Vaginal Wall In Women Research Articles

Enterocele: is there a histologic defect?

OBJECTIVE: To examine the histology of the vaginal wall in women with an enterocele confirmed by physical examination, cystoproctography, and intraoperative exploration. METHODS: Thirteen women with posthysterectomy apical and posterior wall prolapse were evaluated with a detailed physical examination, cystoproctography, and intraoperative exploration. All women had enterocele repair. A specimen of full thickness vaginal wall from the leading edge of the enterocele was excised and examined histologically. The histology of these patients was compared with the histology of two comparison groups, five women undergoing hysterectomy without prolapse and 13 women undergoing radical hysterectomy. RESULTS: One woman with an enterocele repaired intraoperatively did not have an enterocele by cystoproctography. One woman with an enterocele repaired intraoperatively did not have an enterocele detected by physical examination. All women with an enterocele repaired had an intact vaginal wall muscularis. No woman had vaginal wall epithelium in direct contact with the peritoneum. The average vaginal wall muscularis thickness in women with enteroceles was 3.5 ± 1.4 mm, in women with no prolapse 3.2 ± 0.8 mm, and in women undergoing radical hysterectomy 2.8 ± 0.9 mm. CONCLUSION: Women with enteroceles have a well-defined vaginal muscularis between the peritoneum and vaginal epithelium.

VAGINAL LEIOMYOMA PRESENTING AS A URETHRAL DIVERTICULUM

Leiomyoma originating primarily in the vagina is relatively rare with approximately 300 cases reported. 1 The site of origin is the smooth muscle of the vaginal wall and the lesion is usually not associated with uterine leiomyoma. Careful histological examination of these tumors is essential to exclude malignancy, such as leiomyosarcoma. We report an unusual case of vaginal leiomyoma mimicking a urethral diverticulum. CASE REPORT A 36-year-old woman was referred for urological consultation after gynecological evaluation revealed a urethral diverticulum. She complained of dyspareunia and terminal dribbling after voiding as well as a history of frequent urinary infections, although none was documented on urinalysis or urine culture. Urinalysis was negative. There was no abnormal vaginal bleeding and a Papanicolaou smear was normal. Physical examination demonstrated a round, nontender 5 cm. midline suburethral mass in the anterior vaginal wall that was compressible without a purulent discharge via the urethra. Voiding cystourethrography, positive pressure urethrography and cystoscopy did not reveal a urethral diverticulum. At transvaginal exploration a well circumscribed 3 3 3 cm. soft tissue mass was identified extending under the trigone proximal to the left ureteral orifice (fig. 1). There was no connection to the urethra or bladder. The mass was excised completely. Pathological analysis of the specimen revealed leiomyoma (fig. 2). DISCUSSION The differential diagnosis of a suburethral mass includes urethral diverticulum, urethrocele and/or cystocele, Gartner’s duct cyst, vaginal inclusion cyst, urethral cancer, Skene’s abscess, vaginal carcinoma, ectopic ureterocele and leiomyoma. In females complaining of urinary dysfunction, dyspareunia and a palpable suburethral mass the major clinical suspicion is urethral diverticulum. Physical examination enables an accurate diagnosis of urethral diverticulum to be made in approximately 60% of cases, and cystoscopy and voiding cystourethrography have greater than 90% sensitivity. 2 When these diagnostic studies are negative, other possible etiologies should be considered. Vaginal leiomyoma commonly develops in the midline anterior vaginal wall in women 35 to 50 years old. 3 The clinical presentation of these rare tumors varies, and many are small, asymptomatic vaginal masses. Large lesions may cause pain and urinary tract symptoms. Vaginal leiomyoma, a mesenchymal neoplasm, is a rare smooth muscle tumor of the vagina that does not involve the vaginal mucosa or urethral epithelium. Treatment is surgical excision via the vaginal approach. The mass, which may be easily separated from surrounding tissue, is usually firm, well circumscribed, homogeneous and gray-white. Careful histological evaluation to assess the number of mitotic figures as well as cellular pleomorphism is essential to rule out leiomyosarcoma. These tumors are classified as intermediate histology leiomyoma or leiomyosarcoma. Those with an intermediate histology should be followed closely with serial examinations for recurrence. Leiomyosarcoma likely requires more aggressive resection and possibly adjuvant therapy. CONCLUSIONS

Epidermoid carcinoma of the anal canal.

The charts of 67 patients treated for epidermoid carcinoma of the surgical anal canal were reviewed. The clinical presentation, type of surgical procedure performed, lymph node status of the pararectal and inguinal nodes, time of recurrence, site of recurrence, and median survival from the date of primary surgery and from the date of recurrence were determined. There were 55 patients (82%) who had a minimum of 5 years' follow-up since initial treatment. Optimal surgical treatment requires an abdominoperineal resection with wide dissection of the ischiorectal fossa and perineum in all patients, as well as an en bloc excision of the posterior vaginal wall in women. Although excision of the posterior vaginal wall improves the disease-free interval, median survival is not altered, compared with the group without vaginectomy. The predominant sites of local recurrence in men are the pelvis and perineum, and in women, the pelvis and posterior vaginal wall. The status of the pararectal lymph nodes from the operative specimen can give accurate information about the relative risk of recurrence. The presence of inguinal lymph node metastases represents a poor prognosis because of a close association with systemic metastases.