Urinary retention secondary to a Gartner's duct cyst.

A 22-month-old child with a large cyst of Gartner's duct suffered from recurrent episodes of urinary retention. Excision of such large symptomatic cysts has been recommended in the past. Marsupialization is discussed as an alternative to extensive excision.

Labial adhesions in a postpartum patient.

The occurrence of labial adhesions in a patient in the immediate postpartum period is described. The adhesions did not respond to topical estrogen therapy, and sharp separation was required. Factors related to possible etiology as well as management of this condition are discussed.

Functional ovarian cysts in patients cured of ovarian neoplasms.

Twenty-seven patients with ovarian cancer underwent unilateral salpingo-oophorectomy and were followed for 12-215 months (mean 80) after completion of therapy. Of these, nine patients who received pelvic irradiation subsequently developed ovarian failure. Of the remaining 18 patients who maintained ovarian function, 13 (72%) developed a functional ovarian cyst during the follow-up period. Of these 13 patients, eight were observed until the functional cyst regressed, four were treated with oral contraceptives (OCs) to suppress ovarian function, and one underwent oophorectomy for a large corpus luteum cyst. We recommend that OC pills be considered for suppression of ovarian function in postmenarcheal girls after completion of therapy for ovarian neoplasms. Routine use of OCs may simplify the follow-up of these patients by preventing the formation of functional ovarian cysts. In postmenarcheal patients not treated with OCs, the finding of a unilocular ovarian cyst should be considered to represent a functional cyst, and a trial of OCs for 3 months may result in spontaneous regression. Persistent cysts must be operatively removed.

Asymptomatic rupture of a rudimentary uterine horn.

Pregnancy in a noncommunicating rudimentary uterine horn frequently results in rupture. Uterine rupture may cause a massive intraperitoneal hemorrhage, necessitating operative intervention to control bleeding. The following is a report of an unusual patient who had an asymptomatic rupture of a rudimentary horn.

A model clinic approach to the reproductive health concerns of the mentally handicapped.

An interdisciplinary model clinic for the consideration of reproductive health and sexuality concerns in a noninstitutionalized, mentally handicapped population is presented. Common concerns of this population group and their management are discussed. A program for menstrual hygiene control was developed using a combination of hormonal medication and home-based behavior modification training. Group sexuality counseling was provided for both patients and their families to enhance the avoidance of sexual abuse, the understanding of sexual development, and intrafamily communication. An ethics committee, composed of persons within the community, offered advice in questions of contraception and/or sterilization.

Single serum progesterone as a screen for ectopic pregnancy: exchanging specificity and sensitivity to obtain optimal test performance.

OBJECTIVE: To investigate the diagnostic accuracy of screening serum P in diagnosis of ectopic pregnancy (EP) and to identify a cutoff value that provides the best compromise between test sensitivity and specificity. DESIGN: Retrospective analysis. SETTING: University hospital. INTERVENTIONS: Observation only. PATIENTS: First trimester pregnant women at risk for EP. MAIN OUTCOME MEASURE: Single P measurements were obtained from 3,674 pregnancies with outcomes defined as EP, viable intrauterine pregnancy (IUP), and spontaneous abortion (SAB). Diagnostic accuracy of the test was analyzed by generating receiver operating characteristic (ROC) curves, which quantify the ability of the test to distinguish EP and SAB from IUP. RESULTS: Diagnostic accuracy for EP versus IUP was 88.7% +/- 0.1% (mean +/- SEM); for SAB versus IUP, 93.8% +/- 0.4%; and for SAB + EP versus IUP, 92.8% +/- 0.4%. Diagnostic accuracy for SAB versus EP was only 39.4% +/- 0.2%. In the interval of 15.0 to 19.9 ng/mL (47.7 to 63.3 nmol/L), P missed 5.3% of the EPs and incorrectly included 84.3% of the viable IUPs; in the interval of 20.0 to 24.9 ng/mL (63.6 to 79.2 nmol/L), sensitivity improved in that only 3.5% of the EPs were missed but 88.8% of viable IUPs were included incorrectly. A cutoff value of > or = 17.5 ng/mL (55.7 nmol/L), the median point of the 15.0 to 19.9 ng/mL (47.7 to 63.3 nmol/L) interval, missed only 35 of 423 (8.3%) total EPs in the study. CONCLUSION: Analysis of ROC curves demonstrates that single serum P has high diagnostic accuracy for differentiating accidents of pregnancy (SAB and EP) from viable IUP, both individually (SAB versus IUP and EP versus IUP) and collectively (SAB + EP versus IUP); it cannot efficiently discriminate SAB versus EP. We conclude that for P > or = 17.5 ng/mL (55.7 nmol/L), patients thought to be at risk for EP may be followed reasonably without ultrasound or further invasive diagnostic studies.

Adolescent victims of sexual assault.

PURPOSE: The purpose of this study was to evaluate a group of female adolescent victims (n = 176) of sexual assault and assess the similarities and differences between them and older female victims. METHODS: All the adolescents in this study were physically mature. The demographic data and the findings of the medical evaluation are compared with those of women, 25-44 years of age, who were assaulted during the same time period (n = 197). RESULTS: The mean age of the adolescent patients was 15.2 (+/- 1.6), while the control group had a mean age of 31.9 (+/- 5.1). Racial distribution was similar in both groups. One hundred thirty-nine (79%) adolescents reported prior consensual sexual activity and 32 (18%) had been pregnant at least once. Thirty-one adolescents (19%) reported a previous sexual assault. Many adolescent victims (64%) knew their assailant. Weapons or physical force was used less frequently to subdue an adolescent victim, and firearms were used very infrequently in adolescent assault. Use of alcohol or drugs just prior to the assault was prevalent among adolescent victims (47%). Finally, adolescent victims were less likely to sustain physical injuries during the assault. CONCLUSION: The preexisting relationship between the victim and the assailant may explain other elements that distinguish an adolescent rape victim from her adult counterpart. Compared to adolescent victims, the assault on adult women is more often perpetrated by a stranger, the victim is more likely to be abducted, and weapons, especially firearms, are more likely to be used to carry out the victim's capture.

Vaginal bleeding in childhood and adolescence.

Vaginal bleeding in early childhood, regardless of its duration and quantity, is always of clinical importance. This article discusses the examination of the child and adolescent and reviews the various causes of vaginal bleeding in these patient groups.

Child sexual abuse.

It is estimated that the number of child victims of sexual assault is in excess of 200,000 per year. Many of these children are brought to emergency room facilities or to their private physician's office for evaluation. The recent advances in the area of diagnosis and management of children who are the victims of sexual abuse are presented.

Adhesion formation associated with the use of absorbable staples in comparison to other types of peritoneal injury.

Adhesion formation was assessed after inducing peritoneal injury with absorbable staples, absorbable suture, surgical excision or thermal injury. In addition, adhesion formation was assessed in the presence of Hyskon. Absorbable staples were associated with increased adhesion formation when compared to the other methods of injury. Hyskon appears to significantly reduce the formation of peritoneal adhesions at sites of peritoneal suturing, excision, and thermal injury, but did not reduce adhesion formation in the area of stapling.

Use of a menstrual calendar in patients with Rokitansky syndrome. A report of two cases.

In two cases the menstrual calendar was used to determine the cyclic nature of abdominal pain in women with the Rokitansky syndrome who could not otherwise find a regular pattern in their symptoms. Surgical intervention to remove the rudimentary bicornuate uterus was needed in both, and complete resolution of pain was attained. The menstrual calendar is a valuable diagnostic tool in confirming the cyclic nature of pain and can be used in guiding treatment decisions.

Limitations of the medical evaluation for child sexual abuse.

The purpose of this review is to highlight the inherent difficulties that a clinician faces during the evaluation of child sexual abuse cases. Each component of the medical evaluation has its own unique problems. Some of them are caused by the nature of the abusive relationship, while others are the result of the children's limited verbal skills. Readers should be aware of these limitations as they formulate an opinion at the conclusion of the examination.

Paraurethral cyst as an unusual cause of acute urinary retention. A case report.

Acute urinary retention occurs rarely in women. Previously reported causes include anatomic defects, perineal pain, behavioral disturbances and psychiatric disorders. A patient presented with acute urinary retention secondary to an infected paraurethral cyst.

Laparoscopic uterine suspension with Falope rings. A report of three cases.

Three patients underwent successful laparoscopic uterine suspension by round ligament plication with Falope Rings.

Prenatal glucose screening.

Of 3,563 consecutive obstetric patients undergoing glucose screening, 517 (14.5%) were found to have plasma values of greater than or equal to 140 mg%, and 74 (14.3%) of 517 were found to be diabetic on standard oral glucose tolerance testing, for an overall incidence of 2.1%. There was no absolute value on the glucose screen that predicted an abnormal oral glucose tolerance test. Twenty-eight of the 74 diabetics demonstrated none of the classic risk factors for glucose intolerance during pregnancy. Only when combining those patients over 30 years of age and with a mean body weight greater than 120% of the ideal body weight was statistical significance reached when that group was compared to the overall group. Thus, our data support the recommendation for universal prenatal glucose screening.

Treatment of prepubertal girls with labial adhesions.

BACKGROUND: The purpose of this study was to evaluate the efficacy of topical estrogen therapy for the treatment of prepubertal girls with labial adhesions. METHODS: This was a retrospective chart review at a pediatric and adolescent gynecology clinic in Memphis, Tennessee. Participants included 289 prepubertal girls who were referred for evaluation and treatment of labial adhesions. Interventions were gynecologic evaluation, topical estrogen, and manual and surgical labial separation. Main outcome measures were separation of labial adhesions and relief of symptoms. RESULTS: The use of topical estrogen resulted in a separation of the fused labia in approximately half of patients. Separation with the patient under topical or general anesthesia was required in the remaining patients. CONCLUSIONS: Further intervention may be required in many patients with labial adhesions after topical therapy with estrogens. Patients with dense, fibrous adhesions and girls who have undergone previous surgical separation of the labia are less likely to respond to topical estrogen therapy.

Diagnostic accuracy of colposcopic photographs in child sexual abuse evaluations.

STUDY OBJECTIVE: To evaluate the utility of colposcopic photographs in child sexual abuse evaluations and to assess whether such photographs can be reliably used for peer review, second opinion, and court testimony. METHODS: A prospective review of colposcopic photographs at the Pediatric and Adolescent Gynecology Clinic in Louisville, Kentucky. Participants were 189 girls who were referred for evaluation for possible sexual abuse. Interventions used included gynecologic evaluation, colposcopic photographs, and review of photographs. The main outcome measure was the degree of agreement between the examining physician and the reviewers. RESULTS: The reviewers' accuracy for the entire set of 189 cases is uniformly high (93%-95%). Accuracy rates are significantly lower for pubertal girls (83%-90%) and for girls with signs of abuse (58%-88%). CONCLUSIONS: The diagnostic accuracy of the colposcopic photographs is sufficiently high to warrant continued use of medical photography for documentation and peer review. One should anticipate some disagreements between the examining physician and the reviewers, and contradictory opinions are more likely to occur with girls exhibiting physical signs of abuse and with pubertal girls.

Child sexual abuse examination: is there a need for routine screening for N. gonorrhoeae?

PURPOSE: To determine the yield of routine vaginal cultures for Neisseria gonorrhoeae from asymptomatic girls following sexual abuse. METHODS: Cultures were obtained from 865 prepubertal girls seen within 72 hours following an assault. Adult females (2743), age 18 or older, who were treated according to the same protocol constitute the control group. Data were analyzed using chi square analysis and comparison of proportions. RESULTS: It was found that 165 (4.6%) cultures were positive for N. gonorrhoeae. Of the 2743 adults, 153 were positive (5.6%) compared with 12 of the 865 prepubertal girls (1.4%). The differences are statistically significant. All 12 prepubertal children who had positive vaginal cultures for N. gonorrhoeae revealed that they had signs of acute vulvovaginitis. CONCLUSION: Routine vaginal cultures in asymptomatic prepubertal girls may not be indicated as part of the initial evaluation.

Teaching pediatric and adolescent gynecology: a pilot study at one institution.

PURPOSE: To assess resident physicians' clinical recognition skills in Pediatric and Adolescent Gynecology. MATERIALS: 1) A questionnaire to identify demographic data and self-assessment as to the ability to perform a gynecologic evaluation of children. 2) Twenty color photographs of normal genitalia and common gynecologic problems in children. PARTICIPANTS: Sixty-one University of Tennessee resident physicians; 51 from the Memphis campus--20 obstetrics-gynecology (Ob-Gyn) residents, 20 pediatrics residents, and 11 family practice residents--and 10 Ob-Gyn residents from the Chattanooga campus. MAIN OUTCOME MEASURES: Ability to identify normal features of the prepubertal genitalia and to diagnose common gynecologic disorders. RESULTS: Ob-Gyn residents from the University of Tennessee, Memphis scored significantly better (58.1% correct) than did the other three groups; 38.8, 36.9, and 39.1%, respectively (p = .009). Mean performance score increased with higher pediatric gynecology PGY levels. PGY-4s performed best, whereas PGY-1s scored the lowest, with mean scores of 57.5% and 35.3%, respectively (p = .021). Residents who reported having a well-defined program in pediatric gynecology scored significantly better than those who did not have such a program, 55.3% and 39.5%, respectively (p < .001). CONCLUSIONS: A well-defined program in pediatric gynecology enhances resident education and provides them with better tools to perform gynecologic evaluations of children and adolescents.