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

Abstract

Background
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.

Full text

CASE REPORT
Exuberant Granulation Complicating an
Episiotomy Wound: Case Report on the
Treatment Using Surgical Excision and Estrogen
Vaginal Cream
Nnabuike Chibuoke Ngene
1,2
1
Department of Obstetrics and Gynaecology, Rahima Moosa Hospital, Johannesburg, Gauteng, South Africa;
2
Department of Obstetrics and
Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Correspondence: Nnabuike Chibuoke Ngene, Email nnabuike.ngene@wits.ac.za
Background: 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
esh. 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 conrmed 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 esh, surgical excision, wound healing
Introduction
Poor wound healing may limit activities of daily living, quality of life, and compromise future health status. An
Episiotomy, which is an obstetric procedure performed during approximately 21–91% of vaginal births,
1
and has
rightfully experienced restrictive use,
2
may be the site of poor wound healing. Exuberant granulation is one of the
outcomes of poor healing and entails an excessive formation of granulation tissue that grows above the edge of the
surrounding skin of a wound without re-epithelization. It is rarely reported to complicate an episiotomy scar, but has been
found in 49% of 56 women who had dyspareunia after episiotomy.
3
This calls for appropriate management of obstetric
wounds using effective interventions. For instance, a recent systematic review and meta-analysis of randomized
controlled trials on the use of honey for cicatrization and pain control of obstetric wounds including episiotomy showed
that honey accelerates wound healing and decreases reported pain.
4
The index case report is on exuberant granulation tissue in an episiotomy wound with a friable vaginal epithelium. This
case report aims to report the successful treatment of the lesion using surgical excision and postoperative estrogen vaginal
cream therapy.
International Medical Case Reports Journal 2025:18 427–432 427
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International Medical Case Reports Journal
Open Access Full Text Article
Received: 11 November 2024
Accepted: 29 January 2025
Published: 27 March 2025

Case Presentation
A 24-year-old para 1 woman of African descent gave birth to a normal 3100 g female baby at 40 weeks’ gestation in
a district hospital.
5
Five months later, the patient, who was self-referred, presented to the outpatient gynaecology clinic of
a regional hospital with a painful growth at the site of the left mediolateral episiotomy. She had no obvious puerperal
sepsis. The patient had tertiary education, but no history of allergy, nor personal/family history of poor wound healing.
The pain made it difcult for her to attempt coitus after birth. She used topical povidone-iodine ointment with no success.
Physical examination revealed an exuberant tissue on the episiotomy scar at the 5 o’clock position of the introitus that
extended superiorly into the lower third of the vagina and inferiorly into the upper part of the thigh (Figure 1). The lesion
was also present in the fourchette from the 5 to 7 o’clock position. No obvious risk factor for exuberant granulation was
identied, except for being an African.
The differential diagnoses were exuberant granulation tissue, granulomatous disorder (such as foreign body granu-
lomas), pyogenic granuloma (lobular capillary hemangioma) that develops due to irritation, chronic graft-versus-host
disease (cGVHD), keloid, and malignant lesions such as aggressive bromatoses. cGVHD was excluded because there
was no history of tissue grafting. The lack of epithelization excluded keloid. She was counseled, consented to, and
underwent a cold knife excision biopsy aided by local bupivacaine hydrochloride (Marcaine) inltration to minimize
bleeding, and the surgical sites were sutured using polyglactin 2–0. During suturing, the vaginal epithelium in the vicinity
of the lesion was thin and friable, as the stitches easily cut through the vaginal mucosa. There were no other features of
hypoestrogenism. The lesions were discrete and sessile in attachment with a maximum diameter of 1.5 cm.
Postoperatively and after discussion with a multidisciplinary team that included a urogynecologist, to treat the atrophic
vaginal mucosa, she was prescribed topical conjugated equine estrogen vaginal cream 0.625 mg per 1 g, using 0.5 g per
intravaginal application. This was the most appropriate available medication to assist with rejuvenation of the friable
vaginal tissue.
6,7
The patient applied the cream intravaginally twice a week for two weeks and then once a week for one
week. This was an intermediate dose (which ranges from 0.3 to 0.5 mg of conjugated equine estrogen).
8
The therapy was
intermittent and of a short duration to minimize the effects of any systemic absorption. There is no specic dose
Figure 1 Exuberant granulation (arrow in (A)) and site of the lesion following surgical excision (B).
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recommended for premenopausal women,
9
making its use controversial. Despite the controversy, data from a recent
Danish study show a reassuring safety prole.
10,11
Therefore, conjugated equine estrogen remains a recommended
treatment option for vulvovaginal atrophy in women.
12
The histological report conrmed exuberant granulation tissue. No foreign body or residual surgical suture was
identied in the specimen. A follow-up review at 12 weeks and 6 months conrmed normal wound healing and genitalia
function.
Discussion
The phases of wound healing are four, namely: hemostasis, inammation, proliferation, and remodeling.
13
The process
involves the formation of granulation tissues, which are broblasts surrounded by an abundant extracellular matrix, new blood
vessels, macrophages, and other inammatory cells. An abnormality in any of the phases of wound healing may cause
a wound complication. These wound complications may be due to inadequate formation of granulation and scar tissues
causing dehiscence and ulceration; excessive formation of the components of the repair process resulting in hypertrophic scar,
keloid, and/or exuberant granulation tissue formation; and excessive wound size contraction leading to contracture
deformity.
14
An excessive formation of granulation tissue that grows above the edge of the surrounding skin of a wound
without re-epithelization is called exuberant granulation, hypergranulation, overgranulation or proud esh.
15,16
Hypertrophic
scar occurs if collagen formation in the wound becomes excessive, remains within the boundary of the wound, and grows
above the level of the skin with re-epithelization. In contrast, the growth of the re-epithelized excessive collagen beyond the
boundary of the wound is keloid.
14
It appears that keloids have individual susceptibility and racial predisposition as it is
inexplicably predominant among people of African, Asian, and Hispanic descent.
14,17
The risk factors for exuberant
granulation, hypertrophic scar, and keloid include traumatic or thermal injury that extends to the dermis of the skin.
14
Furthermore, invagination of the surface epithelial edge during wound closure is also a risk factor for exuberant
granulation. Other risk factors for exuberant granulation include healing by secondary intention, prolonged occlusive
wound dressing,
15
wound sepsis, non-administration of perioperative antibiotics when indicated,
18
and the use of chromic
catgut compared to polyglactin (Vicryl).
19
For instance, it complicates 10% of post-hysterectomy vaginal vaults closed
with polyglactin, particularly when there is cuff cellulitis,
20
and up to 34% of vaults closed with chromic catgut.
21
Of
these predisposing factors, the patient is African.
Typically, identication of the possible cause
15
and factors associated with the exuberant granulation (such as
atrophic vaginal mucosa as in the index case) as well as the patient’s preferences and local protocol will guide choice
of treatment. The treatment includes the use of the following as a single therapy or in combination with other
interventions. These therapies are wound dressing,
22
topical antibiotics, corticosteroids, gentian violet stain,
23
chemical
cauterization (including the use of silver nitrate or Monsel solution), electrocautery, cryotherapy, and excision biopsy.
19
The use of honey-based products,
24
cadexomer-iodine, or povidone-iodine for approximately 10–14 days are other
effective treatment options.
15
However, success in the treatment of exuberant granulation using honey for wound
dressing for three weeks has been reported.
25
Of note, the patient used povidone-iodine ointment without success.
Cold knife excision of exuberant granulation does not cause thermal damage and prevents artifact formation at the
surgical margin of excision, which assists with histological evaluation of the specimen and is arguably a good management
option. For instance, recurrence of exuberant granulation after excision may occasionally occur due to a condition called
desmoids, or aggressive bromatoses, which is a low-grade tumor with borderline characteristics because it lies at the
interface between malignant and benign neoplasia.
14
This calls for a treatment that allows histological evaluation of the
granulation tissue. Although intralesional corticosteroid inltration is also an option, this involves repeated doses adminis-
tered by the provider and may not be acceptable to some patients. In contrast, topical conjugated equine estrogen vaginal
cream is patient-administered, rejuvenates the vaginal tissue amidst the relative hypoestrogenic state that occurs in
postpartum and breastfeeding mothers,
7
and this informed the preference for its use after surgical excision. Although
topical vaginal estrogen may be safe,
26
it is best administered as a low- or ultralow-dose preparation (such as conjugated
equine estrogen, estriol, estradiol, and promestriene [3-propyl 17β -methyl diether estradiol])
12
to minimize systemic
absorption that can increase endometrial thickness. While honey is effective in the treatment of obstetric wounds and shows
promise in animal studies as a protective agent for genital atrophy, there are no long-term studies and denitive conclusions
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about its efcacy in the treatment of urogenital atrophy in humans as in the index patient with atrophic vaginal mucosa.
27–29
Topical corticosteroid cream, on the other hand, was not used postoperatively in the index patient because of the concern
that the lesion has been excised and the therapy may impair wound healing, unlike topical estrogen cream.
In managing episiotomy generally, a mediolateral episiotomy with an incision made between 45 and 80 degrees
(preferably 60 degrees) from the vertical using appropriate technique;
30–33
avoidance of risk factors for exuberant granula-
tion; and inspection of the wound on postpartum day 7,
34
day 42, and as the need arises are recommended by the author to
prevent complications (Table 1). The inspection will provide an opportunity for the identication of maternal postpartum
danger signs and the management of wound complications.
35
Of note, to enhance the healing of an episiotomy wound, agents
such as honey or curcumin may be applied to the wound.
36
Honey is a cost-effective and accessible wound treatment
option.
37
An innovative meta-analysis conducted by Barbosa et al evaluated the effects of honey on scar tissue formation in
obstetric wounds. According to the study’s results, honey treatments showed greater efciency than placebo and provided
benets to patients by accelerating wound healing and reducing reported pain.
4
The healing/cicatrization properties of honey
include the following effects on the wound: hydrogen peroxide, acidity, osmolarity, antioxidant, prostaglandin, nitric oxide
and nutrition (sugars, vitamins, phenolic acids, avonoids, and minerals).
4,38
However, the challenge is that the composition
of honey may differ depending on the geographical region, climate, owers, and species of bees. Importantly, there are
reports suggesting that the two types of medical-grade honey (MGH) which have shown effectiveness in wound healing and
bactericidal abilities are Medihoney and Manuka honey.
4,24,38
Conclusion
Surgical excision with post-operative estrogen vaginal cream therapy may be effective in the treatment of exuberant
granulation that complicates an episiotomy wound. This treatment may be used when the vaginal epithelium is friable,
although additional data are required from future studies to conclusively show the effectiveness of this therapy. In
patients with similar clinical presentations, however, the use of honey is a potential treatment option.
Data Sharing Statement
All data about the present study are included in this article.
Ethical Approval and Consent for Publication
Written informed consent was obtained from the patient for the publication of this case report. However, institutional approval
was not required to publish the case details. A single case report (less than three in number) is exempted from research ethics
approval in our jurisdiction as stated in: South African National Department of Health. South African Ethics in Health
Research Guidelines: Principles, Processes and Structures 2024. Page 57. Available from: https://www.witshealth.co.za/
Portals/0/2024/Documents/NDoH-2024-Health-Research-Guidelines-3rdEdition-v0.1.pdf (accessed 11 November 2024).
Funding
No fund was received from any individual or organization to write or publish this work.
Table 1 Key Messages
S/No Key Message
1 Exuberant granulation (proud esh) is a complication of wound healing.
2 Risk factors include traumatic or thermal injuries, invagination of surface epithelial edge during wound closure, healing by secondary
intention, wound infection, and use of chromic catgut compared to polyglactin (Vicryl).
3 Exuberant granulation in an episiotomy site with friable vaginal tissues is rarely reported.
4 Surgical excision followed by intravaginal estrogen vaginal cream are effective therapy.
5 Episiotomy site inspection on postpartum days 7, 42 and as needed may improve care.
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Disclosure
The author has no competing interest to declare for this study.
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