66. Vacutainer Tube Alternative Vaginoscopy Technique in a Prepubertal Female: A Case Report

Abstract

<h3>Background</h3> Vaginoscopy is a recommended procedure for multiple indications in the pediatric and adolescent gynecology population. The use of a small sterile tube for circumferential tissue visualization with a fiberoptic scope is used for anoscopy, and has not been suggested as a technique for vaginal tissue visualization during pediatric vaginoscopy. <h3>Case</h3> A 5-year-old female presented to the emergency room with vaginal bleeding from a vulvar straddle injury caused by a fall onto a metal trampoline spring. She was brought to the operating room where a deep laceration at the posterior fourchette to the rectal capsule was repaired surgically. Routine vaginoscopy was attempted by hysteroscope-instilled saline, but adequate vaginal distension was not obtained despite trouble-shooting the equipment. A modified technique using a sterile glass tube was suggested by pediatric surgery colleagues which had been similarly applied in an adapted anoscopy approach by their team. A lavender top vacutainer tube was carefully placed into the vagina after removing the rubber top. The glass tube was secured with one of the operator's hands while the hysteroscope was placed into the tube to the apex. While slowly withdrawing the scope, the cervix and entire circumferential vaginal canal was able to be visualized completely. No distension media was required. No additional lesions, sources of bleeding or lacerations were found. The procedure was completed, and the patient was discharged from the hospital post-operatively without complications. <h3>Comments</h3> In the above described case, routine vaginoscopy during exam under anesthesia was indicated for full evaluation after a penetrating straddle injury. Although many techniques have been described for this simple procedure, functional cystoscope or hysteroscope equipment is required which may produce technical challenges if being performed during an emergent surgery. A clear plastic tube placed in the rectum is used in pediatric anoscopy, but the use of a glass specimen tube inserted partly into the rectum is an available inexpensive modification. The vaginal length in prepubertal girls measures 4 to 5 cm, and increases to 8 cm in length in the peri-menarchal period. A vacutainer or glass specimen tube was available in 7 and 10 cm length, is around 1 cm in diameter, and fits atraumatically into the prepubertal vaginal canal. The described surgical technique in this clinical case by hysteroscopic visualization of the tissue through a transparent glass tube proved to be a fast, effective, and inexpensive modification for routine vaginoscopy. This technique may not be generalizable to adolescents or older women with larger vaginal sizes due to inadequate distention with the available tube sizes.