Vaginal Introitus Research Articles

A Grasp-Like Vaginal Lesion in a 15-Months-Old Child: A Case Report

ABSTRACT Introduction and importance: Rhabdomyosarcoma is the most common pediatric soft tissue sarcoma. It constitutes 4 – 6% of all malignancies in childhood. The botryoid variant is a type of ERMS that is the most common malignancy in the pediatric female genitourinary tract. ERMS of the vagina usually occurs in early childhood, whereas ERMS of the uterus occurs later in age. Since 1959, only 7 cases of uterine botryoid ERMS during infancy have been reported. Case presentation: A 15-months-old girl was admitted to our ED for three reddish, smooth, glistening, polypoidal masses protruding from her vaginal introitus for 9 days. The lesions had a suspicious “grape-like” appearance and tended to come in and out through the vaginal ostium. A pelvic US examination on the patient showed an inhomogeneous aspect of the uterus, which appeared to be occupied and stretched out by an iso-hypoechogenic solid tissue. Additionally, there were some hyperechogenic spots inside as well as evidence of vascular signals on color doppler. A surgical biopsy revealed a malignant mesenchymal tumor consistent with the diagnosis of embryonal rhabdomyosarcoma (ERMS), botryoid variant. Clinical Discussion: The patient completed her first cycle of chemotherapy with ifosfamide, vincristine, and dactinomycin (IVA). When she was 18 months old, she underwent a hysterectomy, which removed the entire mass with a Pfannenstiel approach. The postoperative course presented with no complications. Follow-up visits were scheduled quarterly. Conclusion: Botryoid ERMS of the uterus is a diagnosis not to be missed in an infant. Since rapid diagnosis and treatment are necessary, clinicians should be aware of its presentation to assure optimal management. Highlights:

Clinical image: bartholin gland cyst

Bartholin glands, also known as the greater vestibular glands, are a pair of 0.5 cm glands located in the lower right and left portions at the 4 o´clock and 8 o´clock positions of the vaginal introitus. The Bartholin gland is a mucus-secreting gland, which plays a role in vaginal lubrication. Bartholin glands are generally nonpalpable when not obstructed Bartholin cysts/abscesses are predominantly found in women of childbearing age. The incidence of Bartholin cysts is most often noted at the onset of puberty and increases with age until menopause. Symptomatic Bartholin cysts and abscesses account for 2 percent of all gynecologic visits per year. A 35-year-old patient was apparently all right 2 months back when she noticed a small cyst in the vaginal area which start increasing suddenly in 2-3 days due to obstruction of Bartholin gland which is not painful the patient admitted in government hospital and after all investigation found that it is Bartholin cyst and surgical removal of Bartholin cyst done.

Microbiological Findings of Symptomatic Vulvovaginitis in Chinese Prepubertal Girls.

To study the bacteria and fungi causing vulvovaginitis in prepubertal girls. Swabs from vaginal introitus were collected from patients with vulvovaginitis in 2018, and cultured for the identification of microorganisms with standard microbiological techniques. A children's hospital in Hangzhou, East China. A total of 1235 Chinese prepubertal girls diagnosed with vulvovaginitis. Bacteria or fungi in pure cultures or as the predominant organism were defined as pathogens. A total of 1235 cases were diagnosed as vulvovaginitis, and 515 isolates were identified from 494 patients (40%, 494/1235). The most common pathogen was Streptococcus pyogenes (27.6%,142/515), followed by Haemophilus influenzae (27.2%,140/515), Candida albicans (22.3%,115/515), Staphylococcus aureus (5.8%, 30/515) and Escherichia coli (4.7%,24/515). All S pyogenes isolates were sensitive to penicillin, whereas 53.7% (73/136) of H influenzae isolates were sensitive to ampicillin, and 70.4% (19/27) of S aureus isolates were sensitive to oxacillin. S pyogenes and H influenzae were the 2 most commonly identified pathogenic bacteria found in prepubertal girls with vulvovaginitis. Vulvovaginitis in prepubertal girls caused by C albicans may be more common in older children.

Effects of Fractional CO2 Laser Treatment on Patients Affected by Vulvar Lichen Sclerosus: A Prospective Study.

Background: Fractional carbon dioxide (CO2) lasers are today considered the most effective and efficient treatment for many vulvovaginal disorders, providing mini-invasive procedures without side effects. Previous studies demonstrated the efficacy of fractional CO2 lasers in vulvar lichen sclerosus (VLS), a chronic skin disorder characterized by itching and painful lesions. Complications include pain, sexual and/or urinary dysfunction, with a negative quality of life, and an increased risk of squamous cell carcinoma. A definitive VLS treatment is still lacking. Objectives: This is a prospective, single-center study aimed at evaluating the effect of fractional microablative CO2 laser treatment on women affected by VLS. Materials and methods: Patients with histologically confirmed VLS underwent three fractional microablative CO2 laser treatments, 4 weeks apart, on the genital affected areas. Clinical and VLS-related symptoms, side effects, and patient satisfaction index were assessed and recorded for all the patients using the visual analog scale (VAS). Results: Data from a total of 70 patients were included, paired at different time points and analyzed. VLS-related symptoms and other relevant parameters (pH, vaginal introitus discomfort, dyspareunia, vaginal dryness, itching, and burning) showed a statistically significant improvement (p < 0.001) after the first laser treatment and kept improving after second and third sessions. According to VAS, the two most common symptoms, vaginal introitus discomfort and dyspareunia, went from (mean ± standard deviation) 8.2 ± 2.3 and 8.3 ± 2.2, respectively, at baseline, to 3.6 ± 2.6 and 3.8 ± 2.6, respectively, 1 month after the last treatment. Vaginal dryness, itching, and burning were significantly improved as well. Most patients declared to be very satisfied with the results of the treatment. A total of 62.8% of the women expressed a satisfaction score ≥8 on a scale from 0 to 10. Conclusions: Fractional microablative CO2 laser treatment seems to be safe and effective to treat VLS and improve VLS-related symptoms.

Radiation-Induced Vaginal Stenosis in Patients With Locally Advanced Cervical Cancer

Vaginal stenosis (VS) after definitive radiation therapy (RT) to the pelvis for cervical cancer is a common toxicity that can have detrimental effects on quality of life and can limit surveillance physical examinations. Quantitative measurements of VS are lacking. We investigated radiographic vaginal dimensional changes after RT for cervical cancer as a potential noninvasive marker for VS with the hypothesis that RT would be associated with reduced apical vaginal width on computed tomography (CT) imaging.We retrospectively identified 104 patients with locally advanced cervical cancer treated with definitive RT at our institution who had pre- and post-treatment CT scans available for analysis. Post-treatment scans were acquired within one year of therapy completion. We measured the transverse width at the vaginal apex, mid-canal, and introitus, as well as superior-inferior vaginal length. Changes in mean dimensional measurements were compared between pre- and post-treatment scans. We also compared mean dimensional measurements between CT and MRI where available. Nonparametric paired Wilcoxon rank sum tests were used to test for differences in measurements. Two observers made independent measurements on 15 consecutive patients and interrater reliability was assessed by calculating the intraclass correlation coefficient (ICC). Multivariable linear regression was used to identify covariables associated with change in apical width. Covariables included menopausal status, smoking history, gravida/para status, FIGO stage, tumor grade, and tumor histology. We used a backward model selection technique with stepwise removal of covariables not meeting a significance threshold of P ≤0.20.Mean transverse width at the vaginal apex was 5.87 cm on pre-treatment CT and 5.10 cm on post-treatment CT, with a mean difference of -0.77 cm (P < 0.001). There was also a statistically significant difference in width at the mid-vaginal canal although this was of smaller magnitude (pre-treatment 4.34 cm, post-treatment 4.14 cm, P < 0.001). There were no differences in width at the introitus or with respect to vaginal length. The ICC for independent apical measurements between two raters was 0.91 (95% CI 0.75, 0.97), indicating good-excellent agreement. Apical width was slightly smaller when measured on MRI compared to CT, although a small number of available paired MRI scans limited this analysis. On multivariable linear regression, menopause was correlated with less change in apical width (P = 0.001). Conversely, a smoking history was associated with increased dimensional reduction at the apex (P = 0.04). Number of deliveries and tumor stage were not significant predictors for dimensional change.Radiation-induced vaginal stenosis after definitive RT for cervical cancer treatment was demonstrable as apical and mid-vaginal constrictions on CT imaging that were more pronounced with a smoking history and less evident in post-menopausal women.C.W. Williamson: None. N.V. Kotha: None. K. Morris: None. R. Simoes-Torigoe: None. M. Kohanfars: None. J. Chen: None. B. Li: None. S. Vaitkus: None. M.T. Makale: None. F. Talke: None. J.S. Mayadev: Consultant; Astra Zeneca, NRG Oncology, GOG Foundation, Varian Medical Systems; NRG Oncology Cervix Co-Chair, GOG Foundation Board.

Le Fort Colpocleisis

<h3>Study Objective</h3> To highlight a safe and effective technique of the Lefort Colpocleisis for treating pelvic organ prolapse in an elderly patient. <h3>Design</h3> Educational Video. <h3>Setting</h3> OR. <h3>Patients or Participants</h3> The index patient is an 82-yo G2P1011 patient with symptomatic stage III pelvic organ prolapse; the anterior compartment was the leading edge. Due to the prolapse the patient was unable to exercise and walk as much as she desired. She failed an initial trial of ring pessary. After appropriate counseling, the patient opted for surgical intervention via a Lefort Colpocleisis with the understanding that this would preclude vaginal intercourse in the future. Preoperative evaluation with cystoscopy, urodynamic studies and a pelvic ultrasound were all within normal limits. We started the procedure by marking rectangular areas on the anterior and posterior vagina. The marked areas are then removed by careful sharp and blunt dissection. The edges of the rectangle and the denuded vaginal mucosa were then closed; leaving laterally created tunnels for drainage of cervical mucus. As successive sutures were placed; it was ensured that the knots were within the epithelial lined tunnels. This carefully maneuvered technique allowed the uterus and vaginal apex to be gradually turned inward. A bladder neck plication suture was then placed due to the high risk of stress incontinence accompanying these cases. A perineorrhaphy was completed to narrow the vaginal introitus. A cystoscopy was then performed confirming ureteral patency and excluding lower urinary tract injury. At her postoperative visit the patient had resolution of her symptoms and was pleased with the outcome of her surgery. <h3>Interventions</h3> LeFort Colpocleisis. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> This technique is a good approach for the management of pelvic organ prolapse in elderly patients or those who are not candidates for major reconstructive surgery.

Female genital injury\u2014which findings have to be considered physiological using colposcopy with and without toluidine blue dye?

This study aimed to assess the validity and efficacy of blue dye in colposcopic assessment of genital injury in pre- and postmenopausal women with and without history of consensual sexual intercourse. Two hundred women were prospectively enrolled and examined colposcopically with and without toluidine blue dye in order to detect and categorize genital lesions (laceration, bruise and abrasion). Examination of genital trauma was accomplished in a standardized way and findings were photo documented. A wide range of influencing factors with a potential impact on prevalence and nature of genital injury was recorded beforehand using a questionnaire. The frequency of diagnostic injury differed substantially depending on the examination technique, ranging from 9% using colposcopic magnification only to 28% with the additional use of toluidine blue dye. A vertical laceration affecting the posterior fourchette was the most frequent lesion detected (17%, n = 32). Menopausal status seems to have significant impact on genital injury prevalence (p = 0.0165), as 42% (16/ 38) of postmenopausal compared to 24% (36/ 151) of premenopausal women had at least one genital lesion. Furthermore, vaginal medication (p = 0.0369), vaginal dryness (p = 0.0228), dyspareunia (p = 0.0234) and low frequency of sexual intercourse (p = 0.0022) were found to significantly correlate with the presence of genital lesions. According to our findings, standardized colposcopy in combination with toluidine blue dye facilitates accurate assessment of genital lesions. Genital trauma situated at another site than the posterior part of the vaginal introitus seems to be uncommon after consensual intercourse.

PD31-11 VAGINAL STENOSIS FOLLOWING VAGINOPLASTY IN THE CAH COHORT

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II (PD31)1 Sep 2021PD31-11 VAGINAL STENOSIS FOLLOWING VAGINOPLASTY IN THE CAH COHORT Kiersten Craig, Wael Abosena, Lauren Balsamo, Ardavan Akhavan, and Dix Poppas Kiersten CraigKiersten Craig More articles by this author , Wael AbosenaWael Abosena More articles by this author , Lauren BalsamoLauren Balsamo More articles by this author , Ardavan AkhavanArdavan Akhavan More articles by this author , and Dix PoppasDix Poppas More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002032.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In the last 20 years, techniques in vaginal restorative surgery have evolved. Studies evaluating post-operative outcomes following contemporary surgical approaches in congenital adrenal hyperplasia (CAH) patients with variation in genital anatomy (VGA) remain scarce. Vaginal stenosis (VS) is a complication of vaginal restorative surgery and requires specialized care and management. We reviewed our surgical experience with CAH patients to understand patterns of occurrence, classification, and management of VS at our institution. METHODS: We retrospectively reviewed CAH patients with VGA who underwent primary vaginoplasty from 1996 to 2016. Patient demographics, procedure characteristics, occurrence of VS, and subsequent management were recorded. Prader score was further stratified to a 7-point genital stage. Annual physical exam was performed from post-op to toilet training then after menarche unless clinically indicated. VS was defined as narrowing at the vaginal introitus or inability to use tampons/have penetrative intercourse. VS was further categorized as Suspected (minor narrowing observed on exam without clinical impact, S-VS) or Clinically Significant (severe narrowing requiring intervention once menarche is achieved, CS-VS). Patients without a vaginoplasty or one performed at another institution, identified as male, lost to follow up, or without follow up records were excluded. RESULTS: 130 patients were included for evaluation. Mean age was 3.5 years (0.32-34.5 years). Classic CAH occurred in 94.4%. A genital score of 3 (Prader III) predominated (39,7%). Mean anesthesia and surgery time was 4.3 (2-9.5) and 3.1 (1.1-8.0) hrs, respectively. Mean admission and follow up length was 3.2 days and 4.5 (0.01-17.6) years. S-VS and CS-VS occurred in 13 and 14 patients, respectively. Management of CS-VS included redo vaginoplasty (5, 1 planned but lost to follow-up), expectant management (8). The development of S-VS correlated with procedure type (flap alone p=0.012 and PT + flap p=0.043) and genital score 7 (p=0.022). CS-VS was only associated with PT (p=0.035). Logistic regression to predict VS was not statistically significant. CONCLUSIONS: VS remains a concern following vaginal restorative surgery in CAH patients. This descriptive study at a CAH center of excellence is an initial step toward characterization of VS. Higher genital score and procedure type was associated with the development of VS. In the future, standardization of the definition of VS will help assess clinical outcomes, defining risk factors, and tailoring management. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e543-e543 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kiersten Craig More articles by this author Wael Abosena More articles by this author Lauren Balsamo More articles by this author Ardavan Akhavan More articles by this author Dix Poppas More articles by this author Expand All Advertisement Loading ...

A comparison of two techniques for vaginal speculum placement to reduce patient pain.

Vaginal examination with a speculum is uncomfortable and painful, with approximately 35% of women reporting pain [1-3]. The present study was a longitudinal, prospective, comparative study to compare pain experience after vaginal speculum placement with either a horizontal or vertical technique. For the horizontal technique, the inferior blade of the speculum was placed on the posterior wall of the vagina, at a 90° angle with respect to the antero-posterior axis of the vaginal introitus, and slid forward into the interior of the vagina. With regards to the vertical technique, the superior blade was applied in contact with the right vaginal wall and the inferior blade with the left vaginal wall. The speculum was then slid into the vagina (up to two thirds of the total length of the vagina) and rotated to a horizontal position. In each patient, both techniques were evaluated. Pain was graded on a visual analog scale from 0-10, where 0 indicated no pain and 10 indicated "most intense" perceived pain. Comparison between groups was done by Mann-Whitney U test, and differences between frequencies were calculated by Chi-squared test. The protocol was approved by the Local Ethics in Research Committee 36068 and the Research in Health Committee 3606 with the number R-2020-3606-038. All patients signed an informed consent form for participation in this study.

Role of Elastin Expression in Thickening the Postpartum Vaginal Wall in Virgin and Postpartum Rat Models

Childbirth induces a number of alterations, including ligament weakening and increased vaginal distensibility. The occurrence of vaginal laxity or distensibility is associated with the vaginal wall and introitus overstretching during vaginal parturition while the pathophysiology is due to increased levator dimension and trauma to the levator ani muscle through avulsion (macrotrauma) or overdistension (microtrauma). Elastin is an extracellular matrix protein that confers elastic properties to organs and tissues, particularly those requiring elasticity. Elastin plays a vital role in the functioning of numerous tissues, such as the lungs, blood vessels, heart valves, ligaments, tendons, and skin. It is also a component of the vaginal mucosa. The aim of the present was to evaluate the role of elastin in the thickening of the postpartum vaginal wall composed of epithelial mucosa, and to understand the mechanism underlying vaginal laxity or distensibility within parous and nulliparous animal models. A total of 32 female white rats (Rattus norvegicus) were used in the present study. They were divided into two groups, each group consisting of 16 rats. The control group (C0) consisted of virgin nulliparous rats, which were sacrificed on the second day after vaginal parturition. Pregnant rats (group C1) were sacrificed on the second day after vaginal parturition. The median elastin expression in group C1 was higher (3 ± 0.56) than group C0 (2.85 ± 0.75). The mean thickness of the vaginal mucosal epithelium in group C0 (56,8 931µm) was greater than group C1 (44,98 349µm). The comparison of vaginal mucosal epithelium thickness between the two groups indicated a significant difference between groups C0 and C1. Elastin levels were significantly correlated with epithelial thickness. The expression of elastin significantly affects the vaginal wall thickness, which further affects vaginal laxity or vaginal distensibility.

Modified Passerini-Glazel feminizing genitoplasty outcomes in adults: Two rare cases

IntroductionModified Passerini-Glazel feminizing genitoplasty is typically performed in children with atypical genitalia. In our article, we have performed the procedure in adults with genital anomalies. Case presentationThe first case was a 22 years old woman who was planning to get married. She presented with a chief complaint of having no vaginal canal. Gynecological examination showed no vaginal opening. The common channel was visible, and the size of the perineal body was 3 cm. The patient underwent vaginal reconstruction using a modified Passerini-Glazel technique without amnion graft.The second case was a 20 years old girl planning to get married, with a chief complaint of small vaginal introitus. Gynecology examination showed small minor labia with an introitus size of 1 cm. The patients underwent vaginal reconstruction and labioplasty using a modified Passerini-Glazel technique with an amnion graft.Both patients have undergone anal atresia surgery in childhood. DiscussionThere was no difference in outcome between using amnion graft and without amnion graft following the modified Passerini-Glazel feminizing genitoplasty procedure. The first patient had been pregnant and had successful delivery by elective cesarean section. Moreover, the second patient had no complaint of sexual disorders after the procedure. No cases of dysuria, urinary tract infection, leukorrhea, hematocolpos, or malodorous vaginal discharge were reported in both cases. ConclusionModified Passerini-Glazel feminizing genitoplasty is a safe and effective procedure. Daily vaginal dilation in the postoperative period was unnecessary, and it allowed for an excellent cosmetic result.

Defining mechanisms of recurrence following apical prolapse repair based on imaging criteria

Prolapse recurrence after transvaginal surgical repair is common; however, its mechanisms are ill-defined. A thorough understanding of how and why prolapse repairs fail is needed to address their high rate of anatomic recurrence and to develop novel therapies to overcome defined deficiencies. This study aimed to identify mechanisms and contributors of anatomic recurrence after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair) vs transvaginal mesh (VM) hysteropexy surgery for uterovaginal prolapse. This multicenter study was conducted in a subset of participants in a randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Overall, 94 women with uterovaginal prolapse treated via native tissue repair (n=48) or VM hysteropexy (n=46) underwent pelvic magnetic resonance imaging at rest, maximal strain, and poststrain rest (recovery) 30 to 42 months after surgery. Participants who desired reoperation before 30 to 42 months were imaged earlier to assess the impact of the index surgery. Using a novel 3-dimensional pelvic coordinate system, coregistered midsagittal images were obtained to assess study outcomes. Magnetic resonance imaging-based anatomic recurrence (failure) was defined as prolapse beyond the hymen. The primary outcome was the mechanism of failure (apical descent vs anterior vaginal wall elongation), including the frequency and site of failure. Secondary outcomes included displacement of the vaginal apex and perineal body and change in the length of the anterior wall, posterior wall, vaginal perimeter, and introitus of the vagina from rest to strain and rest to recovery. Group differences in the mechanism, frequency, and site of failure were assessed using the Fisher exact tests, and secondary outcomes were compared using Wilcoxon rank-sum tests. Of the 88 participants analyzed, 37 (42%) had recurrent prolapse (VM hysteropexy, 13 of 45 [29%]; native tissue repair, 24 of 43 [56%]). The most common site of failure was the anterior compartment (VM hysteropexy, 38%; native tissue repair, 92%). The primary mechanism of recurrence was apical descent (VM hysteropexy, 85%; native tissue repair, 67%). From rest to strain, failures (vs successes) had greater inferior displacement of the vaginal apex (difference,-12 mm; 95% confidence interval,-19 to-6) and perineal body (difference,-7 mm; 95% confidence interval,-11 to-4) and elongation of the anterior vaginal wall (difference, 12 mm; 95% confidence interval, 8-16) and vaginal introitus (difference, 11 mm; 95% confidence interval, 7-15). The primary mechanism of prolapse recurrence following vaginal hysterectomy with uterosacral ligament suspension or VM hysteropexy was apical descent. In addition, greater inferior descent of the vaginal apex and perineal body, lengthening of the anterior vaginal wall, and increased size of the vaginal introitus with strain were associated with anatomic failure. Further studies are needed to provide additional insight into the mechanism by which these factors contribute to anatomic failure.

Evaluation of endometrial progesterone receptor expression after 12 weeks of exposure to a low-dose vaginal estradiol insert.

Objective:To evaluate endometrial progesterone receptor (PGR) expression in menopausal women who used vaginal 4-μg and 10-μg estradiol (E2) inserts or placebo.Methods:REJOICE was a randomized, placebo-controlled trial investigating vaginal E2 inserts in women with moderate to severe dyspareunia due to menopause. In this post hoc analysis, 25 eligible women with endometrial biopsies were randomly selected from each treatment group (4-μg and 10-μg E2 vaginal inserts and placebo). Endometrial biopsy sections were immunostained using an anti-PR (A and B) monoclonal antibody. Cell staining was quantified using an artificial intelligence feature-recognition algorithm. Mean PGR expression levels were analyzed between baseline and week 12.Results:PGR expression results were available for 22 women in the 4-μg E2 group, and 25 women each for the 10-μg E2 and placebo groups. Similar PGR expression levels were observed at baseline (0.301-0.470 pmol/mg) and after 12 weeks of treatment (0.312-0.432 pmol/mg) for all treatment groups, with no significant differences between baseline and week 12.Conclusions:No meaningful differences in endometrial PGR expression were observed with the vaginal E2 (4- and 10-μg) inserts at week 12 from baseline, supporting the hypothesis that local exposure to E2 from a low-dose, vaginal insert placed near the vaginal introitus will not be sufficient to upregulate endometrial PGR expression. Coupled with the lack of histologic changes and systemic absorption, our data suggest that these softgel vaginal E2 inserts would not be expected to stimulate endometrial hyperplasia leading to a potential endometrial safety issue in postmenopausal women with moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy. Further study on the endometrial safety of softgel vaginal E2 inserts is under way.

Transverse vaginal septum managed by simple flap surgery technique: A case report.

BackgroundTransverse Vaginal Septum (TVS) is a rare congenital abnormality, classified as the Mullerian duct anomaly development.1,2 TVS incidence range from 1:2.000 to 1:72.000. Management of TVS may only requirement local excision with a simple end to end anastomosis of the vagina, and use of skin grafts, but this technique has been reported has common complications of secondary tissue contracture, which often lead to stenosis of the vagina.3 In this case we managed TVS with simple flap technique to avoid such postoperative complications and maintain caliber of vagina.CaseA 11 years old girl complained cyclical abdominal pain since a year ago without history of menstrual blood. Patient already had vaginal surgery for removing menstrual blood, but after vaginal surgery the menstrual blood cannot be removed, then referred to our hospital. Ultrasound examination revealed hematometra and hemocolpos. The septum location was 3,38 cm proximal distance from vaginal introitus with the thickness of 8.1 mm. We performed simple excision of the septum with formerly performed distal vaginal septum mucosa preparation creating lateral flaps, then approximating the flaps to the edge of the proximal vaginal mucosa with interrupted suture continued with hymenorraphy. The patient has no complaint 6 months after surgery with vaginal length 8 cm, and had regular menstrual cycle.ConclusionA simple flap surgery technique can be done in transverse vaginal septum, with no complication such as tissue contracture, vaginal stenosis, or insightly scarring. This is a simple technique and can be done with hymenorraphy to restore normal anatomy of hymen.

Mucosal Invasion, but Not Incomplete Excision, Has Negative Impact on Long-Term Survival in Patients With Extramammary Paget's Disease.

BackgroundExtramammary Paget’s disease (EMPD) sometimes spreads from the skin to mucosal areas, and curative surgical excision of these areas is challenging. The aim of this study is to analyze the impact of mucosal involvement and surgical treatment on the survival of patients with EMPD.MethodsWe conducted a retrospective review of 217 patients with EMPD. We also assessed the associations between tumor involvement in boundary areas (anal canal, external urethral meatus, vaginal introitus), prognostic factors, and survival in 198 patients treated with curative surgery.ResultsOf 217 patients, 75 (34.6%) had mucosal boundary area involvement. Lesions in these areas were associated with frequent lymphovascular invasion (p = 0.042), lymph node metastasis (p = 0.0002), incomplete excision (p < 0.0001), and locoregional recurrence (p < 0.0001). Boundary area involvement was an independent prognostic factor associated with disease-specific survival, per multivariate analysis (HR: 11.87, p = 0.027). Incomplete excision was not significantly correlated with disease-specific survival (HR: 1.05, p = 0.96).ConclusionBoundary area tumor involvement was a major risk factor for incomplete excision, local recurrence, and poor survival outcomes. However, incomplete removal of primary tumors was not significantly associated with poor prognosis. A less invasive surgical approach for preserving anogenital and urinary functions may be acceptable as the first-line treatment for resectable EMPD.

Hidradenoma papilliferum of the hymen: a case report

BackgroundHidradenoma papilliferum is a rare benign neoplasm arising from apocrine glands. It occurs commonly on the anogenital region of middle-aged women. It usually presents as a slow growing, solitary asymptomatic, skin colored or red nodule less than 1 cm in diameter.Case presentationThe case is a 38-year-old, white woman who presented with a painful nodule occurring within a month in the himenal region of the posterior vaginal introitus. The nodule was excisied and the histology revealed a hidradenoma papilliferum. The diagnosis and treatment of hidradenoma papilliferum is possible with surgical removal and histopathological evaluation of nodules.ConclusionWhen an adult woman presents with a noduler lesion in the anogenital area, sexually transmitted diseases and other benign and malignant vulvar lesions, as well as malignant transformation is very rare but,should be kept in mind; however because it has been reported and long-term clinical follow-up is suggested

Hematometrocolpos secondary to distal vaginal obstruction following childbirth: A Case Report from Monze Mission Hospital, Monze, Zambia

Vaginal outlet obstruction commonly occurs with congenital anomalies resulting in accumulation of menstrual blood in the vagina or both vagina and uterine cavity. Childbirth injuries such as cervical, vaginal and perineal lacerations as well as episiotomies are common and may result in complications like vaginal stenosis and excessive perineal scarring. Reported here is a rare case of complete occlusion of the vaginal introitus secondary to a badly healed injury resulting from childbirth.

OHVIRA-syndrome in a newborn

OHVIRA-Syndrome (Obstructed hemivagina with ipsilateral renal anomaly) is a rare congenital malformation. Diagnosis of this malformation is usually made during adolescence. Delayed diagnosis may result in serious complications with potential future obstetric problems. We report on a newborn girl presenting with an interlabial mass formation, a vaginal introitus on the right lateral aspect and an orthotopic urethral meatus on primary inspection. Ultrasound examination revealed left sided renal agenesis and a hydrocolpos posterior to the bladder. OHVIRA-Syndrome was assumed and a surgical incision of the obstructed left hemivagina for drainage of the hydrocolpos was performed. Further examination confirmed anatomical conditions corresponding to OHVIRA-Syndrome. Aside from routine clinical follow-up and regular ultrasound examination, further interventions were postponed until puberty. In this case report we aim to share our experience of a newborn girl with OHVIRA-Syndrome. We discuss appropriate medical decision-making regarding surgical management of patients with this malformation during each stage of development with a corresponding literature review.

34. Prepubertal Vaginal Bleeding: A Rare Presentation of Prepubertal Metastatic Vulvar Crohn's Disease

<h3>Background</h3> Metastatic Crohn's disease (MCD) is a rare manifestation of inflammatory bowel disease. Vulvar lesions are seen in only 2% of female patients with Crohn's disease (CD) and frequently predate gastrointestinal manifestations in the pediatric population. Subsequently, MCD is a particularly challenging diagnosis in pediatric and adolescent patients with long-term comorbidities and overall decreased quality of life (QOL). <h3>Case</h3> An 8-year-old female presented to her pediatrician with prepubertal vaginal bleeding, described as initially light pink spotting with wiping that progressed to episodes of bright red bleeding that worsened with activity. Her only other complaints were constipation and generalized groin discomfort. Prior work up from her pediatrician included labs which were significant for iron deficiency anemia out of proportion to her described blood loss. Imaging had also been obtained including a normal pelvic ultrasound and a CT scan which showed diffuse mesenteric fat stranding, characterized as nonspecific but possibly secondary to underlying inflammatory process, and prominent lymph nodes noted within the colon. On physical exam, she was Tanner stage I with significant bilateral vulvar edema and erythema without obvious lesions. The urethral meatus was normal, but the vaginal introitus was difficult to visualize in the office due to the vulvar edema. She was also noted to be at the first percentile for weight and zero percentile for height. She was taken to the operating room for further evaluation, and underwent exam under anesthesia (EUA) with vaginoscopy and vulvar biopsies. EUA again showed significant bilateral vulvar edema with no visible lesions; vaginoscopy showed diffuse inflammation of the vagina and cervix but otherwise no lesions or other abnormalities. Vulvar biopsies revealed lymphangiectasia circumscriptum, which has been associated with CD, neoplasia, and hidradenitis suppurativa. Completion of work up with pediatric gastroenterology is pending at time of this submission, but we anticipate confirmation of diagnosis of CD in the next couple of weeks. <h3>Comments</h3> Chronic, untreated MCD can lead to significant scarring, disfigurement, increased morbidity, and overall decreased QOL. Unfortunately MCD manifestations do not consistently correspond with gastrointestinal symptoms or flares, and thus require frequent follow-up and surveillance. Given the rarity of the condition, there is limited data regarding vulvar MCD, and first line treatment remains corticosteroids with compression garments for symptomatic control of vulvar edema. A multidisciplinary approach is essential for these patients, and a high degree of suspicion is necessary for accurate diagnosis and treatment.

Short-term nitrogen dioxide exposure is associated with the spread of S. pyogenes-induced vulvovaginitis in prepubertal girls in Hangzhou, China.

As a cause of vulvovaginitis in prepubertal girls, Streptococcus pyogenes (S. pyogenes) is commonly isolated from vaginal introitus swabs. Studies have identified several risk factors, but have not focused on the correlation between ambient air pollutants and S. pyogenes-induced vulvovaginitis in prepubertal girls. This study was conducted to determine whether ambient air pollutants were associated with S. pyogenes-induced vulvovaginitis in prepubertal girls. Daily data about S. pyogenes-induced vulvovaginitis in prepubertal girls from the outpatient department of Children's Hospital at the Zhejiang University School of Medicine in Hangzhou City between January 1, 2015, and December 31, 2018, were retrospectively reviewed. Ambient air pollutants in Hangzhou were measured daily. A generalized additive model (GAM) was utilized to assess the associations between daily air pollutants and S. pyogenes isolates obtained from vaginal introitus swabs of prepubertal girls. The mean daily concentration of nitrogen dioxide (NO2) in Hangzhou City during the study period was 44.6 μg/m3 (25th-75th percentiles, 32.0-56.0 μg/m3). The GAM showed that the largest estimate effects in S. pyogenes-induced vulvovaginitis in prepubertal girls were found in NO2 with a moving (accumulative) average on day 3. The excess risk of NO2 in terms of the daily number of S. pyogenes isolates obtained from the vaginal introitus swabs was 14.91% (95% confidence interval [CI]: 4.85-25.94%) in the single-pollutant model. The multipollutant model revealed that an increase of 10 μg/m3 in NO2 exposure was associated with an 18.33% increased risk for acquiring S. pyogenes-induced vulvovaginitis in prepubertal girls (95% CI: 1.21-38.35%; P < 0.05). In conclusion, short-term NO2 exposure was strongly associated with the spread of S. pyogenes-induced vulvovaginitis in prepubertal girls.