A proposed classification of vaginal anomalies and their surgical correction

Urogenital sinus malformation: From development to management

Urogenital sinus (UGS) malformation, also known as persistent urogenital sinus (PUGS), is a rare congenital malformation of the urogenital system. It arises when the urethra and vaginal opening fail to form properly in the vulva and fuse incorrectly. PUGS can occur as an isolated abnormality or as part of a complex syndrome, and is frequently associated with congenital adrenal hyperplasia (CAH). The management of PUGS is not well-established, and there are no standardized guidelines on when to perform surgery or how to follow up with patients over the long term. In this review, we discuss the embryonic development, clinical evaluation, diagnosis, and management of PUGS. We also review case reports and research findings to explore best practices for surgery and follow-up care, in hopes of increasing awareness of PUGS and improving patient outcomes.

Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision)

Congenital adrenal hyperplasia is a category of disorders characterized by impaired adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of CAY21A2 and is prevalent between 1 in 18,000 and 20,000 in Japan. The clinical guidelines for 21-hydroxylase deficiency in Japan have been revised twice since a diagnostic handbook in Japan was published in 1989. On behalf of the Japanese Society for Pediatric Endocrinology, the Japanese Society for Mass Screening, the Japanese Society for Urology, and the Japan Endocrine Society, the working committee updated the guidelines for the diagnosis and treatment of 21-hydroxylase deficiency published in 2014, based on recent evidence and knowledge related to this disorder. The recommendations in the updated guidelines can be applied in clinical practice considering the risks and benefits to each patient.

Surgical outcomes and complications of reconstructive surgery in the female congenital adrenal hyperplasia patient: What every endocrinologist should know

Surgical management of classical congenital adrenal hyperplasia (CAH) in 46, XX females has evolved significantly. Virilization of the genitalia of 46, XX females with CAH begins prenatally as a result of excess fetal androgen production. Improved understanding of anatomy and surgical outcomes has driven changes in surgical techniques as well as the timing of surgery. For endocrinologists treating these patients, it is important to understand the outcome of genitoplasty, identify patients who need further treatment and direct these patients to experienced surgeons. We performed a literature search on PubMed of publications addressing CAH and genital reconstruction published in the English language from 1990 to the present. In accordance with our institutional review board, we performed a retrospective analysis of clitoroplasty and/or vaginoplasty procedures performed by a single surgeon at our institution from 1996 to 2015. We found that genital reconstruction in 46, XX CAH patients is associated with few immediate post-operative, infectious, and urinary complications. Vaginal stenosis is a common complication of vaginal reconstruction and requires evaluation by an experienced surgeon. Clitoral pain or decreased sensation can be associated with clitoral recession and clitorectomy. Outcomes in sexual satisfaction and gender identity can also be impacted by surgical technique and success. Long term follow up and patient reported feedback are crucial to our understanding and management of this special group of patients. Improved awareness and understanding of the complications of genital surgery will allow endocrinologists to know what to ask patients and be ready to provide them with a resource with the understanding and experience to help them improve their quality of life.

Anatomical measurements of the urogenital sinus in virilized female children due to congenital adrenal hyperplasia

BACKGROUND

Virilized females due to congenital adrenal hyperplasia represent the most common form of female disorders of sexual development. The anomaly therein is an external virilization to resemble male genitalia and a persistent urogenital sinus.

OBJECTIVES

To study the anatomical details of the virilized female cases operated upon between 2011 and 2015. This anatomical description is presented to support the current surgical strategy of partial urogenital mobilization to correct this anomaly.

METHODS

Thirty cases (presenting to a single tertiary center) were prospectively studied by genitography, cysto-urethroscopy, and operated upon via a single-stage feminizing genitoplasty. A single surgical team operated upon all cases. External virilization was assessed by the Prader classification. The internal anatomy was studied by measuring the length of the urethra proximal to the confluence, and the vertical depth of the vaginal-urethral confluence from the perineum. The correlation coefficients between the external virilization and the internal anatomical measurements were derived.

RESULTS

The median age at surgery was 19 months (range 6-42 months). External virilization did not obviously correlate with the length of the proximal (prejunctional) urethra (r = -0.03, P = 0.5), or strongly with the depth of the vaginal-urethral confluence (r = 0.2, P = 0.2). The mean length of the proximal urethra was 22 mm (range 10-32 mm), and the mean vertical depth of the vaginal-urethral confluence from the perineum was 16 mm (range 8-31 mm).

DISCUSSION

Due to limitations of the radiological and endoscopic evaluation, the accurate anatomical assessment of this condition may be challenging. In order to assess or compare the anatomy of these cases, there are two important points to address: (1) the length of the urethra proximal to the urogenital sinus, as this will impact the urinary outcome; and (2) the depth (level) of vaginal entry into the urogenital sinus, as this will affect the mobilization required to exteriorize the vagina.

CONCLUSION

The degree of external virilization does not totally correlate with the internal anatomy. The depth of the vaginal-urethral confluence from the perineum is an indicator of the required mobilization for the current perineal approach. In 90% of cases in this age group (1-3 years old), this depth is ≤20 mm. This supports the current understanding that partial urogenital mobilization could be suitable for most cases Figure (Summary).

Urinary Continence Following Repair of Intermediate and High Urogenital Sinus (UGS) in CAH. Experience with 55 Cases

AIM

To evaluate postoperative urinary continence in patients with congenital adrenal hyperplasia (CAH) with intermediate (IT) and high urogenital sinus (UGS) who underwent a UGS mobilization maneuver.

METHODS

We called IT to those that although needing an aggressive dissection to get to the vagina, still have enough urethra proximal to the vaginal confluence. Very low variants are excluded from this analysis. Dissection always started in the posterior wall of the UGS with an aggressive separation from the anterior rectal wall. If the wide portion of the vagina was reached dissection stopped and the UGS opened ventrally widening to the introitus. Nineteen patients were treated using this maneuver (Group 1). When more dissection was required the anterior wall of the UGS was dissected and carefully freed from the low retropubic space. Then the UGS was opened either ventrally or dorsally. Thirty three patients required this approach (Group 2). Combined procedures were used in three patients with high UGS (Group 3).

RESULTS

Mean age at the time of the repair and length of the UGS were 12.2 years (4 months-18 years) and 3.75 cm (3-8 cm) for G1; 8 years (5 months-17 years) and 6.34 cm (4-12 cm) in G2 and 8.3 years (2-14 years) and 11.5 cm (11-12 cm) in G3. All patients had been regularly followed. Mean age at last follow up was 14.3, 17, and 9.9 years for Groups 1, 2, and 3, respectively. All patients continue to void normally and are continent. All patients have two separate visible orifices in the vulva. Only three are sexually active.

CONCLUSION

Urogenital sinus mobilization for vaginoplasty in girls with CAH does not compromise voiding function or urinary continence.

Vaginal malformations: a proposed classification based on embryological, anatomical and clinical criteria and their surgical management (an analysis of 167 cases)

BACKGROUND

Although it is virtually impossible to formulate a scheme that can satisfactorily collect all different types of vaginal malformations, a simple classification would be of a considerable value and would permit logical operative decisions. Many classifications of anomalies of uterus and vagina have been proposed: we find them unsatisfactory and confusing, being either too simple or too complex. We propose a new classification, focused only on vagina and based on embryological, anatomical, clinical and surgical criteria.

METHODS

In over 30 years, 167 females with vaginal malformations have been observed in our department. Intersex cases were excluded. The encountered anomalies have been divided into six types and ten subtypes: type I vaginal agenesis (IA associated with uterine agenesis/17 Pts, IB isolated/1 Pt); type II vaginal atresia (IIA proximal/1 Pt, IIB distal/4 Pts); type III vaginal atresia with urethrovaginal fistula-urogenital sinus (IIIA proximal fistula-high sinus/42 Pts, IIIB distal fistula-low sinus/55 Pts); type IV vaginal atresia with transverse septum (IVA transverse septum/6 Pts, IVB imperforate hymen/17 Pts); type V disorders of müllerian ducts fusion (VA vaginal duplication/4 Pts, VB longitudinal septum/4 Pts); type VI cloaca/16 Pts. Of each type and subgroup of malformation the appropriate surgical correction is reported. Types of malformation and surgical treatment are analysed: IA vaginal reconstruction using a sigmoid conduit, IB vaginal reconstruction using a sigmoid conduit, atresic cervical resection and uterus-new vagina anastomosis according to Schmid; II perineal vaginal pull-through; IIIA anterior sagittal transanorectal vaginal pull-through, IIIB perineal flap vaginoplasty; IVA excision with abdominovaginal approach, IVB hymen incision; VA tubularization, VB septectomy via perineal approach; VI posterior sagittal anorectal-vaginal-urethroplasty.

RESULTS

Most of the patients had good aesthetic and functional results. Type III showed relatively more complications: four redo operations (IIIA), four revisions of the vaginoplasty (IIIB). One patient is still waiting for definitive surgical correction.

CONCLUSIONS

An early diagnosis is desirable to correct adequately vaginal malformations, which becomes mostly evident around puberty. The better timing for surgery is early age, to obtain better results and to avoid many of the psychological problems that arise at a later age.

[Anatomic and histological characteristics of vagina reconstructed by McIndoe method]

BACKGROUND/AIM

Congenital absence of vagina is known from ancient times of Greek. According to the literature data, incidence is 1/4 000 to 1/20 000. Treatment of this anomaly includes non-operative and operative procedures. McIndoe procedure uses split skin graft by Thiersch. The aim of this study was to establish anatomic and histological characteristics of vagina reconstructed by McIndoe method in Mayer Küster-Rockitansky Hauser (MKRH) syndrome and compare them with normal vagina.

METHODS

The study included 21 patients of 18 and more years with congenital anomaly known as aplasio vaginae within the Mayer Küster-Rockitansky Hauser syndrome. The patients were operated on by the plastic surgeon using the McIndoe method. The study was a retrospective review of the data from the history of the disease, objective and gynecological examination and cytological analysis of native preparations of vaginal stain (Papanicolau). Comparatively, 21 females of 18 and more years with normal vaginas were also studed. All the subjects were divided into the groups R (reconstructed) and C (control) and the subgroups according to age up to 30 years (1 R, 1C), from 30 to 50 (2R, 2C), and over 50 (3R, 3C). Statistical data processing was performed by using the Student's t-test and Mann-Writney U-test. A value of p < 0.05 was considered statistically significant.

RESULTS

The results show that there are differences in the depth and the wideness of reconstructed vagina, but the obtained values are still in the range of normal ones. Cytological differences between a reconstructed and the normal vagina were found.

CONCLUSION

A reconstructed vagina is smaller than the normal one regarding depth and width, but within the range of normal values. A split skin graft used in the reconstruction, keeps its own cytological, i.e. histological and, so, biological characteristics.

[Sensibility of vagina reconstructed by McIndoe method in Mayer-Rokitansky-Küster-Hauser syndrome]

BACKGROUND/AIM

Congenital absence of vagina is a failure present in Mayer-Küster-Rokitansky-Hauser syndrome. Treatment of this anomaly includes nonoperative and operative procedures. McIndoe procedure uses split skin graft by Thiersch. The aim of this study was to determine sensitivity (touch, warmness, coldness) of a vagina reconstructed by McIndoe method in Mayer-Küster-Rokitansky-Hauser syndrome and compare it with the normal vagina.

METHODS

A total of 21 female persons with reconstructed vagina by McIndoe method and 21 female persons with normal vagina were observed. All female persons were devided into groups and subgroups (according to age). Sensibility to touch, warmness and coldness were examined, applying VonFrey's esthesiometer and termoesthesiometer for warmness and coldness in three regions of vagina (enter, middle wall, bothom). The number of positive answers was registrated by touching the mucosa regions for five seconds, five times.

RESULTS

The obtained results showed that female patients with a reconstructed vagina by McIndoe method, felt touch at the middle part of wall and in the bottom of vagina better than patients with normal one. Also, the first ones felt warmness at the middle part of wall and coldness in the bottom of vagina, better than the patients with normal vagina. Other results showed no difference in sensibility between reconstructed and normal vagina.

CONCLUSION

Various types of sensibility (touch, warmness, coldness) are better or the same in vaginas reconstructed by McIndoe method, in comparison with normal ones. This could be explaned by the fact that skin grafts are capable of recovering sensibility.

Fetal urogenital sinus with consecutive hydrometrocolpos because of labial fusion: prenatal diagnostic difficulties and postpartal therapeutic management

OBJECTIVE

To elucidate the differential diagnoses of tumorous dilations in the fetal pelvic region detected by prenatal ultrasound and the postnatal management demonstrated on a fetus with 29 weeks of gestation with a retrovesical located bottle-like cystic structure measuring 54 x 31 x 27 mm within the pelvis. Postnatal findings were a labial fusion and a consecutive hydrometrocolpos due to a urethrovaginal fistula.

METHOD

Case report of a fetus affected by an intricate cloacal anomaly.

RESULTS

The long-term prognosis for this nonsyndromic form of hydrometrocolpos without any other structural defects or organic failures after operative sanitation is excellent. Final reconstruction is planned at about 12 months of age.

CONCLUSION

Prenatal diagnosis of tumorous dilations in the fetal pelvic region often involves difficulties because of numerous differential diagnoses and possible presentation in late pregnancy. Magnetic resonance imaging could be a useful complementary tool for assessing these anomalies when ultrasonography is inconclusive. In some cases, the final diagnosis cannot be confirmed until after delivery.

Modified posterior sagittal transanorectal approach in repair of urogenital sinus anomalies

INTRODUCTION

To describe the operative details and results of a modified posterior sagittal transanorectal approach for the reconstruction of urogenital sinus (UGS) anomalies.

TECHNICAL CONSIDERATIONS

Six children with UGS anomalies underwent surgery using this technique. In a prone jack-knife position, a midline incision was continued to the puborectalis muscle. A plane of dissection was created circumferentially around the rectum separating it from the underlying UGS. Circumferential transanal mucosectomy and a transanal dissection was carried proximally for 5 to 10 cm. The mucosal tube with the serosal wall was resected, exposing the proximal part of the UGS. The posterior and anterior sphincters, anus, and perineal body were then divided in the midline, completely exposing the UGS. Reconstruction of the urethra and vagina was done. At completion of UGS reconstruction, an endoanal pull through of the rectal tube and a low coloanal anastomosis were performed. The muscle complex and perineal body were closed in layers. The modified technique of posterior sagittal transanorectal approach allowed excellent exposure in all 6 patients. None developed any complications related to suture line leak. Fecal and urinary continence was preserved in patients who were continent before the operation.

CONCLUSIONS

The modified posterior sagittal transanorectal approach is a safe and effective technique in the treatment of UGS anomalies and can be performed without the need for a protective colostomy.

Long-term functional outcomes of female genital reconstruction in childhood

There are two very interesting paediatric urology papers; in the first, authors from London describe the long-term functional outcomes of female genital reconstruction in childhood, and in the second, authors from Italy present a morphological and manometric study of VUR.

Ultrasound-assisted repair of a unique case of distal vaginal agenesis

OBJECTIVE

To describe a unique vaginal outlet obstruction and its ultrasound-assisted surgical correction.

DESIGN

Case report.

SETTING

An academic medical center.

PATIENT(S)

A 12-year-old girl was seen with cyclic abdominal pain, nausea, and an abdominal mass. External genital examination revealed no vaginal opening or dimple. Transabdominal ultrasound revealed a large hematometrocolpos 5 cm proximal to the perineum, with an otherwise normal-appearing uterus and ovaries.

INTERVENTION(S)

Surgical treatment included perineal incision, creation of a 5-cm passage through connective tissue, drainage of the hematometrocolpos, and mobilization of the proximal vagina, allowing for pull-through vaginoplasty. Ultrasound guidance was used throughout the surgery and allowed for a safe transperineal approach. A vaginal form was placed in the neovagina.

MAIN OUTCOME MEASURE(S)

Follow-up clinical evaluation and pelvic ultrasonography.

RESULT(S)

A well-healed perineum and patent 5-cm-long vagina were observed at 4-month follow-up. The patient reported three regular menses. Postoperative pelvic ultrasound scan was normal.

CONCLUSION(S)

We describe a unique case of isolated distal vaginal agenesis of significant length that was successfully treated via a perineal approach with the intra-operative assistance of ultrasound guidance.

Congenital adrenal hyperplasia in adults: a review of medical, surgical and psychological issues

Our knowledge of the experience of adults with congenital adrenal hyperplasia (CAH) as they pass through life is only now emerging. In this review we gather medical, surgical and psychological literature pertaining to adults with CAH and consider this alongside practical experience gained from a dedicated adult CAH clinic. There is increasing awareness for the need for multidisciplinary teams who have knowledge of CAH particularly with respect to gynaecological surgery and clinical psychology for women and testicular function in men. Routine management of CAH comprises adjustment of glucocorticoid and mineralocorticoid treatment according to individual needs balancing biochemical markers, compliance and long term risks. Bone density is one such long term concern and is not greatly reduced in most individuals with CAH. More recently, attention has turned to cardiovascular risk factors and catecholamine deficiency in adults with CAH. Women with CAH require access to an experienced gynaecologist, specialised pregnancy care and psychosexual support. The very low fertility rates for women with CAH previously reported appear to be improving with time. Men with CAH are often lost to follow up and therefore miss out on surveillance for hypogonadism either through the effect of adrenal rests of from suppression of gonadotrophins resulting in a high prevalence of oligospermia.

A new classification for genital ambiguity and urogenital sinus anomalies

OBJECTIVE

To describe a new system for classifying genital ambiguity and urogenital sinus abnormalities. Prader's classification (which attempts to describe the degree of masculinization) has been used for decades, while the urogenital sinus has generally been described as simply high or low; neither classification fits the spectrum of anomalies, nor do they allow for outcome data research.

METHODS

An ideal description of genital ambiguity and urogenital sinus anomalies should include the degree of masculinization, phallic size, external genital appearance, and the true location of the vaginal confluence in relation to the bladder neck and the perineal meatus. We describe a new system to define these variables.

RESULTS

In the PVE classification developed, P represents stretched phallic length and width, V the true vaginal location according to the distance from the bladder neck to the vagina and the distance from the vagina to the perineal meatus, and E the external genital appearance or Prader number.

CONCLUSIONS

The PVE classification system aids in surgical planning and will be helpful in the analysis of surgical outcomes of genital ambiguity and urogenital anomalies.

Feminising surgery in male pseudohermaphrodites

In the framework of the international project between the paediatric surgery clinics of Kaunas Medical University and Copenhagen University Hospital, 34 patients raised as females were examined and treated. Eighteen patients were affected by androgen insensitivity syndrome, and 16 patients by mixed gonadal dysgenesis. All patients had a Y chromosome, although external genitalia was either typically female or had mixed features of both sexes. The particulars of diagnostics and treatment are discussed, focusing on surgical complications.

The impact of prenatal androgens on vaginal and urogenital sinus development in the female mouse

PURPOSE

In females abnormal urogenital virilization can occur secondary to prenatal exposure to exogenous or endogenous androgens. We studied the effects of different doses of prenatal androgens on urogenital sinus development and the location of the vaginal confluence in a mouse model.

MATERIALS AND METHODS

Timed pregnant C57/6 mice were exposed to 2, 5 and 10 mg testosterone propionate on gestational days 14 through 18. On gestational day 19 the genital tubercles and internal genitalia were examined grossly and histologically for the presence of virilization. Three-dimensional computer reconstruction was done and plastic cast injection molds of the urogenital sinus were made in select specimens.

RESULTS

Microscopic analysis confirmed the spectrum of virilization, which occurred in 98% of testosterone propionate treated female fetuses. Plastic cast injection showed that affected females had a longer urogenital sinus, more proximal confluence and shorter vagina in a dose dependent manner. Histological sections and 3-dimensional reconstruction revealed that the bladder neck moved proximal under the pubic bone, also in a dose dependent manner.

CONCLUSIONS

Prenatal exposure to increasing levels of androgen causes urogenital sinus elongation in a female mouse fetus. In the mouse model the confluence area moves proximally together with the bladder neck in a dose dependent manner.

Vaginoplasty with Interceed absorbable adhesion barrier for complete squamous epithelialization in vaginal agenesis

OBJECTIVE

The purpose of this study was to present our experiences of an innovative surgical approach for vaginal agenesis with the use of Interceed absorbable adhesion barrier (Ethicon) to achieve a satisfactory neovagina.

STUDY DESIGN

The current study involved 10 subjects who were diagnosed with vaginal agenesis. After the creation of a vaginal tunnel, a mold that had been wrapped with Interceed was placed in the neovagina.

RESULTS

No operative and postoperative complications were encountered. The duration of the operation was < or =30 minutes, and blood loss was minimal. The postoperative hospital stay was only 2 days. Epithelialization of the neovagina was achieved 1 to 4 months after the operation, and all patients were satisfied with the outcome. The neovagina that was created with this procedure was not much different from the normal adult vagina as far as histologic and physiologic conditions are concerned.

CONCLUSION

This innovative surgical procedure may be a potential alternative approach for the therapy of vaginal agenesis with the use of the absorbable adhesion barrier Interceed with excellent results.

Long-term consequences of childhood-onset congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) is a general term applied to several diseases caused by inherited defects of cortisol synthesis. The most common of these is steroid 21-mono-oxygenase (also termed 21-hydroxylase) deficiency (CAH-21OHD), found in approximately 1:10 000-1:15 000 live births. Potentially lethal adrenal insufficiency is characteristic of about two-thirds to three-quarters of patients with the classic salt-wasting form of CAH-21OHD. Non-salt-wasting forms of CAH-21OHD may be diagnosed based in part on genital ambiguity in affected newborn females, and/or by later evidence of androgen excess in members of either sex. Non-classical CAH-21OHD may be detected in up to 1-3% of certain populations, and is often mistaken for idiopathic precocious pubarche in children or polycystic ovary syndrome in young women. This chapter addresses issues relating to long-term consequences in adult life of CAH-21OHD diagnosed in early childhood or adolescence.

1-Stage feminizing genitoplasty: 8 years of experience with 49 cases

PURPOSE

We retrospectively evaluated the results of a modified technique for 1-stage feminizing genitoplasty in children with congenital adrenal hyperplasia (CAH) and other rare intersex conditions.

MATERIALS AND METHODS

Between 1991 and 1998, 47 infants and 2 adolescents underwent 1-stage feminizing genitoplasty at our hospital. Of the patients 44 had CAH, 2 had the partial androgen insensitivity syndrome and 3 were true hermaphrodites. In 3 patients we used the Passerini-Glazel technique, while in 46 our technique of feminizing genitoplasty was used, which consists of maximal mobilization of the urogenital sinus en bloc including the vagina and urethra via the perineal approach. Two lateral plates built from dorsal split phallic and preputial skin together with the dorsal split urogenital sinus are used to construct the vaginal introitus and labia minora, and the scrotal folds are used to construct the labia majora. Reduction clitoroplasty is done according to the technique of Kogan et al. Mean age plus or minus standard deviation was 0.9 +/- 0.3 years of the patients with CAH and 13 +/- 2.3 of the remainder. Preoperative information, including status of the internal genitalia, anatomical length of the vagina site of communication between the vagina and urogenital sinus, in relation to the pelvic floor, was obtained by transabdominal pelvic ultrasound.

RESULTS

Operating time ranged between 120 and 180 minutes, average hospitalization period was 4 to 5 days and mean followup was 4.7 +/- 2.6 years. Preoperative ultrasound provided the correct data regarding the vaginal and internal genitalia anatomy in all cases, and the exact communication site between the vagina and urogenital sinus was demonstrated in 93%. Complications consisted of intraoperative rectal injury in 1 case and mild wound infection of the buttocks area in 3. In 1 case total clitoris loss was observed. All patients who underwent modified genitoplasty have had successful cosmetic and early functional results. Two patients presented with repeat clitoromegalia due to inadequate adrenal suppression.

CONCLUSIONS

Our adapted technique of 1-stage feminizing genitoplasty provides good cosmetic and functional results. The functional results of this operation should be reevaluated after puberty and in adulthood.

1-Stage feminizing genitoplasty: 8 years of experience with 49 cases

PURPOSE

We retrospectively evaluated the results of a modified technique for 1-stage feminizing genitoplasty in children with congenital adrenal hyperplasia (CAH) and other rare intersex conditions.

MATERIALS AND METHODS

Between 1991 and 1998, 47 infants and 2 adolescents underwent 1-stage feminizing genitoplasty at our hospital. Of the patients 44 had CAH, 2 had the partial androgen insensitivity syndrome and 3 were true hermaphrodites. In 3 patients we used the Passerini-Glazel technique, while in 46 our technique of feminizing genitoplasty was used, which consists of maximal mobilization of the urogenital sinus en bloc including the vagina and urethra via the perineal approach. Two lateral plates built from dorsal split phallic and preputial skin together with the dorsal split urogenital sinus are used to construct the vaginal introitus and labia minora, and the scrotal folds are used to construct the labia majora. Reduction clitoroplasty is done according to the technique of Kogan et al. Mean age plus or minus standard deviation was 0.9 +/- 0.3 years of the patients with CAH and 13 +/- 2.3 of the remainder. Preoperative information, including status of the internal genitalia, anatomical length of the vagina site of communication between the vagina and urogenital sinus, in relation to the pelvic floor, was obtained by transabdominal pelvic ultrasound.

RESULTS

Operating time ranged between 120 and 180 minutes, average hospitalization period was 4 to 5 days and mean followup was 4.7 +/- 2.6 years. Preoperative ultrasound provided the correct data regarding the vaginal and internal genitalia anatomy in all cases, and the exact communication site between the vagina and urogenital sinus was demonstrated in 93%. Complications consisted of intraoperative rectal injury in 1 case and mild wound infection of the buttocks area in 3. In 1 case total clitoris loss was observed. All patients who underwent modified genitoplasty have had successful cosmetic and early functional results. Two patients presented with repeat clitoromegalia due to inadequate adrenal suppression.

CONCLUSIONS

Our adapted technique of 1-stage feminizing genitoplasty provides good cosmetic and functional results. The functional results of this operation should be reevaluated after puberty and in adulthood.

Feminizing genitoplasty in patients with 46XX congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) is the most common cause of ambiguous genitalia in newborns. This paper is based upon review of the literature and personal experience. We focus upon the surgical anatomy, pre-operative evaluation, including imaging, mainly by transabdominal ultrasound, and upon the goals and the history of surgical reconstruction. The various surgical techniques are mentioned with a detailed description of our technique used in 52 patients. The timing and staging of the operation and the implications of prenatal therapy are discussed. In conclusion, we believe that infants with 46XX CAH can undergo one-stage feminizing genitoplasty very early in life with satisfactory cosmetic and functional results.

Congenital adrenal hyperplasias

Congenital adrenal hyperplasia syndromes result from deficiencies of enzymes involved in corticosteroid biosynthesis. Most commonly, they are due to mutations in 21-hydroxylase. This chapter describes the clinical diagnosis and management of congenital adrenal hyperplasias throughout life, including in the fetus, child and adult. These clinical recommendations are explained in the context of the molecular and biochemical characteristics of the diseases.

Vaginal obstruction

Congenital anomalies that result in vaginal obstruction often present with an abdominal mass in the newborn period. Knowledge of the embryological development of the genitourinary tract and its variations is needed to properly evaluate the neonatal patient and to initiate therapy. Because of a high incidence of associated anomalies, a complete urologic evaluation should be undertaken before a definitive surgical repair. The methods of treatment for the various causes of vaginal atresia have shown long-term success and have resulted in appropriate psychosocial and sexual maturation.

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency

More than 90% of cases of congenital adrenal hyperplasia (CAH, the inherited inability to synthesize cortisol) are caused by 21-hydroxylase deficiency. Females with severe, classic 21-hydroxylase deficiency are exposed to excess androgens prenatally and are born with virilized external genitalia. Most patients cannot synthesize sufficient aldosterone to maintain sodium balance and may develop potentially fatal "salt wasting" crises if not treated. The disease is caused by mutations in the CYP21 gene encoding the steroid 21-hydroxylase enzyme. More than 90% of these mutations result from intergenic recombinations between CYP21 and the closely linked CYP21P pseudogene. Approximately 20% are gene deletions due to unequal crossing over during meiosis, whereas the remainder are gene conversions--transfers to CYP21 of deleterious mutations normally present in CYP21P. The degree to which each mutation compromises enzymatic activity is strongly correlated with the clinical severity of the disease in patients carrying it. Prenatal diagnosis by direct mutation detection permits prenatal treatment of affected females to minimize genital virilization. Neonatal screening by hormonal methods identifies affected children before salt wasting crises develop, reducing mortality from this condition. Glucocorticoid and mineralocorticoid replacement are the mainstays of treatment, but more rational dosing and additional therapies are being developed.

The neonatal management and surgical correction of urinary hydrometrocolpos caused by a persistent urogenital sinus

OBJECTIVE

To define the neonatal management and ultimate surgical correction via the anterior sagittal transanorectal approach (ASTRA) in cases of neonatal urinary hydrometrocolpos associated with a persistent urogenital sinus (UGS).

PATIENTS AND METHODS

We report three patients with UGS (with no ambiguous genitalia) and urinary hydrometrocolpos in whom prenatal ultrasonography showed cystic dilatation of the pelvis. Two patients were temporarily treated with intermittent vaginal catheterization and antibiotic prophylaxis, and in one a cystostomy was necessary to temporarily drain the urine. At the age of 6-8 months the patients underwent reconstructive surgery of the UGS via the ASTRA, under a previous protective colostomy.

RESULTS

The mean (range) age of the patients at the last follow-up was 18.7 (8-32) months. A good cosmetic result was obtained in all patients. The vagina was dilated briefly with no anaesthesia in each patient. Patients had normal faecal control after the colostomy was closed and none had urinary incontinence.

CONCLUSIONS

When possible, intermittent vaginal catheterization permits sufficient temporary drainage of the urinary hydrometrocolpos associated with a persistent UGS. Subsequent ASTRA allows good exposure of the UGS, assuring the preservation of the anorectal innervation and of the sphincteric mechanism.

Functional, social and psychosexual adjustment after vaginal reconstruction

PURPOSE

We assessed the long-term functional, social and psychosexual outcome in children who underwent vaginal reconstruction.

MATERIALS AND METHODS

We interviewed and assessed the psychological development of 16 women 17 to 28 years old (mean age 22) who underwent vaginal reconstruction only or in combination with other urogenital reconstructive procedures at ages 11 months to 18 years (mean 8.8). Psychological measures included the Beck Depression Inventory, Draw-a-Person test and Linkowski acceptance of disability scale as well as a standard questionnaire evaluating the sexual adjustment, social adjustment and ability for self-support of these women.

RESULTS

Mean Beck Depression Inventory was 8.5 with less than 9 defined as minimal depression. Mean acceptance of disability score was 83.9 (range 54 to 94), indicating that patients were well adjusted with respect to the disability. Functionally 10 women were satisfied with the appearance of the vagina, 4 were neutral and 2 were dissatisfied. A total of 12 patients had no doubts about their female identity but 2 had occasional, 1 had significant and 1 had chronic doubts. Of the 16 patients 12 have completed high school, 3 are still in high school and 1 has withdrawn from high school. Of the 12 women who have completed high school 9 are currently in college and 3 have completed college. Socially all 16 participants rated family relationships as good and 13 were at least satisfied with their social life. Of the 16 women 12 have had a sexual encounter, including 1 who did not achieve orgasm. Six women are involved in long-term relationships, of whom 1 is married. In regard to the future all patients believe that they will be independent and financially stable with a fulfilling career.

CONCLUSIONS

While women who have undergone vaginal reconstruction may be at risk for avoiding interpersonal relationships and sexual intimacy, we did not note this finding in our series. The majority of these patients were well adjusted to their physical condition, and had a high level of education and a stable family life.

Vaginal atresia and Bardet-Biedl syndrome association: a component or a distinct entity?

Bardet-Biedl syndrome is an autosomal recessive disorder. It is characterized by cardinal anomalies including retinal dystrophy, digital malformations, mental retardation, obesity, and hypogonadism. Recently, renal anomalies also are mentioned among the cardinal signs. Although association of genital anomalies among affected boys are well known, the association of vaginal atresia and other structural genital anomalies are not mentioned among the less-common manifestations of Bardet-Biedl syndrome in girls. Two girls with Bardet-Biedl syndrome presented with hematometrocolpos in the preadolescent period and vaginal atresia was diagnosed. After surgical treatment and extended hospitalization, uncontrolled sepsis resulted in progressive renal failure and death of both patients. Vaginal atresia is often delayed or missed in the early childhood period. In girls with Bardet-Biedl syndrome, vaginal atresia or other structural genital anomalies should be evaluated more systematically during the initial diagnosis of the syndrome. In infancy, the evaluation of a child with vaginal atresia also should include the differential diagnosis of Bardet-Biedl syndrome. Vaginal atresia may either form a component of the syndrome, or girls who present with vaginal atresia in addition to other components of Bardet-Biedl syndrome might form a distinct entity.

Disorders of sexual differentiation

An infant born with ambiguous genitalia requires an accurate and prompt diagnosis so that a management plan can be formulated. This article discusses the signaling cascade of genes that controls sexual differentiation. Clinical disorders involving sex reversal or ambiguous genitalia are discussed in relation to the genes regulating sexual development. An approach to the treatment of these disorders is outlined.

Neonatal disorders of the external genitalia and vagina

Abnormalities of the external genitalia and vagina range from simple lesions to very complex anomalies of the genitourinary and gastrointestinal systems. The author describes the most common disorders of the external genitalia and vagina in the neonate, and current management strategies.

Anterior sagittal transanorectal approach to the urogenital sinus in adrenogenital syndrome: preliminary report

In the female adrenogenital syndrome, the treatment of the urogenital sinus with high implanted vagina still presents a surgical challenge. The conventional technique (perineal vaginal pull-through) has been plagued by a high incidence of vaginal stenosis. A posterior sagittal transanorectal approach was proposed as an alternative to obtain an excellent exposure and thus an adequate mobilization of the vagina. But bivalving a normal rectum and anus has the potential for compromising bowel control and represents a bold maneuver, and the rectum and sphincteric mechanism must be meticulously reconstructed. In the original procedure a protective colostomy must be performed before the operation. To reduce these disadvantages, the authors made the following modifications: sagittal incision of only the anterior rectal wall (Anterior Sagittal Transanorectal Approach--ASTRA) and protective colostomy at the same time as the operation. In this way, maintaining the same excellent exposure and reducing the number of operations from three to two, we operated on 10 girls with adrenogenital syndrome: 4 with high, 3 with intermediate urogenital sinus, and 3 who had previously undergone vaginal pull-through but experienced a vaginal retraction with severe stenosis. At the time of surgery four patients were under 1 year (mean, 9.25 months) and six were from 2 to 11 years of age (mean, 6.5 years). After closing the colostomy, all patients were continent in stools and urine, and the vagina looked normal. The authors suggest using this modified approach as an alternative to the conventional operation and for those patients in whom other techniques have failed.

Pudendal-thigh flap vaginoplasty in the reconstruction of genital anomalies

Children with abnormal genitalia associated with intersex anomalies or cloacal malformations require vaginal reconstruction. Although many procedures using skin grafts, skin flaps, and intestinal segments have been described, they all have disadvantages. In the present study 12 patients with genital defects who required vaginoplasty underwent surgery using a new technique using bilateral pudendal-thigh flaps based on the posterior labial artery. There were six patients with congenital adrenal hyperplasia (CAH), three with vaginal atresia, two with cloacal deformities, and one with testicular feminizing syndrome. Four of the CAH patients and the two with cloaca underwent vaginoplasty as second-stage procedures. All other cases were treated with one-stage operations. This method of vaginoplasty can be combined with correction of other associated abnormalities, and it has proved to be simple and reliable with satisfactory functional and cosmetic results.