Lymphangiectasia of the vulva accompanying congenital lymphedema

Lymphangiectasia is a benign condition with multiple dilated lymph vessels in the dermis. Vulvar localization is rare and mostly depends on disturbing the lymphatic flow. We present a patient with vulvar lesions and ipsilateral congenital lower extremity lymphedema. Surgical excision eliminated the lymphangiectasia and improved the appearance of the edematous vulva.

[Diagnostic image. A woman with a vulvar swelling]

A 25-year-old woman presented with a tumour above the labia minora, due to an epidermal cyst.

Pure vulvar Langerhans cell histiocytosis: a case report and literature review

Langerhans cell histiocytosis (LCH) of the female genital tract is a very rare disease. Only 16 cases of primary vulvar LCH without subsequent systemic spread of disease have previously been published in the literature. We describe an additional case of LCH in which the lesion was confined to the vulva. A 52-year-old Caucasian woman presented for further investigation with a 6-month history of vulvar pruritus. Physical examination revealed multiple fine red papules on both labia minor. A metastatic workup did not reveal any evidence of disease beyond the vulva. The lesion was biopsied, and histological findings were characteristic of LCH. The patient was treated by local extirpation of both labia minor. Ten months after surgery, the patient has no signs of local recurrence or systemic spread. It is necessary to perform a biopsy of the lesions when a woman presents atypical chronic lesions on the vulva. Although different treatment has been proposed, complete surgical excision is fundamental in "pure" genital Langerhans cell histiocytosis as initial therapy.

[Diagnostic image (389). A woman with a multicystic vulvar mass]

A 28-year-old woman presented with a multicystic vulvar mass due to epidermal inclusion cysts, probably caused by trauma to the left labium minus at her last parturition.

Outcomes of surgical management of stage III vulvar hidradenitis suppurativa

OBJECTIVE

To review prior experiences and outcomes of patients treated for stage III vulvar hidradenitis suppurativa (HS) and determine postoperative patient satisfaction.

STUDY DESIGN

Patients managed surgically for stage III vulvar HS at University of Michigan Health Systems (January 2000 to December 2005) were identified. Retrospective record review was undertaken and data collected. Five met study criteria. All underwent radical vulvectomy to excise the HS. Most required extensive excision of the vulva, including mons, perianal area and buttock. One surgical defect was allowed to heal by secondary intention; all others underwent interval closure with split-thickness skin grafting (STSG). After debridement, all wounds were dressed with a vacuum assisted closure device.

RESULTS

Of the 5 patients, 4 were satisfied with their outcome. The patient managed without STSG developed an introital stricture and was the only patient regretting undergoing surgical excision of the hidradenitis suppurativa. Some amount of depression was present in all patients postoperatively. Four were happy with the surgery; 3 said they would undergo surgery again.

CONCLUSION

Patients with severe HS often require radical excision. Data conflict regarding optimal surgical management. Our experience supports good outcome in patients managed with radical excision and STSG.

Recurrent vulvar lymphangitis cured with vulvectomy in a cervical carcinoma patient: a case report

BACKGROUND

Recurrent vulvar lymphangitis secondary to pelvic lymphadenectomy and radiation therapy can be a vexing clinical dilemma.

CASE

A 55-year-old woman was initially treated with radical hysterectomy and 1 postoperative radiotherapy for cervical carcinoma in 1984. In 1987 she developed persistent vulvar, leg, and ankle edema; chronic vulvar pain; and recurrent vulvar cellulitis, which were ultimately attributed to group B Streptococcus. Despite long-term antibiotic therapy and compression stockings, the cellulitis was intractable. In June 2006 the patient underwent a bilateral simple vulvectomy with preservation of the clitoris and insertion of bilateral subcutaneous Jackson-Pratt drains. Her postoperative culture results revealed normal vaginal flora.

CONCLUSION

The patient's wounds healed very well, and she has had no further episodes of vulvitis or lymphangitis. The management of recurrent infections involving lymphedema can be difficult and cause complicated clinical issues.

Surgery for localized, provoked vestibulodynia: a long-term follow-up study

OBJECTIVE

To evaluate the long-term results of vestibulectomy in women with localized, provoked vestibulodynia.

STUDY DESIGN

A retrospective questionnaire survey was filled out by 67 Swedish women who underwent surgery for localized, provoked vestibulodynia during 1992-2003. The questionnaire was completed a minimum of 12 months after the operation. Coital pain, quality of sexual life and psychologic well-being were evaluated.

RESULTS

The mean age at the time of surgery was 27 years (18-56) and the median follow-up time 41 months (12-120). Coital pain, rated with Visual Analogue Scales (VAS(neg)) (0-10), was 8.0 (median) before surgery, 5.0 (p < 0.001) 6 months after surgery and 2.0 (p < 0.001) at follow-up. Quality of sexual life, using VAS(pos) (10-0), was 6.5 (median) before dyspareunia, 0.5 (p < 0.001) prior to surgery and 6.5 (p < 0.001) at followup. Complete or major improvement was reported by 56% of women with secondary vestibulodynia and 17% of women with primary vestibulodynia (p = 0.03). Improved psychologic well-being was reported by 79%.

CONCLUSION

Women with secondary localized provoked vestibulodynia will often benefit from surgery when other treatments fail. Surgical outcome should include both pain relief and psychosexual well-being. In this study women with primary vestibulodynia were less likely to benefit from surgery.

[Labial fusion in the paediatric surgery department of Yopougon University hospital (Côte d'Ivoire): 108 cases]

INTRODUCTION

Labial fusion is a benign genital disorder in girls. It may be either congenital or acquired, sometimes due to poor hygiene. Parental panic about this "absent vagina" contrasts with its simple, rapid, radical treatment. The study reports the result of simplified treatment.

MATERIAL AND METHODS

This retrospective study covers cases from 1 January 1992 through 31 December 2006 and includes only the cases of young girls treated as outpatients. All patients underwent outpatient surgical treatment. They were placed in gynaecological position. After asepsis of the vulva, a curved Halsted mosquito forceps was inserted into the opening for partial adhesions or across the medial transparent membrane for complete fusion. The forceps were then opened gently until complete detachment occurred. Local anaesthesia with EMLA cream ensured the absence of pain; there was sometimes minimal bleeding. All patients had local antiseptic treatment afterwards.

RESULTS

During this study period, 108 patients (including two sisters) with a mean age of 22 months were treated for labial fusion (101 cases of total fusion and 7 partial). Only seven were older than 5 years of age. Overall, 84 patients underwent this basic treatment of section and follow-up antisepsis; none had a recurrence. Twenty girls also received oestrogen cream, and 4 had the surgical section alone.

DISCUSSION

This benign disorder is rare and generally isolated in our regions, unlike in Western countries where it is often associated with hormonal deficits. The principal approach has been either therapeutic abstention or oestrogen therapy, both currently recommended in developed countries. Oestrogen treatment is a long procedure (3 or 4 months), however, and follow-up is far from certain. In Africa, all genital disorders are considered serious. Early repair is desirable for that reason and to prevent urinary tract infections and traditional "treatment". Simple outpatient treatment by surgical section with local antiseptic treatment is effective. Vulvar hygiene is essential to prevent recurrence.

CONCLUSION

This benign disorder can be treated by any physician, but the psychological impact of the site and the necessary speed suggest the choice of management in paediatric units.

A rare case of fibrocystic disease at vulval accessory breast tissue

A 40-year-old female presented with a non-itchy ulcerative nodular lesion at left labium majus since last 1 1/2 years. The lesion progressed to increase in size from 0.5 cm to 1.5 cm in diameter. It was incised and drained. After that a non-healing ulcerative nodule formed. The nodule was firm in consistency and movable on all sides. The ulcer healed with a 5 days course of ceftriaxone. If was excised and biopsy of the lesion showed fibrocystic changes of accessory breast tissue. It is a rare disease entity for which the case report is presented.

[Experiencing pregnancy with human papillomavirus: a case study]

This is a case study which theoretical reference is the Calgary Model of Family Evaluation (CMFE). The aim was to understand the experience of a pregnant woman with vulvar condilomatosis caused by Human Papillomavirus (HPV), and to understand the changes in family dynamics after the clinical and laboratory diagnosis of HPV. The study was conducted at a reference institution in gynecology in Fortaleza, Ceará, Brazil. Data were collected fiom October 2003 through April 2004. Data were analyzed using CMFE, tracing six "developing" events, highlighting that the patient experienced emotional suffering caused by pregnancy and by HPV, as well as physical suffering, due to the surgeries to which she was submitted to. All these facts altered family dynamics.

Successful Treatment with Lymphaticovenular Anastomosis for Secondary Skin Lesions of Chronic Lymphedema

The treatment of severe lymphedema is a difficult challenge. We performed lymphaticovenular anastomosis on two patients with secondary skin lesions of chronic lymphedema; one patient exhibited acquired lymphangioma circumscriptum of the vulva and the other presented elephantiasis nostras verrucosa of the lower leg. Both patients obtained a remarkable improvement in skin lesions and also in the reduction of lymphedema of the lower extremity. During a 6-month-follow-up period, constant reduction in the circumference of the lower extremities without exacerbation of skin lesions was achieved in both patients. Lymphaticovenular anastomosis is a useful surgical treatment for secondary lymphedema in the lower extremities. In addition, this surgical treatment is effective for secondary lesions of lymphedema, including acquired lymphangioma circumscriptum and elephantiasis nostras verrucosa.

[Diagnostic image (333). A girl with vulvar pain]

A 9-year-old girl with a 4 year history of vulvar complaints was thought to be sexually abused but eventually appeared to be suffering from a urethral polyp.

Surgery combined with muscle therapy for dyspareunia from vulvar vestibulitis: an observational study

OBJECTIVE

To explore the dual importance of treating vestibule allodynia and pelvic floor myalgia in correcting dyspareunia associated with severe vulvar vestibulitis.

STUDY DESIGN

In this observational study, 111 women were treated by modified superficial vestibulectomy and were evaluated for referral to physical therapists for pelvic floor myalgia. They were followed with interval repeat examinations. Later cohort assessment was by patient questionnaire surveys. Data from pelvic floor muscle examinations and physical therapy referrals were added by retrospective chart review. Primary outcomes were swab touch sensitivity and dyspareunia.

RESULTS

Eighty-five percent of subjects ultimately had nontender vestibule examinations postoperatively. Fewer, numbering 64%, reported resolution of dyspareunia, 24% had less dyspareunia, 9% were no better, and 3% reported they were worse. Fifty percent of those with continued dyspareunia had no remaining vestibulitis, but had tight or tender pelvic muscles. Failure of surgery and physical therapy to correct dyspareunia related significantly to length of symptoms before therapy (p = 0.02). Follow-up averaged 3.7 years, with a range of 0.25-14.

CONCLUSION

Superficial surgery can correct vulvar vestibulitis, but without treatment for pelvic floor myalgia, women may continue to have dyspareunia. Physical therapy is an important adjunct to achieve comfort.

Postpartum labial adhesions

BACKGROUND

Labial adhesions are common in young girls and menopausal women. Topical estrogen is the first line of therapy for these adhesions. Based on a systematic literature review, postpartum labial adhesions are uncommon in clinical practice. They are not painful but can prevent patients from resuming normal sexual activity. Topical estrogen therapy is an ineffective treatment option for adhesions in this setting. Surgical division under local anesthesia is usually effective.

CASE

A 29-year-old women presented at 6 weeks after an uncomplicated vacuum-assisted delivery for a routine postpartum evaluation. Examination revealed a 5-mm labial adhesion connecting her left and right labia minora. Division under local anesthetic resulted in a complete recovery within 3 days.

CONCLUSION

Postpartum labial adhesions can usually be surgically divided under local anesthetic with complete and rapid recovery.

Hematoma of the labia majora in an adolescent girl

This is a case report of a 19-year-old woman who presented with a large hematoma of her labia majora after consensual sexual intercourse that required surgical intervention. To our knowledge, this is the first case report of such an entity. The following is a summary of the patient's clinical presentation and management, as well as a review of the literature regarding genital injuries in adolescent girls.

CO2 laser therapy of the Bartholin’s gland cyst: Surgical data and functional short- and long-term results

The Bartholin's gland cyst is a condition that occurs in approximately 2% of women, most of whom are of reproductive age. Although benign, it is associated with significant patient discomfort. Definitive treatment involves the surgical removal of the entire cyst. The objective of this study was to describe an alternative conservative surgical technique with CO(2) laser adopted in our institution and to evaluate the feasibility, complication rate, and results obtained with this technique in an office setting. Our study showed that CO(2) laser treatment of the Bartholin's gland cyst can be carried out safely in an outpatient setting, with minimum patient discomfort and high long-term cure rates.

Clitoroplasty: past, present and future

This paper reviews the history of clitoral surgery throughout the twentieth century. The changing operations, from amputation through to attempts to produce a normal clitoris mirror the changing attitudes and available knowledge. It also examines the current issues that arise out of available data on long-term outcomes of clitoroplasty.

Surgical Treatments for Vulvar and Vaginal Dysplasia

OBJECTIVE

To compare pain, adverse effects and recurrence of dysplasia in patients with vaginal intraepithelial neoplasia or vulvar intraepithelial neoplasia prospectively treated by carbon dioxide laser or ultrasonic surgical aspiration.

METHODS

Patients were randomly assigned to receive treatment by laser or ultrasonic surgical aspiration from 2000-2005. Preoperative biopsy was done to confirm presence of dysplasia. Patients completed a visual analog scale regarding pain and were evaluated at 2-4 weeks to assess scarring, wound healing, and adverse effects. Patients returned every 3 months for 1 year for pelvic examination and cytology to assess recurrence. Follow-up colposcopy and biopsy were used at the discretion of the treating physician. Student t test, chi2, analysis of variance and multiple logistic regression were used for analysis.

RESULTS

One hundred ten patients were randomly assigned. Ninety-six (87.3%) patients completed 1 year follow-up. Mean age of patients was 48.5 years. Mean visual analog scale score was significantly lower in patients treated by ultrasonic surgical aspiration (20.7 compared with 35.1; P=.032). For patients with vulvar lesions, there was less scarring with ultrasonic surgical aspiration (P<.01). Recurrence overall was 25% and was similar for ultrasonic surgical aspiration compared with laser (relative risk 0.96, 95% confidence interval 0.64-1.50, number needed to treat 95.6). Recurrence was associated with younger age (P<.01).

CONCLUSION

Patients treated with ultrasonic surgical aspiration for vulvar and vaginal dysplasia reported less postoperative pain. Vulvar scarring was more common in patients treated by the laser. There was no difference in recurrence of dysplasia during a 1-year follow-up period between the two surgical modalities.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00394758

LEVEL OF EVIDENCE

I.

[Synechia vulvae infantum--incidence on Department of Obstetric/Gynaecology, Teaching Hospital Na Bulovce, the First Medical Faculty of Charles University in Prague, Czech Republic from 2001 through 2005]

OBJECTIVE

The aim of this study is to discuss incidence and treatment of synechia vulvae at our Institute in the five years period.

DESIGN

Retrospective analysis.

SETTING

Department of Obstetrics/Gynaecology, Teaching Hospital Na Bulovce, the First Medical Faculty of Charles University in Prague.

METHODS

We performed a retrospective analysis of our set of patients treated at our Institute from 2001 through 2005. We assessed age, type of synechia, symptoms and treatment.

RESULTS

We treated 108 cases of synechia vulvae in 83 patients, 16 cases were relapsing. Most patients were in the group of less than 3 years of age. Almost 64% of all cases were incidental findings of paediatrician. Our set comprised of posterior fusion (79% of patients), subtotal posterior fusion (14%) and the rest was anterior or middle fusion. 87% of all labial fusions were disintegrated without any need of anaesthesia.

CONCLUSION

Our results confirmed high prevalence of posterior labial fusion; most of our cases were treated without any need of anaesthesia.

The simple outpatient management of Bartholin's abscess using the Word catheter: A preliminary study

INTRODUCTION

Bartholin's cysts/abscess affects 2% of women. Conventional treatment is marsupialisation under general anaesthetic. We evaluated a conservative approach in a non-randomised prospective interventional study over 12 months.

METHOD

Women with a Bartholin's abscess were counselled and those who opted for the Word catheter (WC) had it inserted under local anaesthetic (follow up at one week and four weeks, when catheter was removed). Women recorded pain scores and completed a qualitative questionnaire and had telephone follow up at six months. Outcome measures were abscess resolution and acceptability of treatment.

RESULTS

Fifty-eight women attended with a Bartholin's abscess requiring drainage. Twenty-three of 58 (40%) elected for marsupialisation. Thirty-five of 58 (60%) women had a WC inserted. Twenty-seven of 35 (77%) women retained their catheter for four weeks (three catheters fell out within 24 h of insertion, three catheters fell out within one week, one fell out after 11 days and there was one failed insertion). One woman had a recurrence six months after treatment. Abscess resolution occurred in 34 of 35 (97%). No woman reported significant discomfort at one week. Twenty-four of 27 women (89%) said that if they suffered a recurrence, they would have another WC inserted. Three of 27 (11%) women had intercourse within the second week of catheter insertion and reported that it was not uncomfortable. Fourteen women who had marsupialisation were traced and none had suffered a recurrence six months after treatment.

CONCLUSIONS

The WC is a safe and effective treatment for a Bartholin's abscess. It may be considered as an alternative to marsupialisation.

[Vulval tuberculosis: a rare case report]

The authors report an observation of a rare case of vulvar tuberculosis in its hypertrophic form it is observed in a 16-years-old girl. The diagnosis was retained on a beam of arguments anamnestic, clinical, histological and evolutionary. A medical treatment based on antibacillar was founded supplemented of a surgical reduction for aesthetic concern.

The pathomorphology of Bartholin's gland. Analysis of surgical data

Medline data did not reveal any statistical approach to Bartholin's gland pathomorphological lesions, especially when the social aspect was considered. Objectives. To complete knowledge and data according to this subject on the basis of own surgical material analysis. Microscopic examinations of histopathological 5 microm thick specimens stained with hematoxylin-eosin and in selected cases with histochemical and immunohistochemical methods on 104 Bartholin's glands taken from 103 female patients in age of 39.4 +/- 9.6. Retention cysts, suppurating lesions (abscesses), extrauterine endometriosis and neoplasms were separated from obtained samples. Localization of lesions, the patients' age and education status were determined. P < 0.05 was considered as statistically significant. Retention cysts were observed in 84.6% of cases, abscesses in 10.6%, extrauterine endometriosis in 2% and neoplasms in nearly 3% of patients. In 54.1% of cases the lesion was localized on the left side, in 45.9% on the right. 17.2% of female patients presented with university education, 29.9% with elementary education, while 52.9% with secondary education. The average age of operated patients amounted to 33 +/- 9.8 years in case of university education, being significantly lower as compared to the average age of secondary (40.5 +/- 7 years) and elementary (42.4 +/- 12 years) education (p < 0.01 and p < 0.02 respectively). 47.7% of retention cysts demonstrated various degrees of inflammatory infiltration. However, the anatomical variability of the ductal and glandular epithelium was higher in cases of non-inflammatory cysts. Considering three Bartholin's gland neoplasms, two were diagnosed as adenocarcinomas and one as a fibromyoma. All of them were observed in female patients with a rare blood type (twice Rh-minus and once AB Rh-plus). There was no significant relationship between the type of pathomorfological lesions and age of operated patients, in spite of the fact that the lowest mean age was observed in woman with endometriosis while the highest in those with neoplasms. The pathology of Bartholin's gland mostly concerns female patients with secondary education. However, early diagnosis is associated with patients with university education. Thus, further investigations considering the statistical analysis of Bartholin's gland neoplasms in order to determine the possible relationship between blood type antigens and neoplasm development are required.

Extraosseous vulvar chondroma: a case report

BACKGROUND

Extraosseous chondromas are cartilaginous tissue tumors with a nodular appearance on the hands and feet. There are reports of these tumors occurring on the knee, neck, back, liver and testis and in the oral cavity. Occurrence in the pelvis is generally rare. The origin is metaplastic and may be mesenchymal or subcelomic. Treatment is by surgery and requires removing the tumor with a safety margin. Recurrences are infrequent, and distant metastasis has never been reported.

CASE

An 11-year-old girl was referred for a painless solid tumor located on the mons pubis. Surgical removal of the tumor with a safety margin was performed. Macroscopically, the tumor was shiny when cut open and yellowish. Microscopic examination revealed a very distinct cartilage-forming tumor compatible with extraosseous chondroma. Two years after the operation, the patient had no recurrence.

CONCLUSION

Extraosseous chondroma is a rare benign tumor. Finding it in children is even less frequent, and localization in the vulvar region has never before been reported. This appears to be the first such report of this type of tumor in this region and age range.

A review of the surgical treatment of vulval lymphangioma and lymphangiectasia: four case reviews

OBJECTIVE

To evaluate whether surgical management of vulval lymphoedema and/or lymphangiectasia conveys any longstanding patient benefit.

PATIENT AND METHODS

A qualitative analysis of signs and symptoms that occurred before and after surgical treatment for vulval lymphoedema and/or lymphangiectasia was performed. This was done by analysis of patient notes and telephone conducted interview.

RESULTS

From a hospital database search, four patients were found to have had surgical treatment--three for lymphangioma and one for lymphangiectasia. Overall there was a clear improvement in the signs and symptoms associated with these conditions. In particular, all patients reported an improvement (i.e. a reduction or elimination) in the amount of oedema following surgery.

CONCLUSION

Carbon dioxide laser therapy and superficial radiotherapy have been previously described for the management of vulval lymphangioma and lymphangiectasia with limited success, whereas our data suggests surgery offers a more permanent solution. In particular, labial reduction seems to be more successful than methods such as lymphovenous anastomoses and lymphangioplasties. A single operation may provide benefit for up to ten years. This approach has the potential to allow patients to be rehabilitated to normal life and activity.

[Vulvoperineoplasty for vulvar pain in the posterior fourchette (15 cases)]

BACKGROUND

Vulvar pain is a common presenting complaint in dermatology consultations arising from numerous possible causes. Where such pain is mechanical, resulting from stretching of the vulva, particularly during sexual intercourse, the patient should be checked for anatomical features that could account for the pain, localised anatomical adhesions or sclerosis of the fourchette, and amenable to treatment by vulvoperineoplasty.

PATIENTS AND METHODS

A retrospective study of all patients undergoing vulvoperineoplasty for vulvar pain in the fourchette was carried out between 1.1.1993 and 1.1.2003.

RESULTS

Fifteen successive patients were included in the study. The mean rate of sexual intercourse doubled between the pre-operative period and the post-operative period, rising from 5 (0 to 30) to 9.8 (3 to 30). Mean pain intensity during intercourse on a scale of 1 to 10 fell from 7.6 (5 to 9) before surgery to 1.6 (0 to 5) after surgery. None of the patients experienced any sequelae. All patients except one (who was no longer sexually active), expressed willingness to undergo vulvoperineoplasty again if necessary.

DISCUSSION

Vulvoperineoplasty is a simple procedure and proved useful for female patients presenting vulvar pain and adhesions or sclerosis of the fourchette.

Primary vulvar nocardiosis

BACKGROUND

Nocardiosis is an uncommon disease, and the primary skin infection is usually at the site of a recent injury. Nocardia is a saprophytic bacterium of the soil belonging to the order Actinomycetales.

CASE

A 68-year-old woman presented with a painful, hard, dark reddish lesion located in the right hemivulva. She had been treated by radiotherapy for a vulvar leiomyosarcoma arising from the left Bartholin gland at the age of 45. Pathology results demonstrated nocardial infection, initially advanced despite antibiotic therapy. The necrosis extended to and involved the ischiopubic bone, requiring extensive surgical treatment. We performed a radical vulvectomy with partial pubic bone excision to remove the necrotic tissue. A transverse gracilis-myocutaneous free flap was used for vulvar reconstruction. Wound necrosis recurrence required a rectus abdominis myocutaneous flap reconstruction, with an excellent final result.

CONCLUSION

This is the first report of primary vulvar nocardiosis. This infection may simulate advanced vulvar carcinoma requiring extensive surgical treatment.

Outcomes of octogenarians and nonagenarians in elective major gynecologic surgery

OBJECTIVE

The purpose of this study was to determine whether age is a risk factor for perioperative and postoperative complications.

STUDY DESIGN

This was a retrospective case-control study of 120 women over age 79 (group 1) compared with 1,497 younger patients 50-79 (group 2) undergoing major elective gynecologic surgery.

RESULTS

Mean length of stay was 4.8 days for group 1, compared with 3.8 for group 2 (P = .018). Patients hospitalized longer than 1 week was higher (P < .01) among group 1. There were statistically significant increases in UTI, psychiatric events, pulmonary edema, respiratory failure, sepsis, and hypovolemic shock. No significant difference in mortality rate was noted (group 1: 0.83%, n = 1 vs group 2: 0.47%, n = 7).

CONCLUSION

Although length of stay for the elderly is slightly increased, mortality and complication rates are comparable to younger patients with few exceptions. We conclude that age need not be the sole determinant in the decision to undergo major elective gynecologic surgery.

Maladie de Paget de la vulve : intérêt de l'étude du ganglion sentinelle

Paget's disease of the vulva is difficult to diagnose, as far as the extent of this lesion is concerned, since it is often coupled with invasive adenocarcinoma of the vulva. Thus, we present two cases of Paget's disease of the vulva, with use of sentinel lymph node analysis- a non-validated technique in this very context. Evaluation of sentinel lymph node may be useful in case of micro-invasive Paget's disease.

[Postoperative complications of Bartholin's duct abscess. About two cases]

Bartholinitis is the most common infectious vulvar disease and develops in approximately 2% of all women. The choice concerning treatment may be uneasy between medical or surgical modalities, and we have to be cautious because of the risk of severe complications associated with the procedure. We report two cases: one case of sepsis and the other one of bacterial cellulitis after Bartholin's duct abscess marsupialization. In the light of epidemiological and bacteriological date referring to Bartholinitis, we recommend a safe and effective management (particularly the use of broad-spectrum antibiotics) that we will describe.

Nodular hyperplasia of Bartholin’s gland

AIMS

There has been very little mention of benign solid lesions of the Bartholin's gland (BG) in pathology and gynaecology textbooks, and very few cases have been reported in the literature. Among these lesions, the distinction between nodular hyperplasia (NH) and adenoma has not been well defined. We report ten cases of NH of the BG, describe their clinicopathological, immunohistochemical and ultrastructural findings, and review the literature.

METHODS

We examined retrospectively all lesions involving BGs from our surgical pathology records from 1990 to 2004 with emphasis on NH. To separate NH from adenoma, we applied the criteria proposed by Koenig and Tavassoli. Special stains (PAS with and without prior digestion, Mayer's mucicarmine and Alcian blue with and without hyaluronidase) and immunohistochemistry (CAM5.2, AE1/AE3, HMWK, monoclonal CEA, EMA, ER, PR, ALA, SMA, Ki-67, p53 and polyclonal CEA) were performed on NHs. Two cases were examined ultrastructurally.

RESULTS

Using specific criteria, ten cases (age range 23-45 years; mean 36.1) of NH were identified, two of which were diagnosed previously as adenoma, but re-classified as NH. Clinically, these lesions were described either as Bartholin's duct cysts (BDCs) or vulvar lumps. Grossly, NHs were solid, tan and unencapsulated, measuring 12.5-45.0 mm in maximum dimension (mean 23.8). Histologically, the NHs were composed of a proliferation of mucus-secreting acini with preservation of the normal duct-to-acinar relationship. Chronic inflammation and squamous metaplasia were present. Eight lesions focally involved the surgical margins. Intracytoplasmic and intra-luminal secretions were positive for PAS with and without digestion, Alcian blue with and without hyaluronidase and mucicarmine. All lesions showed positive staining for CAM5.2, AE1/AE3, HMWK, EMA, and polyclonal CEA. There was negative staining for Ki-67, ER, PR, ALA, p53 and monoclonal CEA. Periacinar myoepithelial cells stained for SMA. Ultrastructurally, the findings included abundant intracytoplasmic secretory granules, granulofibrillar bodies, prominent Golgi and ribosomes. Myoepithelial cells were identified. There was no tumour recurrence or malignant transformation in eight patients with clinical follow-up.

CONCLUSION

NH of the BG is a rare lesion with benign behaviour. It is a distinct entity and can be separated histologically from an adenoma.

[Endometrial cysts of the vagina and the vulva (case reports and a literature review)]

Two cases of low-genital-tract-endometriosis are presented. First case is of a big endometriotic cyst of the labia minor, clinically presented as a Bartholin's gland cyst. Second case represents a vaginal cyst which mimics urethral diverticulum. In each case the final diagnosis was determined after the hystopathologial examination. A briefe literature review was done. Endometriotic cysts of the vagina and vulva are rare. Usually they mimic other, more frequently encountered lesions. Not always they have the typical symptoms of endometriosis and there diagnosis is rare determined before the surgical procedure and hystopathological examination. A detailed anamnesis, thorough clinical examination and additional methods (cystoscopic. imaging, sonographic) are needed for the diagnosis. Management consists of a surgical removal of the lesions, hormonal suppression of the ovarian function and, by all means, following up the patients for appearance of a recurrence or of a lesion de novo.

Hydrocele of the canal of Nuck as a result of a rare ventriculoperitoneal shunt complication

Patients with ventriculoperitoneal (VP) shunts may have multiple complications. Migration of the peritoneal catheter into some anatomical or congenitally open cavities can cause inguinal or genitourinary manifestations such as hernia, hydrocele or acute scrotum, and these are common in male infants. We report a very rare complication of VP shunt encountered in a female infant, manifesting as hydrocele of the canal of Nuck, the female counterpart of hydrocele of the spermatic cord. It is emphasized that VP shunts may also cause clinical inguinal manifestations in female infants, and groin or external genital organ swelling in these patients may be an important sign of shunt malfunction.

Perivulvar dermatitis in a cat treated by episioplasty

Perivulvar dermatitis is common in obese, older female dogs that have infantile vulvae. Removing the excessive perivulvar skin folds by episioplasty has been recommended as the treatment of choice for perivulvar dermatitis in bitches. This report describes a case of perivulvar dermatitis in a cat that was treated by episioplasty. Ten days after surgery a substantial improvement was noticed, and 67 days later the skin in the perineal/perivulvar area appeared to be normal. The cat had not been given any medication. As in bitches, episioplasty in cats can be successful in reducing perivulvar dermatitis.

Fasciite nécrosante du périnée secondaire à un traitement chirurgical d'un abcès de la glande de Bartholin

Necrotizing fasciitis of the perineum is a rare but of fast evolution, and potentially fatal infectious disease process. It is characterized by progressive inflammation and extensive necrosis of subcutaneous tissue involving the fascia and other adjacent tissues. This infection may be idiopathic or secondary to local trauma or pelvic surgery. Its mortality rate is 20%. We report a case of necrotzing fasciitis of the perineum in a 34-year-old woman following incision and drainage of Bartholin's gland abscess. Streptococcus A, Proteus mirabilis, Escherichia coli, and Candida albicans were isolated. Intravenous broad spectrum antibiotic therapy was promptly instituted. Concurrent surgical debridement of all necrotic areas was required. Post debridement therapy required a long period of dressing changes until cicatrisation. Necrotizing fasciitis of the perineum is a surgical emergency. Early diagnosis and prompt aggressive debridement are the keys to successful management.

Labial adhesions in pubertal girls

Labial adhesions after puberty are rare and are usually the result of chronic inflammation, urinary tract infection, hypoestrogenism or surgical procedures leading to vulval trauma. Sexual abuse leading to labial adhesions is extremely rare in girls who have attained menarche. Complete vulval fusion can rarely occur without any evidence of hypoestrogenism. We address this rare entity in three young pubertal girls wherein one had a history of genital trauma, the second had a history of surgical intervention due to urinary retention and the last one had a history of sexual abuse. All patients had history of genital trauma in common. Accepted management of this condition is adhesiolysis followed by application of estrogen cream in the postoperative period.

Severe haematoma of the vulva and defloration caused by goring

Haematoma of the vulva may occur following a trauma due to its highly vascular structure. We present a case of haematoma of the vulva caused by goring by a cow. The hymen and vaginal wall were also lacerated. Evacuation of the haematoma and repair of lacerated tissues were successfully performed.