Posterior Fourchette Research Articles

Increased blood flow and erythema in the posterior vestibular mucosa in vulvar vestibulitis

OBJECTIVE: To evaluate vascular changes as a possible underlying cause of mucosal erythema in women with vulvar vestibulitis. METHODS: Laser Doppler perfusion imaging was used to map the superficial blood flow in the vestibular mucosa in 20 women with vestibulitis and in 21 healthy control subjects. A possible correlation between perfusion values and graded erythema (1–5) around the vaginal introitus was analyzed. Changes in microvascular density in the posterior part of the mucosa were investigated in sections from ten patients and ten controls by a computer-assisted image-processing program. Induced vasoconstriction of terminal arterioles in the same posterior area was also studied. RESULTS: Significant increases in perfusion values were registered in the posterior parts of the vestibular mucosa in patients compared with controls. The highest blood flow was registered in the posterior fourchette. The most pronounced erythema was also located in the posterior vestibule in the patients. However, there was no significant correlation between perfusion values and degree of erythema in the same individual. The microvascular density or the ability of vestibular arterioles to constrict did not differ between patients and controls. CONCLUSION: Women with vestibulitis have an increased superficial blood flow and erythema in the posterior parts of the vestibular mucosa. The increased perfusion, most probably caused by a neurogenic vasodilatation contributes to, but does not fully explain the erythema. Atrophic changes of the surface epithelium should also be considered in the evaluation of an erythema.

Increased Blood Flow and Erythema in the Posterior Vestibular Mucosa in Vulvar Vestibulitis

In Brief OBJECTIVE To evaluate vascular changes as a possible underlying cause of mucosal erythema in women with vulvar vestibulitis. METHODS Laser Doppler perfusion imaging was used to map the superficial blood flow in the vestibular mucosa in 20 women with vestibulitis and in 21 healthy control subjects. A possible correlation between perfusion values and graded erythema (1–5) around the vaginal introitus was analyzed. Changes in microvascular density in the posterior part of the mucosa were investigated in sections from ten patients and ten controls by a computer-assisted image-processing program. Induced vasoconstriction of terminal arterioles in the same posterior area was also studied. RESULTS Significant increases in perfusion values were registered in the posterior parts of the vestibular mucosa in patients compared with controls. The highest blood flow was registered in the posterior fourchette. The most pronounced erythema was also located in the posterior vestibule in the patients. However, there was no significant correlation between perfusion values and degree of erythema in the same individual. The microvascular density or the ability of vestibular arterioles to constrict did not differ between patients and controls. CONCLUSION Women with vestibulitis have an increased superficial blood flow and erythema in the posterior parts of the vestibular mucosa. The increased perfusion, most probably caused by a neurogenic vasodilatation contributes to, but does not fully explain the erythema. Atrophic changes of the surface epithelium should also be considered in the evaluation of an erythema. Women with vulvar vestibulitis have an increased superficial blood flow and erythema in the posterior parts of the vestibular mucosa.

Adolescent Sexual Assault: Documentation of Acute Injuries Using Photo-colposcopy

Objective: To document the frequency and types of genital injuries in adolescent women examined acutely following a sexual assault, and determine any historical correlates of injury. Design: Retrospective chart review. Setting: Sexual Assault Response Team services at a community hospital in an urban setting. Patients: All female patients aged 14–19 yr who were referred by law enforcement for an acute sexual assault examination and were examined between May 1994 and May 1999. Outcome Measures: The frequency of signs of genital trauma at various anal and genital sites, as recorded by the examining clinician. Results: Charts of 214 female subjects (mean age 16.3 yr) were reviewed. The most common findings were posterior fourchette tear (36%); erythema of the labia minora, hymen, cervix, or posterior fourchette (18%–32%); and swelling of the hymen (19%). Time to examination was highly correlated with the degree of injury noted ( P = .000). The incidence of hymenal tears in self-described virgins was higher than in nonvirgins (19% vs. 3%, P = .008); however, the total number or severity of other injuries was not significantly higher in virgins. Victims reporting anal penetration had a higher frequency of anal injuries than those who denied such contact (14/31, 61% vs. 2/150, 1%; P = .000). Conclusions: Tears of the posterior fourchette or fossa were the most common findings (40%). Hymenal tears were uncommon, even in self-described virginal girls. Timely examination of adolescent victims is important to document injuries; however, many victims will still not have signs of bruising, abrasions, or tears.

Advantages of a posterior fourchette incision in anal sphincter repair.

Delayed repair of obstetric-related anal sphincter injury remains problematic, and perineal wound breakdown is common. The aim of this study was to assess the outcome after overlap anal sphincter repair and to determine the advantages, if any, of a posterior fourchette incision (n = 18) compared with a conventional perineal incision (n = 32). Fifty females of mean parity 2.8 (standard deviation, 1.6) underwent repair in a five-year period. The mean follow-up was 23 months. Assessment was by anal vector manometry, endoanal ultrasound, and continence scoring. Functional outcomes were similar in the two groups. Repair increased squeeze-pressure increment and improved continence scores in both groups. Postoperative wound complications were fewer when a posterior fourchette incision was used compared with a perineal incision (11 vs. 44 percent, respectively; P < 0.05). Delayed anal sphincter repair improves continence. A posterior fourchette approach is associated with fewer postoperative wound complications without compromising the quality of repair and the functional outcome.

Association of a posterior fourchette finding with other evidence of sexual abuse in prepubertal females

BACKGROUND: We have noted a clinical finding in the genital exam of prepubertal females which has not been previously reported in the literature: thinning or diminution of the posterior fourchette.OBJECTIVE: To determine whether thinning of the posterior fourchette is associated with child sexual abuse.METHODS: We performed a case-control study of girls referred to an inner-city public hospital child protection center evaluating 200-250 new patients/year. Logbooks recording every patient seen in the center were used to identify cases and controls. Cases were all 3 to 11 year old prepubertal females who were seen for a sexual abuse evaluation between 1995 and 2000 who had posterior fourchette thinning. Controls were all prepubertal females seen during the study period who matched cases on age, date of visit, ethnicity and examiner, but had normal posterior fourchettes. Medical records were reviewed to confirm eligibility and supplement information about subject disclosure of sexual abuse and physical findings. Cases and controls were compared for evidence of sexual abuse, defined as disclosure of sexual abuse and/or abnormal hymenal findings (transection or thinning). As per protocol, determination of all genital findings was made by 1 of 2 examiners blinded to details of the patients disclosure.RESULTS: 475 girls age 3 to 11 (pubertal and prepubertal) were evaluated for possible sexual abuse. There were 37 cases who were prepubertal with a thinned posterior fourchette, and 89 matched controls. Included in this analysis were the 32/37 cases (86%) and 81/89 controls (91%) with complete data (range 1-4 controls per case). 87.5% of cases had evidence of sexual abuse compared to 24.7% of controls (OR = 21.14, p < .001). These results remained significant even after excluding the 19 cases and 4 controls with abnormal hymenal findings (69.2% vs 20.8%, OR = 8.6, p = .001). In a multiple logistic regression adjusting for age, ethnicity, examiner and date of visit, cases were significantly more likely than controls to have evidence of sexual abuse (adjusted OR = 22.8, p < .001).CONCLUSIONS: In a case-control study of prepubertal girls, thinning of the posterior fourchette was associated with evidence of sexual abuse. Confirmation of these results will require prospective study.

Attachment of the rectovaginal septum to the pelvic sidewall

Objective: To describe the lateral attachment of the rectovaginal fascia to the pelvic sidewall. Study Design: A descriptive study was performed with use of 10 embalmed female cadaveric pelves, each sectioned in the midsagittal plane. The lateral attachments of the pubocervical fascia and the rectovaginal fascia to the pelvic sidewall were examined. Results: The rectovaginal fascia attaches to the pelvic sidewall along a well-defined line. It extends from the perineal body toward the arcus tendineus fasciae pelvis with which it converges approximately midway between the pubis and the ischial spine to form a y configuration. This point of convergence occurs an average of 4.8 cm from the ischial spine, 3.75 cm from the pubic symphysis, and 4.15 cm from the posterior fourchette. Conclusion: The rectovaginal fascia supports the posterior compartment analogous to the pubocervical fascia in the anterior compartment. Moreover, landmarks are identified that will aid suture placement during repair of posterior compartment defects. (Am J Obstet Gynecol 2001;185:41-3.)

Signs of genital trauma in adolescent rape victims examined acutely

Background: Adolescent females are the most frequent victims of sexual assault, but studies to document the presence of genital findings in patients examined within 72 hours, using magnification and dye, have not been published. This study was designed to document the frequency and types of genital injuries in adolescent women following acute sexual assault, using chart and photograph review.Methods: A retrospective chart review was done of examination records of all female patients age 14 to 19 years of age who were evaluated at a Sexual Assault Response Team program over a 5 year period. Data was abstracted from charts by the nurse examiners, and photographs were evaluated by the physician reviewer. Analysis was done to determine the frequency, location, and severity of genital and anal injuries, and any historical factors correlating with injury, using Pearson correlation and two-tailed t tests.Results: Charts of 214 female subjects (mean age 16.3 years) were reviewed. The most common findings recorded by the nurse examiner were posterior fourchette tear (36%), erythema of the labia minora, hymen, cervix or posterior fourchette (18% to 32%), and swelling of the hymen (19%). Uptake of Toluidine dye was noted in 66% of patients in whom it was applied. Overall, 21% of patients were found to have no findings, and 40% had tears of the posterior fourchette or fossa. Time to examination was highly correlated with the degree of injury noted (p = .000). The incidence of hymenal tears in self-described virgins was higher than in non-virgins (19% vs. 3%, p = .008), however the total number or severity of other injuries was not significantly higher in virgins. Reported anal penetration was associated with a high frequency of anal bruising, abrasions or tears (14/23, 61%), while only 2/150 victims who denied anal penetration had tears (1%, p = .000). Victims who reported multiple physical symptoms such as pain, nausea, or vomiting were significantly more likely to be older (p = .034) and to have an increased number of non-genital injuries such as bruising, abrasions, and bite marks (p = .001). A higher number of non-genital injuries was also correlated with a higher number of total genital injuries (p = .003).Conclusions: Adolescent victims of sexual assault who were examined within 72 hours, using a magnification and dye were found to have tears of the posterior fourchette or fossa in 40% of cases. Hymenal tears were rare, even in self-described virginal girls. Timely examination of adolescent victims is important to document injuries, however, many victims will still have non-specific examination findings.

Vulvar vestibulitis syndrome: a descriptive study and assessment of response to local steroid and topical clindamycin treatment

Seventy-six women with insertional dyspareunia and clinical features of vulvar vestibulitis syndrome (VVS) were followed prospectively. The mean age was 26.4 years and the mean duration of symptoms prior to attending the department was 2.7 years. Twenty-nine per cent of women were considered by other clinicians to have no physical cause for their symptoms and had been initially referred for psychosexual counselling. Most women (53/76) had small, localised areas of intoital erythema and tenderness and 15 women revealed, in addition, erythema extending on to the posterior fourchette. Eight women had more extensive introital erythema associated with a distal vaginitis, some of whom exhibited microscopic features suggestive of a desquamative vaginitis in addition to VVS. Approximately 20% of women with localised areas of introital erythema and tenderness responded to a topical potent steroid or to intralesional injection of triamcinolone. Further controlled, long-term follow-up studies using objective methods of clinical assessment are urgently needed.

Patterns of Genital Injury in Female Sexual Assault Victims

San Luis Obispo County Sexual Assault Response Team, San Luis Obispo General Hospital, and California Polytechnic State University, San Luis Obispo, California. Am J Obstet Gynecol 1997;176:609-616.

Patterns of genital injury in female sexual assault victims

OBJECTIVE: New colposcopic protocols allow examiners to better document genital trauma in rape victims. We report our findings on the locations and types of genital injury seen in female assault victims versus women engaging in consensual sex. STUDY DESIGN: Physical examinations were performed on 311 rape victims seen by San Luis Obispo County's Suspected Abuse Response Team between 1985 and 1993 and contemporaneously on 75 women after consensual sexual intercourse. RESULTS: Among 213 (68%) victims with genital trauma, 162 (76%) had 3.1 mean sites of injury. Comparatively, 8 (11%) consenting women had just single-site trauma. Two hundred (94%) victims had trauma at one or more of four locations, as follows: posterior fourchette, labia minora, hymen, fossa navicularis. Trauma types varied by site; tears appeared most often on the posterior fourchette and fossa, abrasions appeared on the labia, and ecchymosis was seen on the hymen. CONCLUSION: A localized pattern of genital trauma can frequently be seen in women reporting nonconsensual sexual intercourse; such findings are useful for the clinical forensic examiner.(Am J Obstet Gynecol 1997;176:609-16.)

Accidental genital injuries in prepubertal females: Aprospective study

Background Differentation of accidental genital trauma from inflicted injury is important. Limitations of retrospective studies describing unintentional injuries in the past include (1)lack of uniform examination by experienced observers and (2)the possibility that sexually abused children were included in the study. The purpose of this study was to prospectively evaluate and describe the injuries incurred by prepubertal females as the result of accidental trauma. Methods Twenty-six prepubertal females who presented to a children's hospital emergency department between 6/94 and 7/95 with the chief complaint of genital trauma that had been either witnessed or resulted immediately after the child was noted to have performed an activity likely to cause an accidental injury (eg, riding a bicycle) were prospectively evaluated by one of two skilled observers. Statistics were performed using SPSS for Windows. Results Twenty-six Tanner 1 females met criteria for the study. Ages ranged from 2 to 9 years (mean age = 3.5). Mechanisms of injury were as follows: fall onto a stationary object (34.6%), straddling a bicycle (26.9%), bathtub related (15.4%), injury from playground equipment (15.4%), and straddling a pool (7.7%). One child had no injuries but bleeding from a prolapsed urethra. The most frequently injured structure was the labia minora (12/25, 48%), followed by the labia majora (48%), clitoris (28%), periurethral area (24%), posterior fourchette (20%), perihymenal tissue (16%), perianal tissue (8%), and buttocks (4%). The hymen was noted to be contused in one patient who fell on a toy in the bathtub. Injuries were further classified as either anterior or posterior using a horizontal line drawn through the hymen from 9 to 3 o’clock. Of the 25 girls with injuries, 40% had anteriorly located, 12% had posteriorly located, and 48% had anteriorly and posteriorly located injuries. There was no association between location and mechanism of injury. No child required suturing or operative intervention. Conclusions Hymenal injury is unlikely to result from unintentional injury. The location of the majority of unintentional genital injuries in prepubertal females has both anterior and posterior components.

Mucinous Adenocarcinomas of the Vulva

An 80-year-old nullipara had a 2.0-cm cystic tumor of the right labium majus. Histologic diagnosis was mucinous eccrine carcinoma. Seventy-five percent of these rare skin adnexal tumors arise on the face, eyelid, or scalp; but none has been reported on the vulva. Indolent localized growth is usual with regional nodal spread in 11% and distant metastases in 3%. A 67-year-old multi-para had a 1.2-cm polypoidal nodule of the posterior fourchette. Histologically, a colonic type mucinous carcinoma was arising within a villous adenoma. Mucicarmine and CEA stains were positive. Extensive workup failed to reveal other primary cancers in either patient. Both patients are well 19 and 17 months after radical vulvectomies and node-negative groin dissections. These cases illustrate further the diversity in cell type and biologic behavior of vulvar adenocarcinomas.

Child Abuse in Saudi Arabia: Report of Ten Cases

Ten abused children under five years of age (four males, six females) were seen in King Faisal Specialist Hospital and Research Centre (KFSH&RC) between 1989G and 1992G. Two children died, five had serious injuries and three had moderately severe injuries. In one of the fatalities, the diagnosis was not suspected until four years after death, when her sister was diagnosed as a case of child abuse. Six children suffered varying degrees of physical neglect and abuse and sexual abuse. The remaining four children had Munchausen syndrome by proxy. Parentally induced illness should therefore be considered in the differential diagnosis of unusual illness with bizarre features, even if the parents' behavior appears normal.

The interpretation of urogenital findings in children with straddle injuries

Because urogenital trauma frequently raises the question of sexual abuse, it is important to be able to relate the mechanism of injury to expected examination findings. This study was undertaken to characterize the trauma that results from straddling and correlate such injuries with the history, examination, and patient characteristics. The charts of 100 patients examined in an urban pediatric emergency department were reviewed; their conditions met the criteria of straddle injury—a blow to the perineum as a result of falling or striking a surface or an object with the force of one's own body weight. Ages ranged from 9 to 187 months (mean, 77.9; median, 67.2); 72% were female. Most injuries were minor lacerations and abrasions of the genitalia. Eleven percent had injury to the posterior fourchette. Hymenal and vaginal injuries were primarily caused by penetrating mechanisms. Five patients who presented with a history of straddling subsequently received the diagnosis of sexual assault based on disclosure by the patient or a witness and inconsistency of physical findings. There were no urethral or perianal injuries resulting from nonpenetrating straddle mechanisms. Straddle injuries include a variety of mostly minor urogenital injuries. Perianal, hymenal, or vaginal trauma suggests a penetrating mechanism, either unintentional or from sexual assault. An investigation for sexual assault should be initiated in the following cases: infants younger than 9 months of age; perianal, hymenal, or vaginal injury; extensive or severe injury; concurrent nonurogenital injuries; and whenever there is lack of correlation between history and physical findings.

How do pediatricians interpret genital findings in children? Results of a survey

Study Objectives: To determine the frequency with which various examination methods and techniques are being used in the medical evaluation of suspected child sexual abuse and how medical examiners interpret the significance of physical and laboratory findings with respect to sexual abuse.Design: An 8-page, 68-item survey was mailed to physicians with a possible interest in sexual abuse evaluation.Participants: One hundred forty-one health professionals (90% pediatricians) who returned the completed surveys.Methods: Tabulations of responses to questions regarding the frequency of examination methods, use of magnification, culturing practices, measurement of orifice size, and interpretation of 57 physical and laboratory findings as normal to abnormal on a 5-point scale.Results: The overall response rate was 44%, after excluding 56 responses from the group with only a 12% response rate. A colposcope was used by 45% of respondents; 51% obtained cultures for sexually transmitted diseases on all female patients, and 42% on all male patients. Findings rated as abnormal by more than 90% of respondents were the presence of sperm or semen; confirmed positive culture for Neisseria gonorrhea; a positive culture for Chlamydia; lacerations of the hymen, posterior fourchette, and perianal tissues; and hymenal transections. Experience level significantly (p < 0.05) affected responses on 15 of the 68 items on the survey (22%).Conclusions: There is a high level of agreement among examiners on the significance of certain findings in suspected sexual abuse. Higher experience level was associated with the rating of several findings as nonspecific rather than abnormal.

Descriptive study of genital variation in healthy, nonabused premenarchal girls

This descriptive colposcopic study of the genitals of symptom-free young girls not thought to have been sexually abused was undertaken to contribute toward our understanding of normal female genital anatomy in this age group. Girls were examined and photographed, with labial traction in a supine frog-leg position while they were under anesthesia before minor elective surgery. The final study sample consisted of 79 premenarchal girls, aged between 3 months and 11 years 7 months (mean, 5 years 4 months). The study demonstrated wide anatomic variation and a high frequency of minor irregularities that have previously been noted in studies of sexually abused girls. Specific findings included increased vascularity (44%), midline avascular areas (27%), "ragged" posterior fourchette epithelium (18%), notch configuration of the posterior fourchette (10%), delicate tethers between the hymen and perihymen (14%), hymenal bumps between the 3 and 9 o'clock positions (11%), and asymmetry of the hymenal tissue (9%). Girls who at initial examination had apparently abnormal vestibules had either large hymenal orifices (11%) or multiple irregularities (11%). The study emphasizes the danger of overinterpreting small anatomic findings when one is evaluating the possibility of sexual abuse in girls; such findings may lie within the range of normal variation.

Perineal Confusion

To the Editor.— The recent study by Drs Kellogg and Parra1 is clearly important in documenting the prevalence of the "linea vestibularis" in the normal neonate. However, this structure is not previously "undescribed," John McCann and colleagues2 described an "avascular midline area" in the posterior fourchette in 25.6% of prepubertal girls selected for nonabuse. In this study, the possibility that some of these lines were caused by labial adhesions was not reported separately. In a study not published at the time of your article, Berenson and colleagues3 found a midline avascular area in 4% of a younger group of girls.

Colposcopy to establish physical findings in rape victims

Conventional rape examination protocols have been poor in yielding genital findings (10% to 30% typically). We report our experience with a revised protocol employing colposcopy to perform genital examinations of victims and to document findings. Physical examinations were performed on rape victims seen by San Luis Obispo County's Suspected Abuse Response Team between 1985 and 1990, and the results were reviewed for this study. Of 131 patients seen within 48 hours and who experienced penile penetration, 114 (87%) had positive findings. Colposcopic magnification allowed examiners to characterize these findings as acute mounting injuries, typically seen at 3, 6, and 9 o'clock on the posterior fourchette and consisting chiefly of lacerations, ecchymosis, and swelling. An examination protocol that includes colposcopy may be the most reliable means to document and characterize genital findings in rape victims and to evaluate whether findings may be linked to a reported sexual assault.

Linea Vestibularis: A Previously Undescribed Normal Genital Structure in Female Neonates

The increasing number of evidentiary examinations conducted for sexual abuse has accentuated the importance of defining normal genital anatomy, particularly within the vestibule of female children. In female newborns, normal anatomical variations of the hymen have been described1,2 but anatomical variations of the posterior vestibule underlying the hymen have not been reported. In children evaluated for sexual abuse a vestibular structure of varying description and location has been reported. A "midline avascular streak," "scar," and "a white area" have been noted in the posterior vestibule, posterior fourchette, and hymen.1,3,4 Whether these descriptions all pertain to a single entity or are multiple lesions is not known.

Ulcerative diphtherial vulvovaginitis: A case report

A 17-year-old black girl chemotherapy patient presented with right labial soreness which caused significant pain with ambulation. Examination revealed acute vulvovaginitis with a large area of ulceration and edema of the labia minora extending to the posterior fourchette. The ulcer was cultured and grew Staphylococcus aureus and Corynebacterium diphtheriae. The patient was treated with erythromycin with complete resolution of symptoms. The authors emphasize that ulcerative lesions of the genital region may be caused by a variety of infectious organisms. Therefore, accurate diagnosis requires the routine use of culture in all patients.