Vaginal agenesis, the hymen, and associated anomalies

Congenital cervico-vaginal aplasia with a functional uterus: A case report and review of literature

Maldevelopment of the vagina and cervix is frequently accompanied by uterine aplasia or hypoplasia. Complete cervico-vaginal aplasia with a normally developing uterus is a very uncommon type of developmental failure. Failure to treat the condition can result in complications such as hematometra and hematosalpinx caused by the retrograde flow of blood into the fallopian tubes. In this case report, we describe the case of a 32-year-old woman experiencing cyclic abdominal pain and primary amenorrhea. The patient exhibited cervico-vaginal agenesis, with a functional uterus that was complicated by hematometra and bilateral hematosalpinx.

Vaginal reconstruction by collagen scaffolds loaded with vaginal epithelial and smooth muscle cells in pigs

In women, a healthy and functional vagina is important for the maintenance of a good quality of life. Various factors, including congenital anomalies, cancer, trauma, infections, inflammation, or iatrogenic injuries, can lead to damage or loss of the vaginal structure, necessitating repair or replacement. Often, such reconstruction procedures involve the use of nonvaginal tissue substitutes, like segments of the large intestine or skin, which are less than ideal both anatomically and functionally. Therefore, there is an urgent need to develop new methods of vaginal reconstruction. In this study, we established a new method for isolation and expansion of vaginal epithelial and smooth muscle cells. Subsequently, collagen scaffolds designed for vaginal reconstruction were loaded with vaginal epithelial and smooth muscle cells in vitro and tested in vivo using the vaginal excision pig model. The results showed that the collagen scaffold loaded with vaginal epithelial and smooth muscle cells significantly promotes the reconstruction of the vagina compared with small intestinal submucosa (SIS) membrane or bare collagen scaffold. Notably, the reconstructed vaginal tissues exhibit remarkable similarity to their normal counterparts, encompassing not only the vaginal epithelium and smooth muscle but also the intricate networks of blood vessels and nerves. These compelling results underscore the feasibility of a tissue engineering approach in vaginal reconstruction, offering promising prospects for improving the quality of life in affected individuals.

Renal agenesis: A meta-analysis of its prevalence and clinical characteristics based on 15 641 184 patients

Our objective was to analyse the newest relevant data on worldwide prevalence and associated symptoms of renal agenesis (RA). This meta-analysis builds on previous systematic reviews to include bilateral RA, its symptoms and data on gender, unilateral RA and anomaly location prevalence. Review of available data included records in English and other languages from PubMed, Embase, ScienceDirect, Web of Science, SciELO, BIOSIS, Current Content Connect Korean Journal Database and Russian Citation Index and Google. A total of 15 641 184 patients were analysed in relation to the prevalence of RA. The pooled prevalence of RA was 0.03% (95% CI: 0.03%-0.04%). Based on 500 subjects, a pooled prevalence of 47.96% (95% CI: 31.55%-64.58%) for unilateral and 52.04% (95% CI: 35.42%-68.45%) for bilateral RA has been set. Our study presents the newest generalized findings on bilateral RA. There appears to be universal disease and symptom prevalence with minor differences between world regions, although quality of future observational research should include genomic data. This will provide even further insight into the prognosis of various renal anomalies and their etiologies.

Surgical disorders in pediatric and adolescent gynecology: Vaginal and uterine anomalies

Obstructive vaginal and uterine anomalies including imperforate hymen, transverse vaginal septum, and vaginal and/or cervical atresia or aplasia, might rarely present in infancy or childhood with hydrocolpos and/or hydrometra but they usually go unrecognized until presentation with amenorrhea and hematocolpos and/or hematometra in puberty. They should always be included in the differential diagnosis of a suprapubic and/or introital mass; in the latter case, vaginal vascular malformations and vaginal tumors should also be considered. Uterovaginal aplasia typically manifests with amenorrhea in puberty and needs to be differentiated from complete androgen insensitivity syndrome and gonadal dysgenesis of genetic males. Uterine fusion anomalies usually present with fertility and/or obstetrical complications in adulthood. However, a unicornuate uterus with a blind rudimentary contralateral horn containing functioning endometrium, and didelphys or septate uterus with a deviating obstructive septum might present in childhood or puberty with sequelae related with secretions or menstrual retention. This review provides a collective account of the most clinically important information about vaginal and uterine anomalies in childhood and adolescence for clinicians involved in the care of young females with the aim to provide guidance in appropriate evaluation and management.

Hymenal Anomalies Interfering with Dilation in Women with Mullerian Agenesis: A Case Series

BACKGROUND

Women with Mullerian agenesis, also known as Mayer-Rokitansky-Küster-Hauser syndrome (MRKH), have aplasia or hypoplasia of the uterus and vagina. Regular use of dilators can successfully create a functional vagina in up to 95% of cases. We present 3 women with Mullerian agenesis who failed dilation therapy due to pain and were subsequently found to have hymenal anomalies.

CASES

Patients presented at age 16 or 17 to initiate dilation. Initial attempts were discontinued due to pain. On examination, a septate hymen was identified in 2 patients and a microperforate hymen in 1 patient. All patients underwent hymenectomy and thereafter continued dilation with less discomfort.

SUMMARY AND CONCLUSION

These cases illustrate the importance of recognizing and treating hymenal anomalies in women with Mullerian agenesis to prevent pain, leading to unsuccessful dilation.

Imaging of congenital genitourinary anomalies

Congenital genitourinary anomalies are among the most frequent types of birth defects in neonates. Some anomalies can be a significant cause of morbidity in infancy, while others remain asymptomatic even until adulthood and can be at times the only manifestation of a complex systemic disease. The spectrum of these anomalies results from the developmental insults that can occur at various embryologic stages, and an understanding of the formation of the genitourinary system is helpful in the evaluation and treatment of a child with a congenital genitourinary anomaly. Imaging plays an essential role in the diagnosis of congenital genitourinary anomalies and treatment planning. In this article, we highlight the embryologic and characteristic imaging features of various congenital genitourinary anomalies, demonstrate the utility of different imaging modalities in management, and review specific imaging modalities and protocols for image optimization.

Decellularization Methods of Vagina and Cervix in Tissue Engineering

The vagina is a fibromuscular elastic tubular tract that connects the cervix with the outer genitals and has an important function discharging uterine secretions, sexual intercourse and acts as the passage for the full-term fetus. Currently, a new field of investigation which aims to design tissues and organs similar to their native origin has been developed recently and was named regenerative medicine (tissue engineering and bioengineering). Malformations in cervix tissue represent a hard challenge for medicine. Experts in bioengineering have tried to reconstruct vaginas or cervix with the aim to achieve cervicovaginal disorders, most of them with congenital cause. However, only few research groups have launched themselves upon the decellularization. The aim of this chapter is investigating the decellularization methods for cervix and vaginal tissues.

Management of Acute Obstructive Uterovaginal Anomalies: ACOG Committee Opinion, Number 779

Obstructive uterovaginal anomalies may present after puberty with amenorrhea, dysmenorrhea, pelvic pain, recurrent vaginal discharge, or infertility. The evaluation of a patient with a suspected obstructive reproductive anomaly should include a detailed medical history, physical examination, and imaging. The genital examination is critical to differentiate a patient with an imperforate hymen from a patient with labial adhesions, urogenital sinus, transverse vaginal septum, or distal vaginal atresia. Pelvic ultrasonography is the initial imaging method recommended for a patient with cyclic pain and amenorrhea or a patient with persistent dysmenorrhea. It is important to note that diagnosis of a uterine or vaginal anomaly by imaging before puberty can be challenging and misleading because of the small size of the prepubertal uterus and the lack of endometrial stimulation and menstrual distention of the vagina. Consultation with a radiologist experienced with imaging of uterovaginal anomalies may be helpful to determine the most accurate diagnosis. In general, obstructive vaginal and uterine anomalies are not surgical emergencies, and the complexities of these conditions are best managed by gynecologic care providers familiar with the surgical management of these conditions. Given the high risk of stenosis and complications associated with transverse vaginal septum, distal vaginal atresia, and cervical atresia, referral to a center with expertise in the management of these anomalies is paramount. The best long-term outcome is achieved with a complete evaluation, clear understanding of the anomaly, mobilization of appropriate surgical resources, sufficient preoperative counseling, and planned surgical intervention.

Double Pedicle Artery Rotation Sigmoid Vaginoplasty for Vaginal Aplasia Management

Sigmoid vaginoplasty has been popular for neovagina reconstruction in vaginal aplasia. The most common surgical complication was vaginal stenosis caused by inadequate vascularization and tension because of graft length. Therefore, ischemia ensued and disrupted wound healing. The selection of double pedicle artery rotation sigmoid vaginoplasty is expected to reduce this problem. Five patients from April to December 2016 were diagnosed with vaginal aplasia; 4 had history of neovagina stenosis. These patients underwent sigmoid vaginoplasty with double pedicle artery rotation. No complications occurred during or after the procedure. Assessment postsurgery was conducted at 1 year. These results suggest that double pedicle artery rotation sigmoid vaginoplasty is a safe and acceptable technique for management of vaginal aplasia. The procedure decreased tension inside vascular pedicles as a result of maintaining abundant vascularization supply. Consequently, this procedure could avert graft necrosis, leakage, and severe stenosis. All of the patients exhibited regular menstrual cycle and satisfactory sexual activity. The outcomes were excellent with remarkable anatomical and functional results.

The little tissue that couldn't - dispelling myths about the Hymen's role in determining sexual history and assault

Conclusions about women's and girls' sexual history are made in some settings based on assumptions about the hymen, a small membranous tissue with no known biological function, which typically occupies a portion of the external vaginal opening in females. Clinicians, however, continue to refer to changes in the hymen to assess for a history of consensual or nonconsensual sexual intercourse. We reviewed published evidence to dispel commonly held myths about the hymen and its morphology, function, and use as evidence in cases of sexual violence.An examination of the hymen is not an accurate or reliable test of a previous history of sexual activity, including sexual assault. Clinicians tasked with performing forensic sexual assault examinations should avoid descriptions such as "intact hymen" or "broken hymen" in all cases, and describe specific findings using international standards and terminology of morphological features.We call on clinicians to consider the low predictive value of a hymen examination and to: 1) avoid relying solely on the status of the hymen in sexual assault examinations and reporting; 2) help raise awareness of this issue among their peers and counterparts in law enforcement and the judicial system; and 3) promote fact-based discussions about the limitations of hymenal examinations as part of clinical education for all specialties that address the sexual or reproductive health of women and girls.

Gynaecology problems in puberty

With the onset of puberty a range of problems may be encountered by the young girl. Some of these include a range of gynaecological issues relating to delayed onset of puberty, delayed menarche, atypical pubertal changes and the identification of anomalies of the genital tract. The distinction between physiological events and pathological problems is important to avoid unnecessary distress and anxiety. The onset of cyclic hormonal changes also provokes a number of "non-gynaecological" problems - where the link to cyclic hormonal events is often overlooked and an important opportunity to potentially intervene and assist is missed. From a global perspective there are a range of problems that are particularly encountered with the onset of puberty including the risks of sexual violence, which in the setting of having achieved the age of reproductive potential result in unplanned pregnancies, unsafe abortions and adolescent pregnancy all of which pose life threatening risks. Sex education in its broadest sense is important for all young people. Access to contraception for adolescents is vital, such that clinicians across all streams of health care who are involved in the care of young people should take the opportunity to educate and provide this care.

Development of the urogenital system is regulated via the 3'UTR of GDNF

Mechanisms controlling ureter lenght and the position of the kidney are poorly understood. Glial cell-line derived neurotrophic factor (GDNF) induced RET signaling is critical for ureteric bud outgrowth, but the function of endogenous GDNF in further renal differentiation and urogenital system development remains discursive. Here we analyzed mice where 3′ untranslated region (UTR) of GDNF is replaced with sequence less responsive to microRNA-mediated regulation, leading to increased GDNF expression specifically in cells naturally transcribing Gdnf. We demonstrate that increased Gdnf leads to short ureters in kidneys located in an abnormally caudal position thus resembling human pelvic kidneys. High GDNF levels expand collecting ductal progenitors at the expense of ureteric trunk elongation and result in expanded tip and short trunk phenotype due to changes in cell cycle length and progenitor motility. MEK-inhibition rescues these defects suggesting that MAPK-activity mediates GDNF’s effects on progenitors. Moreover, Gdnf   ^hyper mice are infertile likely due to effects of excess GDNF on distal ureter remodeling. Our findings suggest that dysregulation of GDNF levels, for example via alterations in 3′UTR, may account for a subset of congenital anomalies of the kidney and urinary tract (CAKUT) and/or congenital infertility cases in humans and pave way to future studies.

Impact of mechanical force on posterior hymen - Implications for sexual abuse injury interpretations

BACKGROUND

Residual anogenital findings following sexual abuse are rare. There is a need for further understanding of the interpretation of hymenal findings.

OBJECTIVES

This study evaluates which is more significant with respect to posterior hymenal tissue morphology - previous consensual penile vaginal penetrations or vaginal delivery.

DESIGN

A post hoc study comparing nulliparous and parous hymen in heterosexually active female volunteers, with the focus on healed hymenal defects. Adult posterior hymen configuration was evaluated using labial separation or traction. When needed, the hymenal status was evaluated using a swab. A colposcopy with photography was used for documentation. Experts reviewed all taken photographs and recorded the posterior hymenal defects. Photographs were analyzed to determine the level of agreement.

PARTICIPANTS

Eighty-seven adult female volunteers were recruited to participate in the study by a personal invitation to a gynecological examination to document anogenital findings. The examination was performed following consensual vaginal intercourse. Age ranged from 20 to 53 (median 26.6years).

RESULTS

Single site posterior hymenal transections were significantly more likely in the nulliparous volunteers, compared to the parous volunteers (22/51, 43.1% vs. 4/36, 11.1%, p<0.001). A deep notch, which extends nearly to the base of the hymen was detected in one (2.0%) sexually active nulliparous volunteer, and surprisingly two (3.9%) volunteers had a single, more superficial hymenal notch, that is not considered a sign of previous vaginal penetration. The width of the ridge of the posterior vaginal wall in the vestibule was measured from the anterior part of the navicular fossa to the base of the hymen. The mean width of the ridge of the posterior vaginal wall was 3.1mm (SD2.2, range 0-8) in the photos of 41 nulliparous volunteers. The prevalence of 'double leaf hymen' was 2/87 (2.3%). The inter-rater reliability with a Kappa score of 0.69 indicated strong agreement.

CONCLUSION

The myth "hymen is present only in virgins" has now been invalidated. The absence of posterior hymen increases delivery by delivery in adult female volunteers. The space between the anterior part of the navicular fossa and the base of hymen, 'the ridge of the posterior vaginal wall' in the vestibule was evaluated for the first time among studies evaluating hymenal status. Careful assessment of the ridge of the posterior vaginal wall is needed to avoid misinterpretations when evaluating the depth of a hymenal defect.

Female Sexual Dysfunction Among Muslim Women: Increasing Awareness to Improve Overall Evaluation and Treatment

INTRODUCTION

Muslim women are an increasingly underserved population in the United States and worldwide. Diagnosis and treatment of female sexual dysfunction bring unique challenges because of the conservative nature of those practicing the religion. Several cultural and religious codes of conduct affect sexual behavior and the dysfunction that can ensue.

AIM

To assess and describe the types of sexual dysfunction that have been found in Muslim women internationally and encourage a better understanding of their issues to enhance health care delivery.

METHODS

A comprehensive review of the literature through Ovid and PubMed was performed in search of articles reviewing female sexual dysfunction, Muslim women, and Islam.

MAIN OUTCOME MEASURES

A brief explanation and review of the interpretations of sexuality within Islam are discussed. The link is made between conservative sexual relations and interpretations and the types of sexual dysfunction experienced. Female sexual dysfunction is explored in relation to how female chastity is extolled and how cultural procedures continue despite the ethical and health concerns related to them.

RESULTS

Most Muslim women experience sexual dysfunction similar to other women, including arousal, desire, and orgasmic disorders related to organic and psychologic factors. Sexual pain disorders might be more prevalent in this population, particularly concerning unconsummated marriage. There are special concerns related to maintaining virginity and preserving the hymen until marriage. Female genital cutting, practiced by some Muslim countries, has potential sexual consequences.

CONCLUSION

Understanding Islamic views on sexuality and how they can affect sexual dysfunction in Muslim women is critical in opening lines of communication with patients and approaching female sexual dysfunction impartially. Although some issues that arise might introduce ethical dilemmas for the provider, having the cultural competence to address these issues will facilitate improved health care delivery. Rahman S. Female Sexual Dysfunction Among Muslim Women: Increasing Awareness to Improve Overall Evaluation and Treatment. Sex Med Rev 2018;6:535-547.

Vaginal atresia and cervical agenesis combined with asymmetric septate uterus: A case report of a new genital malformation and literature review

RATIONALE

A combination of Vaginal atresia and septate uterus as a novel genital malformation has been reported the first time. It offers a support for the bidirectional theory.

PATIENT CONCERNS

A 23-year-old woman presented with the inability to perform intercourse. The unprecedented variant was misdiagnosed by magnetic resonance imaging and ultrasonography as low vaginal atresia associated with complete septate uterus with functional endometrium in both the cavities.

DIAGNOSES

The correct diagnosis was made and confirmed intraoperatively as a genital malformation, vaginal atresia and cervical agenesis associated with septate uterus.

INTERVENTION

laparoscopic and hysteroscopic diagnosis the novel malformation never been reported and a vaginal stent was recommended postoperatively.

OUTCOMES

This rare clinical variant made misdiagnosis. Intraoperatively, unprecedented genital malformation was confirmed. There are no vaginal atresia cases in the literature with a septate functional uterus and single agenesis cervix.

LESSONS

Confirmed diagnosed by operation instead of depending on the imaging should be used for rare genital anomaly.

Imperforate Hymen: Varied Presentation, New Associations, and Management

Aim:

Imperforate hymen is an isolated and sporadic event. The aim of this study was to report varied clinical and management problems of consecutive imperforate hymen in children and to compare the genetic review with literature.

Materials and Methods:

This is a retrospective analysis of eight consecutive imperforate hymen children admitted during 2010–2015.

Results:

Among eight girls, two were infants and six were in the adolescent group. Clinical presentations included varied degree of genitourinary obstruction (7) and incidental finding (1). Genetic analysis of imperforate hymen suggested sporadic event (5), associations (2), and syndromic (1). Ultrasound and magnetic resonance imaging revealed the level of obstruction. Hymenectomy was done in neonate (1), adolescent (6), and one has been under observation. Abdominoperineal pull-through was done in concomitant proximal vaginal atresia.

Conclusions:

Hymen development origin is variable and complex. Imperforate hymen is rarely a part of systemic/genetic anomaly. Genital examination at birth or during puberty is mandatory which often guides the timing of hymenectomy and prevents the sequelae of imperforate hymen. Hymenectomy is ideal during puberty and resolves all genitourinary obstructions.

Biomaterial Scaffolds for Reproductive Tissue Engineering

The reproductive system usually involves gamete producing gonads, a series of specialized ducts, accessory glands and the external genitalia. Despite there are many traditional methods such as hormonal and surgical approaches, at present no effective treatments exist to help patients suffering from serious diseases of reproductive system, including congenital and acquired abnormalities, malignant tumor, traumatic, infectious etiologies, inflammation and iatrogenic injuries. Tissue engineering holds promise for reproductive medicine through the development of biological alternative. Till now, a diverse range of biomaterials have been utilized as suitable substrates to match both the mechanical and biological context of reproductive tissues. The current review will focus mainly on the applications of biomaterial scaffolds and their major achievements in each region of reproductive systems.

Spatiotemporal dynamics of androgen signaling underlie sexual differentiation and congenital malformations of the urethra and vagina

Disorders of sex development (DSDs) are congenital anomalies that affect sexual differentiation of genitourinary organs and secondary sex characters. A common cause of female genital virilization is congenital adrenal hyperplasia (CAH), in which excess androgen production during development of 46XX females can result in vaginal atresia, masculinization of the urethra, a single urogenital sinus, and clitoral hypertrophy or ambiguous external genitalia. Development of the vagina depends on sexual differentiation of the urogenital sinus ridge, an epithelial thickening that forms where the sex ducts attach to the anterior urethra. In females, the sinus ridge descends posteriorly to allow the vaginal opening to form in the vulva, whereas in males and in females with CAH, androgens inhibit descent of the sinus ridge. The mechanisms that regulate development of the female urethra and vagina are largely unknown. Here we show that the timing and duration of, and the cell population targeted by, androgen signaling determine the position of vaginal attachment to the urethra. Manipulations of androgen signaling in utero reveal a temporal window of development when sinus ridge fate is determined. Cell type-specific genetic deletions of androgen receptor (Ar) identify a subpopulation of mesenchymal cells that regulate sinus ridge morphogenesis. These results reveal a common mechanism that coordinates development of the vagina and feminization of the urethra, which may account for development of a single urogenital sinus in females exposed to excessive androgen during a critical period of prenatal development.

Challenging Case of Postmenopausal Bleeding and Complete Urogenital Duplication

BACKGROUND

Müllerian duct anomalies represent a wide spectrum of congenital abnormalities ranging from simple uterine anomalies to more complex multisystem derangements. Complete duplication of uterus, cervix, and vagina may be associated with urologic and caudal gastrointestinal malformations.

CASE REPORT

We present a case report detailing the management of a morbidly obese patient with postmenopausal bleeding and thickened endometrial stripe who had a very rare condition of pelvic organ duplication, including 2 hemiuteri, 2 vaginas, 2 hemibladders, and 2 each of ovaries, fallopian tubes, kidneys, and ureters. Laparoscopic hysterectomy was complicated by difficulties understanding urinary system anatomy requiring intraoperative urology consultation and imaging.

CONCLUSIONS

Management of patients with urogenital duplication and abnormal uterine bleeding requires a thorough understanding of possible associated malformations. Thorough preoperative evaluation, careful surgical exploration, and multidisciplinary approach may be necessary to avoid urologic injury in such patients.

Complete septate uterus with obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) in a young woman—a rare variant of Herlyn–Werner–Wunderlich syndrome

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) is an unusual and special type of Müllerian duct anomaly. Patients usually present in adolescence, soon after menarche, with pain and pelvic mass and rarely with infertility in adulthood. Majority of the cases of OHVIRA have been reported in association with uterus didelphys and the presentation of uterus didelphys with OHVIRA is known as Herlyn–Werner–Wunderlich syndrome. A complete septate uterus with OHVIRA is exceedingly unusual. Less than 30 cases of complete septate uterus with OHVIRA have been reported to date, to the best of our knowledge. We present a rare case of incidentally detected complete septate uterus with OHVIRA in a young woman who presented with acute pain in the right iliac fossa owing to acute appendicitis.

Surgical revirgination: Four vaginal mucosal flaps for reconstruction of a hymen

INTRODUCTION

Over centuries, virginity has been given social, religious and moral importance. It is widely believed as a state of a female who has never engaged in sexual intercourse, and her hymen is intact. Hymenoplasty for torn hymen is carried out not only for the sake of cultural and religious traditions but also for the social status and interpersonal relationships.

MATERIALS AND METHODS

2.5 cm long and 1 cm wide four vaginal mucosal flaps were raised from the anterior vaginal wall just behind labia minora. Two flaps were based proximally, and their two opposing flaps were based distally. These flaps were overlapped in a crisscross fashion and were sutured with 5/0 Polyglactin (Vicryl(®)) sutures leaving no area raw. The donor area was closed primarily. When some remains of a torn hymen were found, one to three vaginal mucosal flaps were added to its remains as per the need for reconstruction.

RESULTS

We operated upon 11 patients. In nine cases, the hymen was reconstructed with four flaps. In remaining two, it was reconstructed from the remains using vaginal mucosal flaps. All flaps healed without any infection or disruption. Sutures got absorbed in 25-35 days. In all cases, this newly constructed barrier broke with only moderate pressure at the time of penetrative sex serving the purpose of the surgery completely.

CONCLUSION

Erasing evidence of the sexual history simply by 'Surgical Revirgination' is extremely important to women contemplating marriage in cultures where a high value is placed on virginity.

A Review of Lesions of the Posterior Fourchette, Posterior Vestibule (Fossa Navicularis), and Hymen

Lesions specific to the posterior fourchette, posterior vestibule (fossa navicularis), and hymen are reviewed. Knowledge of these regional lesions will be helpful if such a patient is encountered.

Regenerative medicine for the treatment of reproductive system disorders: current and potential options

Regenerative medicine has opened new avenues for treating patients with severe reproductive system disorders, such as congenital abnormalities, cancer, trauma, infection, inflammation and iatrogenic injuries. Over the past two decades, scientists have advanced the field of reproductive tissue engineering to restore normal sexual function and preserve fertility in both female and male patients. In this review, we summarize recent advances in the use of cell, tissue, and organ-based regenerative medicine strategies for clinical application in reproductive system disorders.

Non-obstructive müllerian anomalies

BACKGROUND

The nonobstructive group of anatomic variants involving the reproductive tract includes vaginal agenesis as well as the congenital anomalies of the vagina and uterus, occurring without pain during the pubertal years.

OBJECTIVE

The objective is to discuss the non-obstructive morphologic variations in anatomy of the uterus and vagina.

DESIGN

Systematic review using the GRADE system.

RESULTS

These congenital anomalies are not associated with abnormalities of the external genitalia and therefore may be missed on routine physical examination. When these anomalies do cause symptoms they may be as minor as difficulty with menstrual hygiene or more significant such as primary amenorrhea, dyspareunia, recurrent pregnancy loss, and reproductive complications.

CONCLUSIONS

Women with non-obstructive reproductive tract anomalies present at various ages due to the asymptomatic nature or late symptom onset of certain conditions. An MRI is the gold standard in evaluation of such conditions to aid in confirming the müllerian variant. Each condition requires careful counseling because obstetric and gynecologic risks and consequences may differ. Treatment is individualized in cases of uterovaginal agenesis with both nonsurgical and surgical options available for neovagina creation. In cases of uterine or vaginal septae, the treatment timing may vary depending on patient history. Finally, in cases of non-obstructive communicating uterine horns, the risk of ectopic pregnancy is high in the remnant horn. Should a pregnancy occur in this small underdeveloped horn, therefore, excision is recommended.

Malformation syndromes associated with disorders of sex development

When embryological development of the internal and/or external genitalia is disrupted, the patient presents with a disorder of sex development (DSD) in the neonatal period or sometime later in life. Some of these patients have other, nongenital malformations, which makes their overall management more complex than if they just had a DSD. This Review summarises these malformation syndromes and discusses the recent research into their aetiology. The genetic causes of these malformation syndromes, when they are known, will also be described. Many specific genetic mutations are now known in malformation syndromes with a defect in hormonal function. By contrast, the genetic causes remain unknown in many nonhormonal morphological anomalies that affect the genitalia.

Tissue-engineered autologous vaginal organs in patients: a pilot cohort study

BACKGROUND

Several disorders might require vaginal reconstruction, such as congenital abnormalities, injury, or cancer. Reconstructive techniques for which non-vaginal tissue is used can be associated with complications. We assessed the use of engineered vaginal organs in four patients with vaginal aplasia caused by Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS).

METHODS

We invited to participate four consecutive patients who presented over a 3-year period with congenital vaginal aplasia due to MRKHS. Patients were aged 13-18 years. We obtained a vulvar biopsy of autologous tissue from every patient. We cultured, expanded, and seeded epithelial and muscle cells onto biodegradable scaffolds. The organs were constructed and allowed to mature in an incubator in a facility approved for human-tissue manufacturing. We used a perineal approach to surgically implant these organs. We recorded history, physical examination, vaginoscopy, serial tissue biopsies, MRIs, and self-administered Female Sexual Function Index questionnaire results for all patients, with a follow-up of up to 8 years.

FINDINGS

We noted no long-term postoperative surgical complications. Yearly serial biopsies showed a tri-layered structure, consisting of an epithelial cell-lined lumen surrounded by matrix and muscle, with expected components of vaginal tissue present. Immunohistochemical analysis confirmed the presence of phenotypically normal smooth muscle and epithelia. The MRIs, which showed the extent of the vaginal aplasia before surgery, showed the engineered organs and the absence of abnormalities after surgery, which was confirmed with yearly vaginoscopy. A validated self-administered Female Sexual Function Index questionnaire showed variables in the normal range in all areas tested, such as desire, arousal, lubrication, orgasm, satisfaction, and painless intercourse.

INTERPRETATION

Vaginal organs, engineered from the patient's own cells and implanted, showed normal structural and functional variables with a follow-up of up to 8 years. These technologies could be useful in patients requiring vaginal reconstruction.

FUNDING

Wake Forest University and Hospital Infantil de México Federico Gómez.

Gene expression profile of patients with Mayer-Rokitansky-Küster-Hauser syndrome: new insights into the potential role of developmental pathways

Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) is a rare disease characterized by congenital aplasia of uterus and vagina. Although many studies have investigated several candidate genes, up to now none of them seem to be responsible for the aetiology of the syndrome. In our study, we identified differences in gene expression profile of in vitro cultured vaginal tissue of MRHKS patients using whole-genome microarray analysis. A group of eight out of sixteen MRKHS patients that underwent reconstruction of neovagina with an autologous in vitro cultured vaginal tissue were subjected to microarray analysis and compared with five healthy controls. Results obtained by array were confirmed by qRT-PCR and further extended to other eight MRKHS patients. Gene profiling of MRKHS patients delineated 275 differentially expressed genes, of which 133 downregulated and 142 upregulated. We selected six deregulated genes (MUC1, HOXC8, HOXB2, HOXB5, JAG1 and DLL1) on the basis of their fold change, their differential expression in most patients and their relevant role in embryological development. All patients showed upregulation of MUC1, while HOXB2 and HOXB5 were downregulated, as well as Notch ligands JAG1 and DLL1 in the majority of them. Interestingly, HOXC8 was significantly upregulated in 47% of patients, with a differential expression only in MRKHS type I patients. Taken together, our results highlighted the dysregulation of developmental genes, thus suggesting a potential alteration of networks involved in the formation of the female reproductive tract and providing a useful clue for understanding the pathophysiology of MRKHS.

Müllerian duct and related anomalies in children and adolescents

Although many Müllerian duct anomalies do not require treatment, surgical intervention is sometimes necessary to enable sexual activity or to preserve fertility. The identification of these anomalies is important for optimal clinical management or surgical treatment. Magnetic resonance (MR) imaging is a robust method for adequately evaluating and characterizing uterine and vaginal anomalies. The information provided by MR imaging allows for a more complete understanding of the malformation, facilitating management decisions and potentially changing the outcome. In this article, the embryology, classification, and MR imaging findings of Müllerian duct and related anomalies in children and adolescents are reviewed.

A uterovaginal septum and imperforate hymen with a double pyocolpos

The presence of both a uterovaginal septum and imperforate hymen is described in a young patient presenting with ongoing chronic pelvic pain and a double pyocolpos. Ultrasound and magnetic resonance imaging scans were performed. The patient underwent laparoscopic adesiolysis, hymenotomy with drainage of 200 mL of pus, and excision of a complete longitudinal vaginal septum. Over the past 5 years of regular follow-up examinations, the patient has always reported regular menstrual cycles and an absence of pelvic pain.