Vaginal and uterine anomalies in the paediatric and adolescent patient

Creation of a neovagina after Creatsas modification of Williams vaginoplasty for the treatment of 200 patients with Mayer-Rokitansky-Kuster-Hauser syndrome

OBJECTIVE

To present and evaluate the results of the Creatsas modification of Williams vaginoplasty for the creation of a neovagina in young women with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.

DESIGN

Retrospective study.

SETTING

Division of Pediatric-Adolescent Gynecology and Reconstructive Surgery, Second Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece.

PATIENT(S)

Two hundred patients with the MRKH syndrome.

INTERVENTION(S)

Clinical examination, pelvic ultrasound, intravenous urography and/or renal ultrasound, laparoscopy, karyotyping, orthopedics and ears, nose, and throat examination, magnetic resonance imaging, and Creatsas modification of Williams vaginoplasty.

MAIN OUTCOME MEASURE(S)

Neovaginal functional dimentions, neovaginal axis deviation, and quality of sexual life.

RESULT(S)

A functioning vagina of 10-12 cm in depth and 5 cm in width was created in 191 cases (95.5%). A vagina between 7 and 9 cm in depth and 2 and 3 cm in width was created for the remaining nine patients (4.5%). In addition, 94.5% declared themselves to have a satisfactory quality of sexual life, while only 5% of the cases reported an adequate one.

CONCLUSION(S)

Creatsas modification of Williams vaginoplasty is a simple, quick, and effective method for the treatment of vaginal agenesis.

Perforated transverse vaginal septum: a rare case of müllerian duct anomaly presenting only primary infertility

OBJECTIVE

To demonstrate a rare and unusual presentation of transverse vaginal septum (TVS).

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynecology, Atatürk University, Erzurum, Turkey.

PATIENT(S)

A woman with complaint of primary infertility presenting TVS.

INTERVENTION(S)

After comprehensive examination, primary infertility associated with müllerian duct anomaly was surgically treated.

MAIN OUTCOME MEASURE(S)

Primary infertility and anatomic anomaly.

RESULT

After surgical intervention, the patient with primary infertility caused by asymptomatic TVS was successfully conceived.

CONCLUSION(S)

Anatomic congenital defects may contribute to primary infertility. Suspicious evaluation of all primary infertile couples is needed, because a rare asymptomatic anatomic congenital defect could lie behind the infertility.

Diagnosis of Mullerian anomalies in adults: evaluation of practice

OBJECTIVE

To evaluate the circumstances associated with the diagnosis of Mullerian anomalies in adults.

DESIGN

Retrospective observational study.

SETTING

University hospital.

PATIENT(S)

All patients with Mullerian anomalies referred for evaluation.

INTERVENTION(S)

All patients underwent radiologic and operative diagnostic workup using ultrasonography, or ultrasonography and hysteroscopy, and in some cases laparoscopy.

MAIN OUTCOME MEASURE(S)

Clinical symptoms and radiologic investigations leading to the diagnosis. Mode and number of investigations before the diagnosis, and the time since the initial symptoms to the final diagnosis.

RESULT(S)

One hundred ten patients were diagnosed with Mullerian anomalies: 73 septate uteri, 20 bicornuate uteri, 10 uterine hypoplasia, 4 unicornuate uteri, and 3 with Mayer- Mayer-Rokitansy-Küster-Hauser syndrome. The circumstances leading to the diagnosis were infertility (33.6%), repeat miscarriage (18.2%), ultrasonography during pregnancy (12.7%), pregnancy complications during last trimester (11%), abnormal examination (8.2%), and miscellaneous causes (16.3%). Up 50% of patients complained of gynecologic signs before the appropriate diagnosis. Radiologic diagnosis required two complementary imaging techniques in 62% of patients and more than two in 28%. The correct diagnosis was established in only 40% of cases before hospitalization. Most of the anomalies were initially diagnosed at hysterosalpingography and ultrasonography. The mean time between the first imaging examination and the diagnosis in a specialized department was 6.7 (+/-7.1) months.

CONCLUSION(S)

The diagnosis of Mullerian anomalies in adults is often made at the time of conception and obstetric complications. There is a tendency toward the use of multiple imaging techniques and this delayed the diagnosis.

Non-surgical treatment of vaginal agenesis using a simplified version of Ingram's method

Non-surgical vaginal dilation is a safe and effective method for the creation of neovagina in the patient with vaginal agenesis. Compared to surgical methods, non-surgical vaginal dilation has the advantage of low morbidity, the creation of a more physiologic vaginal milieu, and no surgical scarring. To overcome some technical limitations of original Frank's method, in 1981 Ingram proposed a modification of the technique that used dilators of gradually increasing size mounted on a bicycle seat stool. Although several studies have shown satisfactory outcomes using Ingram's method, there are some practical difficulties in making and handling the bicycle seat stool. This article reports a case of a 24-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome whose vaginal agenesis is successfully treated with a simplified version of Ingram's method. This method uses dilators of gradually increasing size mounted on an ordinary chair instead of a bicycle seat stool. When necessary, the patient may use a fulcrum under the dilator.

Congenital vesicovaginal fistula with transverse vaginal septum and ectopic ureter opening in proximal vagina: case report and brief review

Congenital vesicovaginal fistula is an extreme rarity. We report on a case of a 22-year-old lady who presented with menouria and infertility. On evaluation, she was found to have congenital vesicovaginal fistula, a nonfunctioning right kidney with ectopic ureter and transverse vaginal septum. Abdominal repair of the fistula, right nephroureterectomy, and excision of the vaginal septum was performed.

Long-Term Gynecological Outcome of Patients with Persistent Cloaca

PURPOSE

Persistent cloaca is a complex malformation that remains a difficult reconstructive challenge, and data on long-term outcome are scarce. Gynecological abnormalities are common with cloaca but may remain asymptomatic until puberty or adult life. We evaluate long-term gynecological sequelae in these patients with persistent cloaca.

MATERIALS AND METHODS

The records and radiographs of postpubertal patients (mean age 16.8 years, range 10 to 32) treated for cloacal malformation at 1 institution from 1970 to 2001 were retrospectively reviewed. Outcome data at puberty were available in 41 patients. Of the patients 24 are currently older than 16 years and outcome data for sexual activity were available in 21 with 3 lost to followup.

RESULTS

All 41 patients were evaluated at puberty, and 28 (68%) had uterine function, 13 (32%) were menstruating normally and 15 (36%) presented with hematometra/hematocolpos. All 15 girls with an obstructed uterus required surgery, which included hysterectomy in 2, partial hysterectomy with vaginoplasty in 3 and vaginoplasty in 9. There was 1 complex case of fistula. Etiology of the obstructed uterus was vaginal stenosis after reconstruction in 3 cases, stenosis of persistent urogenital sinus (no previous reconstruction) in 11 and cervical stenosis in 1. Ten patients experienced primary amenorrhoea, which was confirmed in 8 (20%) while 2 (5%) continue to be followed for possible cryptic obstruction. In 10 girls the diagnosis of absent/vestigial uterus was made at early laparotomy but this was erroneous in 6 in whom uterine function developed at puberty. Of the 21 older girls (age at review 17 to 32 years, mean 24) 12 are or have been sexually active and 6 have been examined by a gynecologist and have an adequate vagina but are not sexually active. To date 4 patients have required revision vaginal surgery in adulthood to facilitate intercourse (re-do vaginoplasty in 3, introitoplasty in 1). One woman has postponed vaginal reconstructive procedures and 2 others are currently being followed. There have been no pregnancies in this series to date.

CONCLUSIONS

Patients born with persistent cloaca have a high incidence of gynecological problems at the onset of menses and in early adult life. Therefore, it is necessary to reassess these girls at early puberty by ultrasound/magnetic resonance imaging and vaginoscopy. Additional surgery may then be necessary to create a vagina for menstruation and sexual intercourse.

Congenital absence of the vagina: in search of the perfect solution. When, and by what technique, should a vagina be created?

PURPOSE OF REVIEW

To review the Mayer-von Rokitansky-Küster-Hauser syndrome and to address means of diagnosis, patient education and counselling. The timing of, and vast options for, creation of a functional vaginal are also discussed.

RECENT FINDINGS

The diagnosis of Mayer-von Rokitansky-Küster-Hauser usually occurs during an evaluation of primary amenorrhea. Counselling and support are of great importance for affected young women and their families. Educational materials have increased with the availability of Internet web sites and there is a vast number of options for creation of a functional vagina; most international centers promote the utilization of vaginal dilators.

SUMMARY

Young girls, adolescents and women with Mayer-von Rokitansky-Küster-Hauser should be offered a comprehensive evaluation, and presented with information regarding all options for management and support. Ongoing psycho-social and educational support is extremely important. International centers that focus on congenital anomalies of the reproductive tract should be developed. These centers of excellence will facilitate long-term follow up studies to improve patient care and evidence based medical options.