Self-attempted labioplasty with elastic bands resulting in severe necrosis.

BACKGROUND: Labial hypertrophy is protuberant labial tissue extending beyond the labia majora. Self-perception of poor cosmetic appearance is common in young patients and not necessarily pathologic. Labioplasty is indicated for patients with persistent symptoms including entrapment and painful intercourse. CASE: A 26-year-old woman presented with genital pain and foul odor after self-applying elastic bands to her labia minora. The bands were applied for a self-perceived abnormal appearance and lack of insurance for medical consultation. Surgical debridement and revision of the labia were performed using a straight vertical approach. CONCLUSIONS: Self-attempted labioplasty can result in necrosis and infection. Education and counseling of patients on the normal variants of labial anatomy and the recommended therapeutic methods will lead to better cosmetic results and prevent self-mutilation.

Incidence of Abnormal Findings During Pelvic Examinations in Women Aged 21-35 Years.

To describe the incidence of abnormal gynecologic examination findings in asymptomatic compared with symptomatic patients during preventive visits, we conducted a retrospective study of 1,121 visits for patients between the ages of 21 and 35 years from January 2017 to March 2017. Only 1.2% (95% CI, 0.5%,1.9%) of asymptomatic patients had abnormal findings on pelvic examination, compared with 32.4% (95% CI, 27.0%, 37.8%) of those with symptoms ( P ≤.001). In symptomatic patients, the most common symptoms were vaginal discharge (25.1%), pelvic pain (16.4%), and vaginal bleeding (15.7%). In asymptomatic patients, the most common findings were bacterial vaginosis and Candida infection. Asymptomatic patients presenting for a routine preventive visit have low rates of abnormalities detected on examination, and routine pelvic examinations should be re-considered.

Single-site laparoscopic management of a large adnexal mass.

INTRODUCTION: Single-site laparoscopy is gaining acceptance in many surgical fields including gynecology. The purpose of this report is to demonstrate the technique and outcome for removing a large adnexal mass through a single site. CASE DESCRIPTION: A 41-y-old female was referred to gynecology oncology for increased abdominal girth for 3 mo. An ultrasound confirmed a benign-appearing, 37-cm left adnexal mass. The mass was removed through a single-site laparoscopic incision with the aid of drainage and a morcellator. The operating time was 84 min. The patient was discharged 2 h and 35 min later with full return to normal activity in 5 d. CONCLUSION: Large, benign-appearing adnexal masses can be managed safely with superior cosmetic results using single-site laparoscopy.

Levels of Gynecologic Care: A Task Force Consensus Statement.

Systems of care have been established for obstetrics, trauma, and neonatology. An American College of Obstetricians and Gynecologists Presidential Task Force was established to develop a care system for gynecologic surgery. A group of experts who represent diverse perspectives in gynecologic practice proposed definitions of levels of gynecologic care using the Delphi method. The goal is to improve the quality of gynecologic surgical care performed in the United States by providing a framework of minimal institutional requirements for each level. Subgroups developed draft criteria for each level of care. The entire Task Force then met to reach consensus regarding the levels of care final definitions and parameters. The levels of gynecologic care framework focuses on systems of care by considering institutional resources and expertise, providing guidance on the provision of care in appropriate level facilities. These levels were defined by the ability to care for patients of increasing risk, complexity, and comorbidities, organizing gynecologic care around hospital capability. This framework can also be used to inform the escalation of care to appropriate facilities by identifying patients at risk and guiding them to facilities with the skills, expertise, and capabilities to safely and effectively meet their needs. The levels of gynecologic care framework is intended for use by patients, hospitals, and clinicians in the United States to guide where elective surgery can be done most safely and effectively by specialists and subspecialists in obstetrics and gynecology. The key features of the levels of gynecologic care include ensuring provision of risk-appropriate care and regionalization of care by facility capabilities.

Adolescent gynecology: special considerations for special patients.

Developments in the field of adolescent gynecology highlight the specific expertise and care required by this population. Given the ability to shape their future health choices, adolescents are a critical target for preventative health care. The approach to the evaluation and management of this unique population rests not only on the practitioner's adept ability to recognize the unique clinical challenges that may occur, but also rests on his/her understanding of these problems. Here, we review recent guidelines and practice patterns in the evaluation and management of issues in adolescent gynecology.

Adolescent gynecology.

Given new developments in the field of adolescent reproductive health, this review focuses on highlighting new guidelines and practice patterns in evaluation and management of adolescent gynecologic problems. First, understanding the proper techniques for the initial examination is key to establishing a long-term relationship with this age group. Reservations about the first gynecologic examination are common, and the practitioner's goal is foremost to make the patient as comfortable as possible. Preventive health in this patient population is key, and practitioners should become comfortable with providing education about topics as diverse as sexuality, eating disorders, and dating violence. Furthermore, the frequency with which teenagers report sexual activity and the high unintended pregnancy rate in this age group makes counseling regarding effective contraception essential. Additionally, practitioners are encouraged to take the opportunity to discuss the availability of the human papillomavirus (HPV) vaccine with adolescents. In 2007, adolescents were designated as a special population, given the frequency with which they acquire and clear mild HPV-related cervical dysplasia. More conservative treatment in this population is generally favored. During their transition through puberty, disorders of menstruation become the most common complaint requiring the attention of the gynecologist. Most commonly, anovulation serves as the cause behind such abnormal bleeding. Polycystic ovarian syndrome can develop in early puberty and carry its consequences into adulthood. Infertility, diabetes, and hirsutism mark the most important components of the syndrome and require age-appropriate management. Finally, the consequences of endometriosis on the future fertility of adolescents have brought early intervention to light. Recognition and prompt treatment are advocated to prevent the future implications of this disease.

The physical examination in pediatric and adolescent patients.

The initial evaluation and examination of both the pediatric and adolescent patients provides the opportunity for the clinician to establish a relationship that will ensure the successful outcome of the visit. In the younger age group, cooperation of the child before performing an examination should be the focus at the first encounter. This cooperation will enable proper positioning and a systematic approach to examination and documentation of findings. Although the adolescent patients may be older and better able to understand the specifics of the examination, these patients present additional challenges for the examining practitioner.

Surgical considerations and challenges in the pediatric and adolescent gynecologic patient.

It is important for practitioners to recognize that there are special considerations when performing gynecologic surgery in a pediatric or adolescent patient. A provider must be familiar with differences in anatomy, physiology, surgical technique, and psychosocial concerns. This can be challenging for a provider who does not routinely operate on patients in this population. A minimally invasive surgical approach is preferred in the pediatric and adolescent patient whenever possible. While a good command of laparoscopy in the adult patient is certainly a useful skill when operating on pediatric and adolescent patients, there are technical adaptations and challenges to consider. This chapter reviews the pre-operative preparation, operative technique and challenges, and post-operative care of the surgical pediatric and adolescent gynecologic patient.

Gynecologic and Obstetric Consequences of Obesity in Adolescent Girls.

In the past few decades, there has been an overwhelming increase in childhood and adolescent obesity worldwide. Besides the well recognized cardiometabolic complications and other physical conditions associated with obesity, during adolescence, it causes psychological and social distress in a period of life that is already sensitive for a girl. This in turn increases their risk of low self-esteem and depression. Furthermore, obesity diminishes health-related quality of life and years of life. Overweight and obese teenagers are more likely to have gynecologic and obstetric complications, during adolescence and also later in life. Consequences of obese and overweight childhood and adolescence include sexual maturation and reproductive dysfunction, alterations in menstruation, dysmenorrhea, risky sexual behavior, and inefficient use of contraception, polycystic ovary syndrome, bone density abnormalities, macromastia, and an increased risk of breast and endometrial cancer. Obese adolescents are at greater risk of pregnancy and perinatal complications, such as preeclampsia, gestational hypertension and preeclampsia, gestational diabetes mellitus, primary cesarean delivery, and induction of labor, to mention a few. Evidence shows that infants born to obese teenagers are also more likely to have complications including preterm or post-term delivery, small-for-gestational age newborns, macrosomia, meconium aspiration, respiratory distress, and even stillbirth, among others. This comprehensive review focuses on the gynecological and obstetric consequences of obesity in adolescent girls.

Management of Large Ovarian Neoplasms in Pediatric and Adolescent Females.

The overwhelming majority of ovarian cysts in pediatric and adolescent girls are physiologic; however, large simple and complex ovarian lesions often require surgical intervention due to the increased risk of neoplasia. In this review article, we discuss the preoperative evaluation and intraoperative management of large ovarian neoplasms. We review the current literature regarding long term ovarian function and fertility, rates of recurrence and residual disease, and novel surgical approaches. Managing large ovarian neoplasms in the pediatric and adolescent population requires careful preoperative and intraoperative care to optimally resect neoplasia while maximizing fertility and minimizing pain.

Massive edema of the ovary: a case report and review of the pertinent literature.

BACKGROUND: Massive edema of the ovary is a rare entity affecting mainly young women. It is often misdiagnosed for a malignancy, posing the young patient at risk for over-treatment with resultant loss of hormonal function and fertility. CASE: A 13-year-old premenarchal girl presented with a large solid pelvic mass after recurrent episodes of self-limited abdominal pain. With a working diagnosis of malignant ovarian tumor, an exploratory laparotomy was done in which a twisted ovarian mass was found and excised completely. Pathological examination of the mass revealed massive edema of the ovary with hemorrhagic necrosis. CONCLUSION: After extensive review of the literature, it seems most cases were over-treated, as was ours. This entity should be suspected in women at the fertile age range with solid enlargement of the ovary and definite treatment should be undertaken only after confirmed pathological diagnosis. Conservative treatment is feasible and should be the rule in these cases, where fertility preservation is mandatory.

Bilateral retinal occlusion progressing to long-lasting blindness in severe preeclampsia.

BACKGROUND: Temporary blindness in pregnancy associated with preeclampsia has been reported. Most cases have been attributed to cortical cerebral edema with transient vision impairment. We present a patient with bilateral retinal arteriole occlusions causing permanent blindness. CASE: A teenage primigravida at term presented with uterine contractions and preeclampsia. Twenty-four hours after delivery she developed sudden visual loss that progressed to total bilateral blindness. Imaging studies ruled out cerebral edema and an ophthalmologic examination found retinal hemorrhages and infarcts consistent with bilateral central retinal arteriole occlusions. At 2- and 6-month follow-up there was marked persistent visual impairment. CONCLUSION: The combination of blindness and preeclampsia is rare. Evaluation for ophthalmologic findings should be part of the initial patient assessment with preeclampsia.

Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills.

Adolescents' compliance with use of oral contraceptive pills has been described in the literature. The purpose of this study was to compare traditional Sunday Start to a same day (Quick Start) approach. A retrospective study of patients 22 years of age and younger was performed comparing compliance at 3 months and 12 months and side effects. The groups were divided into Quick Start (N = 77, 40%) and Sunday Start (N = 116, 60%). One hundred twenty-five (65%) patients were compliant at 3 months; 68 patients (35%) were compliant at 12 months. Quick Start users were more likely to comply at 3 months (72% vs. 56%, p = 0.059), especially if they were Caucasian (80% vs. 65%, p = 0.007), with dysmenorrhea (86% vs. 62%, p = 0.006), nulligravid (77% vs. 58%, p = 0.008), or nulliparous (73% vs. 59%, p = 0.038). There was no difference in side effects. There was no significant difference at 1 year in compliance or side effects. Findings suggest better compliance in adolescents at 3 months with the Quick Start approach while maintaining side effect profile.

Viable intrauterine pregnancy with acute salpingitis progressing to septic abortion. A case report.

BACKGROUND: A viable intrauterine pregnancy with salpingitis has been reported rarely. CASE: A 27-year-old woman at 10 weeks' gestation developed abdominal pain, fever, leukocytosis, peritoneal signs, closed cervix and a viable pregnancy. Progression from acute salpingitis to septic abortion was documented. CONCLUSION: Acute salpingitis in the presence of a viable pregnancy warrants aggressive intervention.

Premenarchal recurrent periclitoral abscess: a case report.

BACKGROUND: Periclitoral abscesses in premenarchal girls is a serious condition and can have negative implications for future reproductive health. Recurrent periclitoral abscess in premenarchal girls is rare. CASE: An 11-year-old, premenarchal girl presented complaining of dysuria, vulvar swelling, pain and erythema of the clitoral hood and a similar episode 12 months previously. Intravenous antibiotics and local measures resulted in spontaneous drainage of the abscess. On day 3 the area was healing, and the patient was discharged on oral antibiotics and sitz baths. At her 6-month follow-up, she had a normal clitoral hood without tenderness or erythema. CONCLUSION: Broad-spectrum antibiotics and local measures may prevent surgical treatment and potential associated reproductive morbidity.

Vulvar intraepithelial neoplasia in adolescents with abnormal Pap smear results: a series report.

OBJECTIVE: The objective of this study was to determine the prevalence of vulvar intraepithelial neoplasia (VIN) in adolescents presenting for cervical colposcopy in an adolescent gynecology office. MATERIALS AND METHODS: We conducted a retrospective chart review from 1999 to 2002 of the concomitant diagnosis of cervical intraepithelial neoplasia and VIN in our private general pediatric and adolescent practice in patients younger than 22 years of age who underwent cervical colposcopy as well as evaluation of the vulva secondary to gross and microscopic visualized lesions. RESULTS: Sixty-one patients underwent colposcopy for abnormal Pap smears; we found a 10% overall prevalence of vulvar intraepithelial neoplasia. Forty-four percent (n=27) underwent concomitant evaluation of the vulva; from these, 22% (n=6) fulfilled the characteristics of vulvar and cervical intraepithelial neoplasia. CONCLUSION: In the presence of cervical cytology abnormalities, VIN may be more common than recognized and careful screening is definitely warranted.

Bone mineral density in adolescent females using depot medroxyprogesterone acetate.

STUDY OBJECTIVE: To examine bone mineral density (BMD) on a semi-annual basis among control subjects and adolescent females receiving depot medroxyprogesterone acetate (DMPA) injection or oral contraceptives. DESIGN: Non-randomized prospective study. SETTING: Teenage pregnancy prevention intervention clinic. PARTICIPANTS: Adolescent females who were new users of DMPA injection (N=58, age 12-21) or the oral contraceptive pill (N=71, age 11-19) and normal menstruating girls (N=19, age 15-18). INTERVENTIONS: Baseline and 6-monthly measures of lumbar vertebral BMD using dual-energy X-ray absorptiometry over a 2-year period. MAIN OUTCOME MEASURES: comparison of percent change on BMD over time between DMPA users, pill users, and normal menstruating girls. RESULTS: There was no difference on group characteristics at baseline except for the ethnicity between the controls and the DMPA group. There was a statistically significant decrease in BMD between DMPA users and controls at 6 months (-3.02% change, P=0.014) 12 months (-3.38% change, P=0.001) 18 months (-4.81% change, P<0.001) and 24 months (-6.81% change, P=0.010). There was no statistical difference between pill users and controls. CONCLUSION: There is a relationship between DMPA use and a decrease in BMD compared to normal menstruating controls that seems to persist up to 24 months.

Development of a web-based laparoscopic technical skills assessment and testing instrument: a pilot study.

OBJECTIVE: Current surgical training programs rely heavily on subjective assessments to measure operative proficiency, despite heavy emphasis on standardized testing as a means to rank scholastic ability. A compact laparoscopic simulator was developed with the intention to create a technical skill evaluation system that resembles standardized testing to provide the user with real-time percentile scores in a variety of skill metrics. The calculation of percentiles is only accurate if the pool of scores resembles a specific distribution (e.g., normal or log-normal distribution). We hypothesize that the grading measures provided by the simulator will follow normal or log-normal distributions. MATERIALS AND METHODS: A total of 29 surgical trainees with varying levels of laparoscopic experience were surveyed regarding their current training, proficiencies, and experience with the Fundamentals of Laparoscopic Surgery curriculum and then asked to perform a standard peg-transfer task 5 times. A proprietary device placed along the trocars of a laparoscopic box trainer was used to gather data that, when subjected to unique algorithms, gave real-time, web-based feedback to trainees on the following metrics: volume of instrument use, economy of movement, angular instrument path, instrument rotation, bimanual coordination, smoothness, time to task completion, and depth perception. Numerical data were plotted on a frequency histogram. Minitab software was used to identify if individual metrics fit a standard distribution curve. Analysis of variance was used to differentiate among 3 established physician skill levels, as a means of assessing construct validity. RESULTS: In the goodness-of-fit tests performed, angular path, depth perception, rotation, and smoothness were found to best fit a log-normal distribution (p > 0.1). Bimanual coordination was found to fit a normal distribution (p ≥ 0.067). However, both normal and log-normal distributions were rejected (p ≤ 0.01) for the metrics of time, volume, and economy of movement. After separating participants into 3 groups based on level of experience with the Fundamentals of Laparoscopic Surgery curriculum, analysis of variance showed significant differences among all group means across the 5 metrics (i.e., angular path, depth perception, rotation, smoothness, and bimanual coordination; p ≤ 0.023). CONCLUSION: A proprietary device provided quantitative assessment of laparoscopic skills, which can be used to differentiate among skill levels. Of the 8 tested metrics, 5 fit a normal or log-normal distribution, meaning the scores can statistically be ranked by percentile. Time, volume, and economy of movement did not fit desired distributions. The grading system proved to have construct validity, indicating it may be useful in the longitudinal assessment of laparoscopic skills of surgical trainees.