Common Benign Chronic Vulvar Disorders.

Common benign chronic vulvar conditions include genitourinary syndrome of menopause (formerly called vulvovaginal atrophy), lichen sclerosus, lichen planus, lichen simplex chronicus, and vulvodynia. Genitourinary syndrome of menopause results from the hypoestrogenic state that leads to atrophy of normal vulvar and vaginal tissues. It is typically treated with lubricants, moisturizers, and intravaginal estrogen. Lichen sclerosus is an inflammatory condition characterized by intense vulvar itching. It is treated with topical steroids or, in some cases, topical calcineurin inhibitors. Patients with lichen sclerosus are at risk of vulvar squamous cell carcinoma and should be monitored closely for malignancy. Lichen planus is an inflammatory autoimmune disorder that can affect the vulva and vagina in addition to other skin and mucosal surfaces. The first-line treatment is topical steroids, and significant scarring can occur if left untreated. Lichen simplex chronicus manifests as persistent itching and scratching of the vulvar skin that leads to thickened epithelium. Breaking the itch-scratch cycle, often with topical steroids, is the key to treatment. Vulvodynia is a common vulvar pain disorder and is a diagnosis of exclusion. A multimodal treatment approach typically includes vulvar hygiene, physical therapy, psychosocial interventions, and antineuropathy medications.

The Importance of Distinguishing Menstrual and Peripheral Blood in Forensic Casework: A Case Report.

This report presents a case of an 18-year-old woman found unconscious by police officers outside a club suspected to be victim of a sexual assault. She was not able to give information about the dynamics of the assault, since she was under the effect of a high amount of alcohol. She affirmed to be virgin.The forensic genetic analyses were performed on vaginal and rectal swabs as well as bloody-like traces present on the slip. DNA and RNA analysis were performed using a multiplex for 15 autosomal short tandem repeat markers and of 19 primers specific for different tissues, respectively.No male DNA was identified on vaginal and rectal swabs and on blood spots on the underwear. Blood, vaginal, and skin markers were scored observed in the samples obtained from slip traces and vaginal swab.The forensic genetic analysis supports the proposition that the victim had a sexual intercourse, in the absence of male biological material, in a case where the victim, altered by high blood alcohol levels, was unable to provide information.

Genitoanal Injury in Sexually Assaulted Adult Women: Six-Year Retrospective in Bangkok.

Sexual assault persists as a global problem. Even when sexual assault does not result in obvious visible wounds, genitoanal injury must be evaluated because it is often pertinent for legal outcomes. Macroscopic ("naked eye") examination is valuable when colposcope is not available or when patients do not consent. This study reviewed the genitoanal injuries of 117 sexually assaulted adult women evaluated macroscopically. Genitoanal injury prevalence was 47%, and nongenitoanal injury prevalence was at 44%. The most common injury type was abrasion, and the most common site was posterior fourchette. Most injury patterns were singular. The number of women who did not report a history of sexual intercourse in the sample and usage of fingers/palm during assault may have affected pattern and/or injury type. There was a significant relationship between hymenal old tear below the 3- to 9-o'clock area and prior sexual intercourse. Factors related to genitoanal injury were prior sexual intercourse, vaginal delivery, and spermatozoa detection. In conclusion, all sexually assaulted women should be encouraged to have a pelvic examination: nothing overtly visible does not mean that nothing happened.

Genital trauma and vaginal bleeding: is it a lapse of time issue? A case report of a prepubertal girl and review of the literature.

Child victims of sexual abuse may present with physical findings whose interpretation requires the most exhaustive evaluation and an accurate collection of a detailed history. Genital bleeding is usually considered as an acute sign, related to a trauma that occurred shortly before its appearance. We report a case of a 34-month-old child who was referred to the emergency room with a significant vaginal hemorrhage, originating from a wide laceration of the posterior fourchette, and a negative history for accidental trauma. The characteristics of the lesion, compared to the temporal evolution of the healing process, and the witnesses' depositions led us to assume that the time elapsed between the abusive event and the physical examination was longer in respect to what had appeared at the first sight. The judicial reconstruction of the events confirmed our assumption, allowing the charge of the right abuse perpetrator. As the literature regarding this eventuality is very poor, we report this case to stress the importance for physicians to consider that an active bleeding may be the manifestation of a trauma that occurred very long before.

Prevalence of unrepaired third- and fourth-degree tears among women taken to the operating room for repair of presumed obstetric fistula during two fistula camps in Kenya.

INTRODUCTION AND HYPOTHESIS: More than 2 million women on earth today are said to be suffering from obstetric fistula (OF), a communication between the vagina and either the urinary tract or rectum. Since unrepaired third- and fourth-degree perineal tears often manifest with symptoms identical to OF, we hypothesized that the global burden of OF is in part due to these unrepaired deep obstetric tears. METHODS: Four consultant gynecologists retrospectively reviewed the medical and operative records of all obstetric fistula cases that underwent surgical repair during the July and August, 2014, Kenyatta National Hospital and Embu Provincial Hospital Fistula Camps in Kenya. RESULTS: One hundred and eighty charts were reviewed. All 180 women had fecal incontinence (FI), urinary incontinence (UI), or both as their primary complaint. Sixty of the 180 (33 %) women had isolated FI as their presenting symptom, and at operation, 57 of these 60 (95 %) were found to have unrepaired third- and fourth-degree obstetric tears. Ninety-two of the 180 (51 %) women with OF symptoms ultimately had true OF confirmed at operation. CONCLUSION: These findings suggest that many women with OF symptoms in Kenya may harbor unrepaired third- and fourth-degree tears. Additionally, women with isolated FI may be more likely to suffer from third- and fourth-degree tears than from true OF. Immediate postpartum diagnosis and repair of third- and fourth-degree perineal tears could significantly reduce the overall burden of women with symptoms of OF.

Vulvovaginal laceration as a risk factor for uterine disease in postpartum dairy cows.

The main objective was to evaluate the association between vulvovaginal laceration and uterine diseases in dairy cows. The secondary objectives were to evaluate the association between vulvovaginal laceration and cyclicity, and reproductive performance. The vulvovaginal region of 660 Holstein cows from a 5,000 lactating-cows herd was inspected at 4d in milk (DIM) for the presence of lacerations, and scored (VLS) as follows: 0=no laceration; 1=laceration <2cm at the dorsal commissure of the vulva or lateral walls of the vulva/vagina; 2=laceration ≥2cm at the dorsal commissure of the vulva or at the lateral walls of the vulva/vagina, or both. Vaginal discharge was scored at 4, 6, and 8 DIM for diagnosis of metritis, and then at 32 DIM for diagnosis of purulent vaginal discharge (PVD). Data were analyzed using LOGISTIC and PHREG procedures of SAS. Cows with VLS 2 had greater incidence of metritis than cows with VLS 0 (69.1 vs. 42.4%), and cows with VLS 1 tended to have greater incidence of metritis than cows with VLS 0 (52.0 vs. 42.4%). Cows with VLS 2 had greater incidence of PVD than cows with VLS 0 (56.5 vs. 43.1%). A lower proportion of cows with VLS 2 than VLS 0 were cyclic by 64 DIM (70.0 vs. 86.8%). A lower proportion of cows with VLS 2 than VLS 0 were pregnant at 60 d after first AI (28.7 vs. 33.6%). Proportion of pregnant cows at 60d after AI tended to be lower for VLS 1 than VLS 0 (28.4 vs. 33.6%). Hazard of pregnancy by 300 DIM was not affected by VLS. Hazard of pregnancy was decreased for cows with metritis, PVD, and anovular cows. In summary, vulvovaginal laceration was associated with uterine disease and cyclicity, which were negatively associated with reproductive performance. Vulvovaginal laceration was recognized as a risk factor for postpartum uterine disease.

Obstetric vulvar lacerations and postpartum dyspareunia.

OBJECTIVE: To report the type and prevalence of obstetric lacerations in a primigravid patient population after term spontaneous vaginal delivery without episiotomy. We examined the characteristics of lacerations in patients with postpartum dyspareunia or vulvodynia. STUDY DESIGN: This was a retrospective cohort of primiparous patients who spontaneously delivered in the residents' service at a large urban hospital under the supervision of Ob/Gyn faculty. Data was extracted from medical records using discharge diagnosis codes. Postpartum medical records and diagnostic codes of all patients with lacerations and postpartum dyspareunia were reviewed. The study was IRB approved. RESULTS: A cohort of 1617 primiparous patients with spontaneous vaginal delivery met the inclusion criteria. No tears were recorded in 836 patients (51.7%), first-degree tears in 413 cases (25.5%), second-degree tears in 271 cases (16.8%), third-degree tears in 58 cases (3.6%), fourth-degree in 21 cases (1.3%), and 18 cases (1.1%) were not further classified. Only 51 patients (3.2%) with first- and second-degree lacerations had postpartum complications, and merely 6 (0.4%) had vulvar pain and 6 (0.4%) had dyspareunia. However, 4 of those patients (33.3%) required vulvoplasty for complete dyspareunia remission. CONCLUSION: Almost half of patients with spontaneous vaginal delivery without episiotomy experienced some type of vaginal laceration. A first degree was documented in >25% of cases; however, <10% of those subsequently had complaints of vulvar pain or dyspareunia.

Identifying the prevalence of genital injuries amongst patients attending Saint Mary's sexual assault referral centre following an allegation of digital penetration.

This study aimed to (1) add to the limited evidence base regarding genital injury associated with digital vaginal penetration and (2) identify predisposing or protective factors to the identification of a genital injury. Data collection was performed retrospectively on the paper case files of 120 female adult (>18 years) patients alleging digital vaginal penetration with no penile vaginal penetration that had an acute FME at Saint Mary's Sexual Assault Referral Centre (SARC) Manchester. Descriptive statistics were used to investigate differences in the demographics of those reporting digital penetration, with and without injuries. Overall, 18% had genital injuries noted at the time of the FME. Posterior fourchette was the most common location of genital injury and abrasion was the most common injury type. It is worth further noting that all 22 patients where an injury was noted were of white ethnicity, only 12 patients in the sample were not white so caution is needed in interpretating this finding of a non-significant difference. Future research should consider injury and ethnicity more specifically. The findings from this study add to the existing evidence base and should prove useful to expert witnesses when called upon to interpret examination findings of sexual assault complainants as they relate to an allegation of digital penetration.

Medicolegal study of child sexual abuse in greater Cairo, Egypt, during a 7-year period: 2005-2011.

Child sexual abuse has gained public attention and has become 1 of the most high-profile crimes. This study aimed to determine the demographic and medicolegal aspects of child sexual abuse in greater Cairo, Egypt. This is a retrospective study from January 1, 2005, to December 31, 2011. Data were collected from a Cairo medicolegal department and were statistically analyzed. The total number of cases was 1832 victims; 57.9% were males and 42.1% were females. Most assaults occurred in 2010 (16.2%) and 2011 (17.5%). The age group 6 to 12 years accounted for higher rate (49%), mostly in males (71.8%). A total of 83.3% of the victims belonged to low social class, and 72.3% of the victims were out of school. Only 1.9% of the victims had a mental disability. The crime scene was an unknown place in 78.1%. All offenders were males; most cases had 1 offender (82.5 %); and most offenders were extrafamilial (94.2%), of low social level, illiterate, unemployed, and between 18 and 30 years old. The unmarried offenders assaulted the females more than the males, whereas the married assaulted the males more than the females. A total of 5.8% were intrafamilial offenders; 62.7% of these cases were incest against girls and 37.3% were sodomy against boys. Clothes were normal in 48.8%. Anal assault (52.3%) and incomplete vaginal penetration (32%) were the commonest types. There was no significant relation between findings, investigations, and time. In conclusion, child sexual abuse in greater Cairo represents a problem. Therefore,forensic medicine should be a part of a multidisciplinary approach to prevent, investigate, and treat the problem.

Labial hair tourniquet: unusual complication of an unrepaired genital laceration.

Hair tourniquet syndrome has been recognized as a medical entity since the 1600 s. Appendages develop acute ischemia from tightening of hair strands circumferentially wrapped around them. Most commonly affected sites are fingers, toes, and penis, but limited reports have described involvement of the female genitalia. Although hair strangulation involving the labia minora or clitoris has been described, it typically occurs in young children. We present a case of an adolescent girl with a labial appendage hair tourniquet resulting from a previous unrepaired genital laceration. This is one of the oldest patients in whom a genital hair tourniquet has been reported, as well as description of a posttraumatic genital appendage. Genital hair tourniquets are medical emergencies that require prompt diagnosis and treatment to avoid tissue necrosis and possible amputation. Genital trauma in general requires surgical evaluation.

Pre-ramus passage of inside-out transobturator sling.

Groin pain after transobturator tape is not uncommon. Differential diagnosis and treatment strategies are becoming elaborated in the literature. A patient presented with partial improvement in her stress incontinence and persistent groin and vulvar discomfort for 3 months after "inside-out" transobturator tape. The sling was removed secondary to malposition anterior to the inferior pubic ramus, i.e., a trans-vulvar passage. Her vulvar and groin complaints resolved. Recommendations are made to facilitate the "inside to out" transobturator dissection and trocar passage to prevent this complication.

Genital injuries and allegation of digital vaginal penetration - A retrospective examination of forensic case notes.

OBJECTIVE: To determine the prevalence of genital injuries following alleged sexual assault by digital penetration of the vagina in the absence of penile penetration of the vagina or anus in women age 16 and over; and to compare with the prevalence of genital injuries following alleged sexual assault by penile vaginal penetration in the absence of penile penetration of the anus or digital penetration of the vagina and/or anus. POPULATION: 1428 adults and children attending a forensic medical examination between September 2017 and January 2020 at the Haven sexual assault referral center situated in Paddington, London, UK. DESIGN: Retrospective review of forensic notes. METHODS: Eligible cases were identified through the standardized forensic notes and relevant data was extracted. RESULTS: 109 cases of women 16 years and over alleging digital penetration only and 110 cases of women 16 years and over alleging penile vaginal penetration only were included. The 110 cases of penile vaginal penetration only were randomly selected for comparison purposes. 7.6% of Haven attenders fulfilled the digital penetration only category. In this category, the patients mean age was 27.2 years. Thirteen patients (11.9%) sustained genital injuries; of those with genital injuries, eleven (84.6%) sustained one or more abrasions. The most common site of injury was the labia minora (46.2%). There were no significant differences between the 2 groups (digital penetration only and penile vaginal penetration only) in terms of number of patients with genital injuries, type or location of injury. There were differences regarding the relationship between patient and assailant: more stranger assaults in the digital penetration group 27/109 (29%) vs 13/110 (12%) in the penile penetration group. There was one assault by multiple assailants in the digital penetration group and 8 (7.3%) in the penile penetration group. In the digital penetration group there was more alcohol use [71/109 (65.1%) vs 62/110 (56.4%)] but less drug use [21/109 (19.3%) vs 30/110 (27.3%)] than in the penile vaginal penetration group. CONCLUSION: The majority of patients examined following an allegation of digital vaginal penetration without penile penetration sustained no injuries. Of those who did, abrasions were the most common type of injury, with the inner labia minora being the most common location for injury. There were no significant differences with the injuries seen in the penile vaginal penetration group in terms of number of patients with genital injuries, type or location of injury.

Ear acupuncture or local anaesthetics as pain relief during postpartum surgical repair: a randomised controlled trial.

OBJECTIVE: To evaluate two methods of pain relief during postpartum surgical repair in regard to effectiveness, wound healing and patient evaluation. DESIGN: A randomised controlled trial testing a pragmatic set-up of brief training of clinicians. SETTING: Delivery ward at a Danish district hospital with approximately 1600 annual deliveries. POPULATION: Primiparous women with a vaginal delivery at term who needed surgical repair of lacerations to the labia or the vagina, perineal lacerations of first or second degree or mediolateral episiotomies. METHODS: The trial was set up to evaluate the effect of a brief 2-hour hands-on training in the use of ear acupuncture. All midwives (n = 36) in the department had previous experience in using acupuncture for obstetric pain relief. Pain and wound healing were evaluated using validated scores. Data collection was performed by research assistants blinded towards treatment allocation. Randomisation was computer assisted. A total of 207 women were randomised to receive ear acupuncture (105) and local anaesthetics (102), respectively. MAIN OUTCOME MEASURES: The primary outcome was pain during surgical repair. Secondary outcomes were wound healing at 24-48 hours and 14 days postpartum, participant satisfaction, revision of wound or dyspareunia reported 6 months postpartum. RESULTS: Pain during surgical repair was more frequently reported by participants allocated to ear acupuncture compared with participants receiving local anaesthetics (89 versus 54%, P < 0.01). Pain intensity during surgical repair was also reported higher (Visual Analogue Scale score 3.5 versus 1.5, P < 0.01). The ear acupuncture group received more additional pain relief during repair (53 versus 19%, P < 0.01). No difference was observed in wound healing at 24-48 hours or 14 days postpartum. Revision of wounds was rare, and no difference occurred in this trial. Comparable proportions of participants reported dyspareunia at 6 months. Patient satisfaction with the allocated pain-relief method was lower in the ear acupuncture group (69 versus 91%, P < 0.01) and fewer women would recommend the method to a friend (74 versus 91%, P < 0.01). CONCLUSIONS: Ear acupuncture as used in this trial was less effective for pain relief compared with a local anaesthetic. No difference was observed in wound healing, need for revision of wound or dyspareunia. Patient satisfaction with allocated pain-relief method was lower in the ear acupuncture group.

[Differential diagnosis of child sexual abuse]. / A fiatalkorúakkal szemben elkövetett szexuális bántalmazás elkülöníto diagnosztikája.

The evaluation of a child presenting with an anogenital complaint or lesion can be challenging for both the clinician and the patient. The doctor met the real possibility that a diagnosis of a condition caused by sexual abuse will affect significantly the child and the family. A misdiagnosis of abuse or failure to recognize a treatable condition can also have detrimental consequences. Most primary care physicians are not trained to recognize the variety of systemic and dermatologic problems that affect the anogenital area. Dermatologists and other specialists often do not appreciate the possibility of sexual abuse. In this article we present a systematic approach to the child with anogenital complaints which may mimic sexual abuse.

Evacuation of a large traumatic vulvar haematoma with an intravaginal cosmetic approach.

A healthy youngwoman presented 3 days after a jet ski accident with a large left vulvar haematoma measuring 12 cm. Immediately postinjury, she was managed conservatively in the emergency room of another hospital. However, the haematoma continued to slowly expand. She presented to our clinic with difficulty walking and severe discomfort. Decision was made to drain the haematoma surgically. The patient was sceptical to have scarring on her vulva. Thus, the haematoma was evacuated by a vertical incision on the left vaginal sidewall. After evacuation and achieving haemostasis, the was closed with two interrupted sutures. Edges of the incision were secured similar to marsupialisation with five interrupted sutures to allow continual drainage. Her discomfort resolved immediately postsurgery and she had an uncomplicated postoperative course. The intravaginal approach yielded superior aesthetic result with no scarring on the external vulva.

Use of toluidine blue dye in detection of anogenital injuries in consensual sexual intercourse.

The usefulness of Toluidine blue dye in the detection of anogenital injuries in sixty females aged 16-40 years of age with a history of consensual sexual intercourse within 48 h of intercourse were included for the study from the Gynaecology outpatient department of the Institute of Medicine, Maharajgunj, Kathmandu, Nepal over a period of 10 months. Injuries were identified and documented using TEARS classification (tears-ecchymosis-abrasion-redness-swelling) before and after the application of toluidine blue dye (TBD). Anogenital injuries were detected in 6.7% participants (4 out of 60) before the dye application and 20% participants (12 out of 60) after the dye application. Thus, TBD application increased the detection of anogenital injuries three times compared to that of the naked-eye examination. Applying the Chi-square test, there were significant differences in the detection of tears and abrasions after TBD application (p-value - 0.035 and 0.042 respectively).

Female Genital and Vaginal Plastic Surgery: An Overview.

LEARNING OBJECTIVES: After studying this article and viewing the video, the participant should be able to: 1. Accurately describe the relevant aesthetic anatomy and terminology for common female genital plastic surgery procedures. 2. Have knowledge of the different surgical options to address common aesthetic concerns and their risks, alternatives, and benefits. 3. List the potential risks, alternatives, and benefits of commonly performed female genital aesthetic interventions. 4. Be aware of the entity of female genital mutilation and differentiation from female genital cosmetic surgery. SUMMARY: This CME activity is intended to provide a brief 3500-word overview of female genital cosmetic surgery. The focus is primarily on elective vulvovaginal procedures, avoiding posttrauma reconstruction or gender-confirmation surgery. The goal is to present content with the best available and independent unbiased scientific research. Given this relatively new field, data with a high level of evidence are limited. Entities that may be commonly encountered in a plastic surgery practice are reviewed. The physician must be comfortable with the anatomy, terminology, diagnosis, and treatment options. Familiarity with requested interventions and aesthetic goals is encouraged.

Analysis of non-obstetric vaginal and vulvar trauma: risk factors for operative intervention.

Vaginal and vulvar trauma may occur accidentally or because of an act of violence. Due to its rarity, little is known about risk factors effecting need for operative intervention. We sought to perform a large descriptive analysis of adult non-obstetric vulvovaginal trauma (VVT) and elucidate risk factors for requiring operative intervention. A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. Patients ≥ 16 years old with vaginal or vulvar trauma were identified. Risk factors for surgical intervention were identified using a multivariable logistic regression analysis. From 2,040,235 female patients, 2445 (< 0.2%) were identified to have VVT with the majority being injury to the vagina (68.6%). In patients with injury to the vagina, age > 65 (OR = 0.41, CI 0.26-0.62, p < 0.001), Injury Severity Score > 25 (OR = 0.66, CI 0.50-0.86, p = 0.01) and victims of rape (OR = 0.39, 95% CI 0.26-0.57, p < 0.001) were less likely to require operative intervention. In patients with injury to the vulva, age > 65 (OR = 0.45, CI 0.21-0.94, p = 0.02), victims of rape (OR = 0.26, CI 0.08-0.87, p = 0.01) and gunshot violence (OR = 0.10, CI 0.02-0.59, p = 0.02) were less likely to require operative intervention, but those with a concomitant injury to the vagina were more likely to require operative intervention (OR = 2.56, CI 1.63-4.03, p < 0.001). Injuries to the vagina or vulva occur in < 0.2% of traumas. Interestingly, in both vulvar and vaginal trauma, older age, and involvement in rape were associated with lower risk for operative intervention. A combined injury to the vagina and vulva increases the need for operative intervention.

Gynecologic emergencies.

Gynecologic emergencies are relatively common and include ectopic pregnancies, adnexal torsion, tubo-ovarian abscess, hemorrhagic ovarian cysts, gynecologic hemorrhage, and vulvovaginal trauma. The purpose of this article is to provide a concise review of these emergencies, focusing on the evaluation and treatment options for the patient. In many cases, other causes of an acute abdomen are in the differential diagnosis. Understanding the tenets of diagnosis helps the surgeon narrow the etiology and guide appropriate treatment.