Bilateral bartholin's gland abscesses in a 4-year-old girl with vitamin a deficiency: a case report

BACKGROUND

A Bartholin's gland abscess is one of the most common infections in women of reproductive age. Although Bartholin's gland abscesses have been reported in prepubertal children, they are rarer in prepubertal children than in adults. Herein, we report a case of bilateral Bartholin's gland abscesses in a 4-year-old girl with vitamin A deficiency.

CASE PRESENTATION

A 4-year-old girl diagnosed with autism spectrum disorder was admitted to the hospital for close examination and treatment because of persistent fever and malaise. The child was a marked fussy eater and was diagnosed with corneal ulceration and night blindness secondary to vitamin A deficiency. Both of the patient's labia were swollen, and a diagnosis of a bilateral Bartholin's gland abscess was made using computed tomography. Incisional drainage was performed under general anesthesia. The patient's postoperative course was uneventful, and she was discharged from the hospital on day 8 after the surgery. During hospitalization, attempts were made to correct the vitamin deficiency by adding nutritional supplements to the diet. Three months after the surgery, no recurrence of abscesses was noted.

CONCLUSIONS

Decreased immunocompetence and mucosal barrier function due to vitamin A deficiency is thought to be the underlying cause of Bartholin's gland abscesses. Although prepubertal Bartholin's gland abscesses have been reported, they are rare. To the best of our knowledge, no reports of bilateral Bartholin's gland abscesses potentially caused by vitamin A deficiency have been reported. When prepubertal girls present with Bartholin's gland abscesses, the presence of immunodeficiency due to vitamin or trace element deficiency should also be considered.

Comparison of Word Catheter and Marsupialization in the Management of Bartholin's Glands: A Systematic Review and Meta-Analysis

OBJECTIVE

There is no consensus on the best option for the management of Bartholin's gland abscesses. This systematic review and meta-analysis aimed to compare the Word catheter placement and marsupialization methods in the management of women with a cyst or abscess of the Bartholin's glands.

DATA SOURCES

The PubMed, Scopus, Embase, Web of Science, and Cochrane Library databases, as well as Google Scholar, were searched to retrieve articles published between January 1990 and July 2023, comparing the Word catheter treatment with marsupialization for women with a cyst or abscess of the Bartholin's glands.

STUDY SELECTION

Both observational studies and randomized controlled trials (RCTs) were included in this meta-analysis.

DATA EXTRACTION AND SYNTHESIS

After the review, out of 9 relevant articles, only 4 (2 observational studies and 2 RCTs) were included in this meta-analysis, providing the data of 735 patients (396 in the Word catheter group vs. 339 in the marsupialization group). The data was extracted from the selected articles, using a data extraction form. Comparison of the Word catheter and marsupialization methods suggested that the risk of recurrence was approximately 7.6% in the Word catheter group and 9.4% in the marsupialization group. The findings indicated no significant difference in the recurrence of cysts or abscesses when comparing the Word catheter treatment with marsupialization (odds ratio = 0.99, 95% confidence interval: 0.29-3.43, P = 0.990, I2 = 77%).

CONCLUSION

This meta-analysis found no significant difference in the rate of recurrence between the Word catheter and marsupialization methods. In general, marsupialization and Word catheter placement in the treatment of Bartholinitis seem to be equally effective.

Outcomes After Lysis of Adhesions and Dilator Placement for Treatment of Vulvovaginal Agglutination Due to Lichen Planus

OBJECTIVE

The aim of the study is to determine intraoperative and postoperative surgical outcomes for the treatment of vulvovaginal agglutination secondary to lichen planus (LP) following a standard protocol using intraoperative dilator placement and postoperative intravaginal steroid use.

MATERIALS AND METHODS

This was a retrospective chart review of patients who underwent surgical management of vulvovaginal agglutination due to LP following a protocol that included surgical lysis of vulvovaginal adhesions, intraoperative dilator placement and removal 48 hours later, and high-potency intravaginal corticosteroid and regular dilator use thereafter. Demographic and clinical data were abstracted from the medical record and analyzed using descriptive statistics.

RESULTS

Thirty-four patients, with mean age 51.2 ± 11 years and body mass index 32.8 ± 8.5 kg/m 2 , underwent lysis of vulvovaginal adhesions between 1999 and 2021 with 8 different surgeons at a single institution. The mean preoperative, immediate postoperative, and 6-week postoperative vaginal lengths were 2.8 ± 1.8 cm ( n = 18), 8.0 ± 1.9 cm ( n = 21), and 7.9 ± 2.2 cm ( n = 16), respectively. The mean estimated blood loss intraoperatively was 16 ± 15 mL. No patients had a documented surgical site infection or reoperation within 30 days after surgery. Of patients who had it documented ( n = 26), 70% (18/26) reported postoperative sexual activity. Where documented, 100% (18/18) reported preoperative dyspareunia, while 17% (3/18) did postoperatively. Six percent (2/34) had recurrent severe agglutination and 3% (1/34) underwent reoperation.

CONCLUSIONS

Lysis of vulvovaginal adhesions, intraoperative dilator placement, and postoperative intravaginal corticosteroids with dilator use is a safe and effective treatment option to restore vaginal length for those with vulvovaginal LP.

Differentiated Exophytic Vulvar Intraepithelial Lesions: Case Reports and Review of Literature

OBJECTIVES

The aims of this article were to describe 2 patients with a pathological diagnosis of differentiated exophytic vulvar intraepithelial lesion and to summarize the literature regarding this relatively new diagnosis.

MATERIALS AND METHODS

The existing literature was searched on December 1, 2021, using the MEDLINE database (1966-2021), and all combinations of the following search terms were used: "differentiated exophytic vulvar intraepithelial lesion" and "differentiated vulvar intraepithelial neoplasia."

RESULTS

Patients were postmenopausal and reported persistent vulvar itch associated with white hypertrophic plaques. Initial biopsies did not identify differentiated exophytic vulvar intraepithelial lesion. Invasive squamous cell carcinoma was found in both cases after surgical excision.

CONCLUSIONS

Differentiated vulvar intraepithelial lesions and invasive squamous cell carcinoma should be considered in the differential diagnosis of vulvar itch associated with hypertrophic plaques in postmenopausal women. Excision of suspicious plaques is recommended for definitive diagnosis.

Ectopic mammary tissue in vulva: case report and systematic literature review

Objective

To report the case of a patient diagnosed with ectopic mammary tissue in the vulva, and to conduct a literature review of the diagnosis, treatment and prognosis of this condition in that location.

Materials and Methods

A 49-year-old patient who presented with a painful vulvar mass to a private intermediate complexity center in Bogotá, Colombia. The lesion was assessed on ultrasound and then surgically excised; histopathology showed ectopic mammary tissue with absence of malignancy. A search was conducted in the PubMed, Embase, Cochrane, LILACS and Scielo databases using the keywords “Vulva,” “Breast” and “Ectopic.” Case reports and case series of women with histopathology-confirmed mammary tissue in the vulva were included.

Results

Overall, 184 titles were identified and, of these, 94 were ultimately included, for a total of 126 cases, with 57.9% being benign tumors, 95% in women under 50 years of age, and 42.06% being malignant tumors, 92% in women over 50 years of age. Diagnosis was made on the basis of the clinical findings, with ancillary diagnostic imaging, tumor markers and immunohistochemistry in some cases. Local excision was performed in 91% of cases with benign pathology and in 43% of cases with malignant pathology, with the diagnostic method being therapeutic.

Conclusions

Ectopic mammary tissue in the vulva must be considered as part of the differential diagnosis of vulvar masses, prognosis being different in pre and postmenopausal women. Further studies are needed to enhance the characterization of this condition and define the ideal course of treatment in terms of relapse and survival.

Vulvar Crohn's disease in an adolescent diagnosed after unsuccessful surgical treatment

BACKGROUND

This case report presents a case of Vulvar Crohn's disease (VCD) in an adolescent, that is an uncommon manifestation of Crohn's disease (CD) without gastrointestinal symptoms. Before treating CD itself with proper medication, vulvar abscess continued to recur without improvement.

CASE PRESENTATION

We report the case of an 18-year-old woman with VCD. After treatment with azathioprine 50 mg daily and mesalazine 1 g three times daily, vulvar lesions resolved after 6 weeks. We collected electronic medical data on patient characteristics, and evaluated findings of physical examinations, pelvic MRI, and biopsy specimen obtained from gastroduodenoscopy/colonoscopy.

CONCLUSIONS

VCD is a rare manifestation of CD that may be misdiagnosed in the absence of gastrointestinal symptoms leading to delayed treatment. If a patient has an unexplained vulvar inflammatory lesion and with repeated failed surgical treatment, gynecologists should consider the possibility of a VCD.

Manual separation of labial synechiae: A cost-effective method in prepubertal girls

BACKGROUND

Labial synechiae is a fairly common gynaecological problem that occurs as a result of inflammation leading to fusion between the labia minora. Being in a developing country with limited resources and poor compliance of patients to prolonged treatments, we are faced with immense challenges in the management of these girls.

AIMS

We wanted to evaluate the efficacy and the cost-effectiveness of manual separation and topical antibiotics with perineal hygiene in the management of pre-pubertal girls with labial synechiae.

MATERIALS AND METHODS

Design.

Prospective, non-randomised interventional study. Participant: Pre-pubertal girls presenting with the diagnosis of labial synechiae in the period from September 2015 to January 2018. Interventions: Manual separation followed by topical antibiotic ointment application for 1 week with local hygiene. Outcomes measure: Complete release of the synechiae and no recurrence up to 6 months.

RESULTS

Out of the total 55 patients, only 48 patients were included, their age ranged from 3 months to 7 years (mean 2.8 years). Almost half of our patients were asymptomatic, and other half had symptoms (urinary tract infection, dripping of urine and itching). Majority of our patients belong to low middle class status. We had 100% complete release of synechiae and no recurrence on 6 months follow-up.

CONCLUSION

Manual separation followed by topical antibiotics is a cost-effective method of the treatment of labial synechiae with immediate response and low recurrence rate.

Surgical management and clinical follow-up of post-coital severe vulvar hematoma in a 14-year-old adolescent girl: A case presentation

BACKGROUND

Vulvar hematoma is often puerperal. A case of non-puerperal vulvovaginal hematoma is rare in the literature. There is no consensus on the management of vulvovaginal hematoma. In this study, we discussed the approach to a rare case of non-puerperal vulvar hematoma.

CASE

We present the case of a 14-year-old adolescent female with a severe vulvar non-obstetric hematoma that occurred after she had been illegally and voluntarily married.

CONCLUSION

In conclusion; vulvar hematoma is the most common non-obstetric cause of perineal trauma and carries the risk of mortality by causing hypovolemic shock. The conservative approach is preferred for small and non-growing hematomas; however, surgical hematoma drainage is used for large and enlarging hematomas. Selective arterial embolization procedure is not common as the required equipment is not available in all healthcare facilities.

Evaluation of the efficacy of fractional CO2 laser in the treatment of vulvar and vaginal menopausal symptoms

PURPOSE

The objective of this study was to evaluate the efficacy of fractional CO₂ laser to manage vulvar and vaginal symptoms of Genitourinary Syndrome of Menopause (GSM) in postmenopausal women.

METHODS

All postmenopausal women with symptoms of GSM undergoing fractional CO₂ laser treatment in our centers were asked to fill out a validated quality of life questionnaire (Global Quality of Life Questionnaire), Visual Analog Scale (VAS) for symptoms, a questionnaire on overall discomfort related to pelvic floor symptoms, and the Female Sexual Function Index (FSFI) at several points: before each session (three sessions at monthly intervals) and one 3 months after treatment completion. Statistical analysis compared pre-therapy data and data at 3 months of treatment.

RESULTS

Forty-six women were included with a mean age of 57.3 years (± 11.1 years). A significant improvement was demonstrated in vaginal dryness (p = 6.34 10^-6) and for symptoms of stress urinary incontinence (p = 0.043). Among sexually active patients, there was a significant improvement in the degree of symptom discomfort affecting their satisfaction (p = 0.007), dyspareunia (p = 0.001) and sensitivity during sexual intercourse (p = 0.001). Significantly, more women were able to achieve (p = 0.026) and maintain (p = 0.018) lubrication during intercourse.

CONCLUSION

CO₂ laser treatment seems to improve the quality of life and sexual health of patients as well as GSM symptoms at 3 months of treatment; long-term reevaluation is necessary to demonstrate that improvement persists over time.

Labial adhesion in a postmenopausal female: A case report

RATIONALE

Voiding difficulty is more common in males, although it is not uncommon in females. Female voiding difficulty can be caused by iatrogenic, anatomic, and neurogenic factors, and specifically urethra stricture, impaired detrusor contractility, primary bladder neck obstruction, and detrusor-external sphincter dyssynergia. Labial adhesion is a rare cause of female voiding difficulty.The incidence of labial fusion has been reported to be 0.6% to 1.4% in children; however, the incidence in the elderly has yet to be fully elucidated.

PATIENT CONCERNS

We present the case of a postmenopausal and sexually inactive 76-year-old female patient who had nearly total vaginal and urethral occlusion due to labial adhesion. She had no underlying diseases and came to our clinic with a 10-month history of voiding difficulty, postmicturition dribbling, and involuntary urinary leakage when getting up.

DIAGNOSIS

A genital examination revealed nearly total fusion of the labia minor with only a 3-mm pinhole opening at the posterior end.

INTERVENTIONS

Treatment included surgical separation, the local application of estrogen cream, and self-dilatation. She also received an antimuscarinic agent to treat overactive bladder secondary to bladder outlet obstruction which was caused by labial adhesion.

OUTCOMES

No surgical complications occurred. Moreover, no labial adhesion or voiding dysfunction was found immediately after the surgery or after 6 months of follow-up.

LESSONS SUBSECTIONS

Genital examinations are a basic but very important noninvasive skill for physicians. This case report highlights that genital examinations should be a priority for patients with gynecological or urological symptoms.

The impact of CO2 laser for treatment of Bartholin's gland cyst or abscess on female sexual function: a pilot study

The aim of this study is to evaluate the sexual functionality before and after treatment of Bartholin's gland diseases (BGD) with CO₂ laser and to compare our results to patients who underwent surgical cold knife and to a healthy control group (HCG). Consecutive patients (n = 15) affected by BG cyst or abscess who underwent CO₂ laser treatment were evaluated. Patients were asked to complete the Italian translation of the Female Sexual Functioning Index (FSFI) before and 4 weeks after treatment. Results after CO₂ laser were compared with two control groups: patients affected by BG cyst (n = 15) or abscess treated with surgical cold knife treatment and a HCG (n = 18). A statistically significant advantage of CO₂ laser versus cold knife treatment in terms of lubrication, pain and global score were recorded. Both the single scores of five domains and total score of FSFI were globally higher after any treatment compared to before (CO₂ and cold knife) of BGD. According to our data, CO₂ laser therapy is often well tolerated by patients and correlated with a favorable sexual health recovery.

Periclitoral accessory breast tissue in a lactating woman: A case report

RATIONALE

The accessory breast is residual mammal tissue which does not regress during the embryonic development. The accessory breast is so rare that it is easily ignored in diagnosis of disease.

PATIENT CONCERNS

We report a 29-year-old lactating woman presented with complaints of periclitoral lesions without any pain or discomfort.

DIAGNOSES

Periclitoral accessory breast tissue.

INTERVENTIONS

We performed wide local resection of the lesions. Pathologic examination confirmed the lesions were ectopic breast tissues with secretory changes. The patient was followed up for 3 months and she was totally recovered.

LESSONS

Accessory breast tissue should be considered as a diagnosis when a mass grow fast on the milk line, especially the masses changes obviously with sex hormones according to the clinical findings.

Surgical management of a huge post-circumcision epidermoid cyst of the vulva presenting unusually in a postmenopausal woman: a case report

BACKGROUND

Epidermoid cysts of the external genitalia are one of the late complications of female genital mutilation. These cysts are usually small and painless. The presentation of a giant vulvar cyst in a postmenopausal woman has not been reported; the surgical management of a large cyst is often challenging.

CASE PRESENTATION

A 60-year-old, para VI, Ethiopian woman presented with an 18 cm by 12 cm sized, fluctuant, multi-lobulated, mobile, non-tender vulvar mass involving the mons pubis. She had undergone genital cutting and sewing during her childhood. Informed consent was obtained for surgery and the vulvar cyst was excised successfully without any significant bleeding or injury to the adjacent structures. Her postoperative course was smooth and histopathology confirmed epidermoid cyst of the vulva.

CONCLUSIONS

Huge epidermoid vulvar cysts following genital mutilation are rare and presentation in a postmenopausal woman has not been reported. Practitioners in areas where female genital mutilation is prevalent should be aware of the peculiar anatomic and technical aspects of the surgical removal of these giant vulvar cysts for successful therapeutic and cosmetic outcomes.

Unilateral ectopic breast tissue on vulva in postpartum woman: A case report

RATIONALE

Ectopic mammary gland tissues occur in about 2% to 6% of women in general population. Vulva is considered a rare site for the ectopic breast tissue.

PATIENT CONCERNS

We report a rare case of a 27 year-old woman, para 2 and presenting as a vulvar mass in the postpartum period.

DIAGNOSES

Ectopic mammary tissue in vulva.

INTERVENTIONS

The mass was removed by wide local excision. Histopathological assessment revealed features of ectopic mammary tissue CONCLUSION:: The vulvar region is one of the reported sites for ectopic breast tissue in the body. The presence of a rapidly enlarging, well-encapsulated mass in the vulvar region associated with recent delivery or lactation is suggestive of ectopic breast tissue.

LESSONS

It is important for clinicians to get a good history and consider ectopic breast tissue on vulva in postpartum women and confirm diagnosis via biopsy with histopathological examination.

Necrotizing fasciitis. Possible profiles of professional liability with reference to two cases

Necrotizing fasciitis is one of the most dangerous complication of an abscess and it is still a disease with a high mortality. In this work, we decided to consider two cases: the first one concerns a male subject, aged 66, deceased because of a fatal necrotizing fasciitis associated to a cervical descending mediastinitis, which evolved from a primary peritonsillar abscess; the second is about a 50-year-old woman with a perineal abscess, then evolved into necrotizing fasciitis associated to a fatal septis shock. After a systematic consideration of necrotizing fasciitis as pathology and an analysis of the possible related risks to a diagnostic or therapeutic delay, we analyzed the particular history of both cases to underline the possible critical issues in professional behavior of the medical staff intervened.

KEY WORDS

Abscess, Medical malpractice, Mortality, Necrotizing fasciitis, Professional liability.

Therapeutic Assessment of Vulvar Squamous Intraepithelial Lesions with CO2 Laser Vaporization in Immunosuppressed Patients

OBJECTIVE

 A vulvar squamous intraepithelial lesion is deemed to be a preceding lesion to vulvar cancer, especially in women aged under 40 years, holders of an acquired or idiopathic immunosuppression. Several treatments have been used to treat these lesions. One of the aesthetically acceptable therapeutic methods is the CO2 laser vaporization.

METHODS

 In a transversal study, 46 records of immunosuppressed women bearing a vulvar low grade and/or high grade squamous intraepithelial lesion were selected out of the retrospective analysis, computing age, date of record, date of vulvar lesion treatment with CO2 laser, the time elapsed between the first and the last visit (in months), the number of visits, the presence or absence of condylomatous lesions in other female lower genital tract sites and whether or not recurrences and persistence of intraepithelial lesions have been noticed during the follow-up.

RESULTS

 Patients bearing vulvar high-grade squamous intraepithelial lesion and immunosuppressed (serum positive for human immunodeficiency virus [HIV] or with solid organs transplantation) have shown a higher level of persistence of lesions and a higher chance of having other areas of the female lower genital tract involved.

CONCLUSION

 While the CO2 laser vaporization is the most conservative method for the treatment of vulvar high-grade intraepithelial lesions, it is far from being the ideal method, due to the intrinsic infection features considered. The possibility of persistence, recurrences and spontaneous limited regression indicates that a closer surveillance in the long-term treated cases should be considered, in special for immunosuppressed patients.

Skene's gland cyst: a simple marsupialization technique

INTRODUCTION AND HYPOTHESIS

We present a simple approach to the marsupialization of a Skene's gland cyst.

METHODS

Our technique facilitates suture placement to exteriorize the cyst wall to efficiently treat a distal Skene's gland cyst and reduce the risk of recurrence.

CONCLUSION

Marsupialization is an accepted option for the surgical management of Skene's gland cyst. This technique is an effective and streamlined approach to Skene's gland marsupialization.

A case of condyloma acuminata with giant and multiple lesions on the vulva and breast: successfully treated with surgical operations

We report a case of a 24-year-old female patient with a history of giant and multiple lesions of condylomata acuminata on the vulva and breasts which were treated by surgical excision.

Clitoral Epidermal Inclusion Cyst Resection With Intraoperative Sensory Nerve Mapping Technique

BACKGROUND

Despite the ever increasing popularity of labial and clitoral surgeries, the best practices and long-term effects of reconstructive procedures in these regions remain unknown. This is particularly noteworthy because the presentation of nerve-related symptoms may be delayed up to a year. Despite the convention that these surgical procedures are low risk, little is known about the best practices that may reduce the postoperative complications as a result of these reconstructive surgeries. We describe a preoperative sensory mapping technique in the context of a symptomatic inclusion cyst in the clitoral region. This technique delineates anatomical and functional regions innervated by the dorsal clitoral nerve while minimizing the vascular watershed area in the midline.

CASE

A prototypical case of a patient with a clitoral mass is discussed with clinical history and surgical approach. Prior to surgical excision, the dorsal clitoral nerve distribution was mapped in order to avoid a surgical incision in this sensual zone.

CONCLUSIONS

In our practice, preoperative sensory mapping is a clinically useful planning tool that requires minimal instrumentation and no additional operating time. Sensory mapping allows identification of the functional zone innervated by the dorsal clitoral nerve, which can aid in minimizing damage to the area.

Innovative use of chemodenervation in the treatment of postoperative genital hyperhidrosis-like symptoms

Postoperative complications present in many forms and can cause great morbidity and even mortality in patients who experience them. Frey syndrome is an example of a postoperative complication in which aberrant nerve regeneration following parotidectomy leads to hyperhidrosis induced by gustatory stimuli. We present a unique but similar case of aberrant nerve regeneration and resulting hypersecretion that emerged 6-7 months following perineoplasty and labial reduction for lichen sclerosus in a 53-year-old woman. An exhaustive investigation ruled out genitourinary causes of her symptoms. Pads, tampons, and surgical procedures provided no relief. We propose that the mechanism of her excessive watery secretions is similar to that which causes Frey syndrome: iatrogenic damage to nerves that aberrantly regenerate to innervate local structures involved in secretory control. The parallels between our patient's condition and Frey syndrome are evident in the duration between surgery and onset of symptoms and the response to treatment with onabotulinum toxin, highlighting a shared cholinergic pathway. Onabotulinum injections are well tolerated by patients with localized hyperhidrosis and symptom control typically lasts several months. In this manuscript we present a novel mode of delivery of onabotulinum toxin topically to a mucosal region. With these treatments, the patient's hyperhidrosis-like symptoms remain well controlled for 3-4 months, at which point she returns to clinic for treatment. The patient did not experience symptomatic relief until this unique treatment plan was initiated. Her case illustrates the need for further understanding of recalcitrant postoperative complications involving local structures controlling liquid secretion, such as sweat glands and vascular plexuses.

Surgical management of vulvovaginal agglutination due to lichen planus

Lichen planus is a rare dermatological disorder that is often associated with painful and disfiguring vulvovaginal effects. At the University of Michigan Center for Vulvar Diseases, we see many women with vulvovaginal lichen planus each year, with marked scarring and vulvovaginal agglutination that precludes vaginal intercourse and causes difficulty with urination. Through our experience, we developed a protocol for the operative management and postoperative care for severe vulvovaginal agglutination. Our objective is to share this protocol with a wider audience so that providers who see patients with these devastating effects of lichen planus can benefit from our experience to better serve this patient population. The figure represents a case of erosive lichen planus with early vaginal agglutination. The video reviews the pathophysiology and presentation of lichen planus. We then present a case of scarring and agglutination in a young woman, including our surgical management and postoperative care recommendations.

Classification of Hypertrophy of Labia Minora: Consideration of a Multiple Component Approach

Labia minora hypertrophy of unknown and under-reported incidence in the general population is considered a variant of normal anatomy. Its origin is multi-factorial including genetic, hormonal, and infectious factors, and voluntary elongation of the labiae minorae in some cultures. Consults with patients bothered by this condition have been increasing with patients complaining of poor aesthetics and symptoms such as difficulty with vaginal secretions, vulvovaginitis, chronic irritation, and superficial dyspareunia, all of which can have a negative effect on these patients' sexuality and self esteem. Surgical management of labial hypertrophy is an option for women with these physical complaints or aesthetic issues. Labia minora hypertrophy can consist of multiple components, including the clitoral hood, lateral prepuce, frenulum, and the body of the labia minora. To date, there is not a consensus in the literature with respect to the classification and definition of varying grades of hypertrophy, aside from measurement of the length in centimeters. In order to offer patients the most appropriate surgical technique, an objective and understandable classification that can be used as part of the preoperative evaluation is necessary. Such a classification should have the aim of offering patients the best cosmetic and functional results with the fewest complications.

Periurethral and vulval condylomata acuminata: an unusual juvenile venereal disease in a 3-year-old girl

We present a case of giant condyloma acuminatum (CA) in a 3-year-old girl with rapidly growing vulval and periurethral lesions, which was investigated thoroughly and successfully treated with excision biopsy. Genital warts in the form of giant alarming vestibular, vulval and periurethral lesions of CA are very rare in children. There is need for a multidisciplinary approach with potential sociomedicolegal implications. Surgical excision is safe, effective and provides an opportunity to assess the extent of the lesion and tissue for accurate diagnosis. Genital warts in the form of giant alarming vestibular, vulval and periurethral lesions of CA are very rare in children. Indications for surgical treatment include large, recurrent or refractory lesions, as well as the need for histological identification and acquiring tissue for immunotherapy when necessary. The strategy of an extended follow-up is recommended so as to ensure identification of any risk situations.

Reconstruction for extensive groin hidradenitis suppurativa using a combination of inferior abdominal flap and medial thigh-lift: a case report

Various methods for reconstructing hidradenitis suppurativa of the groin have been reported. However, it is difficult to attain favorable results both aesthetically and functionally. This report describes a case in which a defect was reconstructed using a combination of inferior abdominal flap and medial thigh-lift after radical excision of extensive groin hidradenitis suppurativa. A 37-year-old woman patient underwent radical excision of bilateral groin hidradenitis suppurativa. After the excision, an inferior abdominal flap and bilateral medial thigh flaps were created and advanced to close the defect. The operative procedure was simple and did not require a donor site. The postoperative scar coincided with the inguinal folds and was concealed by undergarments. No functional disorder remained. Reconstruction for extensive groin hidradenitis suppurativa using this method can attain good aesthetic and functional results. The combination of inferior abdominal flap and medial thigh-lift is potentially a useful option for reconstruction of extensive groin hidradenitis suppurativa.

LEVEL OF EVIDENCE IV

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Vulvar defect after pelvic trauma and its repair with reverse TRAM flap: report of a case

Vulvar defect and soft tissue loss secondary to pelvic trauma is rare. Many reconstructive procedures for large vulvoperineal defects have been described. The case of a woman with severe vulvar defect following a previous pelvic trauma and treatment with reverse TRAM flap is reported.

Heterologous type of malignant mixed Müllerian tumor of the uterus presenting as a vulvar mass

Carcinosarcoma is a rare, extremely aggressive tumor of the uterus with a poor prognosis. The authors describe a case of a 78-year-old woman who presented with a giant mass protruding through the cervix, vagina, and vulva. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. The histopathological examination of the surgical specimen revealed a malignant mixed Müllerian tumor. The clinical and pathological features, molecular data, and prognosis of this aggressive neoplasm are discussed. Although uterine carcinosarcomas are extremely rare, when a postmenopausal woman with a vulvar mass is admitted to the gynecology clinic, the physician should consider that the mass may be a carcinosarcoma.

Severe gynecologic sequelae of Stevens-Johnson syndrome and toxic epidermal necrolysis caused by ibuprofen: a case report

BACKGROUND

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a serious, drug-induced, life-threatening condition characterized by an epidermal blistering rash with necrosis, desquamation and mucosal surface involvement. This patient represents the youngest and most significant case report in the literature of gynecologic damage due to TEN.

CASE

A 31/2-year-old girl developed TEN involving 90% of her body surface area after exposure to pediatric ibuprofen. After onset of puberty she required surgery to treat vulvar, vaginal and cervical adhesions, stenosis and hematometra.

CONCLUSION

While delaying evaluation and treatment of the extremely young child with this disorder until puberty has been the standard, consideration should be given to earlier evaluation and intervention.

Staged endovascular and surgical treatment of slow-flow vulvar venous malformations

OBJECTIVE

The objective of the study was to report our experience in a rare series of treated symptomatic slow-flow vulvar venous malformations (VVMs) using a staged, multidisciplinary approach.

STUDY DESIGN

Consecutive patients with symptomatic lesions treated over a 7 year period (2005-2012) were followed up for technical success, resolution of symptoms, aesthetic outcomes, and complications. Direct endovenous sclerotherapy (DEVS) using sodium tetradecyl sulfate (STS) foam was performed in all patients under ultrasound and contrast-enhanced fluoroscopic guidance. Surgical excision and layered primary closure was performed within 24 hours after the last DEVS session.

RESULTS

Eleven patients (mean age, 25 years; range, 4-43 years) were treated. Presenting symptoms included pain (n = 11), soft tissue swelling (n = 11), local heaviness (n = 11), dyspareunia (n = 2), and dysmenorrhea (n = 2). Most were isolated lesions (n = 8). There were 2 cases of Klippel-Trénaunay syndrome and 1 case of Maffucci syndrome. The latter required Nd:YAG laser photocoagulation prior to sclerotherapy. On average, approximately 3 DEVS sessions were required prior to surgical excision (range, 1-6). Mean estimated surgical blood loss was 130 mL (range, 20-400 mL). Mean follow-up was 23 months (range, 3-55 months). Elimination of pain and soft tissue redundancy was achieved in all patients with satisfactory aesthetic outcomes. All patients experienced minor pain and swelling after DEVS. Following surgical excision, there was 1 case of hematoma and wound dehiscence requiring surgical evacuation. No other reinterventions, endovascular or surgical, were required.

CONCLUSION

VVMs require increased awareness and appropriate preoperative evaluation for proper identification and treatment. A multidisciplinary approach can provide improvement in clinical signs and symptoms with satisfactory cosmesis and minimal complications.

Traumatic vulvar hematoma masquerading as a bartholin duct cyst in a postmenopausal woman

Vulvar hematomas, while typically occurring following vaginal delivery, are occasionally seen in the nonpregnant patient following perineal trauma. When these, as well as any vulvar mass, are discovered in a postmenopausal woman, concern regarding a neoplasm exists.

CASE

A 66-year-old woman was found to have a large vulvar mass which was initially believed to be a Bartholin duct cyst. At surgery a vulvar hematoma was found and evacuated. Subsequent biopsy was negative for malignancy.

CONCLUSION

Any vulvar mass discovered in a postmenopausal woman warrants meticulous evaluation to exclude malignancy. Although usually occurring in younger women, a vulvar hematoma may be noted in older women who have sustained trauma to the perineum.

[Outcome prediction of single-period CO(2) laser therapy for vulvar condylomata acuminate]

OBJECTIVE

To evaluate the outcome of CO(2) laser treatment as primary therapy for vulvar condylomata acuminate and examine the risk factors and prediction model of single-period CO(2) laser treatment.

METHODS

Between March 2009 and December 2010, a multicenter prospective study was conducted at three 3A hospitals of China (Peking Union Medical College Hospital, Zhejiang Women's Health Hospital & Tongji Hospital). All enrolled patients of vulvar condylomata acuminata received CO(2) laser vaporization as the primary therapy and had return visits at 1, 3 and 6 months individually after treatment. Therapeutic recurrence and side effects were recorded. Logistic regression was used to analyze the associations between demographic or clinical characteristics and the outcome of single-period CO(2) laser treatment and a prediction model was established subsequently. The optimal cutoff value of model was evaluated by area under the receiver operating characteristic curve (AUC ROC).

RESULTS

A total of 160 patients completed a 6-month follow-up with a loss rate of 9.1% (16/176). And 131 patients (82%) were cured after the single-period CO(2) laser therapy with a total recovery rate of 94% (150/160). Side effects occurred in 50 (31%) patients with a complete self-recovery within 6 months. The most common side effects were local ulceration, pain and edema. No severe side effect was present. Large area of lesion (>8 cm(2)), vagina involved and unemployment were associated with the failure of single-period treatment while pain symptom was a protective factor of effectiveness. Age, marital status, symptom-free and vaginal involvement were not related with outcome. A prediction model was established as follows: Logit (P(0)) = -1.511+1.573X(1)+1.679X(2)+3.254X(3)-1.685X(4) (X(1)-X(4) representing area of lesion > 8 cm(2), vaginal involvement, unemployment and pain symptom respectively). The optimal cutoff value of P(0) was 0.35 with AUC ROC of 0.816 (P < 0.01). The sensitivity, specificity, positive predictive value and negative predictive value of model were 58.6%, 91.6%, 60.7% and 90.9% respectively.

CONCLUSION

CO(2) laser is effective and safe therapy for vulvar condylomata acuminata. A prediction model has been proposed to predict the outcome of single-period CO(2) laser therapy in initially diagnosed patients. It may guide clinical decision-making.

Vulvar endometriosis presenting with dyspareunia: a case report

BACKGROUND

Superficial dyspareunia can be caused by a multitude of medical and psychological conditions, including pathologic conditions of the vulva. Although infectious and inflammatory causes are more common, vulvar endometriosis is a rare and often overlooked etiology of dyspareunia.

CASE

A 33-year-old woman, gravida 1, para 1, presented for a gynecologic consultation with a 2-year history of increasing dyspareunia and cyclical vulvar pain associated with a vulvar mass. Previous treatment with analgesics and sitz baths did not alleviate the symptoms. Pelvic examination revealed a right Bartholin's gland mass that was tender to palpation. The working diagnosis was a Bartholin's cyst as the cause of the dyspareunia, and the patient was scheduled for marsupialization and/or resection. Examination under anesthesia revealed an irregular, 5 cm, solid mass that extended into the labia majora, which was excised. Pathologic examination of the mass revealed endometriosis. The postoperative course was unremarkable and the patient reported complete resolution of symptoms.

CONCLUSION

This case illustrates that superficial dyspareunia associated with cyclical vulvar pain can be caused by endometriosis involving the labia majora.

Spontaneous vulvar hematoma during pregnancy: a case report

BACKGROUND

Vulvar hematoma is a relatively uncommon occurrence. Most have been described resulting from traumatic injury in nonpregnant women or as an uncommon complication of childbirth. We describe a case of a spontaneous 6-cm vulvar hematoma that presented as unexplained vulvar edema in a 35-weeks-pregnant woman.

CASE

A pregnant woman presented to the obstetrics triage unit with rapid onset unilateral vulvar swelling and no preceding traumatic event. A detailed physical examination and radiologic evaluation revealed a spontaneous vulvar hematoma as the cause. After incision and drainage of the hematoma, her edema resolved and the patient went on to have an uneventful vaginal delivery 4 weeks later.

CONCLUSION

Spontaneous vulvar hematoma is a rare event. Rapid recognition and treatment in this case allowed for complete recovery and enabled this pregnant woman to continue a normal pregnancy with uncomplicated spontaneous vaginal delivery.

Vulvar endometrioma: a case report

Endometriosis is a benign and common disorder that is characterized by ectopic endometrium outside the uterus. Extrapelvic endometriosis, like of the vulva, is rarely seen. We report a case of a 47-year-old woman referred to our clinic due to complaints of a vulvar mass and periodic swelling of the mass at the time of menstruation. During surgery, the cyst ruptured and a chocolate-colored liquid escaped onto the surgical field. The cyst was extirpated totally. Hipstopathological examination showed findings compatible with endometriosis. She was asked to follow-up after three weeks. The patient had no complaints and the incision field was clear at the follow-up.

Labial fusion first diagnosed during pregnancy with voiding difficulty and its management: a case report

INTRODUCTION

Labial fusion is described as partial or complete adherence of the labia minora. Adhesions of the labia are extremely rare in the reproductive population with only a few cases described in the literature and none reported with pregnancy.

CASE PRESENTATION

A 24-year-old woman who had extensively fused labia with a pinhole opening at the upper midline with menstrual delay was diagnosed at six weeks of pregnancy. The case and its management are presented.

CONCLUSION

The condition was treated surgically with complete resolution of the urinary symptoms.

Clitoral epidermoid cyst secondary to blunt trauma in a 9-year-old child

Epidermoid cysts are slowly growing tumors arising from invagination of the epidermis into the dermis traumatically or spontaneously. This implantation in the clitoris is most commonly induced by female genital mutilation. The reported cases with spontaneous onset of this clitoral lesion are scarce. Trauma other than female circumcision predisposing to the onset of the cyst has not been mentioned before. A nine-year-old girl was presented for swelling in the pubic region with the onset following an accidental trauma; the diagnosis was determined to be epidermoid cyst of the clitoris after a brief preoperative evaluation and an accurate surgical management.

Vulvar abscess: a retrospective review

Vulvar abscesses can progress to cause significant illness requiring disfiguring surgical debridement, broad spectrum antibiotics, and require hospitalization. A retrospective review of de-identified charts of 13 patients admitted for inpatient care for vulvar abscesses from 2004-2009 at West Virginia University Hospitals was conducted. Risk factors for vulvar abscess in these patients included obesity and diabetes. Body mass index (BMI) is directly proportionate to the size of the abscess and increased risk of intensive care unit admission. Most patients did not seek medical care prior to hospital admission. Polymicrobial infections were common, and methicillin resistant Staphylococcus aureus was seen in two cases. The presence of multiple risk factors increased the length of hospitalization. Clinicians should be aware of these risk factors and initiate aggressive therapy for patients with elevated BMI or multiple risk factors.

A case of labial fusion and urinary pseudo-incontinence in an elderly woman. A surgical treatment and a review

Labial fusion is defined as either partial or complete adherence of the labia minora (1), and also called vulvar fusion, adhesions of the labia minor or conglutination of the labia minora and sinechia of the vulva. The complete and severe labial fusion is a rare pathology with a small number of cases reported in the literature in adults. We present a case report of a postmenopausal woman who presented with voiding difficulty and incontinence and was treated by surgical division of the adhesions and immediate resolution of the urinary incontinence confirmed by multichannel urodynamic test postoperatively.

Hypertrophic tuberculosis of vulva--a rare presentation of tuberculosis

The authors report a rare case of hypertrophic vulval tuberculosis of primary origin in a 26-year-old female patient. The diagnosis was mainly based on histopathological examination. Good outcome was obtained with antitubercular chemotherapy supplemented with surgical reduction for aesthetic concern.

[Nodular hyperplasia of the Bartholin gland]

Swelling of the Bartholin gland is most often due to inflammation and/or cysts, whereas solid lesions are rare. The majority of solid lesions are carcinomas and only a few cases of benign solid lesions have been reported in the literature, and these are either nodular hyperplasia or adenoma. In this case report, a woman presented with swelling of the labium majus, and she was clinically thought to have a Bartholin cyst. The lesion was excised, and histological examination revealed nodular hyperplasia of the Bartholin gland.

Factors complicating surgical management of the vulvar abscess

OBJECTIVE

To delineate risk factors and demographics in those patients with vulvar abscess that required surgical intervention, identify the most common bacterial isolate present at the time of surgery and comment on the progression to necrotizing fasciitis and the need for reoperation.

STUDY DESIGN

Retrospective chart review.

RESULTS

A total of 47 vulvar abscesses with cellulitis were managed surgically. The most common isolate was methicillin-resistant Staphylococcus aureus (MRSA), which comprised 43% of the total. The median length of stay was 4 days (1-66), and 17% had stays >7 days. Diabetes was significantly related to hospitalization >7 days (38% vs. 6%, p<0.01), reoperation (25% vs. 3%, p=0.02) and progression to necrotizing fasciitis (19% vs. 0%, p=0.01).

CONCLUSION

When treating abscess of the vulva with cellulitis, antibiotic coverage of MRSA should be undertaken. Inpatient management with aggressive treatment for abscess of the vulva in those patients with concomitant diabetes is recommended.