and patient selection

• Documents informed consent process, noting risks, benefits, and alterna­tives

Abbreviation: ASA, American Society of Anesthesiologists.

Modified from American College of Obstetricians and Gynecologists. Report of the presidential task force on patient safety in the office setting: appendix G. Quality and safety in women's health care. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2010. p. 91-108.

Facilities

The ambulatory surgical setting should provide the highest quality care in an environment supportive of the patient's individual comfort, rights, and dignity. The following three general levels of ambulatory surgical facility care are recognized by the American College of Obstetricians and Gynecologists:

• Level I—provides for minor surgical procedures performed under topical and local infiltration blocks with or without oral or intra­muscular preoperative sedation.

• Level II—provides for minor or major surgical procedures performed in conjunction with oral, parenteral, or intravenous sedation or under analgesic or dissociative drugs. When more extensive pro­cedures are performed using local anesthesia, or when conscious intravenous sedation is used, a more advanced level of training of personnel and more extensive preoperative, intraoperative, and postoperative monitoring are required.

• Level III—provides for major surgical procedures that require gen­eral or regional block anesthesia and support of bodily functions. Procedures that may require major emergency laparotomy should not be performed in any ambulatory surgical setting.

The appropriate facility for a given patient will depend on many factors, including the following:

• Condition of the patient

• Type of anesthesia to be used

• Resources of the facility

— Facility design

— Safety management

— Emergency treatment availability

— Hospitalization services

— Ancillary services (onsite and offsite)

? Pharmaceutical services

? Laboratory services

? Pathology services

? Diagnostic imaging services

? Blood product availability

A physician, the surgeon, the anesthesiologist, or a combination of these practitioners determines the appropriate facility based upon the safety and well-being of the patient.

The selection of patients is based on the condition of the patient and the potential risks of the procedure. This evaluation involves clinical judg­ment based on history, physical examination, and preoperative laboratory studies. The American Society of Anesthesiologists (ASA) has created a system for classifying the physical status of patients before surgery (Box 4-14).

Box 4-14. American Society of Anesthesiologists’ Physical Status Classification System ^

ASA Physical Status 1—A normal, healthy patient

ASA Physical Status 2—A patient with mild systemic disease

ASA Physical Status 3—A patient with severe systemic disease

ASA Physical Status 4—A patient with severe systemic disease that is a constant threat to life

ASA Physical Status 5—A moribund patient who is not expected to survive without the operation

ASA Physical Status 6—A declared brain-dead patient whose organs are being removed for donor purposes

Abbreviation: ASA, American Society of Anesthesiologists.

Reprinted with permission from American Society of Anesthesiologists. ASA physical status classification system. Available at: http://www.asahq.org/Home/For-Members/ Clinical-Information/ASA-Physical-Status-Classification-System. Retrieved September 30, 2013.

Physical Status #1 and #2 criteria. Level II and level III facilities in some cases provide care to patients who meet ASA Physical Status #3 and #4 cri­teria, but documented evidence of preoperative evaluation by a physician is required. When compromise or dysfunction is identified, consultation with an appropriate specialist may be necessary.

Not all patients are good candidates for surgery in the office setting. Box 4-13 lists examples of contraindications for office procedures. For certain patients, it is not practical to use the office setting for procedures that require a level of patient cooperation, such as dilation and curettage or hysteroscopy. The patient’s mental or emotional suitability for ambulatory surgery and the social and environmental setting into which she will return also should be taken into consideration.

Selection and Management of Anesthesia

The type and level of anesthesia should be dictated by the procedure with input based on patient preference. The decision regarding type of anesthesia should not be altered based on limitations of equipment or personnel.

Box 4-15. Types of Sedation or Analgesia

Minimal Sedation (Anxiolysis)—A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate Sedation or Analgesia (“Conscious Sedation”)—A drug-induced depression of consciousness during which patients respond purposefully[§§§§§] to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous venti­lation is adequate. Cardiovascular function is usually maintained.

Deep Sedation or Analgesia—A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully* following repeated or painful stimulation. The ability to independently main­tain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to indepen­dently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug- induced depression of neuromuscular function. Cardiovascular function may be impaired.

Table 4-7. Continuum of Depth of Sedation* Short neck

• Anatomic abnormalities of the face or mouth

• Large thyroid

• Asthma or other chronic pulmonary diseases

• Cardiac disease

• History of problems attributable to anesthetics

• Bleeding disorders

• Other significant medical complications

Policies on Emergency Medication, Resuscitation, and Ability to Rescue Patient From Excessive Sedation

These policies should be based on the ASA levels or other scale according to level of invasiveness. When local anesthesia with minimal preoperative oral anxiolytic medication is used, personnel with training in basic life support should be immediately available until all patients are discharged home. Emergency equipment for cardiorespiratory support and treatment of anaphylaxis must be readily available (and in good working order) for those who are trained to use it.

The use of moderate sedation requires that a minimum of two staff individuals must be on the premises, one of whom shall be a licensed physician with current training in advanced resuscitative techniques (eg, advanced cardiac life support or pediatric advanced life support), until all patients are discharged home. In addition, at least one physician must be present or immediately available any time patients are present. Emergency equipment, advanced cardiac life support medication, and trained per­sonnel for cardiorespiratory support and treatment of anaphylaxis must be immediately available.

According to the ASA, because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners who intend to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physi­ologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia, and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. Health care providers who administer moderate sedation or analgesia (“conscious sedation”) should be able to rescue patients who enter a state of deep sedation or analgesia, whereas those who administer deep sedation or analgesia should be able to rescue patients who enter a state of general anesthesia.

Preoperative Care

When surgery is being considered, certain criteria should be fulfilled to determine the appropriateness of the surgical procedure. The proposed procedure must be indicated, based on targeted history and physical exami­nation. Alternative treatments should have been considered, and it should be determined that the benefits to the patient outweigh the risks. Known contraindications and risk factors should have been ruled out or consid­ered. Informed consent must have been obtained from the patient or legal guardian. The surgeon and all other participating physicians must have the necessary credentials and privileges to perform the specific procedures required. The facility must have the equipment and staff necessary for the procedure and any anticipated complications.

Preoperative Evaluation and Tests

The extent of preoperative counseling and testing needed to prepare patients for ambulatory surgery depends on the type of procedure being performed. Preoperative tests and procedures should be individualized based on the patient’s age and medical status with respect to the planned surgery. This testing should be aimed at evaluating the patient’s known disease and at screening for unsuspected pathologic findings that would warrant further preoperative evaluation or alter the surgeon’s planned therapeutic approach. The guiding principle is to determine any contrain­dications or risk factors that should be known and to establish baselines that may be important in managing the postoperative course.

The following should be completed before outpatient surgery, and the findings should be noted in the medical record:

• A recent general and targeted history and physical examination should be performed, with specific attention to pregnancy status, preexisting or concurrent illness, medications, allergies, and adverse drug reactions that may have an effect on (or contraindicate) the operative procedure or anesthesia, as well as medications and sup­plements that might affect blood coagulability. Some patients are allergic or sensitive to common operating room materials, such as latex, povidone-iodine, adhesive tape, and metal used for surgical staples. Patients should be evaluated for such allergies during the preoperative examination and during the “time out.”

Because many diagnostic and therapeutic modalities may pose a direct or indirect risk to an embryo, facilities should establish specific procedures, applicable to all services, for identifying unsuspected pregnancies in women of reproductive age. A menstrual history and physical examination can be helpful in this determination. If there is any reason to suspect pregnancy, a pregnancy test should be per­formed in advance of any such procedure.

• Laboratory data should be collected, as indicated based on the patient’s needs and condition and on the procedure. Laboratory testing will vary considerably with the extent of the planned surgery, the patient’s age, preexisting conditions, potential complications, institutional policies, and insurance requirements.

• Informed consent should be obtained, including an informed con­sent form or other documentation indicating that the diagnosis, the reason for the surgery, a description of the planned procedure, the intended benefits, risks, and possible alternatives have been explained to the patient.

• Preoperative written instructions should be given to the patient, if appropriate, and include directions regarding any necessary restric­tions on food and fluid intake and warning that failure to heed such directions may result in cancellation of the procedure.

On the day of surgery, the following should be performed, with results noted in the medical record:

• Preanesthetic evaluation, including an interval history, medical record review, and heart and lung examination.

• Careful selection of medications used for preoperative medication and surgical anesthesia, to minimize the risk of major adverse reactions.

Other issues to be considered preoperatively include the following:

• Prophylactic use of antibiotics. Prophylactic antibiotics are recom­mended for the following procedures: hysterectomy, urogynecologic procedures, hysterosalpingography, chromotubation, and abortion via suction curettage or dilation and evacuation; details can be found in the American College of Obstetricians and Gynecologists’ Practice Bulletin No. 104, Antibiotic Prophylaxis for Gynecologic Procedures (see Bibliography). The American Heart Association no longer recommends the administration of antibiotics solely to pre­vent endocarditis for any patient undergoing genitourinary or gas­trointestinal tract procedures, even patients with the highest risk of adverse outcomes due to bacterial endocarditis (see Bibliography).

• Skin preparation. The goal of skin preparation is to reduce bacterial counts while minimizing skin irritation. Hair removal should be performed only when necessary for adequate visualization. Clippers should be used to minimize the amount of skin disruption. Razors should never be used because they can cause small cuts and nicks to the skin, which increases the risk of wound infection.

• Prevention of venous thrombosis. Preoperative patients should be classified according to levels of risk of thrombosis to determine the benefits and risks of pharmacologic and physical methods of preventing venous thromboembolism. Factors to consider include patient age; procedure type and duration of surgery; and clinical risk factors, such as prior deep vein thrombosis or pulmonary embo­lism, malignancy, estrogen therapy, and obesity. Evidence-based recommendations from the American College of Chest Physicians for venous thromboembolism prophylaxis are available (see Resources).

• Jewelry. All body jewelry, including piercings, should be removed before surgery.

Protocols and Checklists

In 2003, The Joint Commission on Accreditation of Healthcare Organ­izations (now The Joint Commission) initially published the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. The universal protocol is updated annually and is based on three activities before initiation of any surgical procedure: 1) conducting a pre­operative verification process, 2) marking the operative site (as appropri­ate), and 3) taking a “time out” before the procedure (see also the “Patient Safety” section in Part 1).

The “Safe Surgery Saves Lives” initiative was established by the World Health Organization (WHO) Patient Safety program as part of the WHO’s efforts to reduce the number of surgical deaths across the globe. Ten essen­tial objectives for safe surgery were identified and compiled to form the WHO Surgical Safety Checklist. A complement to the Universal Protocol, the WHO checklist involves confirming a set of surgical safety standards before induction of anesthesia, before skin incision, and before the patient leaves the operating room (see also the “Patient Safety” section in Part 1).

An additional resource is the “Office Surgical Safety Checklist” developed by the American College of Obstetrician and Gynecologists’ Presidential Task Force on Patient Safety in the Office Setting (see Box 4-16). This tool is not comprehensive and, just as the Universal Protocol and WHO checklist, should be adapted to best suit individual practices.

Box 4-16. Office Surgical Safety Checklist ^

Preoperative (Before Anesthesia or Analgesia)

• Confirm patient identity, site (marked), procedure, and consent

• Ensure no change in patient's medical condition since last office visit

• Check preoperative vital signs

• Review current history and physical

• Review and record all medications taken previously that day

• Confirm nil per os (NPO—nothing by mouth) status, if appropriate

• Confirm preoperative instructions followed by patient

• Review patient allergies

• Confirm presence of any indicated laboratory results (eg, glucose level in a patient with diabetes)

• Assess airway or aspiration risk

• Complete anesthesia and medication check

• Display essential imaging

Preoperative (Before Initiation of Procedure)

• Perform time-out (confirming correct health care provider, patient, site, and procedure)

• Administer any indicated antibiotic prophylaxis within 60 minutes before incision

• Confirm pulse oximetry is being recorded accurately

• Prepare for anticipated critical events (critical or nonroutine steps, antici­pated blood loss, length of case, patient-specific concerns, equipment issues)

Intraoperative

• Count and record number of instruments, needles, and sponges, if appropriate

• Record intraoperative medications

• If sedation is used, monitor and document oxygen saturation, blood pressure, pulse, and level of alertness every 5 minutes

• For hysteroscopic procedures, record cavity assessment per manufac­turer's guidelines and document fluid balance

(continued)

Box 4-16. Office Surgical Safety Checklist (continued)

Postoperative

• Complete instrument, sponge, and needle counts, if appropriate

• Confirm specimen labeling

• Document equipment problems

• Document key concerns for recovery and management of patient Discharge

• Record vital signs and ensure return to within 20% of baseline, if appropriate

• Confirm there is no evidence of active bleeding

• Document adequate level of consciousness and ambulation, pain and nausea control, ability to tolerate liquids by mouth, and ability to void (if appropriate for the procedure)

• Provide discharge instruction sheet that includes how to recognize an emergency during the postoperative period and the steps to follow should one occur after discharge (eg, hemorrhage)

• Schedule a follow-up call 24-48 hours after procedure, if appropriate

• Schedule an appropriate postoperative follow-up appointment

• Following any level of sedation, the patient should be discharged in the company of a responsible adult licensed to drive a vehicle or able to accompany the patient home by public transportation

• Record the long-term outcome of the procedure

• Record any complications

Modified from American College of Obstetricians and Gynecologists. Report of the presidential task force on patient safety in the office setting: appendix G. Quality and safety in women's health care. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2010. p. 91-108.; and Patient safety in the surgical envi­ronment. Committee Opinion No. 464. Obstet Gynecol 2010;116:786-90.

Intraoperative Care

Proper positioning of the patient and the retractors are important to pre­vent nerve injury. Care should be taken to avoid excessive flexion or exter­nal rotation of the patient's hips to prevent a femoral neuropathy. Proper positioning of the foot and leg will prevent pressure on the peroneal nerve, and is best achieved by using lateral thigh supports.

Fluids must be monitored carefully. In operative procedures, such as hysteroscopy, in which osmotically active solutions are used for visual­ization, careful intraoperative management of fluid balance is critical to patient well-being.

In elderly patients, operative management should include minimizing anesthesia doses to promote cognitive recovery. It also should include avoiding dehydration, careful positioning to accommodate joint fragility and minimize pain, and ensuring sufficient padding of bony surfaces and cushioning to prevent ulceration.

With the exception of those specimens exempted by the facility’s gov­erning body and The Joint Commission, tissue removed during surgery should be submitted to a pathologist for examination. Routine pathologic examination of tissue is not necessary after an induced abortion via suction curettage or dilation and evacuation in which embryonic or fetal parts can be identified with certainty. In such instances, the physician simply should record a description of the gross products of conception.

The Joint Commission includes unintended retention of a foreign object in a patient after surgery or other procedure as a reviewable sentinel event. The American College of Surgeons recommends consistent application and adherence to standardized counting procedures and documentation of the surgical counts, instruments or items intentionally left as packing, and actions taken if count discrepancies occur. Other protocols to prevent unintentional retention of foreign objects during surgery have been devel­oped (see Resources).

Postoperative Care

The following issues should be addressed as part of postoperative care:

• Staff should monitor the patient carefully for pain and treat her as appropriate.

• Nasogastric tube insertion should not be used routinely because it is uncomfortable, increases the incidence of pulmonary complica­tions, and does not reduce the incidence of wound complications.

• Oral feeding with a regular diet immediately postoperatively is safe for most patients who have undergone an ambulatory surgical procedure.

• The patient should be informed of the operative findings when not under the influence of anesthesia.

• Early mobilization and rapid removal of any restraints are important.

• In the elderly, extra precautions should be taken to prevent falls.

Delirium is a serious risk of surgery in the elderly; early investigation for medical causes is important, and treatment should be augmented with frequent auditory, visual, and somatosensory orientation.

• Any complications should be recorded.

Adverse Reactions

Vasovagal reactions are the most common adverse reactions to gynecologic procedures performed in the ambulatory surgical setting. These reactions include a number of cardiovascular and autonomic or central nervous sys­tem reactions, such as bradycardia, hypotension, diaphoresis, nausea, and convulsions.

A vasovagal reaction usually is the result of patient anxiety but also may occur with cervical dilation or peritoneal stretching, or as a result of pain. In patients who do not have cardiovascular disease, vasovagal reactions usually terminate spontaneously without the need for specific therapy.

Vasovagal reactions may be prevented by the following measures:

• Preoperative patient counseling

• Reassurance during the procedure

• The administration of preoperative atropine or promethazine hydrochloride

Oxygen should be used in cases of prolonged apnea. Assisted respiration is rarely necessary.

A vasovagal reaction should not be confused with the much less com­mon allergic reactions to a local anesthetic or preoperative medication. True allergic reactions to commonly used anesthetic and preoperative medications do not occur often, but personnel should be familiar with common allergic reactions and their appropriate management. Allergic reactions may include urticaria, hives, edema, asthma, and anaphylaxis.

Allergic reactions may be treated with diphenhydramine intrave­nously, or epinephrine may be given intramuscularly or subcutaneously. Anaphylaxis, whether it is due to a reaction to latex or another factor, is a life-threatening event. Prompt recognition and treatment are critical. Any patient with an anaphylactic reaction should be monitored for recur­rent symptoms after initial treatment and resolution. The World Allergy Organization recommends that the length of observation be individualized based on the type of reaction. Additional guidelines for the diagnosis and management of anaphylaxis are listed in the Bibliography.

Recovery and Discharge

There should be a designated recovery area with staff and equipment to ensure that the patient has the level of monitoring appropriate for the procedure and anesthesia. When local anesthetic agents are used for office surgery, minimum space and services are necessary for proper postopera­tive recovery. When patients are alert, are oriented, have stable vital signs, are free of major pain, and are able to sit up and dress themselves, they may leave the office. When moderate or conscious sedation is used, an area sufficient for patient recovery should be provided and staffed by personnel who continue monitoring vital signs and level of consciousness.

During the recovery period, a member of the health care team should observe the patient closely. This person should maintain a complete record of the patient’s general condition, including vital signs, blood loss, and occurrence of complications. When procedures have been performed in an ambulatory surgical facility, a physician, preferably the anesthesiologist, should be present in the facility until the patient has been discharged. This physician should oversee the postanesthetic recovery area and should share with the surgeon the responsibility for discharging patients or transferring them to the backup hospital.

The patient should remain in the recovery area until recovery is suf­ficient to permit safe discharge according to the criteria listed in Box 4-16. The patient should be examined by a health care provider with appropriate clinical privileges and be discharged on written order. Alternatively, other practitioners may discharge patients according to approved criteria.

Cosmetic Surgery

As cosmetic procedures receive increased attention from the media and patient requests for such procedures grow, there is a corresponding need to determine the proper role of obstetrician-gynecologists in this evolv­ing field. The scope of obstetric-gynecologic practice includes more than reproductive health care. The specialty’s broad focus on women’s health may include cosmetic services and procedures, just as this broad focus includes a wide variety of preventive care. The obstetrician-gynecologist may provide services that fill a need not adequately met in commercial offices, provide safer or more efficacious treatments than those available in nonmedical settings, or provide services as a convenience to patients.

However, cosmetic procedures (such as laser hair removal, body pierc­ing, tattoo removal, and liposuction) are not considered gynecologic procedures and, therefore, generally are not taught in approved obstetric and gynecologic residencies. Because these are not considered gynecologic procedures, it is inappropriate for the College to establish guidelines for training. As with other surgical procedures, credentialing for cosmetic procedures should be based on education, training, experience, and dem­onstrated competence equivalent to other specialists who typically perform these procedures.

As with other women’s health care procedures, the health, well-being, and safety of the patient who receives cosmetic services must be para­mount, and the obstetrician-gynecologist must be knowledgeable of the ethics of patient counseling and informed consent. Inquiries regarding cos­metic products, services, and procedures must come from the patient, and the patient should feel no pressure or obligation to purchase or undergo any cosmetic services. As many patients look to their physicians, often particularly their obstetrician-gynecologists, to define “normal” anatomy, behavior, or function, any unsolicited comments or innuendo could create a perceived need for alteration when none was considered previously.

Special care must be taken when patients are considering procedures in an effort to enhance sexual appearance or function. Although procedures, such as reversal or repair of female genital cutting and treatment for labial hypertrophy, may be medically indicated, female sexual response has been shown to be an intricate process determined predominantly by brain function and psychosocial factors, not by genital appearance. Other pro­cedures, including “vaginal rejuvenation,” “ re-virgination,” and “G-spot amplification,” are not medically indicated, and their safety and effective­ness have not been documented. Clinicians who receive requests from patients for such procedures should discuss with the patient the reason for her request and perform an evaluation for any physical signs or symptoms that may indicate the need for surgical intervention. Women should be informed about the lack of data to support the efficacy of these procedures and their potential complications, including infection, altered sensation, dyspareunia, adhesions, and scarring (see also the “Sexual Function and Dysfunction” section earlier in Part 4).

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