Vagina Fog

Rebecca is a maitre d' at an exclusive Italian restaurant on Federal Hill. The attractive twenty-five-year old works six lunches and dinners each week. Her outfit is never wrinkled, but under her formal black tuxedo and hidden beneath her flowered panties, her venereal warts rub together as she escorts the well-groomed patrons to their quiet corner tables.

She cried quietly when I first explained the cauliflower growths were normal skin transformed into pedunculated masses by the Human Papilloma Virus. HPV is the same virus that causes plantar and other skin warts, only this virus subtype was likely obtained during a sexual encounter. Doctors called it condylomata acuminatta. She told me the warts had been growing slowly over the last year. She was afraid this was her cancer. I reassured her that her pap smear done at our last (and first) visit showed no evidence of cancer, and explained that we could chemically treat her lesions, which would cause them to blister up and die. It was not a cure, but could get rid of them indefinitely. She agreed to the procedure; I asked her to get undressed.

The pelvic exam is disliked by both patient and doctor. It is an invasion into the most intimate of private parts with a hard metal speculum. It is uncomfortable. For the inexperienced physician, it is stressful, time consuming, and often results in blood or pus from the withdrawn speculum ending up on one's pants.

Pelvic examinations also require the presence of an additional woman. The purpose of this chaperone is to help protect against allegations of sexual misconduct which have recently become commonplace in the medical world. In addition, finding the cervix buried deep in the vagina takes practice. I learned how to do a pelvic examination in medical school, under the tutelage of a fifty-year-old woman with extraordinarily large vaginal lips. She and eleven other "professional patients" came to the medical school to teach both procedural and communication skills. Most of these professionals were either out of work actresses, or people who had some prior negative interaction with a physician and hoped to change the system. Professional patients would earn fifty dollars a day to have their insides vigorously probed by student after student. A student doctor in the afternoon class often discovered vaginal abrasions and small anal lacerations where prior colleagues had gone astray.

As Rebecca undressed, I went to the resident's office to figure out how to chemically treat her venereal warts. From my last exam, I knew there were about ten pedunculated growths, most on the labia minora. A few, however, were located deep inside her vagina, about half way down toward her cervix. During my six-week obstetrical & gynecology rotation in medical school, I had used liquid nitrogen to freeze outer vaginal warts. I had never frozen inside warts and was unsure if liquid nitrogen was considered appropriate treatment.

I quickly flipped through the reference texts strewn about the back room of the clinic. Podophyllum resin was acceptable, the text said. I had no experience with podophyllum, a blistering agent extracted from beetles. Trichloracetic acid, one text said, was contraindicated on mucosal surfaces. I guessed a vagina was considered mucosa. I looked for a preceptor to discuss the best approach to these warts, but she was busy helping another intern decide how to ask a five-year old patient about good touch and bad touch.

When I returned, Rebecca sat on the examining table in a thin cotton johnnie; her legs and arms bent at funny angles to better conceal her private parts. She looked anxiously at the medical assistant who carried a Styrofoam cup filled with liquid nitrogen. Thick wisps of heavy nitrogen gas slowly climbed over the cup and fell toward the floor.

"Is this gonna hurt?" Rebecca asked.

"It will sting a bit. It works best if I can freeze the lesions twice, giving a minute between freezes to allow your skin to thaw. If it's too uncomfortable, just say stop and I'll stop."

The medical assistant, usually a high school graduate with an additional six to eighteen months of training, helped the patient assume the position: feet in steel stirrups with knees bent out like a frog's. I asked Rebecca to lie back.

"Now slide down. More. More..." Rebecca's buttocks, sweaty with anxiety, briefly stuck to the exposed vinyl before pulling free with a Velcro-like sound.

"Try to let your legs fall apart. It's much easier and less uncomfortable if you can relax a bit." Rebecca cautiously released her thigh muscles exposing her groin to me, the medical assistant, the yellowed window dressings, and a video camera hanging from the ceiling which somebody had forgotten to turn off. (Videotaping patient encounters was one of many teaching techniques at our residency.)

I sat on a stool between Rebecca's legs, dunked a long Qtip-like applicator into the liquid nitrogen, then removed the smoking stick.

"First we'll do the outer lesions. How you doing?"

Rebecca quietly said she was okay. She winced but didn't jump as I pressed the applicator against a growth. I reassured here while counting silently to ten. The skin-colored lesion turned white and froze.

"It stings, but I'm okay. Are you almost done?

"A couple more to go," I responded, pulling another cotton-tipped applicator from the liquid nitrogen.

Without incident, I went from lesion to lesion, freezing her skin and killing the inhabiting viruses. As each wart froze, the previous one began to thaw back to skin color. I repeated the entire process again; she tolerated the procedure well.

"Now it's time to do the inside lesions," I said.

The medical assistant took the cold metal speculum from the table and warmed it with hot tap water. I inserted it slowly into her vagina, trying not to catch the hair or skin. She held her breath as the duck-mouthed device entered.

"I don't hear you breathing," I said lightheartedly. She tried to exhale but couldn't.

"I hate these things," Rebecca told the medical assistant, who smiled knowingly.

The three intravaginal warts were on the left side of Rebecca's vagina, in about three inches. I took the long applicator and moved it toward her vagina. A drop of liquid nitrogen fell from the steaming cotton tip onto my right thigh. It burned for an instant before immediately evaporating into a small puff of gas.

As the applicator entered Rebecca's birth canal, the three warts suddenly vanished behind a dense cloud. Nitrogen gas quickly filled her entire vagina. It sat there, nearly motionless, like a valley fog at sunrise. I moved my face closer to the opening, and peered into the thick opaque gas. Everything had been going so smoothly, and this seemed like an interesting setback. Instinctively, I pursed my lips, and blew.

Fog slowly poured out from the bottom of Rebecca's vagina and passed over her tight anus like a cloud obscuring the sun on a humid spring day. As the nitrogen gas cleared out of her vagina, the warts darted in and out of view. I blew some more. Her pubic hair swayed. Suddenly, I began to sweat.

First I was aware of how quiet the examining room had become. Then I realized what exactly I was doing. For a moment, I was in a carpeted courtroom with twelve pant-suited jurors staring at me as Rebecca's attorney accused me of the sexual crime.

"You blew on my client's vagina!" he yelled while looking at the stern jurors.

I stopped blowing. I withdrew the speculum.

"You can sit up now," I said.

As Rebecca closed her legs and sat up, a smoke-ring of nitrogen escaped with a belch.

"Everything went well," I lied.

I left the room while Rebecca dressed. She seemed more distant now, and I wondered if she knew what had occurred. When I returned, Rebecca was standing with arms crossed. Her fleece jacket was zipped to her neck.

"I ran into a bit of trouble with the liquid nitrogen welling-up inside," I said. "I wasn't able to freeze the inner warts. I'll have you come back in a few weeks and we'll use something else on those."

Without saying a word, Rebecca took the encounter form and exited.

One of the most important aspects of a continuity clinic, is the ability to punt patient management issues to a future period of time. This gives the physician an opportunity to find out how to handle a problem. The art of punting is to make it seem that you have all the answers now, and you just want to see the patient back to make sure they are doing okay. In Rebecca's instance, the punt would allow time to find out how to treat internal condalomata lesions, and how to best address this procedural faux-pas.

Two weeks later, though, Rebecca did not return for a podophyllum treatment. And since that time, I've neither used liquid nitrogen on intravaginal warts, nor eaten pasta on Federal Hill.