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Ochoa B, Weidler EM, Parks MA, Speck KE, van Leeuwen K. Novel Approaches to Patients with Differences of Sex Development. Adv Pediatr 2024; 71:151-167. [PMID: 38944480 DOI: 10.1016/j.yapd.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Patients with differences of sex development (DSDs) have complex anatomy and surgical needs related to both Mullerian and non-Mullerian structures. Approaches to vaginal reconstruction for these conditions are guided by individual anatomy, with the goal of establishing unobstructed outflow for the reproductive, urinary, and gastrointestinal tracts. Patients may have anatomy requiring vaginoplasty for either outflow tract obstruction or chosen sexual function. In this article, the authors focus on management of differences in vaginal anatomy with delayed vaginoplasty for the newborn with DSD.
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Affiliation(s)
- Brielle Ochoa
- Department of Surgery, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85016, USA
| | - Erica M Weidler
- Department of Surgery, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85016, USA
| | - Melissa A Parks
- Department of Gynecology, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85016, USA
| | - Karen Elizabeth Speck
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, 1540 E. Hospital Drive, SPC 4211, Ann Arbor, MI 48109, USA
| | - Kathleen van Leeuwen
- Department of Surgery, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85016, USA.
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Yuan ZL, Ren J, Huang ML, Qi YF, Gao X, Sun YY, He YL, Zhu L, Xue HD. A new magnetic resonance imaging-based PUMCH classification system for congenital cervical malformations: devising a standardised diagnosis pathway. Insights Imaging 2024; 15:177. [PMID: 39020237 PMCID: PMC11255164 DOI: 10.1186/s13244-024-01708-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/26/2024] [Indexed: 07/19/2024] Open
Abstract
OBJECTIVES To develop an innovative magnetic resonance imaging (MRI)-based PUMCH (Peking Union Medical College Hospital) classification system aimed at standardising the diagnosis of congenital cervical malformations (CCMs) by identifying their distinctive MRI features. METHODS Seventy-nine consecutive patients with CCM underwent pre-treatment pelvic MRI; three experienced gynaecological radiologists retrospectively analysed these images. Qualitative assessments included Rock et al's classification; PUMCH classification; haematometra; cervical signal features; ovarian endometriosis; haematosalpinx; and uterine, vaginal, urinary, and musculoskeletal malformations. Quantitative assessments involved the uterine volume, sagittal cervical length, and maximum ovarian cross-sectional area. The surgical treatment types were also recorded. Statistical methods were used to incorporate differences in clinical features and surgical methods into our classification. RESULTS Morphologically, CCMs were categorised into three types: type I (53%) was characterised by the presence of a cervix with visible cervical canals; type II (23%) featured an existing cervix with concealed cervical canals; and type III (24%) indicated cervical aplasia, which involves a blind end in the lower part of the uterine corpus. Haematometra was significantly more prevalent in patients with type I CCM than in those with type II (p < 0.001). There were three cervical signal patterns: no signal (27%), no evident layer differentiation (21%), and multi-layer differentiation with haematocele (52%). Most patients (94%) had complete vaginal atresia. Type I CCM patients had a higher likelihood of regaining normal uterovaginal anatomy compared to types II and III. CONCLUSIONS Our proposed PUMCH classification system has a high potential for enhancing the efficiency of clinical diagnosis among patients with CCM. CRITICAL RELEVANCE STATEMENT The proposed new PUMCH classification promised to elevate the conventional diagnostic trajectory for congenital cervical malformations, offering a valuable framework to refine the selection and planning of surgical interventions, thereby enhancing overall clinical efficacy. KEY POINTS Effective classification of congenital cervical malformations is desirable to optimise the diagnostic process. We presented a PUMCH classification of congenital cervical malformations using pelvic MRI. The new classification significantly aids clinical triage for congenital cervical malformations.
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Affiliation(s)
- Zhi-Lin Yuan
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China
| | - Jing Ren
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China
| | - Meng-Lin Huang
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China
| | - Ya-Fei Qi
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China
| | - Xin Gao
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China
| | - Yi-Ying Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Yong-Lan He
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China.
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China.
| | - Hua-Dan Xue
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China.
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Xu X, Tian Y, Zhou J, Li Z, Meng L, Huang X, Zhang M. A rare case report of Herlyn-Werner-Wunderlich syndrome: Unraveling unusual urinary anomalies and literature review. Heliyon 2024; 10:e33558. [PMID: 39071571 PMCID: PMC11276916 DOI: 10.1016/j.heliyon.2024.e33558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/23/2024] [Accepted: 06/24/2024] [Indexed: 07/30/2024] Open
Abstract
Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare congenital genitourinary abnormality defined by uterine didelphys, obstructed hemivagina, and ipsilateral urological anomalies. Accurate diagnosis and prompt commencement of therapy can be difficult owing to heterogeneous genitourinary malformation among different patients. This is a case report of a patient with rare HWWS with uterine didelphys, obstructed hemivagina, vagina-ureteral remnant fistula (Gartner's duct cyst), and ipsilateral kidney dysgenesis who complained of intermittent abdominal pain during menstruation. The right ureteral remnant of the patient was distinctive, with three portions. The upper section was connected to the right dysplastic kidney, the lower section formed the fistulous tract with the vagina and bladder, while the middle section communicated with Gartner's Duct Cyst, which merged with the vagina and opened to the posterior cavity of hemivagina. The lower section of the right ureter was excised and ligated during laparoscopic surgery, while the upper section was excised. The patient recovered after surgery. We presented this rare case and conducted a literature review to provide a more comprehensive understanding of HWWS. This could help gynecologists effectively reduce misdiagnosis and missed diagnosis, especially when combined with complicated urinary malformation.
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Affiliation(s)
- Xiaotong Xu
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, PR China
| | - Yanpeng Tian
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, PR China
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, PR China
| | - Jingwen Zhou
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, PR China
- Department of Gynecology, Loujiang New City Hospital of Taicang, Suzhou, Jiangsu, 215334, PR China
| | - Zhongkang Li
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, PR China
| | - Li Meng
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, PR China
| | - Xianghua Huang
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, PR China
| | - Mingle Zhang
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, PR China
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Pearce E, Malik A. Hematocolpometra Diagnosed with Point-of-Care Ultrasound in a Pediatric Patient with Right Lower Quadrant Abdominal Pain. J Emerg Med 2024; 66:e725-e727. [PMID: 38777709 DOI: 10.1016/j.jemermed.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/06/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Elspeth Pearce
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Adrienne Malik
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas
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Walawender L, Santhanam N, Davies B, Fei YF, McLeod D, Becknell B. Müllerian anomalies in girls with congenital solitary kidney. Pediatr Nephrol 2024; 39:1783-1789. [PMID: 38197956 PMCID: PMC11026257 DOI: 10.1007/s00467-023-06266-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND The prevalence of Müllerian anomalies (MA) among patients with congenital solitary functioning kidney (SFK) is not well defined. A delay in diagnosis of obstructive MA can increase the risk of poor clinical outcomes. This study describes the prevalence of MA in patients with congenital SFK. METHODS A retrospective review was performed of patients within the Nationwide Children's Hospital system with ICD9 or ICD10 diagnostic codes for congenital SFK defined as either unilateral renal agenesis (URA) or multicystic dysplastic kidney (MCDK) and confirmed by chart review. Patients with complex urogenital pathology were excluded. Renal anomaly, MA, reason for and type of pelvic evaluation, and age of diagnosis of anomalies were evaluated. RESULTS Congenital SFK occurred in 431 girls due to URA (209) or MCDK (222). Pelvic evaluation, most commonly by ultrasound for evaluation of abdominal pain or dysmenorrhea, occurred in 115 patients leading to MA diagnosis in 60 instances. Among 221 patients ages 10 years and older, 104 underwent pelvic evaluation and 52 were diagnosed with an MA of which 20 were obstructive. Isolated uterine or combined uterine and vaginal anomalies were the most common MA. MA were five-fold more common in patients with URA compared to MCDK. In 75% of patients, the SFK was diagnosed prior to the MA. CONCLUSIONS The prevalence of MA in patients with congenital SFK was 24% among those age 10 years or older, and 38% were obstructive. This justifies routine screening pelvic ultrasound in girls with congenital SFK to improve early diagnosis.
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Affiliation(s)
- Laura Walawender
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, OH, USA
| | - Natasha Santhanam
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Benjamin Davies
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Y Frances Fei
- Section of Pediatric and Adolescent Gynecology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Daryl McLeod
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
- Department of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Brian Becknell
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
- Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, OH, USA.
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Management of Hematometra and Hematocolpos in Obstructive Mullerian Anomalies by Image-Guided Drainage with Interventional Radiology: A Multi-Institutional Case Series. J Pediatr Adolesc Gynecol 2023:S1083-3188(23)00277-2. [PMID: 36878355 DOI: 10.1016/j.jpag.2023.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/07/2023]
Abstract
STUDY OBJECTIVE To describe cases of image-guided drainage of symptomatic hematometrocolpos from obstructive Mullerian anomalies as a temporizing measure to manage acute pain symptoms and delay definitive management of the obstructive Mullerian anomalies which require complex reconstruction. METHODS IRB exemption from all included institutions was obtained. A retrospective case series of eight females from three academic children's hospitals under the age of 21 with symptomatic hematometrocolpos due to obstructive Mullerian anomalies drained by image-guided percutaneous transabdominal vaginal or uterine drainage with interventional radiology were reviewed and described. RESULTS Eight pubertal patients with obstructive Müllerian anomalies (six patients with distal vaginal agenesis, one patient with an obstructed uterine horn, one patient with a high obstructed hemi-vagina) and symptomatic hematometrocolpos are reported. All patients with distal vaginal agenesis had greater than 3 cm lower vaginal agenesis, which would usually require complex vaginoplasty and use of post-operative stents. Given immaturity and inability to use stents or dilators post-operatively or medical complexity, they subsequently underwent ultrasound-guided drainage of hematometrocolpos with interventional radiology (IR) to relieve pain symptoms, followed by menstrual suppression. The patients with obstructed uterine horns had complex medical and surgical histories requiring perioperative planning, also had ultrasound-guided drainage of hematometra as a temporizing measure to manage acute symptoms. CONCLUSION Patients presenting with symptomatic hematometrocolpos due to obstructive Müllerian anomalies may not be psychologically mature enough to undergo definitive complex reconstruction which requires vaginal stent or dilator use post-operatively to prevent stenosis and other complications. Image-guided percutaneous drainage of symptomatic hematometrocolpos serves as a temporizing measure by offering pain relief until patients are ready to undergo surgical management and/or allow time for complex surgical planning.
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Mentessidou A, Mirilas P. Surgical disorders in pediatric and adolescent gynecology: Vaginal and uterine anomalies. Int J Gynaecol Obstet 2023; 160:762-770. [PMID: 35880405 DOI: 10.1002/ijgo.14362] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 07/03/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Anastasia Mentessidou
- Department of Paediatric Surgery and Urology, Cambridge University Addenbrooke's Hospital, Cambridge, UK
| | - Petros Mirilas
- Department of Pediatric Surgery, Aghia Sophia Children's Hospital, Athens, Greece
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Long JR, Gomez-Lobo V, Sharma K. Treatment of Hematometrocolpos Associated with Vaginal Agenesis Using Ultrasound-Guided Active Drainage. J Vasc Interv Radiol 2022; 33:1624-1626. [PMID: 36108899 PMCID: PMC11130715 DOI: 10.1016/j.jvir.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/29/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022] Open
Affiliation(s)
- Jessica R Long
- Pediatric and Adolescent Division, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Dr., 8N248, MSC1840, Bethesda, MD 20892.
| | - Veronica Gomez-Lobo
- Pediatric and Adolescent Division, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Dr., 8N248, MSC1840, Bethesda, MD 20892
| | - Karun Sharma
- Interventional Radiology Division, Children's National Hospital, Washington, DC
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9
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Imperforate Hymen: Clinical Pearls and Implications of Management. Clin Obstet Gynecol 2022; 65:699-707. [PMID: 36260009 DOI: 10.1097/grf.0000000000000703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Imperforate hymen is a common condition that with classic appearance and presentation in puberty. This may be diagnosed in a neonate when mucocolpos is noted. There are many great pretenders of this condition, but the hallmarks include a bulging hymen with blue hue at puberty. If this is not seen on external genital exam, the provider should proceed with magnetic resonance imaging to better assess the reproductive tract anatomy before engaging in surgery. For providers uncomfortable in managing conditions often confused with an imperforate hymen, referral to a Pediatric and Adolescent Gynecologist or specialist comfortable managing these conditions, is recommended.
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10
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Fontana E, Parma M, Fedele F, Girardelli S, Parazzini F, Candiani M. Forty-two normomenstruating adolescents with Müllerian obstructive anomalies: Presentation, pitfalls in the dagnosis and surgical management. Acta Obstet Gynecol Scand 2022; 102:92-98. [PMID: 36285343 PMCID: PMC9780719 DOI: 10.1111/aogs.14454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 07/03/2022] [Accepted: 08/18/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION We analyzed the frequency, presentation and pitfalls in the diagnosis and surgical management of a large group of normomenstruating adolescents with obstructive reproductive tract anomalies. MATERIAL AND METHODS Retrospective analysis of prospectively collected data. Of the 143 outpatients referred for severe dysmenorrhea and persistent pelvic pain, 42 (29.3%) young women with obstructive Müllerian anomalies and regular menstrual flow were identified. These patients were divided into four groups: (1) patients with duplicate uterine cavities, obstructed hemivagina and ipsilateral renal agenesis (n = 34); (2) patients with unicornuate uterus and noncommunicating cavitated rudimentary horn (n = 5); (3) patients with accessory cavitated uterine mass (n = 2); (4) patients with partially obstructed transverse vaginal septum (n = 1). All 42 patients were conservatively treated via laparoscopy and 35/42 patients had also vaginal surgery. RESULTS Of the four groups, patients in groups 2 and 3 (n = 7) were conservatively managed by laparoscopy alone; for patients in groups 1 and 4 (n = 35), laparoscopy and the vaginal approach were used. Patients of group 1 were treated by resecting the obstructed vaginal septum with drainage of retained collections. In patients in group 2, surgery consisted of the removal of the rudimentary horn. Patients of group 3 were treated by the removal of myometrial neoformations. In the patient in group 4, treatment consisted of removal of the septum. All surgical procedures were successful and no major complications were recorded. Follow-up reports highlighted the disappearance of obstruction and clear improvement in pain symptoms. CONCLUSIONS Unilateral obstructive anomalies of the female genital tract are difficult to identify. Early diagnosis allows the preservation of reproductive activity and avoids potential complications.
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Affiliation(s)
- Eleonora Fontana
- Obstetrics and Gynecology DepartmentIRCCS San Raffaele Scientific InstituteMilanItaly,Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoUniversity of MilanMilanItaly
| | - Marta Parma
- Obstetrics and Gynecology DepartmentIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Francesco Fedele
- Obstetrics and Gynecology DepartmentIRCCS San Raffaele Scientific InstituteMilanItaly,Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoUniversity of MilanMilanItaly
| | - Serena Girardelli
- Obstetrics and Gynecology DepartmentIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Fabio Parazzini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoUniversity of MilanMilanItaly
| | - Massimo Candiani
- Obstetrics and Gynecology DepartmentIRCCS San Raffaele Scientific InstituteMilanItaly
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Sun Y, Grimbizis GF, Zhu L. Perspectives on diagnosis and surgical treatment of congenital cervical malformations. Sci Bull (Beijing) 2022; 67:1935-1938. [PMID: 36546198 DOI: 10.1016/j.scib.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Yiying Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100032, China
| | - Grigoris F Grimbizis
- 1st Department of Obstetrics and Gynecology, Medical Faculty, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki 56403, Greece
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100032, China.
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12
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Ludwin A, Tudorache S, Martins WP. ASRM Müllerian Anomalies Classification 2021: a critical review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:7-21. [PMID: 35678250 DOI: 10.1002/uog.24905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 06/15/2023]
Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - S Tudorache
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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13
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Fei YF, Quint EH, Hryhorczuk AL, Winfrey OK, Dendrinos ML. Distal Vaginal Atresia with Spontaneous Perforation: A Case Report. J Pediatr Adolesc Gynecol 2022; 35:383-386. [PMID: 34752931 DOI: 10.1016/j.jpag.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/05/2021] [Accepted: 10/28/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The definitive treatment of distal vaginal atresia is surgery, but menstrual suppression is often helpful for initial management. CASE A 13-year-old presented with primary amenorrhea and progressive abdominal pain. She was diagnosed with distal vaginal atresia and started on hormonal suppression. She then re-presented with heavy vaginal bleeding, and follow-up imaging revealed that spontaneous perforation had occurred. There was now evidence of a tract leading from the obstructed vaginal bulge to the introitus. Vaginoplasty was complicated by the tortuosity of the tract. Under ultrasound guidance, a pull-through vaginoplasty was performed. SUMMARY AND CONCLUSION Spontaneous perforation of an atretic vagina is rare, but in such cases, urgent vaginoplasty is indicated to prevent infection. Despite the presence of a spontaneous tract leading to the obstruction, vaginoplasty can be complex, and intraoperative ultrasound could be beneficial.
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Affiliation(s)
- Y Frances Fei
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, Michigan.
| | - Elisabeth H Quint
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, Michigan
| | | | - Olivia K Winfrey
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, Michigan
| | - Melina L Dendrinos
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, Michigan
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14
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Brander EPA, Vincent S, McQuillan SK. Transverse Vaginal Septum Resection: Technique, Timing, and the Utility of Dilation. A Scoping Review of the Literature. J Pediatr Adolesc Gynecol 2022; 35:65-72. [PMID: 34517117 DOI: 10.1016/j.jpag.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/03/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Transverse vaginal septae (TVS) are congenital, obstructive anomalies of the vagina typically presenting with abdominal pain and amenorrhea. Currently, the literature about surgical management is sparse. Postoperative complications are common. Vaginal dilation either pre- or postoperatively is sometimes recommended, the outcomes of which are poorly described. The aim of this scoping review was to guide surgical planning, namely, timing and postoperative care, to improve surgical outcomes. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES This scoping review followed the Joanna Briggs Institute framework. The population of interest was patients 21 years of age or younger with a TVS. MEDLINE, OVID and CINAHL databases were searched using the subject headings listed herein. Literature written in English and French were included. Excluded were reports on patients with concurrent urogenital anomalies or severe developmental disabilities. The resultant articles were reviewed by 2 independent researchers. A third researcher was used in cases of disagreement. Using a descriptive analytical method, data were extracted from the included articles. RESULTS We screened 1441 articles for eligibility; 41 articles met criteria, which described 152 cases of TVS. The most common management was simple vaginal excision. Five studies included outcomes from preoperative dilation, and 11 from postoperative dilation. There were 21 cases of postoperative vaginal stenosis; half (11/21) occurred without postoperative dilation. CONCLUSION The goal of this review was to describe how TVS are managed and provide guidance for management options. Although the literature was sparse, the authors believe that management in a tertiary center, and surgical delay until the patient is ready to participate in vaginal dilation will improve outcomes for patients with TVS. Further prospective studies are needed to guide surgical planning.
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Affiliation(s)
- E P A Brander
- Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, Baylor College of Medicine, Houston, Texas.
| | - S Vincent
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - S K McQuillan
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
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Magnetic resonance imaging of Müllerian anomalies in girls: concepts and controversies. Pediatr Radiol 2022; 52:200-216. [PMID: 34152437 DOI: 10.1007/s00247-021-05089-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/28/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
Female Müllerian anomalies are the result of failure of formation, fusion or resorption of the Müllerian ducts and are relatively common, with a prevalence of 5.5-7.0% in the general population. While some of these anomalies are asymptomatic, those presenting with obstruction require accurate identification for optimal clinical management including potential surgical treatment. MRI is a useful adjunct to sonography in the evaluation of Müllerian anomalies, typically allowing a more complete characterization of the malformation. Technical aspects, embryologic concepts and controversies regarding classification systems are highlighted in this review. Several Müllerian anomalies are discussed and illustrated in more detail utilizing various cases with pelvic MRI studies.
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16
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Wang J, Zheng F, Wang D, Yang Q. Case report: Hysteroscopy combined with a vaginal mold for severe recurrent vaginal adhesion and stenosis with pyocolpos after pelvic fracture in a 13-year-old female. Front Pediatr 2022; 10:966724. [PMID: 36340718 PMCID: PMC9634117 DOI: 10.3389/fped.2022.966724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Vaginal adhesions and stenosis are infrequent long-term sequelae following pediatric pelvic fractures. Patients may not present with signs and symptoms before menarche, leading to delayed diagnosis and treatment. We report an adolescent girl who presented with a post-abdominal trauma pelvic fracture and urethrovaginal fistula and subsequent severe vaginal adhesion, which resulted in infection and obstructive symptoms after menarche. Hysteroscopy-guided vaginal adhesion release using an epidural catheter and ultrasonography was performed, followed by vaginal dilation, to resolve obstructive symptoms. For girls with pelvic fractures, education on possible long-term sequelae is required, as is regular follow-up. Timely diagnosis and treatment are important, and hysteroscopic release of vaginal adhesion and postoperative regular vaginal dilation may be an effective treatment.
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Affiliation(s)
- Jiao Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Fei Zheng
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dandan Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Qing Yang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
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Teo SY, Ong CL. A systematic approach to imaging the pelvis in amenorrhea. Abdom Radiol (NY) 2021; 46:3326-3341. [PMID: 33569613 DOI: 10.1007/s00261-021-02961-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/07/2021] [Accepted: 01/15/2021] [Indexed: 11/29/2022]
Abstract
This is a pictorial review on the radiological approach to patients with amenorrhea using a level-based framework. The prevalence of amenorrhea is 3 to 4% with wide-ranging causes involving multiple clinical disciplines. Normal menstruation depends on complex coordinated hormonal functions of the hypothalamic-pituitary-ovarian axis exerting its effect on an intact uterine end-organ and outflow tract. A disruption of any of these factors may result in amenorrhea. Categorizing the causes of primary and secondary amenorrhea into uterine, ovarian/gonadal, and intracranial levels provides a logical framework for its evaluation. A systematic level-based approach by targeted ultrasound of the pelvic structures is suggested, with different aims in primary versus secondary amenorrhea. Pelvic sonographic findings of various conditions within the uterine and ovarian/gonadal levels are illustrated. Conditions due to an intracranial cause result in downstream effects on the uterus and ovaries and can often be suspected based on a combination of clinical assessment, ultrasound findings, and laboratory investigations. By correlating pelvic ultrasound findings with underlying pathology, the clinical radiologist is able to provide useful diagnostic information in the management of these patients.
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Affiliation(s)
- Sze Yiun Teo
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, 229899, Republic of Singapore.
| | - Chiou Li Ong
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, 229899, Republic of Singapore
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18
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Sunyecz A, Snider M, Minniear E, Duenas-Garcia O, Payton A, Shapiro R. Herlyn-Werner-Wunderlich Syndrome: A Case Report on a Congenital Uterine Anomaly With Literature Review. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2021. [DOI: 10.1177/87564793211012633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
During fetal development, abnormalities during Mullerian duct formation can lead to varied types of uterine, cervical, or vaginal anomalies. Herlyn-Werner-Wunderlich Syndrome (HWWS) is a rare, congenital Mullerian duct anomaly characterized by the triad of uterine didelphys, obstructed hemi-vagina, and ipsilateral renal agenesis. If the diagnosis is delayed or missed, permanent sequalae such as chronic pain, infection, and infertility can result. This is a case of a 16-year-old woman with heavy vaginal bleeding and menstrual cramping in which sonography was used in the diagnosis of HWWS. Sonography plays a vital role in this diagnosis, as it is the most common initial imaging examination. For this reason, it is important that the characteristics of uterine anomalies, like HWWS, be recognized with sonography. It is important that this diagnosis is made early and treatment can be initiated to prevent irreversible complications.
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Affiliation(s)
- Alec Sunyecz
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Megan Snider
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Elizabeth Minniear
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Omar Duenas-Garcia
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Amber Payton
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Robert Shapiro
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, WV, USA
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The Prevalence of Müllerian Anomalies in Women with a Diagnosed Renal Anomaly. J Pediatr Adolesc Gynecol 2021; 34:154-160. [PMID: 33242594 DOI: 10.1016/j.jpag.2020.11.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/27/2020] [Accepted: 11/13/2020] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE To characterize the prevalence of Müllerian anomalies (MAs) among patients with renal anomalies (RAs). DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective chart review of female patients with RAs who presented to an academic pediatric hospital between 2007 and 2019 was performed. Patients were identified using International Classification of Diseases 9th and 10th revision codes. Data collected included the type of RA, presence and type of MA, method of diagnosis, and associated anomalies. RA subtype analysis was performed. RESULTS We identified 5590 cases of RA for the years 2007 through 2019. A random, retrospective chart review was performed resulting in a study population of 363 RA patients. The prevalence of any MA in the overall RA population was 104/363 (29%) (95% confidence interval, 24% - 33%). The prevalence of MA for patients with renal agenesis was 59/182 (32%) compared with 45/181 (25%) for patients with renal dysgenesis. The most common MA were failures of Müllerian duct fusion. Only 73/352 (21%) of patients received screening for a MA at the time of RA diagnosis. Of patients without a diagnosed MA 187/259 (72%) were unscreened and either not yet menarchal or had unknown menarchal status. CONCLUSIONS Of all RA patients, 29% (n = 104/363) had an underlying MA. No difference was found in the prevalence of MA in patients with renal agenesis vs dysgenesis. Limitations noted are that some patients might be of an age at which assessment of the Müllerian structures is suboptimal or who might not have been screened. These results suggest the need for a prospective study to determine evidence-based guidelines for screening for MA among patients diagnosed with any RA to avoid complications from an unrecognized MA.
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20
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Basnet T, Pradhan T, Yadav P, Sah MK, Yadav J, Rai Y, Thapa R. Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome Rare Obstructive Uterovaginal Anomaly: A Case Report. JNMA J Nepal Med Assoc 2020; 58:805-808. [PMID: 34504376 PMCID: PMC7654496 DOI: 10.31729/jnma.5043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Indexed: 11/23/2022] Open
Abstract
Obstructed Hemivagina and Ipsilateral Renal Anomaly syndrome is a rare obstructive uterovaginal anomaly involving both mesonephric and paramesonephric ducts. It usually presents after menarche with non-specific symptoms like pelvic pain, dysmenorrhea, or paravaginal mass and examination findings of paravaginal or pelvic mass. Because of non-specific symptoms and signs, the diagnosis is usually overlooked, which leads to complications like endometriosis, tubo-ovarian abscess compromising patient's fertility, and quality of life. Therefore, in presence of these nonspecific clinical features along with imaging findings of uterine didelphys and unilateral renal agenesis, this syndrome should be considered in the diagnosis. We present a case of a 17-year-old lady with Obstructed Hemivagina and Ipsilateral Renal Anomaly syndrome, diagnosed by finding of paravaginal mass on examination and uterine didelphys with ipsilateral renal agenesis in USG and managed successfully by resection of vaginal septum.
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Affiliation(s)
- Tulasa Basnet
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Tarun Pradhan
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Punita Yadav
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Manoj Kumar Sah
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Jyotsna Yadav
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Yashaswi Rai
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Rashmi Thapa
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
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Transverse Vaginal Septum with a Hemiuterus: A Laparoscopic-Guided Abdominoperineal Approach. J Pediatr Adolesc Gynecol 2020; 33:590-593. [PMID: 32437978 DOI: 10.1016/j.jpag.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Transverse vaginal septum is a rare Müllerian anomaly that can coexist with other defects. CASE A 12-year-old patient was referred to our clinic for cyclic, lower abdominal pain. Magnetic resonance imaging revealed the presence of a transverse vaginal septum, a hemiuterus with a nonfunctioning rudimentary horn, and left unilateral ureter and kidney. The septum was excised laparoscopically assisted by a vaginal dilator to guide the dissection. The mucosal gap of the vagina was then bridged with sutures using the perineal approach. The postoperative course was uneventful and the patient was discharged with instructions for vaginal dilations. SUMMARY AND CONCLUSION Early identification of a transverse vaginal septum and careful planning of the operation can improve the outcome of corrective surgery and prevent possible complications.
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Abstract
The association between obstructed müllerian duct anomalies and endometriosis has been well established and the pathogenesis is attributed to the theory of retrograde menstruation. However, this relationship with endometriosis is less clear in women with unobstructed müllerian duct anomalies and in those with rudimentary uterine structures that lack functioning endometrial tissue. This article reviews the embryology, genetics, pathophysiology, and American Society for Reproductive Medicine (ASRM) classification for müllerian duct anomalies together with the genetics and pathophysiology of endometriosis to provide a framework for understanding the complex relationship between these two entities. Available published data examining the coexistence of endometriosis in relationship to müllerian duct anomalies, including studies that stratify this relationship according to specific classes of anomalies, are reviewed and organized. Awareness of the increased prevalence of endometriosis among patients with uterine anomalies, particularly those with outflow obstruction, may facilitate early diagnosis of endometriosis and subsequent intervention, with the potential to reverse disease symptoms and arrest disease progression.
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Abstract
Congenital gynecologic anomalies result from interruption of embryologic development of the female reproductive tract. The anomalies may be hymenal, vaginal, cervical, or uterine. The impact of these anomalies is variable: some are asymptomatic, incidental findings that require no intervention, others require simple surgical management, while some complex anomalies may require a multidisciplinary approach with extensive surgical expertise for optimal outcomes. Uterovaginal anomalies may occur in isolation or in association with other malformations, such as renal anomalies. The origin, presentation, evaluation and treatment of these conditions are reviewed here.
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Abstract
INTRODUCTION Endometriosis is a common disease in women of reproductive age. In addition to causing pain, it may also reduce fertility. The coexistence of endometriosis and congenital uterine anomalies (CUA) has been frequently reported in the published literature. The present report is a review of existing studies on the subject and our own hitherto unpublished data. EVIDENCE ACQUISITION The electronic search was conducted using the Pubmed database with specific keyword combinations including endometriosis, adenomyosis, infertility, Müllerian malformations/anomalies, and septate uterus. The principal aspects addressed in the present study were: diagnosis, management, and classification of CUA, their impact on fertility and coexistence with endometriosis. EVIDENCE SYNTHESIS Endometriosis and CUA are frequently detected in the exploration of infertility, because both of these are liable to impair fertility. Endometriosis is associated with obstructive anomalies and nonobstructive malformations, especially those concerning the septate uterus. The diagnosis and management of CUA have been discussed for several years. Various classification systems have been proposed. CONCLUSIONS The analysis of the existing literature has revealed the absence of any consensus about the management, diagnosis, and classification of CUA, especially with regard to the septate uterus. We need to find and speak a common language in order to avoid inappropriate or unnecessary surgery and optimize the individual patient's treatment. The combined presence of endometriosis or adenomyosis and CUA is a reason to perform precise diagnostic imaging investigations and early surgery for the purpose of enhancing the chances of pregnancy in infertile patients. Further research is needed on the subject.
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Affiliation(s)
- Damaris Freytag
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Liselotte Mettler
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Nicolai Maass
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Veronika Günther
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Ibrahim Alkatout
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany -
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25
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Adams Hillard PJ. Dilators for the Vajayjay. J Pediatr Adolesc Gynecol 2019; 32:347-348. [PMID: 31511175 DOI: 10.1016/j.jpag.2019.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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