Nearly-complete labial adhesions diagnosed with repetitive cystitis in postmenopausal women: A case report

BACKGROUND

Nearly-complete labial adhesions diagnosed with repetitive cystitis in postmenopausal women: A case report

CASE SUMMARY

The case of an 83-year-old woman who presented with dysuria, urination disorders, recurrent cystitis, and bacteriuria and was admitted to a private hospital after 1 mo of antibiotic treatment without improvement of her symptoms. Upon examination, labial adhesions were observed with nearly-complete labial fusion with a pinpoint opening. Bacteriuria was detected in urine analysis, and the urine culture test was positive for Escherichia coli. Therefore, a parenteral antibiotic (Fosfomycin) and topical estrogen cream were administered. However, since the adhesion did not separate after 2 wk of treatment, surgical correction was performed. First, adhesiolysis was conducted with a blunt instrument. Then, hysteroscopy and cystoscopy were performed. Hysteroscopic findings showed no abnormalities of the endometrium and endocervix, and the cystoscopic results were also normal. Finally, labiaplasty was completed to prevent adhesion recurrence. One month after the surgery, the discomfort while urinating was eliminated and the adhesion did not recur.

CONCLUSION

Labial adhesions in postmenopausal women cannot be successfully treated with estrogen creams, and surgical treatment should be considered.

A preliminary observational study on the vascular, nerve, and lymphatic anatomy and histology of the labia minora from cadaveric and surgical samples

INTRODUCTION AND HYPOTHESIS

To better understand details of the fine anatomy of the labia minora, present images of the vascular anatomy and characterize the nerve and lymphatic distribution of the labia minora.

METHODS

Two fixed and five fresh cadaveric specimens were perfused and dissected, and the vascular network was photographed. Labia minora samples, prepared from cadavers, and tissue resulting from labia reduction surgery underwent hematoxylin and eosin staining and S100 and D2-40 immunohistochemical staining.

RESULTS

Arteries emanated from the base to the edge of the labia minora, where there was a larger feeding artery, and the arteries were anastomosed. The veins formed anastomotic branches in the same direction as the edge of the labia minora. Arteries and veins that accessed the labia minora were successfully perfused at the same time with no obvious association. Sensory nerve endings were abundant, mostly larger with myelinated nerve trunks and Schwann cells in the central area with suggested neurovascular associations and smaller with no obvious aggregation at the edge. The medial area had 23.63 ± 11.82 nerves/view, the lateral area 21.30 ± 11.49 nerves/view (P > 0.05). The thickest nerve bundle was 3.16 ± 1.41 mm from the medial epidermis and 3.13 ± 1.47 mm from the lateral epidermis. Lymphatic vessels showed no obvious regional distribution. Labia minora were 21.77 ± 5.69 mm wide with 252.87 ± 63.01 lymphatic vessels at 3.67 ± 1.61/mm2 density. The shortest inner diameter of dilated lymphatic vessels was 161.09 ± 49.99 μm.

CONCLUSION

A larger feeding artery exists in the labia minora, which should be noticed in the pre-surgery design of labiaplasty. No difference was observed in the nerve distribution between the medial and lateral sides. Lymphedema might not be the cause of labial hypertrophy.

MRI of female genital tract congenital anomalies: European Society of Urogenital Radiology (ESUR) guidelines

Objective

To develop imaging guidelines for the MR work-up of female genital tract congenital anomalies (FGTCA).

Methods

These guidelines were prepared based on a questionnaire sent to all members of the European Society of Urogenital Radiology (ESUR) Female Pelvic Imaging Working Group (FPI-WG), critical review of the literature and expert consensus decision.

Results

The returned questionnaires from 17 different institutions have shown reasonable homogeneity of practice. Recommendations with focus on patient preparation and MR protocol are proposed, as these are key to optimised examinations. Details on MR sequences and planning of uterus-orientated sequences are provided.

Conclusions

The multiplanar capabilities and soft tissue resolution of MRI provide superb characterisation of the wide spectrum of findings in FGTCA. A standardised imaging protocol and method of reporting ensures that the salient features are recognised, contributing to a correct diagnosis and classification of FGTCA, associated anomalies and complications. These imaging guidelines are based on current practice among expert radiologists in the field and incorporate up to date information regarding MR protocols and essentials of recently published classification systems.

Key Points

• MRI allows comprehensive evaluation of female genital tract congenital anomalies, in a single examination.

• A dedicated MRI protocol comprises uterus-orientated sequences and vaginal and renal evaluation.

• Integration of classification systems and structured reporting helps in successful communication of the imaging findings.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06750-8) contains supplementary material, which is available to authorized users.

[Female reproductive system dysplasia: a clinical study of 924 cases]

Objective: To explore the relationship between different types of female reproductive system dysplasia and age of visit, clinical manifestations, common types of combined malformations and endometriosis. Methods: The patient's medical records in the Second Hospital of Hebei Medical University from December 2002 to June 2016 were collected and retrospectively analyzed. Results: Among 924 cases of genital tract dysplasia, uterine dysplasia (65.3%, 824/1 261) was the most common, followed by vaginal dysplasia (28.3%, 357/1 261), hymen atresia and urogenital fistula (3.7%, 47/1 261), and cervical dysplasia (2.6%, 33/1 261). (1) The youngest age was in patients with hymen atresia and urogenital fistula, with a median of 14.5 years old, while the older age were in patients with uterine, vaginal and cervical dysplasia, with median age of 25.0, 24.0 and 23.0 years old, respectively. (2) The clinical manifestations were lack of specificity, mainly abnormal findings of physical examination or accessory examination, primary amenorrhea, lower abdominal pain, infertility, adverse pregnancy history. (3) About other systemic malformations, urological malformations were the most common (4.8%, 44/924), followed by spinal malformations (0.5%, 5/924), inguinal hernia (0.4%, 4/924), heart malformations (0.2%, 2/924), cleft lip and palate (0.2%, 2/924). Oblique vaginal septal syndrome and MRKH syndrome were the most likely to be associated with other system malformations. (4) About combination with endometriosis, there was no significant difference between obstructive genital tract malformations (2.3%, 9/385) and non obstructive genital tract malformations (1.7%, 9/539; P=0.469). Conclusions: Female reproductive system dysplasia is the most common in uterine dysplasia, followed by vaginal dysplasia, hymen atresia and urogenital fistula, and cervical dysplasia. The age of visit is generally older, often found by abnormal findings of physical examination or accessory examination, primary amenorrhea, lower abdominal pain, infertility, adverse pregnancy history;and could be combined with a variety of other system malformations, most seen by urinary system malformations,there is also the risk of endometriosis.

"I Don't See That as a Medical Problem": Clinicians' Attitudes and Responses to Requests for Cosmetic Genital Surgery by Adolescents

Labiaplasty is a form of genital surgery to reduce large or protruding labia minora. Internationally, the rates of this surgery among women and girls is increasing and is viewed as a worrying trend. Currently, the main clinical strategy is to reassure adolescents that they are normal by talking about the variation of labia size and appearance and showing pictures demonstrating the wide range of normal female genital appearance. For the most part, policy documents recommend against labiaplasty in adolescents, claiming that it is medically non-essential surgery. In this paper, we contrast findings from our interviews with clinicians with the existing literature and policy documents and we point out areas needing more thought. This is qualitative research using semi-structured interviews. We set out to find out on what basis clinicians decide how to treat or manage adolescent patients seeking labiaplasty. We interviewed clinicians who are likely to be approached by under-eighteens requesting labiaplasty. We use interpretive content analysis and thematic analysis to analyse the data. Our findings support the emphasis on education and reassurance as the first step for all patients, but other issues that have not figured previously in the literature that would alter clinical strategies for managing patients emerge as well. Key findings are that reassurance does not always work and that the distinction between functional and appearance concerns is not a solid foundation in itself for deciding whether surgery is ethically appropriate. We conclude that the distinction between functional and appearance concerns is not ethically relevant. It is open to different interpretations and is not regarded by all clinicians as the definitive factor in relation to surgery. The focus of clinicians should be on relieving distress whatever the cause. Appearance reasons may sometimes justify surgery but, also, functional reasons may sometimes not be sufficient justification for surgery.

Postpartum haemorrhage due to genital tract injury after vaginal delivery: safety and efficacy of transcatheter arterial embolisation

OBJECTIVES

To evaluate the safety and efficacy of transcatheter arterial embolisation (TAE) managing postpartum haemorrhage associated with genital tract injury (PPH-GTI) and to determine the factors associated with clinical outcomes.

METHODS

From 2002 to 2017, a retrospective analysis was performed in 60 patients (mean 31.5 years) undergoing TAE for PPH-GTI. Information regarding clinical data, angiography and embolisation details, and clinical outcomes was obtained. Univariate analyses were performed to determine the factors related to clinical outcomes.

RESULTS

Technical and clinical success was achieved in 98% and 88%, respectively. Bleeding foci were observed on angiography in 56 patients (93%). The major bleeding artery was the vaginal artery (32%, 24/74), followed by the uterine artery (cervicovaginal branch) (n = 18), internal pudendal artery (n = 13), cervical artery (n = 9), inferior mesenteric artery (n = 4) and external pudendal artery (n = 3). Embolic agents were gelatin sponge particles (n = 23), gelatin sponge with permanent embolic agents (microcoils, n-butyl cyanoacrylate) (n = 34) and permanent embolic agents only (n = 3). In seven patients, bleeding control failed and was managed by repeat TAE (n = 5) or surgery (n = 2) and with eventual bleeding control in all of these patients. Univariate analysis showed that paravaginal haematoma, massive transfusion and long hospital stay were related to clinical failure. During the mean follow-up period of 33.1 months, regular menstruation resumed in 95.2% (40/42) and 14 of them became pregnant.

CONCLUSIONS

TAE is safe and effective for treating PPH-GTI. Massive transfusion, paravaginal haematoma and long hospital stay were related to the failure of bleeding control.

KEY POINTS

• PPH-GTI had a high detection rate of active bleeding foci on angiography. • Besides vaginal artery, inferior mesenteric and external pudendal arteries were notable bleeding foci. • Permanent embolic agents were used more than only gelatin sponge particles. • Paravaginal haematoma and massive transfusion were related to clinical failure. • TAE for PPH-GTI was safe and effective with preservation of menstrual cycles.

Clinicopathological Features and Treatment Analysis of Rare Aggressive Angiomyxoma of the Female Pelvis and Perineum - a Retrospective Study

The study was to evaluate the clinicopathological features of aggressive angiomyxoma (AAM) of the female pelvis and perineum and its treatments. This was a retrospective study of female patients with AAM admitted to our hospital. Clinical and pathological data were analyzed, as well as the postsurgical follow-up. Median age at initial presentation was 41 years. Thirteen patients had lesions involving adjacent organs. Eighteen patients underwent complete tumor resection, while one patient underwent partial tumor resection. The tumors were soft in texture, pink in color, and had mucus on the surface. A microscopic examination revealed that the tumors were non-encapsulated, with spindle cells and stellate cells of almost identical size loosely distributed in the myxoid stroma, and vessels of different sizes and wall thicknesses. Immunohistochemistry indicated that AAMs were strongly positive for CD34 and smooth muscle actin, moderately positive for desmin, estrogen receptors and progesterone receptor, and mostly negative for S-100. After a median follow-up of 24 months, the recurrence rate was 33.3 %. Four recurrences were in patients with positive initial margins. AAM is a slow growing, locally invasive, benign tumor. Complete resection could lead to lower recurrence rate compared with incomplete resection. Follow-up is necessary for recurrent cases with repeated surgeries. The overall prognosis could be favorable.