External Meatus Research Articles

Objective documentation of hypospadias anatomy with three-dimensional scanning

The absence of a standardized classification of hypospadias hinders understanding of the anatomic differences among patients and the evaluation of outcomes following surgical repair. In working towards a standardized, objective method of recording patients' hypospadias anatomy, we describe our initial experience using a non-invasive three-dimensional scanner. An Artec3D Space Spider scanner was used to obtain 3D scans in 29 patients undergoing hypospadias repair. Measurements of the urethral plate width, urethral plate length, glans width, penile shaft length, and penile shaft width were made by 2 pediatric urology attendings and 1 pediatric urology fellow. Measurements were compared and inter-rater reliability was calculated. A total of 435 measurements were made on 29 successfully generated 3D scans, ranging from distal to proximal hypospadias. The inter-rater reliability of measurements from the generated 3D models shown good inter-rater reliability of urethral plate width (ICC0.87 [95%CI:0.76,0.93]), penile shaft length (ICC0.87 [95%CI:0.70,0.94]) and glans width (ICC0.83 [95%CI:0.68,0.92]), excellent inter-rater reliability of urethral plate length (ICC0.96) and moderate inter-rater reliability of penile shaft width (ICC0.69 [95%CI:0.44,0.84]). There was a high degree of reliability of measurements made across multiple users. Calculation of the ratio of the urethral plate length/total penile shaft length objectively defined the initial position of the urethral meatus. When compared to the 3-dimensional volume of the glans, a more proximally positioned urethral meatus was associated with a lower glans volume. 3D scanning offers a rapid, reproducible, and non-invasive method of documenting hypospadias anatomy. The ability to evaluate three dimensional features (i.e. glans volume) offers an exciting opportunities for robust investigation of hypospadias outcomes and further understanding of the relationship between a patient's genotype and phenotype.

Primary urothelial carcinoma in distal urethral meatus

Primary urothelial carcinoma in distal urethral meatus

STUDY OF SURGICAL OUTCOME OF HYPOSPADIUS CORRECTION BY MODIFIED SNODGRASS (TUBULARISED INCISED PLATE URETHROPLASTY) TECHNIQUE

Background:The incidence of hypospadias is around 1 in 300 male live births. It is the most common congenital abnormality of the urethra. Diagnosis is made on physical examination. There are three characteristic features, including an ectopic ventrally located urethral meatus usually a ventral penile curvature (chordee) and an incomplete dorsal hood prepuce Surgical repair of hypospadias deformity is a challenging and complex issue. However, the technique of Snodgrass and its modifications attend promising functional and cosmetic results. Aims & Objectives: The paper aims at finding the outcomes of correction of distal and mid-shaft hypospadias by modified snodgrass technique and to compare it with the data available for other techniques Patients And Methods: Source- All patients undergoing surgical correction of hypospadias within the study period of 6 months( 15th March 2023 to 15th September 2023) Type Of The Study: prospective observational study Sample size: 15 patients Inclusion criteria: 1) Patients with distal and mid shaft hypospadias 2) all patients giving consent for the surgery Exclusion criteria: 1) Patients with severe chordee 2) Patients with immunocompromised status 3) Patients not willing to stay in hospital for long as this procedure needs careful dressings and hospital care as we are dealing with children 4) Patients who already underwent modified snodgrass technique Result: This study includes 15 boys with hypospadias. On Presentaion Two Patient Had Mid Shaft Hypospadias With Severe Chordee Rest All Patients Had Distal Shaft Hypospadias With Minimal Chordee. Their ages ranged from 3 to 8 years average 5 years The mean follow up was 3 months and complications were observed in only FIVE (33%) patient. Conclusion: From 15th MARCH 2023 to 15th SEPTEMBER 2023 over 6 months this study has emphasized on the clinical outcomes including any urethrocutaneous fistula , hemorrhage,infection,recurrence of chordee or any stricture formation following modified snodgrass technique and only 20% cases developed urethrocutaneous fistula.

Effect of different disinfectants on preventing asymptomatic bacteriuria and catheter-related urinary tract infection: a network meta-analysis

ObjectiveTo analyze the effect of different types of disinfectants for perineum and urethral meatus cleaning in preventing catheter-associated asymptomatic bacteriuria and catheter-associated urinary tract infection (CAUTI).MethodsChinese and English databases were searched to collect randomized controlled trials (RCTs) of different disinfectants for perineum and urethral meatus cleaning to prevent CAUTI, and the positive rates of urine culture with different cleaning methods were contrasted by network meta-analysis.ResultsA total of 18 RCTs were included in this study to analyze the effect of 10 disinfectants in preventing CAUTI. The disinfectants were 0.1% chlorhexidine (CHG), 0.5% CHG, 2% CHG, 0.1% benzalkonium bromide (DBDAB), 0.05% iodophor, 0.5% iodophor, acidic oxidizing potential water (EOW), normal saline (NS), Shehuang lotion, and sterile water. Meta-analysis showed that the positive rates of urine culture in the 0.5% CHG cluster, EOW cluster, 0.5% iodophor cluster, and Shehuang lotion cluster were remarkably lower than that in the 0.1% DBDAB cluster (P < 0.05). The positive rate of urine culture in the 0.5% CHG cluster was remarkably lower than that in the 0.05% iodophor cluster (P < 0.05), whereas the positive rates of urine culture in the 0.5% CHG cluster, 0.5% iodophor cluster, Shehuang lotion cluster, and EOW were remarkably lower than that in the normal saline cluster (P < 0.05). The positive rate of urine culture in the 0.5% CHG cluster and EOW cluster were remarkably lower than those in the sterile water cluster (P < 0.05). The results of the area under the cumulative ranking probability plot (SUCRA) analysis showed that the probability ranking of the preventive effect of different disinfectants was as follows: 0.5% CHG > Shehuang lotion > EOW > 0.5% Iodophor > 2% CHG > 0.1% CHG > 0.05% Iodophor > Sterile Water > 0.1% DBDAB > Saline. Conclusion0.5% CHG, Shehuang lotion, EOW, and 0.5% iodophor can be used to clean the perineum and urethral meatus in patients with indwelling catheters.Systematic review registrationChinese Clinical Trial Registry (ChiCTR), identifier ChiCTR2100052260.

An innovative method for occluding the urethral meatus and accessing urethra strictures in retrograde urethrography in males

ObjectivesTo observe and evaluate the effectiveness and safety of using a sponge plug method to occlude the urethral meatus during retrograde urethrography (RUG) for accessing male urethral strictures.Methods40 male patients with a mean age of 51.4 years and a history of urethral injury were primarily diagnosed with urethral stricture using a urethrocystoscope. RUG was performed using a ureteral catheter with a sponge plug inserted into the external meatus. Iodixanol, a contrast medium, was injected into the urethra or bladder for performing RUG and voiding cystourethrography (VCUG). The patients were positioned obliquely to obtain urethrograms.ResultsAll X-ray radiologic procedures for performing urethrography were successful without any overflow of contrast liquid observed. In all cases, the sponge plugs became visible in the resulting images. The external meatuses were directly visualized in all cases on the obtained images, allowing identification of the number, location, and length of strictures as well as coexistent pathologies such as fistulas. In one case, the plug slipped off the meatus immediately after completing the procedure. The pain Visual Analogue Scale (VAS) was 0 to 2, mean 0.35. No instances of complication or adverse reactions was observed.ConclusionsThe sponge plug effectively occludes the external urethral meatus for retrograde urethrography, enabling visualization of the actual caliber of the entire urethra, including the strictures and external meatus, by filling it with contrast liquid. This technique is safe and well-tolerated by patients.

Assessment of functional and cosmetic outcomes of Extended-Tubularized incised plate for mid-shaft and distal hypospadias as a modification of Snodgrass repair: a cross-sectional study.

Hypospadias is a congenital abnormality of anterior urethral and penile development where the urethral meatus is ectopically located on the ventral aspect of the penis. It is a relatively common condition affecting ~1 in 250 male birth. Extended-Tubularized Incised Plate (E-TIP) is a modification of Snodgrass repair by extending the midline incision to the apical part of the glans resulting in a more normal appearing location of the meatus and straight urinary stream without increasing the risk of complications. To evaluate functional and cosmetic outcomes of E-TIP repair for mid-shaft and distal hypospadias as a modification of Snodgrass repair. A prospective cross-sectional study including 53 cases of mid-to-distal hypospadias repaired with the E-TIP technique between November 2019 and February 2022 in Baghdad. The authors start with the standard technique described by Snodgrass, but the midline incision of the urethral plate extended up to the apical part of the glans tip, and tabularization started distally creating a slit-like a neomeatus. Outcome assessment depended on an objective evaluation of the following parameters: maximum flow rate, post-void residual, Hypospadias Objective Score Evaluation (HOSE) score, and direction of the urinary stream. The mean age was 3.4±2.1 years, ranging from 0.6 to 9 years. The mean duration of follow-up was 14.4±6.9 months, and the location of the meatus was coronal in 16 patients (30%), subcoronal in 25 (47%), and mid-distal shaft in 12 (23%). The glans width was greater than or equal to 14mm in 46 patients (87%) and less than 14mm in 7 (13%). Q.max was above the fifth percentile of age-related uroflowmetry nomograms for healthy children 5-15 years old in 29 boys (93.5%) and below the fifth percentile in 2 (6.5%). Post-void residual urine was less than 10% of voided volume in 28 out of 31 boys (90%) and greater than 10% in 3 (10%). Regarding cosmetic outcomes, 50 boys (94%) had good penile appearance and their HOSE score greater than or equal to 14 with a slit-like meatus located at the tip of the glans, while 3 (6%) of them their score was less than 14. The overall mean HOSE score postoperatively for all patients was 15±0.9. Six patients (11%) had a deviated urinary stream and 47 (89%) had a straight stream. E-TIP repair is a good alternative to standard Snodgrass repair for mid-shaft to distal hypospadias with a good functional and cosmetic outcome, particularly the neomeatus position at the tip of the glans, which is similar to the normal one without increasing the risk of meatal stenosis.

Beyond the tip of the iceberg: A meta-analysis of the anatomy of the clitoris.

An understanding of ranges in clitoral anatomy is important for clinicians caring for patients including those who have had female genital mutilation, women seeking genital cosmetic surgery, or trans women seeking reconstructive surgery. The aim of this meta-analysis is to investigate the ranges in clitoral measurements within the literature. A meta-analysis was performed on Ovid Medline and Embase databases following the PRISMA protocol. Measurements of clitoral structures from magnetic imaging resonance, ultrasound, cadaveric, and living women were extracted and analyzed. Twenty-one studies met the inclusion criteria. The range in addition to the average length and width of the glans (6.40 mm; 5.14 mm), body (25.46 mm; 9.00 mm), crura (52.41 mm; 8.71 mm), bulb (52.00 mm; 10.33 mm), and prepuce (23.19 mm) was calculated. Furthermore, the range and average distance from the clitoris to the external urethral meatus (22.27 mm), vagina (43.14 mm), and anus (76.30 mm) was documented. All erectile and non-erectile structures of the clitoris present with substantial range. It is imperative to expand the literature on clitoral measurements and disseminate the new results to healthcare professionals and the public to reduce the sense of inadequacy and the chances of iatrogenic damage during surgery.

URETHRAL INJURY IN REGIONAL HOSPITAL IN THE BPJS ERA: A CASE REPORT

ABSTRACT
 Objective: To present a case of urethral injury treated in a male adult. Case(s) Presentation: A 48 year old Asian male patient previously involved in a motor vehicle accident presented to the hospital with a chief complaint of pain and bleeding from the genitalia. On examination, it is revealed bleeding from the urethral meatus, pain in touch, palpable bladder, high riding prostate, and a butterfly-shaped bruising on the perineum. X-ray examination demonstrated soft tissue mass in the right scrotal region. The patient is diagnosed with urethral rupture with urinary retention and then underwent ultrasonography-guided cystostomy and perineal hematoma evacuation. The patient is followed-up 1 month later with a complaint of difficulty in voiding and erectile dysfunction. The patient is then diagnosed with urethral stricture and underwent direct vision urethrotomy. Discussion: Urethral injury is a rare type of injury of genitourinary trauma that may cause long term morbidity such as strictures, incontinence, impotence, and infertility. Urethral injury can be classified into posterior urethral injury which is associated with pelvic fracture and anterior urethral injury which is associated with blunt trauma. The gold standard of radiographic examination in urethral injury is dynamic retrograde urethrography. Prompt diagnosis, staging, and selecting intervention must be done for minimalizing complications. Sequelae may also develop which also affects quality of life. The usage of universal health coverage such as BPJS in In Indonesia can increase the accessibility of medical treatment. Conclusion: Urethral injury is a rare injury that requires prompt and careful management to minimize complications and increase the patient’s quality of life.
 Keywords: Urethral Injury, urethrotomy, urethral stricture.

Unraveling the complexity of bladder-centric chronic pain by intravesical contrast enhanced MRI

Bladder pain, a common symptom associated with various urological conditions, poses a diagnostic challenge as existing imaging modalities fail to pinpoint the bladder as the definitive source of pain. While bladder pain is often linked to localized inflammation resulting from urinary tract infections (UTIs) or Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS), which can be exacerbated by emotional stress, current urine-based markers cannot precisely identify the specific site of inflammation within the urinary tract, spanning from the kidneys to the urethral meatus. Cystoscopy, currently considered the gold standard, is recommended by the American Urological Association (AUA) prior to aggressive treatment for IC/BPS patients, as it confirms the presence of bladder inflammation, particularly in Hunner lesions, and predicts a higher response rate to anti-inflammatory medication like cyclosporine. Nonetheless, the invasiveness of cystoscopy, which relies on investigator expertise, coupled with the significant variability in detecting Hunner lesions, underscores its limitations for inflammatory phenotyping. These factors contribute to the reluctance in choosing cystoscopy as a preferred diagnostic method and may also contribute to the lack of success observed in clinical trials assessing the efficacy of novel anti-inflammatory drugs. Given that immune cell infiltration into inflammatory sites relies on tight junction dilatation, the paracellular entry of injected or instilled paramagnetic dyes, mimicking the extravasation of colored dyes such as Evans blue dye could be a robust index of vascular or urothelial hyperpermeability—a characteristic sign of inflammation. This article aims to delve into the pathophysiology of bladder-centric chronic pain within the context of the challenging diagnosis of IC/BPS and explore the pivotal role of Stokesian and Fickian diffusion in the evolution of intravesical contrast-enhanced MRI (ICE-MRI) as a phenotyping tool for bladder pain, transitioning from laboratory research to practical clinical application.

METTL3-dependent m6A modification mediates bladder remodeling after partial bladder outlet obstruction through CCN2 activation.

N6-methyladenosine (m6A) modification is a critical posttranscriptional event in gene regulation. Thus, identifying methyltransferase, demethylase, or m6A binding protein-mediated m6A modifications in cancer or noncancer transcriptomes has become a promising novel strategy for disease therapy development. However, novel insights into m6A modification in partial bladder outlet obstruction (pBOO) and detailed information about the drivers of bladder remodeling remain to be elucidated. Here, we first characterized the m6A modification landscape in pBOO and investigated potential actionable pharmaceutical targets for future therapies. We generated an improved animal model of pBOO in SD rats with urethral meatus stricture induced by suturing. Urodynamic investigations and cystometry were carried out to evaluate the physiologic changes elicited by pBOO. Whole-transcriptome sequencing (RNA-seq) and m6A-modified RNA immunoprecipitation sequencing (MeRIP-seq) were subsequently performed to analyze the expression pattern associated with bladder remodeling in pBOO. The cystometric evaluation of bladder function demonstrated obvious increases in pressure-related parameters in the pBOO group. Hematoxylin and eosinstaining and Masson's trichrome staining validated the occurrence of bladder remodeling. A global elevation in m6A RNA methylation levels was observed in parallel to a increased expression of METTL3 in the pBOO group. High-throughput sequencing revealed the differences in expression patterns between the pBOO and sham-operated groups. Furthermore, potential m6A-modified genes, including CCN2, may serve as new pharmaceutical targets to reverse bladder remodeling. Exploring the roles of m6A-modified genes identified as associated with bladder remodeling by integrating RNA-seq and MeRIP-seq data can offer new insights for developing promising treatments for pBOO patients.

Megameatus intact prepuce, a rare variant of hypospadias: report of two cases and literature review

Megameatus intact prepuce is an unusual variety of the distal hypospadias, characterized by a widely splayed (fishmouth) coronal or subcoronal meatus, a deep glanular groove with normal prepuce, and no chordee. Physically, the glans penis has disunion with an abnormally large meatus associated with a deep glans cleft. Because the foreskin is intact, the condition is frequently overlooked; as a result, the patient seeks medical attention later, when the purpose is to address other urogenital issues. Cosmetic remodeling should be performed to avoid affecting a child’s psychological state. We present 2 cases of the mentioned condition (circumcised and uncircumcised) with blunderbuss external urethral meatuses, admitted to our pediatric surgery department. Both patients underwent tubularized incised plate urethroplasty along with spongioplasty and a vascularized dartos flap over the urethroplasty for fistula prevention. The cosmetic and functional results were satisfactory.

Condyloma of the urethra in women: A case report

Condyloma acuminata or warts are benign lesions caused by the human papilloma virus (HPV) ; sexually transmitted, it affects both men and women and is often found in adults in the anal or genital area . However, the urethral localization of condyloma in women is very rare and can be the origin of an obstruction hindering the flow of urine. We report the case of a young woman complaining of difficulties in urinating, the clinical examination found a small solid mass delivered by the urethral meatus. the answer of the anatomopathological study was an acuminous condyloma of the urethra, this last one can be treated by a local excision as an effective method allowing an early improvement of the bladder outlet.

(004) Using Genital Anesthesia Testing (GAT) in the Management of Bothersome Genital Dysesthesia

Abstract Introduction For women experiencing bothersome genital arousal, pain, or other dysesthesia symptoms (e.g. feelings of itching, burning, pulsating, tearing), it is important to ascertain whether symptoms are secondary to pathology in the genital area, or are referred from upstream pathology in the pelvis or perineum, cauda equina, spine, and/or brain regions. Specific understanding of the location of the trigger associated with the genital dysesthesia is critical to directing treatments for disease modification management. Objectives The aim of this study is to review the methodology of minimally-invasive genital anesthesia testing including the clitoral anesthesia test (CAT – Figures 1a, 1b), vestibular anesthesia test (VAT – Figure 2), urethral anesthesia test (UAT) and/or Bartholin cyst anesthesia test (BAT). Methods Prior to genital anesthesia testing the patient documents the symptom score intensity on a scale of 0 to 10 where 10 is most severe. It is critical that the patient have significant symptoms in the specific genital region(s) (clitoris, vestibule, urethral meatus and/or Bartholin’s cyst); the patient may need to perform some maneuvers to trigger the dysesthesia symptoms and/or reduce or discontinue medications that offer relief from the dysesthesia. The area to be tested is demarcated under vulvoscopic examination with a marking pen. Using a cotton swab as an applicator, benzocaine (20%), lidocaine (8%), tetracaine (8%), (BLT) is first applied to the inner arm to assess for allergies. Assuming there is no allergic reaction, the BLT is applied generously to the specific genital region. If needed, local subcutaneous administration of 1% lidocaine using a 30-gauge needle can supplement the anesthesia. After 10 minutes, provocative maneuvers are performed to determine whether or not there is clinically significant symptom reduction from the pre-genital anesthesia test symptom score. Results A positive genital anesthesia test is consistent with clinically significant symptom reduction from the pre-genital anesthesia test symptom score intensity. A positive genital anesthesia test implies that the local genital region (clitoris, vestibule, urethral meatus and/or Bartholin’s cyst) is the trigger of the genital dysesthesia so appropriate treatment strategies may be offered. For example, a positive CAT may require lysis of adhesions. A positive VAT may require hormone management for hormone mediated vestibulodynia, or vestibulectomy for neuro-proliferative vestibulodynia. A positive UAT may require surgical reconstruction of the urethral meatus. A positive BAT may require marsupialization. A negative genital anesthesia test is consistent with upstream pathology leading to testing of the integrity of the pudendal nerve or assessment of the cauda equina with neuro-genital testing and lumbar/sacral MRI. Conclusions Genital anesthesia testing is an excellent minimally invasive, in office diagnostic test to help localize the trigger of the genital arousal, pain, or dysesthesia in the genital region. Recognizing the location of the trigger associated with the genital dysesthesia as emanating from the genital region rather than the pelvis or perineum, cauda equina, spine, and/or brain region, will allow for disease modification and specific management strategies of the clitoris, vestibule, urethral meatus and/or Bartholin cyst. Disclosure No.

(005) The Forgotten Region of the Vestibule: The 12:00 Location

Abstract Introduction The vestibule, consisting of the urethral meatus and minor and major vestibular glands, is a unique surface of endodermal tissue between Hart’s line, at the inner aspect of the labia minora, and the hymen, just at the vaginal opening. The vestibule releases mucinous lubrication during sexual arousal, achieved, in part, by robust vestibular innervation. Although not well studied, this likely consists of both somatic (perineal nerve), and autonomic (pelvic and hypogastric) nerves. The vestibule is commonly involved in entrance dyspareunia pathology related to infectious, dermatologic, hormonal, neurologic, pelvic floor, neuro-proliferative and other factors. Examination of the vestibule in symptomatic patients is best performed by vulvoscopy, and usually involves cotton swab testing of the 1:00, 3:00, 5:00, 6:00, 7:00, 9:00, and 11:00 locations, assessing for intensity of pain and degree of erythema. However, this examination does not assess the entire vestibule. The vestibule actually extends superiorly from just above the urethral meatus to just below the clitoris/right and left frenulum and laterally to Hart’s line. This may be considered as the “12:00” region of the vestibule; few providers examine there, and few surgeons excise the 12:00 region during vestibulectomy. Objectives The primary goal was to assess the relationship of the pathology of the 12:00 region to pathology in the usual vestibular locations. A secondary goal was to assess for presence of ostia of minor vestibular glands in the 12:00 region of the vestibule. Methods Women presenting to our clinic for sexual dysfunction were consented and underwent vulvoscopy with photography and cotton swab testing using a vulvoscope (Wallach Zoomscope) with attached camera (Cannon). Figure 1 shows cotton swab testing for pain and erythema at 12:00. Pain intensity was rated 0 – 10, with pain >3/10 considered clinically significant. Erythema was rated absent, mild, moderate or severe with any erythema considered clinically significant. Results Of 88 patients (mean age 42 +/− 19, range 13-83 years) with various sexual dysfunctions who underwent vulvoscopy with photography and cotton swab testing, 19 (22%) had absent pain and absent erythema throughout the usual vestibular locations as well as at the 12:00 location. Of 54 (61%) patients with positive findings of significant pain and erythema in at least 4 of the usual locations, 38 (70%) also had significant pain and erythema at 12:00. 26% of photographs examined revealed obvious single or multiple ostia of minor vestibular glands in the 12:00 region of the vestibule. Figure 2 shows 2 minor vestibular glands at 12:00. Conclusions While the vestibule extends from Hart’s line to the hymen including the usual 1:00, 3:00, 5:00, 6:00, 7:00, 9:00, and 11:00 locations, it also includes the region superiorly from just above the urethral meatus to just below the clitoris/right and left frenulum and laterally to Hart’s line. There are minor vestibular glands in this 12:00 region of the vestibule that can contain significant pathology. Providers are encouraged to consider the entire vestibule during diagnosis and treatment of women with sexual dysfunction. Disclosure No.

(001) Excess Density of Mast Cells and Nerves with Neuroproliferative Vestibulodynia: Defining the Extent of the Vestibulectomy Surgical Excision

Abstract Introduction Congenital neuroproliferative vestibulodynia (NPV) is associated with lifelong entrance dyspareunia, starting with initial tampon insertion. Acquired NPV is associated with pain-free penetration until after a severe candidiasis infection and/or allergic reaction to a locally applied agent. NPV is diagnosed by ruling out other forms of vestibulodynia. Based on immunohistochemical examination of excised vestibular tissue specimens from women with NPV, the pathophysiology is related to high density of mast cells and nerves throughout the entire surgical specimen If conservative, non-operative strategies fail, or are not appropriate, surgical excision may be considered as vestibulectomy has a high success rate. The extent of surgical excision, however, varies by surgeon, from an excision of the posterior vestibule to a wider excision involving posterior vestibule along with left and right anterior vestibule, millimeters next to the urethral meatus. Few providers perform an even wider excision when appropriate including vestibular tissue inferior to the clitoris/right and left frenulum, and superior to the urethral meatus, the “12:00” vestibule. The extent of vestibular tissue excision related to patient outcome in NPV has not been studied. Objectives This study compares the density of mast cells and nerves from the 12:00 vestibule to the posterior and left and right anterior vestibule using immunohistochemistry. Methods Surgical specimens (12:00 vestibule; posterior and left and right anterior vestibule) from 6 women (mean age 27 +/− 11 years) were fixed in formalin, paraffin embedded blocks and labelled. 5 um sections from each block were stained with hematoxylin and eosin and slides analyzed by light microscopy. Antibodies to CD117 and PGP 9.5 were used for immunostaining. Multiple regions were examined and photographed using a Zeiss AxioCam HR high resolution digital microscope. Density of CD117 and PGP9.5 positive cells were determined by counting the number of dark brown stained cells per high-power field (hpf = x 20 magnification). Specimens from control subjects have values of 8 mast cells or less per hpf, as reported by Bornstein. Results High densities of CD117-positive cells in vestibular epithelium and stroma were noted in the 12:00 vestibule (mean density of 43 +/− 18 per hpf) versus in the posterior and left and right anterior vestibule (mean density of 38 +/− 14 per hpf). High densities of PGP9.5-positive cells were noted in vestibular stroma in the 12:00 vestibule (mean density of 31 +/− 20 per hpf) versus the posterior and left and right anterior vestibule (mean density of 33 +/− 18p er hpf). Figures 1 and 2 show CD117-positive cells and PGP9.5 positive cells, consistent with excess mast cells and nerves, respectively at the 12:00 vestibule and from the posterior and left and right anterior vestibule. Conclusions We demonstrate, for the first time, that the 12:00 vestibule contains the same increased number of mast cells and nerves as the rest of the vestibule. If anesthetizing that region pre-operatively provides pain relief, excision during surgery should be considered. In patients with NPV, excising the 12 o’clock region at the top of the vestibule may result in improved post-operative success rate. Disclosure No.

Vaginal Bleeding In Prepubertal Girls-A Case Series in Malaysia

The etiology of prepubertal vaginal bleeding varies from isolated pubertal causes to malignant tumors and generates significant anxiety among girls and their caretakers. Hence, these cases require careful assessment and management. This is a report of five cases of prepubertal vaginal bleeding with various causes and were managed in a tertiary referral center in Malaysia. The first case was a 6-year-old girl who had no pubertal changes with 3 weeks’ history of bleeding. She underwent examination under anesthesia and found to have multiple vaginal polyps. Another 6-year-old girl noted to have a doughnut-shaped mass protruding from her urethral meatus. She was treated with estrogen cream and sitz baths. Another child had early breast development while pelvic ultrasound revealed a multiseptated ovarian cyst requiring a cystectomy. A 19-month-old toddler had a large intravaginal mass. She required further investigation, referral to the pediatric surgeon and oncologist for treatment of a malignant yolk sac tumor. Lastly, an 8-year-old girl was noted to have monthly vaginal spotting without any secondary sexual characteristics development. Prepubertal vaginal bleeding is abnormal thus requires prompt assessment to ascertain the cause and administer appropriate management. It is important to rule out sexual abuse and malignancy. Examination under anaesthesia and vaginoscopy is recommended when imaging modality is inconclusive. Referral to tertiary centres experienced in managing such cases ensures good outcomes. Thorough targeted history-taking and pediatric-specific gynecological examination skills are crucial to formulate accurate diagnosis and appropriate management.

Hygiene management of intermittent self-catheterization using reusable silicone catheters in people with spinal cord lesions: A cross-sectional Internet survey in Japan.

To investigate hygiene management and catheter maintenance of reusable silicone catheters for intermittent self-catheterization (ISC) in Japan and examine their relationship with symptomatic urinary tract infection (sUTI). We conducted a cross-sectional Internet survey of people performing ISC using reusable silicone catheters owing to spinal cord lesions in Japan. Hygiene management and catheter maintenance of reusable silicone catheters and the incidence and frequency of sUTI were evaluated. We also examined the significant risk factors for sUTI. Of 136 respondents, 62 (46%), 41 (30%), and 58 (43%) washed hands with water, washed hands with soap, and cleaned or disinfected the urethral meatus every time or most of the time before ISC, respectively. No significant difference was observed in the incidence and frequency of sUTI between respondents who adhered to these procedures and those who did not. There were no significant differences in the incidence and frequency of sUTI in respondents who changed their catheters every month and in those who changed their preservation solution within 2 days compared with those who did not. In multivariate analysis, pain during ISC, inconvenience of indoor mobility, bowel management problems, and participants' feeling of never having received instruction on catheter replacement were significant risk factors for sUTI. There are individual differences in hygiene management and catheter maintenance of reusable silicone catheters, but the influence of these differences on the incidence and frequency of sUTI is not clear. Pain during ISC, bowel management problems, and inadequate instruction on catheter maintenance procedures are factors associated with sUTI.

Vulvo-vaginal aging

Age produces changes in the vulva and vagina, but the key moment is the decrease in estrogen, the main cause of vulvovaginal atrophy (VVA). The main consequence of a hypoestrogenic environment are signs and symptoms that can adversely affect tissues as the labia majora, labia minora, vestibule, clitoris, vagina, urethra, urethral meatus, bladder, pelvic floor muscles, and periurethral anterior vaginal wall.After menopause, the vaginal epithelium loses its rugae, and tissues grow thin and pale. Elastic fibers are fragmented and connective tissue increases. Elasticity is reduced, and the vagina is shortened and narrowed and has reduced distensibility. As vaginal secretions decrease, lubrication is reduced.

Diagnosis and treatment of primary urethral melanoma with regional lymphatic metastasis in an elderly woman: a case report and review of available therapies

BackgroundMucosal melanomas account for 17% of melanomas, and less than 1% affect the urogenital tract. Primary urethral melanoma is extremely rare; less than 200 cases have been reported so far since it was first described. The clinical presentation is usually delayed, and the prognosis is generally poor.Case presentation.An 86-year-old female was referred to urology due to the presence of a three-month-old violaceous mass in the urethral meatus protruding through the vagina. On physical examination, a pedunculated, hyperpigmented, friable, and tender lesion was seen in the urethral meatus bulging between the labia minora. After initial diagnostic studies, the patient was taken to surgical resection of the lesion. The pathology report identified the lesion as a malignant melanoma of the urethra, and staging studies revealed regional lymph node metastases. After discussing the treatment options with the patient, palliative therapy with nivolumab was started. In follow-up at 26 months, the patient had evidence of extensive lymph node involvement, but a conserved performance status and no visceral metastases.ConclusionPrimary melanoma of the female urethra is an uncommon disease with a poor prognosis. Despite the deficiency in literature regarding its management, it is important to consider patient expectations and preferences when treating this rare disease.

(011) Beneficial Effects of Vaginal Prasterone (DHEA) on the Vaginal Histology of Women with GSM Beyond the Epithelium

Abstract Introduction There is mounting evidence that androgens play an important role, together with estrogens, in the maintenance of genitourinary health. Objective Vaginal prasterone was used to characterize the histological changes associated with the dual androgen - estrogen stimulation of the vaginal wall in the treatment of the genitourinary syndrome of menopause (GSM). Since prasterone is converted to androgens which are subsequently aromatised in estrogens, a group of patients on aromatase inhibitors (AI) was included to isolate changes attributable to androgens. Methods Vaginal biopsies and vulvar pictures were collected before and after 12 weeks of treatment with 6.5 mg intravaginal prasterone daily (Intrarosa®). Eight women with GSM were recruited, including two breast cancer survivors on AI. Results Following treatment, the epithelium showed striking histological improvements, regaining thickness, ridges, active proliferation and glycogen synthesis. In the lamina propria, treatment led to increases in elastin content and nerve endings density. Visual evaluation of the vulva showed reduction of the redness and inflammation in the vestibule and the urethral meatus as well as a relaxation of the vaginal entrance. All observations were consistent between the groups with and without AI. Conclusions Data presented here are believed to be the first demonstration of the beneficial effects of androgens deep into the lamina propria of GSM patients both together with or independently from estrogens. Tissue changes observed could help understand some of the GSM symptomatology improvements observed before on dyspareunia and other sexual function parameters. While further studies are warranted to better understand how androgens and estrogens work synergistically in the treatment of GSM, the data presented here strongly suggest that prasterone has deep beneficial impacts on the urogenital tissue. Disclosure Yes, this is sponsored by industry/sponsor: Endoceutics Clarification: Industry initiated, executed and funded study Any of the authors act as a consultant, employee or shareholder of an industry for: Endoceutics