Patent Vagina Research Articles

Isolated distal vaginal hypoplasia and megalourethra in a regularly menstruating female treated by pull through procedure

This case report describes a case of isolated (not associated with other anomalies) lower vaginal hypoplasia complicated by megalourethra (urethral dilatation) due to frequent urethral sexual intercourse in a regularly menstruating (hypomenorrheic) woman. The patient was a 24-year-old woman who underwent transperineal ultrasonography as well as magnetic resonance imaging followed by sequential cystoscopic and vaginoscopic examinations. Finally, a pull-through procedure was used to create a new vagina. The main outcome measure was patent vagina formation. The procedure successfully corrected isolated lower vaginal hypoplasia. The postoperative course was smooth, with the restoration of regular intercourse in the correct location. It was concluded that all gynecologists should have increased awareness of rare female genital anomalies to avoid serious sequelae, particularly in newly married patients.

Aqueous vaginal contrast and scheduled hematocolpos with magnetic resonance imaging to delineate complex müllerian anomalies

To demonstrate the advantage of using aqueous vaginal contrast and scheduled hematocolpos with magnetic resonance imaging (MRI) to improve the delineation of gynecologic anatomy and to recommend that this modality be considered in patients with complex müllerian anomalies. Video demonstration of MRI adjuncts to improve visualization of gynecologic anatomy. Academic Hospital. A patient with obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) who presented for definitive surgical management. OHVIRA is a unilateral obstructed müllerian anomaly that presents typically after menarche with progressively worsening dysmenorrhea caused by progressive distension of the obstructed hemivagina and uterine horn. The definitive treatment for this anomaly is resection of the unilateral obstruction. When the obstructed hemivagina is within close proximity to the patent hemivagina, vaginal septum resection should be performed to relieve the obstruction successfully. However, when the obstructed hemivagina and uterine horn are not adjacent to the patent hemivagina, a simple septum resection is not feasible and there is a high rate of restenosis if anastomosis is attempted. In this case, laparoscopic removal of the obstructed uterine horn, fallopian tube, cervix, and vagina should be considered as an alternative approach to resolving the obstruction. A surgical approach can be recommended only once the surgeon has a clear understanding of the patient's pelvic anatomy and the magnitude of the obstruction. In the presented case, a 17-year-old patient with OHVIRA presented for definitive surgical management. While on hormonal suppression, a pelvic MRI was performed that identified a uterus didelphys with a left hemiuterus and cervix communicating with a patent vagina. The right hemiuterus and cervix were measured 2.5 cm from the patent vagina. However, because of hormonal suppression, the vaginal cavity was decompressed, making it very difficult to discern the relationship between the two uteri and vaginas. To better determine whether vaginal septum resection to relieve the obstruction was feasible, norethindrone was discontinued to allow menstrual blood to fill the obstructed hemivagina followed by a subsequent pelvic MRI with aqueous vaginal contrast to fill the patent vagina with contrast gel to improve the visualization of the decompressed vaginal cavities. Advantage of aqueous vaginal contrast and scheduled hematocolpos with MRI to image pelvic anatomy in a patient with a complex müllerian anomaly to guide surgical decision-making. The addition of vaginal aqueous contrast clearly delineated the course and caliber of the patent vagina and its relationship to the obstructed hemivagina, now filled with blood. The inferior margin was in closer proximity to the patent vagina, but with only a very narrow segment (<1 cm) adjacent to the patent vagina and the obstructed cervix was displaced superiorly, now measuring 3.5 cm above the patent vagina. Surgical management options were discussed with the patient, and given the superior location of the obstructed uterus and cervix with only a narrow border of the vagina in continuity with the patent vagina, the risk of postoperative stenosis after vaginal septum resection was determined to be too high. The decision was made to proceed with a laparoscopic resection of the obstructed right side, and the patient underwent laparoscopic resection of the right hemiuterus, fallopian tube, cervix, and vagina. Intraoperatively, a survey of the pelvis again confirmed that the two vaginas were too far to reconnect safely without a high risk of stenosis. The patient recovered without complications postoperatively and her menses resumed without any pain. We highlight the use of two techniques to optimize MRI imaging of pelvic anatomy in a patient with a complex müllerian anomaly. First, the use of aqueous vaginal contrast with MRI is advantageous to clearly delineate the course and caliber of the patent vagina in patients with complex gynecologic anatomy. Second, cessation of hormonal suppression to allow menstruation to cause hematocolpos helped delineate the relationship between the obstructed vagina and patent vagina. In the presented case, these MRI adjuncts provided necessary detail that could not be appreciated with standard MRI to confirm that vaginal septum resection to preserve the right uterus would be too high a risk for postoperative stenosis in this patient. Aqueous vaginal contrast and scheduled hematocolpos should be considered as adjuncts to MRI when standard imaging modalities are unable to clearly describe the relationship between pelvic structures in cases of complex müllerian anomalies to help guide treatment recommendations.

AQUEOUS VAGINAL CONTRAST AND SCHEDULED HEMATOCOLPOS WITH MAGNETIC RESONANCE IMAGING TO DELINEATE COMPLEX MÜLLERIAN ANOMALIES

To demonstrate the advantage of using aqueous vaginal contrast and scheduled hematocolpos with MRI to improve the delineation of gynecologic anatomy, and to recommend that this modality be considered in patients with complex müllerian anomalies. OHVIRA is a unilateral obstructed müllerian anomaly that can be definitively treated with resection of the obstruction. When the obstructed hemivagina is within close proximity to the patent hemivagina, vaginal septum resection should be performed. However, when the obstructed hemivagina and uterus are not adjacent to the patent hemivagina, the risk of post-resection stenosis is increased due to the thickness of the obstructing tissue. Laparoscopic removal of the obstructed side should be considered as an alternative approach. In the presented case, a 17-year-old patient with OHVIRA presented for definitive surgical management. A pelvic MRI was performed, but due to hormonal suppression the vaginal cavity was decompressed, making it very difficult to discern the relationship between the two uteri and vaginas. To better determine whether vaginal septum resection was feasible, norethindrone was discontinued to allow menstrual blood to fill the obstructed hemivagina, followed by a subsequent pelvic MRI with aqueous vaginal contrast gel to improve the visualization of the decompressed vaginal cavities. The addition of vaginal aqueous contrast clearly delineated the course and caliber of the patent vagina and its relationship to the obstructed hemivagina, now filled with blood. The inferior margin had a <1 cm narrow segment adjacent to the patent vagina, and the obstructed cervix was superiorly displaced 3.5 cm above the patent vagina. Given these findings, the risk of post-operative stenosis following a vaginal septum resection was determined to be too high. The decision was made to proceed with a laparoscopic resection of the obstruction, and a laparoscopic resection of the right hemiuterus, fallopian tube, cervix, and vagina was performed. The patient recovered without complication post-operatively, and her menses resumed without any pain. We highlight the use of two techniques to optimize MRI imaging of pelvic anatomy in a patient with a complex müllerian anomaly. First, the use of aqueous vaginal contrast is advantageous to clearly delineate the course and caliber of the patent vagina. Second, the cessation of hormonal suppression to allow menstruation to develop hematocolpos helped delineate the relationship between the obstructed vagina and the patent vagina. These MRI adjuncts provided necessary detail that could not be appreciated with standard MRI to confirm that vaginal septum resection to preserve the right uterus would be too high risk for post-operative stenosis in this patient.

Endoscopic treatment with concomitant ultrasound monitoring of obstructive septum in Robert's uterus following pregnancy

Background: To further understand Robert’s uterus and sum up the experience of diagnosis and treatment for Robert’s uterus. A 17-year-old woman came to our hospital for dysmenorrhea in 18 April 2012. She had had severe dysmenorrhea [VAS (visual analogue scales): 6 marks] since her menarche occurring in December 2010. Gynecological examination: patent vagina and a smooth cervix. Type-B ultrasonic instrument indicated two uterine cavities. The right uterine cavity contained a liquid anechoic area. There was no continuous echo between the right uterine inferior segment and cervical canal, and there was only a cervical echo. For further diagnosis and treatment, the patient underwent hysteroscopy combined with laparoscopy. The patient was diagnosed with Robert’s uterus and received removal of the uterine septum. Five years later, the patient smoothly gave a full-term baby boy. Conclusion: Gynaecologists must pay close attention to the primary dysmenorrhea occurring in juvenile females in order to find uterine malformation early as much as possible.

1655 Laparoscopic Unification of Non Communicating Horn with Hemi-Uterus

Video Objective To demonstrate new idea of laparoscopic unification of functional non – communicating horn with hemi-uterus instead of removal to improve obstetric outcome in future. Setting an academic tertiary care hospital. A 14-year-old girl presented with complaints of pain in lower abdomen, on and off for 2 months. Her previous 2 cycles were regular; she had cyclic dysmenorrhoea since her menarche which was now become intolerable and continuous. Secondary sexual characteristic was normal. hormone profile normal and on local examination normal external genitalia found. A thin dilator passed into vagina to confirm patent vagina. ultrasound suggested a unicornuate hemi uterus and right non communicating horn with a turbid collection. MRI also confirm the same. Interventions On Hysteroscopy a small right uterine cavity with only one ostium on right. Cervical canal was normal with normal crypts. vagina also normal and spacious. On diagnostic laparoscopy: A unicornuate right hemi- uterus with a non-communicating left horn was noted on the right side of the round ligament, tube and ovary were seen normal with small hemi-uterus. On the left, small uterine horn seen with absent tube but normal ovary and round ligament attachment. First, we were planned resection of non-communicating horn as described in literature but after assessing the anatomical proximity and good size of horn and small size of hemi-uterus we decided for unification of both. After injecting diluted inj. vasopressin, linear medial incision given in full thickness of myometrium with monopolar energy and opening the cavity with scissors. Both the walls sutured together first posteriorly and then anteriorly in double layer with no. 1 polyglactin 910 suture. Conclusion Good normal size, shape and contour of uterus appreciated after completion of procedure. After surgery patient had one normal menses without any pain suggest success of surgery.

Laparoscopically Assisted Vaginal Pull-Through in 7 Cases of Congenital Adrenal Hyperplasia with High Urogenital Sinus Confluence: Early Results.

Surgical management of the high urogenital sinus (UGS) is challenging. Presence of a short urethra is a contraindication for UGS mobilization as this is likely to affect urinary continence. In addition, vaginal reconstruction of the high suprasphincteric confluence is complex and prone to complications and failure. This study included 7 girls who underwent a laparoscopically assisted vaginal pull-through in the past 2 years. All cases included were diagnosed with congenital adrenal hyperplasia (CAH), with a high UGS, and a short urethra of ≤15 mm above the confluence. Patients were preoperatively assessed by genitography. Mobilization of the vagina was pursued until the confluence became visible and the vaginal caliber tapered off at its junction with the urethra. The connection was sutured or clipped and divided. Uterine round ligaments were divided to allow delivering the vagina to the perineum with minimum tension. The tract for the pull-through was created and the vagina was pulled outside and sutured to the perineal skin. Good vaginal mobilization allowed a direct perineal anastomosis without skin flap augmentation of the vaginal wall. Clitoroplasty and labiaplasty were deferred. Mobilization of the vagina was possible in all cases attempted, without injuries to the adjacent pelvic structures. Calibration and dilatation started 2 weeks postoperatively. At 12-month follow-up, all the patients had a patent vagina with good caliber, and were able to retain urine without dribbling. The laparoscopically assisted vaginal pull-through approach provides optimal exposure, facilitates vaginal dissection, separation from the urethra, and avoids injuries to the urinary structures. This allows vaginal reconstruction without tension.

82: The treatment of vaginal shortening with autologous buccal mucosa graft augmentation without vaginal mold

To present a case in which vaginal shortening after hysterectomy was treated with an autologous buccal mucosa graft augmentation without vaginal mold. A 61-year-old woman 5 years status post robotic-assisted hysterectomy with foreshortened vagina and vaginal stricture sought care secondary to dyspareunia and limited ability to have sexual intercourse. Gynecologic examination revealed a narrow vaginal introitus and 4cm vagina, surgically absent cervix and uterus, normal reflexes and external and rectal examination. MRI revealed an additional 3cm of scarred vagina proximal to the 4cm of patent vagina. The patient was counselled on potential treatment option including progressive vaginal dilation, surgical exploration, creation of neovagina with bowel or skin, and novel autologous buccal mucosal placement without the use of mold. This technique avoided the traditional 5-7 days of bedrest required when a vaginal mold is used. She consented and was taken to the operating room where blunt and sharp dissection were used to prepare the vagina for graft. Bilateral buccal mucosa grafts were harvested with careful attention was used in identifying the Stenson duct and buccinator muscle (Figure 1). Both buccal mucosal grafts were then prepared and defatted. To obtain optimal size of each graft, and to prevent hematoma/seroma accumulation, the grafts were meshed using a 3:1 mesher. The buccal mucosa was then attached to the underlying posterior fibromuscularis region using 2-0 PDS interrupted suture. A 60-degree Z-plasty was performed at the perineal body allowing the vaginal opening to admit 3 fingerbreadths. The vagina was then packed with estrogen cream. Post-operatively, the patient’s pain was well controlled on by-mouth pain medications and chlorhexidine mouthwash, and was discharged home on postoperative day 1. She was given strict pelvic rest precautions. She was instructed to follow up twice weekly for 4 weeks post operatively for peroxide vaginal irrigation and 4 grams of estrogen cream application under direct visualization. By her 1 week follow up she denied significant vaginal tenderness and by her 4-week postoperative visit, the incisions in her mouth were completely healed. She continued 4 grams of estrogen cream per vagina twice weekly. At 8-weeks post-op her vagina was 8 cm long and able to admit 3 fingerbreadths comfortably. She reported being very satisfied with the result. Vaginal shortening after hysterectomy can be repaired using autologous buccal mucosal grafting without the need for a vaginal mold or 5-7 days of bedrest. Hysterectomy can lead to significant vaginal shortening which can decrease patient quality of life and impede penetrative intercourse. Buccal mucosa can be harvested and used without a vaginal mold or multiday bedrest for patients with vaginal foreshortening. Care for patients with vaginal shortening requires a multidisciplinary approach given the complex anatomy of these patients.

Transverse Vaginal Septum With Secondary Infertility: A Rare Case

Study ObjectiveTo demonstrate the technique of laparoscopic vaginal reconstruction in a rare case of mid-vaginal septum with secondary infertility. DesignA step-by-step explanation of the technique using videos and pictures (Canadian Task Force classification IV). SettingTransverse vaginal septum is a rare condition, with an incidence of only 1 in 30,000 women. It is usually a congenital mullerian fusion defect; few cases of acquired septum have been reported. Roughly 40% of cases occur in the mid-vagina. Transverse vaginal septum typically presents with primary amenorrhea and hematocolpos. The goal of surgery is to create a patent vagina with restoration of fertility. The laparoscopic approach has proven superiority over the open technique. InterventionsLaproscopic vaginal reconstruction was performed in a 24 year female with transverse vaginal septum. Dissection was done laproscopically up to mid vagina. Incision was given on vagina excising the septum followed by reconstruction. ConclusionThe laparoscopic approach to vaginal reconstruction avoids the abdominal incision, with its associated pain and possible adhesion formation. It also provides a better view for dissection. In this patient, a patent vagina was created in a single operation, with no postoperative dyspareunia, and fertility was restored.

Concurrent imperforate hymen and transverse vaginal septum: A rare presentation and management with minimal invasive technique

A 13 year old girl not attained menarche presented as a case of acute abdomen; she had a mass per abdomen, on ultrasound diagnosed as haematometra and hematocolpus; clinically had an imperforate hymen; further evaluation by MRI revealed a high vaginal cause of obstruction which cannot be differentiated as vaginal atresia or a combination of transverse vaginal septum and imperforate hymen; operative findings showed a imperforate hymen with a patent lower vagina and a transverse vaginal septum separating upper and lower vagina; surgical correction done and drained 1000 ml of blood and post operatively patient is followed up for a month and bleeding through vagina during the next cycle is noted showing the patent vagina. This is a first case of concurrent transverse vaginal septum and imperforate hymen without any other genitourinary anomalies in literature.

Tissue Engineering a Complete Vaginal Replacement From a Small Biopsy of Autologous Tissue

In women, a healthy, patent vagina is important for the maintenance of a good quality of life. Apart from congenital abnormalities, such as cloacal exstrophy, intersex disorders, and an absence of the posterior two thirds of the organ, individuals may also suffer from cancer, trauma, infection, inflammation, or iatrogenic injuries leading to tissue damage and loss -- all of which require vaginal repair or replacement. Of necessity, reconstruction is often performed with nonvaginal tissue substitutes, such as segments of large intestine or skin, which are not anatomically or functionally ideal (Hendren and Atala, J Urol 1994; 152: 752; Hendren and Atala, J Pediatr Surg 1995; 30: 91). Whenever such tissue is used additional complications often ensue, such as strictures, infection, hair growth, graft shrinkage, diverticuli, and even malignancy (Filipas et al., BJU Int 2000; 85: 715; Lai and Chang, Changgeng Yi Xue Za Zhi 1999; 22: 253; Parsons et al., J Pediatr Surg 2002; 37: 629; Seccia et al., Ann Plast Surg 2002; 49: 379; Filipas, Curr Opin Urol 2001; 11: 267). Using a rabbit model, we report here the construction of a functional vagina using autologous cells expanded from a small vaginal biopsy. RESULTS.: Six months after total vaginal replacement, radiographic analysis of rabbits implanted with the neovagina demonstrated wide, patent vaginal calibers without strictures. Histologic analysis revealed well-organized epithelial and muscle cell layers. Physiologic studies showed normal-range responses to electrical stimulation or to an adrenergic agonist. These data indicate that a tissue engineering approach to clinical vaginal reconstruction in women is now a realistic possibility.

Phodopus campbelli detect reduced photoperiod during development but, unlike Phodopus sungorus, retain functional reproductive physiology

Golden (Mesocricetus auratus) and Siberian (Phodopus sungorus) hamsters are widely used as animal models for seasonal reproduction; but M. auratus shows no developmental delay in short days until after sexual maturity, whereas P. sungorus juveniles delay development in short days. As the photoperiodic response of Phodopus campbelli is not well established, litters of the two Phodopus species were gestated and reared under long days (14 h light:10 h darkness) or short days (10 h light:14 h darkness) until 70 days of age. As expected, under short photoperiod P. sungorus showed reduced body, testes, epididymides, uterus, and ovary weight; antral follicles and corpora lutea were absent and vaginae remained closed. Animals moulted to winter pelage, and low concentrations of each of leptin, testosterone, and prolactin were present in male serum. Phodopus campbelli juveniles also responded to the short photoperiod as measured by reduced body, testes, epididymides, and ovary weight. The summer pelage persisted. However, both sexes of P. campbelli developed functional reproduction under 10 h light:14 h darkness. All females had a patent vagina by 10 weeks; ovaries contained antral follicles and corpora lutea, and uteri were not reduced in weight. In males, the concentrations of testosterone, leptin, and prolactin were not reduced by short photoperiod. Developmental patterns in the three species of hamster, therefore, differ and are not predicted by relatedness or latitude of origin. Other ecological traits, such as predictability of summer rainfall, ambient temperature, and differential responses to social cues might be important.

The pitfalls of vaginal construction

To evaluate a group of young women undergoing complex vaginoplasty, which may be defined as where there has already been previous complex pelvic surgery and the patient is unsuitable for conservative treatment or minor surgical revision. All patients who had undergone a complex vaginoplasty between 1997 and 2004 were reviewed retrospectively. Information was recorded on the underlying condition, previous surgery and preoperative assessment. The operative technique and complications were noted, and the outcome in terms of menstruation and sexual activity. In all, 15 patients fulfilled the criteria (mean age 22.2 years, range 17-36) and the mean follow-up was 4.75 (0.75-7) years. Fourteen patients had complex congenital anomalies of the lower genital tract and 11 of these had associated anomalies of the urinary and gastrointestinal system; four were XY females. The 15 patients had had 31 vaginal procedures, including ileal vaginoplasty, mobilization of perineal skin flaps and split-skin grafting. Three patients required osteotomies to increase pelvic outlet diameter. The commonest complications were stenosis (six patients) and fistula formation (four). Eight patients are now sexually active; the remaining seven have not attempted sexual intercourse. Complications are common and can be major; most patients require many repeat operations to achieve a patent vagina. Unfortunately at present, this is the only option for this group of young women to achieve a functional vagina. Patients with complex congenital anomalies of the reproductive and genital tracts are increasingly surviving into adulthood, and the numbers of these patients is likely to increase in the future.

Congenital Juvenile Granulosa Cell Tumor of the Testis in a Fetus Showing Full 69, XXY Triploidy

Testicular juvenile granulosa cell tumor (TJGCT) occurs predominantly in infancy and may be associated with sex chromosomal abnormalities. We report a fetus aborted because of cytogenetically confirmed complete XXY triploidy. External genitalia of the fetus were female, with a short and patent vagina. The tumor presented as an abdominal multicystic mass with typical histologic and immunohistological features of JGCT. It was connected with a tubular uterus-like structure. The other gonad was an inguinally localized testis that showed histologically a Sertoli cell adenoma. Malformations typical for triploidy were also present: agenesis of the corpus callosum, stenosis of the pulmonary ostium, and hypoplasia of the lungs and adrenals. To our knowledge this is the first case of TJGCT in a triploid fetus.

Abdominal-retroperitoneal sacral colpopexy for the correction of vaginal prolapse

Complete genital or vaginal prolapse affects a large number of middle-aged to elderly females. Satisfactory correction of prolapse with maintenance of vaginal patency has been a challenge to the pelvic surgeon for many years. We present a retrospective review of 147 patients undergoing abdominal sacral colpopexy using dacron graft or expanded polytetrafluoroethylene. The anatomical basis of repair, operative technique, and results are described. Ninety-three percent of the patients experienced long-term success over 5 years, including those with previous failed repairs. Both short- and long-term complication rates were acceptable. Only four patients experienced graft erosion, and only one of those had recurrent prolapse. Abdominal sacral colpopexy offers those affected with genital prolapse an opportunity for long-term relief, with maintenance of a patent vagina.

Reproductive anatomy and gametogenesis inShipleya inermis(Cestoda: Dioecocestidae)

Study of the reproductive anatomy in 65 strobilae of the dioecious cestode Shipleya inermis Fuhrmann, 1908 (Acoleata: Dioecocestidae) showed that a common genital duct, probably arising through fusion of the vas deferens and the proximal portion of the vaginal duct, compensated functionally for the loss of a patent vagina. Gonochorism was characteristic, but rudimentary genital organs of the opposite sex were present in 26% of males and 9% of females; two strobilae (3%) were hermaphroditic. Hermaphrodites had normally developed male organs and were capable of cross-fertilization as males; their female organs were much reduced in size but were functional, and eggs or fertilized ova in the uteri indicated that self-fertilization occurred. Gametogenesis was traced, mainly in chromosomal preparations. The diploid chromosomal complement in embryos and germ-line cells consisted of four pairs of homologues (2n = 8, n = 4, FN = 14). Based on observation in female cestodes of one pair of chromosomes having non-homologous or non-pairing segments due to influence of heterochromatin, the authors suggest that females produce gametes of two types relative to heterochromatic DNA, while males are homogametic, and that sex-determining effects are associated therein. In males, meiosis included chromosomal pairing and recombination, after which heterochromatin was eliminated from germline cells through fragmentation. Other biological characteristics of S. inermis in the hosts, Limodromus spp. (Charadriiformes), are briefly discussed.

Didelphys with unilateral vaginal obstruction and ipsilateral renal agenesis ? neonatal management

The syndrome of duplication of the uterovaginal tract with unilateral vaginal obstruction and ipsilateral renal agenesis is well described as presenting in the teenage female with haematometrocolpos. I present two patients who were diagnosed in the neonatal period when they presented with perineal cystic swellings. The patent vagina was seen as a slit-like opening on the side of the cyst. Diagnosis is made by vaginogram through this slit and by injection of radio-opaque material into the cyst. Intravenous pyelography is essential. Management is by simple “decapping” of the cyst and vaginal dilatations.

The double uterus associated with an obstructed hemivagina and ipsilateral renal agenesis

Twelve patients with a double uterus, unilateral vaginal obstruction, and ipsilateral renal agenesis are described. The clinical presentation varies, depending on whether the obstruction was partial or complete. In rare instances a communication existed between the obstructed vaginal pouch and the opposite patent vagina through a defect in the septum of the double uterus. Early accurate diagnosis followed by the excision of the obstructing vaginal septum offers complete relief of symptoms while preserving reproductive capacity.