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.

Enfermedad de Paget extramamario primario de vulva concurrente con Lesión intraepitelial escamosa vulvar: reporte de caso / Concurrence of primary extramammary Paget's disease of the vulva and vulval intra-epithelial neoplasia: A case report

La enfermedad de Paget extramamario y la neoplasia intraepitelial vulvar son lesiones comunes de la vulva. No obstante, su ocurrencia sincrónica es una manifestación sumamente rara en la misma localización. Presentamos el caso de una paciente de 77años, quien hace 16meses aqueja de prurito y sarpullido en la región vulvar con sangrado escaso que empezó a incrementarse en frecuencia y en cantidad. Es sometida a hemivulvectomía derecha y vulvectomía simple izquierda. El informe de patología reportó la presencia concurrente de enfermedad de Paget vulvar y neoplasia intraepitelial vulvar de alto grado.(AU)

Extramammary Paget's disease and intraepithelial vulvar neoplasia are common lesions in the vulva. However, their simultaneous occurrence is extremely rare. We present the case of a 77year-old woman who presented with a 16month history of pruritus and a rash in the vulvar region with gradually increasing bleeding. She underwent a right hemivulvectomy and a left simple vulvectomy. The histopathology revealed a coexistence of both Paget's disease and high grade intraepithelial vulvar neoplasia.(AU)

Úlceras vulvares: un reto diagnóstico / Vulvar ulcers: A diagnostic challenge

Las úlceras vulvares son una entidad patológica relevante por su repercusión en la calidad de vida de la mujer y suponen un desafío diagnóstico dada la variedad etiológica y de presentación clínica. El diagnóstico se basa en la anamnesis, la exploración física detallada y pruebas complementarias.Presentamos el caso clínico de una paciente de 39 años con diagnóstico de úlceras vulvares graves, recidivantes, que requirió ingreso hospitalario prolongado en tres ocasiones. Se describe el proceso de identificación, los posibles diagnósticos diferenciales y el resultado del tratamiento aplicado.(AU)

Vulvar ulcers are an important pathological condition due to their impact on the quality of life of women. It is a diagnostic challenge given the aetiological variety and clinical presentation. The diagnosis is based on anamnesis, detailed physical examination, and complementary tests.The clinical case is presented of a 39-year-old patient diagnosed with severe, recurrent vulvar ulcers, and who required prolonged hospital admission on three occasions. The diagnostic process, possible differential diagnoses, and the outcome of the applied treatment are described.(AU)

Siringomas vulvares; cuando el diagnóstico diferencial es un reto / Vulvar syringomas; when differential diagnosis is a challenge

El interés de esta entidad radica en su adecuado diagnóstico, ya que es a menudo confundida con otros procesos patológicos. Esto tiene como consecuencia la realización de pruebas innecesarias y tratamientos ineficaces, con las implicaciones que ello pudiera tener. Los siringomas son tumoraciones benignas que tienen su origen en las glándulas sudoríparas ecrinas a nivel dérmico. Dada su benignidad clínica e histológica no requieren tratamiento específico. Los de localización genital, por su infrecuencia, suponen un reto diagnóstico y obligan al clínico a realizar un extenso diagnóstico diferencial con otras entidades nosológicas: condiloma plano, verruga vulgar, linfangioma circunscrito y quiste epidermoide, entre otros.(AU)

The interest in this condition lies in its correct diagnosis, since it can be easily misdiagnosed. As a consequence, patients are often tested and treated in many and empiric ways, with the impact that these actions could have. Syringomas are benign tumours originating from the dermic eccrine glands. Considering its clinical and histopathological benign behaviour, they do not require any specific treatment. Genital syringomas are usually difficult to identify, as such, on a first examination, owing to their infrequency and similarity with other pathological processes such as flat condylomas, vulgar warts, circumscribed lymphangioma, or epidermoid cyst, among others.(AU)

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.

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.

Úlcera vulvar en paciente menopáusica. Ampliando el diagnóstico diferencial / Vulvar ulcer in a menopausal patient. Expanding the differential diagnosis

Las úlceras genitales constituyen un motivo frecuente de consulta en urgencias, especialmente en ginecología. Sin embargo, debido a la baja frecuencia de algunas de ellas, junto con el amplio diagnóstico diferencial que puede plantear cada caso, hacen que el diagnóstico de dichas lesiones, en ocasiones, sea difícil o erróneo. Presentamos el caso de una paciente menopáusica que consultó por una úlcera genital, cuyo diagnóstico fue de carcinoma basocelular. El conocimiento de esta entidad y sus hallazgos clínicos característicos, junto con una correcta anamnesis, permitirán realizar un apropiado diagnóstico de sospecha, facilitando el manejo de estas pacientes y evitando exploraciones innecesarias

Genital ulcers are a common reason for consultation in the emergency department, especially in Gynaecology. However, due to the low frequency of some of them, together with the wide differential diagnosis that can arise in each case, the diagnosis of these lesions can sometimes be difficult or erroneous. We present the case of a menopausal patient that consulted due to a genital ulcer, and was diagnosed with of basal cell carcinoma. The knowledge of this entity and its characteristic clinical findings, together with a correct anamnesis, will lead to an appropriate diagnostic suspicion, facilitating the management of these patients, and avoiding unnecessary examinations

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.

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.

Dermatitis perianal y test de diagnóstico rápido / Perianal dermatitis and rapid diagnostic test

No disponible

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).

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.

Early secondary repair of labial tears, 1st and 2nd degree perineal lacerations and mediolateral episiotomies in a midwifery-led clinic. A retrospective evaluation of cases based on photo documentation.

OBJECTIVES: To examine whether early secondary repair of labial tears, 1st and 2nd degree perineal lacerations and episiotomies provided an anatomically acceptable result. STUDY DESIGN: A retrospective analysis of 126 women undergoing an early secondary repair of birth lacerations not involving the sphincter complex within 21 days postpartum. Patients were included from 1 January 2014 to 11 August 2017 at Aarhus University Hospital, Denmark. Photo documentation of the wound was available just before the early secondary repair and at the follow-up visit after the repair. Photos were evaluated by two trained Urogynaecological Consultants. MAIN OUTCOME MEASURES: Whether the anatomic result of the early secondary repair was acceptable based on photo documentation. RESULTS: Early secondary repair was performed by a specialised team of midwives in 94.4% and by doctors in 5.6% of the cases. In all, 72.2% were 2nd degree perineal lacerations. The most common indications for early secondary repair were wound dehiscence (55.3%) and suboptimal primary repair (34.1%). At the follow-up clinical examination seven days after the early secondary repair, the result was considered anatomically acceptable in 67.5% of the cases, not optimal in 22.2% and not possible to evaluate in 10.3% of the cases. In 7.9% of the cases, wound infection was suspected after the early secondary repair. CONCLUSIONS: Based on photo documentation, early secondary repair of birth lacerations not involving the sphincter complex provides an anatomically acceptable result in the majority of cases without risk of serious complications.

Child sexual abuse - Initial suspicion and legal outcome.

OBJECTIVES: To evaluate the association of primary reason to suspect child sexual abuse with the legal end-point in medically examined, police reported cases. STUDY DESIGN: Observational post hoc analysis of retrospective review of records of 155 medically examined, police reported alleged child sexual abuse (CSA) cases during 2001-2009. Primary referral indications for medical examinations or criminal investigations were analyzed with an end-point in the legal process. The data consists of official investigation documents from University Hospital records, police, crime laboratories, state prosecutor, and courts of Law. RESULTS: The median age of the children was 7.1 years (range 11 months-17.5 years) at the time when suspicion of sexual abuse was reported to police. Conviction of the alleged perpetrator was significantly more likely in cases where the child's disclosure was the reason for the initial suspicion of CSA, compared to cases with referrals for "suspicious circumstances" (39/92, 42.4% vs. 7/37, 19%, p<0.001). In 92 (59.5%) cases the initial suspicion of CSA arose from child's disclosure. The forensic interviewer's report supported more likely CSA allegations where the suspicion of CSA arose by child's clear, detailed and credible disclosure of what had happened, compared to the other initial reasons of suspicion (35/61, 57.4% vs. 13/42, 31.0%, p=0.001). In child's age category of 4-9 years conviction was significantly more likely where the initial suspicion of CSA arose with child's disclosure, compared to other reasons of suspicion (21.45, 46.7% vs. 5/27, 16.7%, p=0.001). No association was found regarding to whom the initial suspicion of CSA arose and legal outcome. Forensic interviewer's report supported the allegation of CSA more often if the suspicion was arose first to a neutral person (p=0.019). Legal outcome of conviction was associated with child's disclosure of perpetrator's physical contact regardless of how the suspicion arose (45/99, 45.5% vs. 10/46, 21.7%, p<0.001). CONCLUSION: The reason which initially arise a suspicion of child sexual abuse plays an important role in the criminal investigation. Initial suspicion of CSA by child's disclosure, an eyewitness or objective material may lead to higher conviction rates. If a concerning physical symptom or finding arise the suspicion of CSA, referral to expert consultation is recommended to prevent unnecessary allegations and investigations. Other possible differential diagnostic medical conditions need to be evaluated. Furthermore, when child's disclosure arise a suspicion of CSA, it needs to be thoroughly investigated, regardless to whom the child discloses to.

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.

Nuevas vías de tratamiento en la úlcera de Lipschütz / New treatment options in Lipschütz ulcer

Presentamos el caso de una paciente de 24 años, sin antecedentes médicos de interés, que acude a urgencias por aparición súbita de lesiones vulvares muy dolorosas. Ante la sospecha de úlceras de Lipschütz se pauta tratamiento con antiinflamatorios vía oral sin obtener a las 48 horas buenos resultados. Se decide entonces junto a la unidad de úlceras de nuestro centro realizar tratamiento local en 3 pasos, con excelentes resultados en 72 horas

We report a 24 year old girl case without medical relevant history who attended emergency room with the sudden appearance of very painful vulvar ulcers, suspecting Lipschütz ulcer we treat her with oral anti-inflammatory without any results in 48h. We decided together with ulcers unit to try a 3 step treatment with excellent results in 72 hours

Genital injuries acute evaluation and management.

Genital trauma may result in external injuries to the labia, vulva or vagina, urethra and anus and internal injuries to the bony pelvis, bladder, bowels and reproductive organs. Worldwide, the most common cause of genital trauma in reproductive age women is injury sustained during childbirth, but in this chapter we will focus on accidental genital injuries as well as those arising from sexual violence, and female genital mutilation. While genital injuries alone rarely result in death; if not properly managed, chronic discomfort, dyspareunia, infertility, or fistula formation may result. Clinicians need to be able to recognize these injuries and provide initial management, and assure that the patient's mental, emotional and physical needs are addressed.