An unusual cause of apareunia

A 49-year-old woman with history of rheumatoid arthritis presented with worsening pelvic pain. A pelvic computed tomography (CT) scan demonstrated a fracture and a lytic expansile lesion within the right superior and inferior pubic rami. The diagnosis of "insufficiency fractures secondary to rheumatoid arthritis" was established. Six months later, she started describing pain and fullness sensation in the vagina which eventually led to a complete apareunia. An x ray confirmed healing of the previous fractures, fracture of both left superior and inferior pubic rami, and an upwards shift of the right hemi-pelvis. Conservative management was chosen. Twelve months later, no improvement occurred and she was still apareunic. A "corrective osteotomy surgery" was performed and the displaced pubic rami and ischial tuberosities were remodelled bilaterally through a vertical incision over each labia majora. These bones were partially excised until an adequate vaginal opening was established. Her symptoms have impressively resolved with complete reverse of the apareunia.