Labia Majora Research Articles

A girl with labium majus swelling

Asymmetric vulva swelling during prepubertal period is related to a variety of inflammatory and neoplastic lesions. An 11-year-old girl with childhood asymmetric labium majus enlargement is presented.

Use of a Silicone Gel Sheet Vaginal Mold in McIndoe Vaginoplasty

Use of a Silicone Gel Sheet Vaginal Mold in McIndoe Vaginoplasty

Postoperative Clitoral Hood Deformity After Labiaplasty

Aesthetics of the female genitalia have come under increasing scrutiny with the popularity of Brazilian waxing trends and media promotion of sheer fashions. Women seek to have a clean and youthful appearance of the vaginal region, with minimal if any labial minora show beyond the labia majora. Labiaplasty by edge resection of the redundant labia minora tends to be the preferred method of treating labia minora hypertrophy by most gynecologists and plastic surgeons. This technique is effective in removing the excess circumferential rim of the labia minora, thus decreasing bulk and protrusion from the introitus. However, in select patients with redundant clitoral hood tissue, edge trim techniques may result in an imbalanced postoperative result where the hood actually looks larger. These patients complain of a prominence of the clitoral hood not present prior to their labiaplasty. In this case report, the author describes 2 cases of excess clitoral hood prominence after free-edge resection labiaplasty. Both patients were unhappy with the result of their labiaplasties and sought surgical correction. Presentation, anatomical findings, options for treatment, and avoidance of such deformity are discussed.

Vaginal Labiaplasty: Defense of the Simple “Clip and Snip” and a New Classification System

Vaginal labiaplasty has become a more frequently performed procedure as a result of the publicity and education possible with the Internet. Some of our patients have suffered in silence for years with large, protruding labia minora and the tissue above the clitoris that is disfiguring and uncomfortable and makes intercourse very difficult and painful. We propose four classes of labia protrusion based on size and location: Class 1 is normal, where the labia majora and minora are about equal. Class 2 is the protrusion of the minora beyond the majora. Class 3 includes a clitoral hood. Class 4 is where the large labia minora extends to the perineum. There are two principal means of reconstructing this area. Simple amputation may be possible for Class 2 and Class 4. Class 2 and Class 3 may be treated with a wedge resection and flap advancement that preserves the delicate free edge of the labia minora (Alter, Ann Plast Surg 40:287, 1988). Class 4 may require a combination of both amputation of the clitoral hood and/or perineal extensions and rotation flap advancement over the labia minora.

Vulvar Swelling, Plaques, and Nodules in a Young Adult Woman

A 26-YEAR-OLD WOMAN PRESENTS WITH5WEEKS OF VULVAR SWELLING,PRURITUS, and progressively enlarging vulvar plaque accompanied by 2 months of occasional constipation and recurrent bloody, mucoid diarrhea. She has no history of anogenital warts and is monogamous with her husband. She has had no bloodtransfusions, contactwith trichloroaceticacid, spermicides,oranyother toxic agents or irritants. Physical examination reveals bilateral purple swelling of the labium majora and multiple moist, edematous, 1to 8-mm wart-like skin nodules on the perineal and perianal surfaces (FIGURE 1). A 2-mm ulcer is observed inside the right labium minus. Digital rectal examination shows bloody mucus mixed with loose stool. White blood cell count is normal (4 10/L), as is neutrophil count (2.07 10/L);hemoglobin level is slightlydecreased(10.2g/dL).Erythrocyte sedimentation rate is 71 mm/h (reference range, 0-20 mm/h), and C-reactive protein level is 28 mg/L (reference range, 0-5 mg/L). Bacterial and fungal swab cultures from the ulceration are negative. Vaginal and urethral swabs are negative, with moderately increased polymorphonuclear leukocytes. Results of serologic testing for Treponema pallidum and human immunodeficiency virus are negative. What Would You Do Next?

Treatment of recurrent Langerhans cell histiocytosis of the vulva with lenalidomide.

e16555 Background: Langerhans cell histiocytosis (LCH) of the female genital tract is an extremely rare disease. We report a 14 year follow up of a patient with LCH successfully treated with lenalidomide in the relapsed setting. Methods: N/A. Results: A 43 year old Ethiopian woman initially presented to another institution with a nodular lesion on her left vulva with biopsy consistent with LCH. Metastatic workup at the time did not reveal evidence of distant disease. The patient was initially treated with radiotherapy to the vulva and 2 years later she was diagnosed with recurrent disease in the vulva and underwent a wide local excision. Six months afterwards she developed a lesion on her right labium majus consistent with disease recurrence. She was treated with radiotherapy again and underwent a wide radical vulvar excision. She recurred only 3 months later and was started on salvage therapy with thalidomide, 3 years after the initial diagnosis. Within 2 months of starting thalidomide therapy, the patient experienced resolution of vulvar lesions and symptoms. She remained symptom free for 8 years while on thalidomide but then presented to our institution with a new central vulvar lesion after being off therapy for 4 months. Vulvar biopsy confirmed the presence of LCH. She was subsequently restarted on thalidomide and achieved symptom control for an additional 18 months before developing worsening pain and neuropathy associated with therapy. Imaging revealed no evidence of metastatic disease. We then started lenalidomide therapy at dose of 10 mg daily for 21 days in a 28 day cycle and subsequently increased the dose to 25 mg daily continuously. She achieved marked improvement in vulvar symptoms within a month of initiation of lenalidomide. She has tolerated therapy well with no neuropathy or cytopenias. Conclusions: Primary vulvar LCH is a rare disease with no standard therapies. Thalidomide has been described in the literature as an effective treatment option. We describe the use of lenalidomide as an alternative and well tolerated therapy in the relapsed setting. Further investigation is required to determine whether lenalidomide is a viable first line therapy for this rare disease.

Esthiomene: An unusual presentation of elephantiasis

To the Editors Genital elephantiasis is an important medical problem in the tropics as it is associated with physical disability and extreme mental anguish especially in females. Genital elephantiasis is a very rare condition and due to prevalence of sexually transmitted infections (STIs) it is even rarer. Elephantiasis and chronic genital ulceration in women is called ‘Esthiomene’ [1]. A 40­year­old married female, mason by occupation, presented with swelling of the vulva and genital ulcer for the past five years. She complained of difficulty in micturition and difficulty in walking. She also had history of painful swellings in the inguinal region, on both sides, for the past seven years. There was no history of fever, cough with expectoration or weight loss. Her menstrual cycles were regular. She had two healthy children. She gave a history of her husband’s extramarital contacts. On genital examination two large nodular swellings of size 15×7×5 cmwere present involving both the labia majora (Figure 1). Multiple nodules were present on the mons pubis. Multiple superficial and deep ulcers of varying size were present on the inner aspect of both labia majora. Multiple, firm, non­tender, matted lymph nodes involving both the horizontal and vertical groups of inguinal lymph nodes were found bilaterally. Groove sign was present. Per rectal examination was normal. Systemic examination was normal. Mantoux test was negative. X­ray chest and ultrasound abdomen were LETTER TO EDITORS OPEN ACCESS

Lipoma Vulvar: Um Diagnóstico Raro

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Recurrent Vulvar Melanoma in 35-Year-Old Pregnant Women

Vulvar melanoma represents between 3% and 10% of vulvar neoplasms. We present a case of a 34-year-old pregnant woman presenting with a pigmented lesion on the left labium majus; she reported no family history of melanoma. The histological diagnosis was malignant melanoma, superficial spreading type, with Breslow thickness of 0.9 mm; the excision was complete. Eight months before, an atypical genital nevus was completely excised from a nearby location. The pregnancy was finished by cesarean delivery at term, and 3 months later, another pigmented lesion was noticed near but not within the scars. Partial right vulvectomy was performed, and histological diagnosis was malignant melanoma of superficial spreading type, with Breslow thickness of 0.7 mm. The specimen obtained in the first operation was reviewed, and although histological examination was diagnostic for atypical genital nevus, Vysis Melanoma Fluorescence in situ hybridization Probe Kit revealed increased copy numbers of RREB1, which could be consistent with a diagnosis of malignant melanoma.

Comparison between ultrasound parameters and clinical examination to assess fetal head station in labor

Several ultrasound parameters, including intrapartum transperineal ultrasound (ITU) head station, angle of progression (AOP), head-perineum distance (HPD) and head-symphysis distance (HSD), have been suggested to assess fetal head station during labor. The aim of this study was to analyze the relationship between these ultrasound parameters and to compare them with digital palpation. We analyzed 106 stored volume dataset pairs that had been acquired at Stavanger University Hospital, Norway, from nulliparous women at term with prolonged first stage of labor. The volumes were acquired using a three-dimensional transducer applied between the labia majora in a mid-sagittal plane and perineally in a transverse plane. Digitally palpated head station and cervical dilatation were also noted. The results were compared using regression and correlation coefficients. There were good correlations between ITU head station and HPD (r = 0.71), between ITU head station and HSD (r = 0.74) and between HSD and HPD (r = 0.75). Palpated head station showed only moderate correlation with ITU head station (r = 0.52). Cervical dilatation showed a weak correlation with ITU head station (r = 0.30). The ultrasound parameters showed a high degree of correlation with each other, but only moderate correlation to vaginally palpated fetal head station.

Neisseria gonorrhoeae in a prepubertal child

B This two and a half year old female had been in the care of an adult male who was being investigated for sexual abuse based on the disclosure of an older child. On the morning of the child’s appointment the mother noticed a green discharge on the child’s panties. On examination, the labia majora were markedly erythematous (Panel A). Green discharge was present on the panties. A white mucoid discharge at the vaginal area was noted. The mucosa appeared edematous. The hymenal rim was not well demarcated (Panel B), presumably due to swelling. The rest of the exam was normal. A culture of the vaginal discharge was positive for gonorrhea. Gonorrhea in a toddler is highly suggestive of sexual abuse and confirms mucosal contact with infective secretions. The child received a ceftriaxone injection. A follow up examination revealed genital mucosa without discharge or edema. The hymenal rim was normal without tears or scars (Panel C). It is possible that infection is transmitted with exchange of body fluids by intimate touching, but not necessarily intercourse, where child victims have described the offender rubbing their genitals on genital areas. Most child sexual abuse victims will have a normal exam. Follow up labs were negative. The offender’s testing status was unknown. The case was reported to child protection and law enforcement.

Radical resection and reconstruction with bilateral gluteal fold perforator flaps for vulvar hemangiolymphangioma

Hemangiolymphangioma is a rare type of lymphatic malformation characterized by vascular and lymphatic elements on histologic examination [1]. The present paper reports a rare case of vulvar hemangiolymphangioma and the successful surgical reconstruction with bilateral gluteal fold perforator flaps. A 16-year-old patient was referred in August 2012 for progressive swelling of the genitals that had been ongoing for 8 years. The patient complained of intermittent discharge of a white fluid mixed with blood from her perineum since the age of 8 years. On physical examination, erythema and tenderness of the labia majora were present, with friable bleeding upon palpation. Seven months prior to evaluation, the patient had experienced an episode of massive perineal hemorrhage resulting in severe anemia (7 g/dL). The hemorrhage was managed conservatively with pressure and blood transfusions. The following month the patient underwent sclerotherapy, but no subsequent reduction in mass size or symptoms was noted. Given the severity of the patient's condition, the decision was ultimately made to proceed with a radical resection of the involved areas. Bilateral vulvectomy was performed and the resulting defect was reconstructed with bilateral gluteal fold flaps based on internal pudendal artery perforators (Fig. 1). The flap dimensions were 15×6 cm on the right and 17×8 cm on the left side. Both the defect and donor sites were primarily closed (Fig. 2). The postoperative course was

Perineal hernia extruding into the labium majus after multiple surgeries for pelvic organ prolapse

A 78-year-old woman presented with a large bulge in the right labium majus. She had a previous history of two anterior and posterior vaginal wall prolapse repairs, a vaginal hysterectomy for uterovaginal prolapse, a sacrospinous ligament fixation for vaginal vault prolapse, and a LeFort partial colpocleisis for recurrent vault prolapse. Magnetic resonance imaging (MRI) revealed an anterior perineal hernia containing small bowel. Surgery was performed to close the pelvic floor defect through a perineal approach, and polypropylene mesh was used as a bolster. The hernial sac contained small bowel with very thin adhesions. Over 6 months of follow-up, there was no recurrence of the hernia or mesh complications. Perineal hernias after gynecological surgeries for benign diseases are rare. The indications for repair and the optimal surgical approach are not well described.

Reducción funcional y estética de los labios menores: labioplastia con técnica de resección con colgajos especulares en «S»

Women with hypertrophic or enlarged labia minora usually have functional and psychosocial problems. Labial hypertrophy is defined as labia minora that extend beyond the labia majora when the woman is in a normal position. Many affected women have local irritation, interference with sexual intercourse, difficulty with hygiene, and discomfort during walking, sitting, biking or horse-riding. Several surgical techniques can be used to perform labioplasty. One of most common procedures is a simple and straight amputation of the protuberant segments and oversewing of the edge. To prevent the complications associated with this technique, we perform a specular S-shaped resection with interdigitated suturing of the protuberant labium. This technique results in a natural, softer, and more rounded labial edge, with fewer complications. We present our experience in 7 cases with successful outcomes.

Congenital Agenesis of Scrotum and Labia Majora in Siblings

Congenital agenesis of the scrotum and labia majora is very exceptional. To date, only 6 cases of scrotal agenesis have been reported. To our knowledge, the anomalies of the labioscrotal folds in siblings have not yet been reported. We report the complete agenesis of the scrotum and labia majora within the 3 members of the same family. Additionally, successful reconstruction of the neoscrotum was performed for the first time for congenital scrotal agenesis.

English

Accessory breasts are an uncommon entity & more uncommon when it is functioning. They may present as asymptomatic mass along the mammary ridge or symptoms evident during menarche, menstruation, pregnancy & lactation. We report a case of unilateral accessory breast in right axilla which was secreting milk on day 3rd postpartum. CASE REPORT: A 28 years old primipara presented with swelling in right axilla of 4 years duration which slowly increased to present size. The swelling was small in the beginning then in 4th month of pregnancy she noticed marked increase in size. There is also h/o pain in the swelling during menses. Caesarean section was done for cephalo-pelvic disproportion. On 3rd postoperative day she started complaining of pain & milk secretion from the accessory breast. On examination ,a large pendulous swelling was palpable in right axilla, the size being 7cm x 4cm in size , mobile, with skin free from the underlying tissue. It was hyperpigmented with a small opening from where milk could be expressed. Clinically, other pathology of breast was excluded. Sonomammography was done which showed normal breast tissue. Thus a diagnosis of functioning accessory breast was made. She was advised regular feeding with expression of milk from the accessory breast &follow up after 6 months for definite treatment. DISCUSSION: Aberrant breast tissue is usually present along the milk line above or below the normal breast location. This results due to incomplete embryological regression of mammary ridges. Occasionally they are found in unusual locations, such as the axilla, scapula, thigh & labia majora. Accessory breasts occur in 0.4% of women. They may present as asymptomatic masses or cause pain, restriction of arm movements, cosmetic problems, or anxiety. Commonly accessory breasts are bilateral & usually become noticeable only after hormostimulation, during puberty, pregnancy or lactation. Accessory tissue may range from a subcutaneous focus of breast tissue to full accessory breast complete with areola and nipple. When nipple and areola are absent, the diagnosis becomes exceedingly challenging. It may also be a diagnostic challenge, as other benign and malignant lesions occur in the body. Interestingly, soft tissue sarcomas (malignant fibrous histiocytoma) have been reported. Mammographic and sonographic findings include mass like density that is identical of the normal breast parenchyma in the axilla. Fine needle aspiration is a useful tool. Ectopic

A case of aggressive angiomyxoma of the vulva.

Aggressive angiomyxoma (AA) is a rare mesenchymal neoplasm of the female pelvis and vulva, which has a tendency for local recurrence. AA is occasionally misdiagnosed as Bartholin's gland cyst or abscess, lipoma, simple labial cyst, or soft tissue tumors. We describe a case of AA on the outside of the left labium majus pudendi in a 28-year-old female. We were able to make the preoperative diagnosis of AA by magnetic resonance imaging (MRI) and ultrasound (US), and to perform complete surgical excision with a transperineal minimally invasive approach. The novelty of this case is the use of ultrasound for the diagnostic workup of the perineal tumor and determination of the incision line.

Lichen sclerosus of the vulva

Lichen sclerosus is a non-neoplastic chronic inflammatory dermatosis that can affect any cutaneous body surface, showing particular predilection for the anogenital area in females. It is clinically characterized by progressive and worsening degeneration of the dermal/epidermal layers, which determines hyperkeratinization, and a thick scar-like appearance of the external genitalia. Very often, atrophic changes of the genital structures – labia majora and minora, clitoris and vulvar vestibule – are evident with architectural alterations of the genitalia that cause significant sexual discomfort. Chronic and severe vulvar itching, especially at night, is the predominant symptom reported by almost all patients. Diagnosis is often delayed by long-term self-administered topical preparations, or by the clinician’s unawareness of the disease. Indeed, the condition is often misdiagnosed as an aspecific vulvitis. Postmenopausal women are more frequently affected, but young girls and even children may also suffer fro...

Use of dermal fat graft for augmentation of the labia majora

Use of dermal fat graft for augmentation of the labia majora

Granular Cell Tumor of the Vulva

Granular cell tumors are uncommon neoplasms that can involve the skin and subcutaneous tissue. Currently, they are thought to be of neurogenic origin and most likely originate from Schwann cells. This is a case of a 33-year-old woman with a growing vulvar tumor during the past year. Physical examination reveals a 2 × 1-cm mass in the lower third of the right labium majus and adjacent perineal skin. The lesion is excised, and the pathological report informs of the presence of a granular cell tumor. Granular cell tumors are uncommon neoplasms but should always be included as a possibility in the differential diagnosis of vulvar lesions. The treatment of choice is local wide excision, which is curative in most of the cases.