Validation of noninvasive focal depth measurements to determine epithelial thickness of the vaginal wall.

OBJECTIVE: This study investigates whether noninvasive focal depth (FD) measurements correlate with vaginal wall epithelial thickness (ET). If FD accurately reflects ET of the vaginal wall, this would allow noninvasive longitudinal assessment of (newly developed) treatment modalities aiming to increase ET, without the need for invasive biopsies. METHODS: Fourteen women, median age 62 years (inter quartile ranges: 57-65), undergoing vaginal prolapse surgery because of anterior and/or posterior compartment pelvic organ prolapse were included. We used the CytoCam, a handheld video microscope based on incident dark field imaging, and performed FD measurements of the vaginal wall before surgery. Histology was performed on tissue that was removed during the surgical procedure, and ET was measured in stained sections. We compared ET with FD interindividually, and determined the expected linear correlation and agreement between the two measurements. RESULTS: Seventeen ET measurements (mean 125 µm ±â€Š38.7, range 48-181 µm) were compared with 17 FD measurements (mean 128 µm ±â€Š34.3, range 68-182 µm). The lineair correlation between the two measurements was strong (r = 0.902, P < 0.01). Bland-Altman analysis demonstrated a mean difference of 13.5 µm when comparing ET to FD. CONCLUSIONS: The results demonstrate good agreement between ET and FD measurements. We consider the mean difference demonstrated with Bland-Altman analysis acceptable for these measurements. This suggests that FD accurately reflects ET, which further supports the use of FD to measure ET of the vaginal wall. For a complete assessment of the vaginal wall, FD measurements are preferably combined with the assessment of vaginal angioarchitecture.

Hymenal polyps in two infants.

Pathological conditions of the hymen are rare in everyday medical practice. Hymenal polyps are polypoid formations originating from the hymenal rim and are benign and disappear spontaneously within a few weeks of onset. We report two cases of hymenal polyps in two infants.

Spontaneous Reformation of Imperforate Hymen after Repeated Hymenectomy.

BACKGROUND: Imperforate hymen prevents menstrual blood drainage, which causes cyclic lower abdominal pain and amenorrhea. Untreated patients might develop serious complications such as endometriosis and infertility. Hymenectomy represents the adequate treatment. CASE: In a 16-year-old female virgin presented with recurrent lower abdominal pain, urine retention, and secondary amenorrhea after 3 hymenectomy surgeries. The examination revealed imperforate hymen. A fourth hymenectomy was performed with continuous locked sutures over all of the edges. SUMMARY AND CONCLUSION: Recurrent imperforate hymen after hymenectomy should be suspected if symptoms recur. Diagnosis can be achieved through meticulous clinical examination and appropriate imaging techniques.

Hymenal lesions and legal outcome in sexually abused girls with a history of vaginal penetration.

PURPOSE: In many cultures, it is commonly accepted that the hymen remains unchanged throughout childhood, until it is torn at the first episode of sexual intercourse. Therefore, the definition of virginity is directly linked to a normal hymen. However, most girls referred for medical forensic colposcopic examination have normal or nonspecific findings, the prevalence of abnormal findings in girls with a history of genital penetration being only 4-6%. The aim of this study was to investigate the relation between hymenal findings seen at the colposcopic examination and the legal outcome: prosecution in court and conviction in court. RESULTS: During the 80-month period of our study, 426 girls with a median age of 9 years (range 0-15 years) were included. A history of at least one vaginal penetration was given in 226 of the girls with a median age of 12 years (range 2-14 years). The hymenal findings were described as normal in 125 of the 226 cases (55%). In 50 cases (22%), hymenal clefts were found, 17 (34%) of which were complete and 33 (66%) incomplete. The finding of hymenal clefts increased with age. Of the 226 cases of girls being sexually assaulted with vaginal penetration, 119 cases (53%) were prosecuted in court, 102 of which (86%) resulted in conviction. Thirty-five (70%) of the cases with hymenal clefts and 100 (57%) of the cases without hymenal clefts were prosecuted in court, showing a correlation between hymenal clefts and conviction; however, the correlation was not significant (χ(2) test=2.1 and P=0.14). In total, 29 (58%) of the cases with hymenal clefts and 88 (50%) of the cases without hymenal clefts were convicted in court, which shows no significance (χ(2) test=1.0 and P=0.33). CONCLUSIONS: The single most important feature for conviction in court is the child's testimony and not hymenal findings seen at the colposcopic examination. Especially the testimony of the older children leads to conviction, raising the question whether the videotaped testimonies are aimed at the court proceedings, or whether hearing the child's testimony directly in court has a more powerful effect. Overall, it is crucial that the videotaped police questioning of the younger children is performed by specialized personnel, with the aim of presenting the testimony in a detailed and credible manner in court, giving children of all ages a fair trial.

Spontaneous hymeneal endometriosis: a rare cause of dyspareunia.

Vulvar endometriosis can occur after surgery or trauma and cause dyspareunia. A 30-year-old woman presented with orificial dyspareunia lasting for 5 months. Her history was marked by a vaginal birth without perineal injury and the removal of a cyst from the left Bartholin's gland. On examination, we observed a selectively painful, superficial and retractile lesion, 5 mm in diameter at the junction of the hymen at some distance from the bartholinitis scar. Endometriosis was suspected due to the exacerbation of pain during menses. The surgery consisted of excision of the hymenal area of the painful lesion. Pathological examination confirmed the presence of endometrial tissue. The painful symptoms resolved and no additional treatment was administered. Any vulvar lesion, regardless of its appearance and location, can be related to endometriosis. Surgical resection is recommended to relieve the symptoms and provide histological proof.

A uterovaginal septum and imperforate hymen with a double pyocolpos.

The presence of both a uterovaginal septum and imperforate hymen is described in a young patient presenting with ongoing chronic pelvic pain and a double pyocolpos. Ultrasound and magnetic resonance imaging scans were performed. The patient underwent laparoscopic adesiolysis, hymenotomy with drainage of 200 mL of pus, and excision of a complete longitudinal vaginal septum. Over the past 5 years of regular follow-up examinations, the patient has always reported regular menstrual cycles and an absence of pelvic pain.

Concomitant resorptive defects of the reproductive tract: a uterocervicovaginal septum and imperforate hymen.

OBJECTIVE: To review a case of concomitant longitudinal uterocervicovaginal septum and imperforate hymen. SETTING: A university-based tertiary care center. PATIENT(S): A 14-year-old girl with a septum spanning the length of the uterus, cervix, and upper two-thirds of the vagina, as well as an imperforate hymen. INTERVENTION(S): Hymenotomy with subsequent vaginal septoplasty. MAIN OUTCOME MEASURE(S): NA. RESULT(S): NA. CONCLUSION(S): Anatomic anomalies of the reproductive tract may be found in tandem and when suspected, a full evaluation including advanced imaging to clearly delineate the exact anatomy, should be performed before proceeding with surgical correction.

Medical findings and legal outcomes in sexually abused children.

A previous study published in 2000 on a small group of children concluded that the medical examination in cases of sexual child abuse seldom provided legal proof of sexual abuse [J Forensic Sci 45(2000):115-7]. The present consecutive study included children referred to the police for a forensic medical examination. A colposcope was used to evaluate the anogenital findings which were classified as normal, nonspecific, and abnormal. Four hundred and eighty-two children were included. Abnormal anogenital findings were found in 38% of the girls and 20% of the boys, but there was no relation between abnormal anogenital findings and the two legal outcomes: "appearing in court" and "being convicted." However, the age of the child turned out to be a more important factor in relation to legal outcome than the physical findings. The results of this study suggest that the child's statement and not the physical findings were important for legal outcome.

Volumoso hidrocolpo em neonato: relato de caso / Newborn hydrocolpos secondary to congenital imperforate hymen: a case report

Os autores relatam um caso de hímen imperfurado congênito determinando volumoso hidrocolpo em recém-nascido. Esta anomalia é uma condição rara, pois a maioria dos casos de hímen imperfurado é diagnosticada na fase pré-púbere com o atraso da menarca. O objetivo deste relato é demonstrar os achados ultrassonográficos do hidrocolpo no recém-nato e realizar uma breve revisão de literatura sobre o assunto. É de fundamental importância nestes pacientes o rastreamento de outras malformações congênitas que podem estar associadas ao quadro.

The authors report a case of newborn hydrocolpos secondary to congenital imperforate hymen. This anomaly is a rare condition, since most cases of imperforate hymen are diagnosed in the prepubertal period with the delay of menarche. The objective of this report is to demonstrate ultrasound findings of newborn hydrocolpos and make a review of literature about it. It is vital to search other congenital malformations that may be associated.

Himen imperforado con hematocolpus y hematometra secundario: presentación de un caso / Imperforate hymen with Hematocolpus and Secondary Ematometra: presentation of a case

El himen imperforado es una patología poco frecuente del tracto genital femenino. Presentamos un caso de himen imperforado, en una paciente virgen de 17 años de edad con amenorrea, dolores en bajo vientre de forma cíclica con intervalos de más o menos 15 días y un aumento de volumen en hipogastrio, la que fue atendida durante nuestra misión médica realizada en el hermano país de Venezuela. Se realizó ecografía abdominopélvica con la vejiga llena y se observaron imágenes sugestivas de colpohematometra. La paciente fue intervenida quirúrgicamente, se le realizó incisión y resección de la porción central de la membrana himeneal, con evacuación del contenido sanguinolento, confirmándose el diagnóstico. No se presentaron otras complicaciones y la paciente fue dada de alta con evolución satisfactoria. Se revisó y actualizó la literatura al respecto.

The imperforate hymen is not a very frequent pathology of the feminine genital tract. A case of imperforate hymen was presented, in a 17 year-old virgin patient with amenorrhea, having pains in low stomach in a recurrent way with intervals of more or less 15 days and an increase of volume in hypogastrium, the one that was assisted during our medical mission carried out in Venezuela, our brother country. An echography was carried out abdominopelvic with the full bladder and suggestive images of colpohematometra were observed. The patient was intervened surgically. An incision and resection of the central portion of the membrane hymeneal was carried out to the patient with evacuation of the bloody content being confirmed the diagnosis. There were not any other complications and the patient was discharged from the hospital with satisfactory evolution. It was revised and it modernized the literature in this respect.

A large hymenal polyp in a 21-year-old virgin.

Pathological conditions of the hymen are rare in everyday medical practice. They are usually encountered in the pediatric patient population and are sometimes a matter of forensic interest. We report an interesting case of a large hymenal polyp in an adolescent virgin that presented only a cosmetic problem. The polyp was excised, the hymenal ring was preserved, and the sample was histologically verified.

Hysteroscopic management of lower genital tract lesions in females with limited vaginal access.

OBJECTIVE: To show that hysteroscopy is a feasible and safe method of evaluation in females with limited vaginal access. DESIGN: Retrospective review of two patients who received hysteroscopy for evaluation of uterus didelphys with hemivagina and a cervical polyp. SETTING: Private hospital. PATIENT(S): Two patients with either a vagina septum or cervical polyp. INTERVENTION(S): Hysteroscopy for visualization and resection. MAIN OUTCOME MEASURE(S): Resection of a vagina septum and cervical polyp. RESULT(S): No more cyclic dysmenorrhea in the patient with uterus didelphys and cessation of abnormal bleeding in the patient with a cervical polyp. Our results suggest that hysteroscopy can provide precise visualization of vagina and cervical lesions if the approach is difficult with decreased access, and allows concurrent treatment of pathologic conditions accordingly. CONCLUSION(S): Hysteroscopy is favorable in the diagnosis and treatment of vaginal and cervical lesions in women with limited vaginal access because of age or a narrower vagina. In the Eastern culture, it is very important for females to maintain their state of virginity signified by an uninjured hymen ring. This problem is solved, as hysteroscopy allows the evaluation of malformations of the female genital tract.

[Sexual abuse of prepubertal children]. / Seksuelle overgrep mot prepubertale barn.

BACKGROUND: During the last 15 years, a considerable change has taken place regarding the understanding of anatomical and microbiological anogenital findings in children. At the end of the 1980s, abnormal findings were described in more than 50 % of allegedly abused children. Today such findings are described in 5 %. An important consequence of this change is that absence of abnormal findings should never be used to exclude abuse, not even abuse with anogenital penetration. The main reason for this change is increased knowledge about normal variation and healing after injury, as well as an improvement in standardisation of terminology. MATERIAL AND METHODS: This paper is based on relevant literature published on this topic. RESULTS AND CONCLUSIONS: During this period, several findings have been reclassified from abnormal to normal or non-specific. Examples of such findings are anal dilatation, large and gaping hymenal opening and narrow hymenal brim. Some of the previously reported cases of anogenital scarring are probably mis-classified normal structures. Research-based international classification scales are now established in order to aid the physician in diagnosing sexual abuse, and these are revised on a regular basis. It is currently common to classify medical findings into three main categories; normal/unspecific findings, indeterminate findings and diagnostic findings.

Villoglandular adenocarcinoma in situ of intestinal type of the hymen: de novo origin from squamous mucosa?

Adenocarcinomas of the lower genital tract are rare diseases, and most of them arise from the Bartholin glands. Villoglandular adenocarcinoma of intestinal type is a very uncommon neoplasm of unknown origin with only few cases described on the vulva and in the vagina. It is characterized by villoglandular architecture, mucinous-type epithelium with intestinal differentiation (goblet cells), and direct apposition of the tumor with the surface epithelium. We report a case that developed on the hymen of a 64-year-old woman and discuss its possible origin as arising de novo from the squamous epithelium.

Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings.

STUDY OBJECTIVE: To review all existing studies of genital anatomy in girls selected for nonabuse, clarify terminology used to describe hymenal morphology and nonspecific findings, and test consensus terminology in the reevaluation of hymenal morphology and nonspecific findings in 147 premenarchal girls selected for nonabuse. METHODS: Over six months, the authors identified and evaluated 147 premenarchal girls without history of sexual abuse who were referred for gynecological examination. Parents and patients were screened for possible abuse or significant past medical or behavioral history, and each girl was interviewed and then received a complete examination including a genital examination documented by colposcopy with both 35 mm camera and video capabilities. Using established terminology(1) each case was then independently reviewed and hymenal morphology and nonspecific findings documented. RESULTS: The study population consisted of 147 premenarchal girls; 76.9% were Hispanic, 12.3% African-American, and 10.3% Caucasian. Subjects had a mean age of 63 months (+/minus sign 38). Hymenal configurations included: annular (concentric) 53%, crescentic (posterior rim) 29.2%, sleeve-like (redundant) 14.9%, septate 2%, and other (imperforate, cribriform) < 1%. Nonspecific findings included peri-hymenal bands, 91.8%; longitudinal intravaginal ridges, 93.8%; hymenal tags, 3.4%; hymenal bumps/mounds, 34%; linea vestibularis, 19%; ventral hymenal cleft/notch at 12 o'clock in 79% of annular or redundant hymens; ventral cleft/notch not at 12 o'clock, 19%; failure of midline fusion, 0.6%; hymenal opening size > 4 mm, 30.6%; erythema, 48.9%; change in vascularity, 37.4%; labial adhesions, 15.6%; posterior hymenal notch/cleft (partial), 18.3%; posterior notch/cleft (complete), 0%; posterior hymenal concavity or angularity, 29.5%. In addition, each case was assessed for the presence of a thickened (45.5%) or irregular (51.7%) and narrowed (22.4%) hymenal edge. Each case was also reviewed for exposed intravaginal anatomy (93%). CONCLUSIONS: The authors concluded that improved techniques and photo documentation have provided examiners with a better understanding of hymenal morphology and that nonspecific genital findings are commonly found in a population of girls selected for nonabuse. A thorough understanding of normal studies and a consistent application of established terminology can prevent the misinterpretation of nonspecific or congenital findings as posttraumatic changes.

Pyocolpos: diagnosis and treatment.

Pyocolpos is a rare complication of hydrocolpos. Hydrocolpos usually presents during adolescence and is associated with an imperforate hymen. The following is a case of a 3-month-old girl with pyocolpos. Her history was significant for a urinary tract infection (UTI) at 7 weeks of age. The authors believe that her UTI was caused by urinary retention secondary to hydrocolpos. A complete evaluation may have prevented the complication of pyocolpos.

Colposcopic genital findings in prepubertal girls assessed for sexual abuse.

After the introduction of the colposcope for the examination of children suspected of being sexually abused in Leeds, a study was undertaken to describe the findings in detail. A total of 109 consecutive prepubertal girls, mean age 70.4 months were assessed including colposcopic genital and anal examination, and peer group review of reports and photographs. Fifty nine children had signs consistent with blunt force penetrating trauma (hymenal transection/major notch, scar, or hymenal attenuation). Transections were encountered most commonly at 6 o'clock (directly posterior). In 46 the hymenal orifice was gaping with thigh abduction only and in 47 the hymenal orifice transverse diameter was greater than 4 mm on labial separation. Overall, physical findings were commonly present and in only two cases were no signs recorded. Non-specific and frequent findings included patterns of labial and introital reddening. Supportive hymenal signs including swelling, rounding of edge, thickening, distortion, and loss of symmetry were common. Labial fusion was present in 20. Urethral dilatation with labial separation was noted in 14. Physical findings including normality are consistent with abuse and even minor anogenital signs as well as negative findings should be documented. Colposcopy and photography are valuable tools in peer review, teaching, and case management.

Concave hymenal variations in suspected child sexual abuse victims.

The purpose of this study was to describe and analyze the characteristics of, and the clinical correlates to, concave hymenal variations in a large number of suspected child sexual abuse victims. Thirteen hundred eighty-three female child and adolescent suspected sexual abuse victims were comprehensively evaluated. Photocolposcopy was used for the anogenital examinations. Concave hymenal variations were found in 174 patients (12.6%). Sixty-one (35.1%) were anterior. Of these, 40 (65.6%) were curved and smooth, and 21 (34.4%) were angular and/or irregular. One hundred (57.5%) were posterior/lateral. Of these, 33 (33%) were curved and smooth, and 67 (67%) were angular and/or irregular. Thirteen patients (7.5%) had multiple hymenal concavities. Posterior/lateral location was associated with penile-vaginal contact (P = .004), penetration (P = .006), stranger perpetrator (P = .032), hymenal rim narrowing (P less than .001), and posterior fourchette abnormality (P = .049). Angular and/or irregular features were associated with penile contact (P = .005), vaginal contact (P = .035), penile-vaginal contact specifically (P less than .001), penetration (P = .046), abnormal general physical examination (P = .018), and hymenal rim narrowing (P less than .001). Logistic regression analysis demonstrated that age-specific prevalence trends for posterior/lateral (P less than .001) and angular and/or irregular (P = .011) concavities were consistent with acquired anatomic findings. An interobserver exercise with five "blinded" raters evaluating photographs of 49 patients showed significant agreement among observers in sorting posterior/lateral and angular concavities into the diagnostic categories "suggestive of trauma" and "trauma."(ABSTRACT TRUNCATED AT 250 WORDS)