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Genital Tract Obstruction  Labial adhesions  Result of inflammation and erosion of superficial layers of mucosa (infection, dermatitis, mechanical trauma)

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Presentation on theme: "Genital Tract Obstruction  Labial adhesions  Result of inflammation and erosion of superficial layers of mucosa (infection, dermatitis, mechanical trauma)"— Presentation transcript:

1 Genital Tract Obstruction  Labial adhesions  Result of inflammation and erosion of superficial layers of mucosa (infection, dermatitis, mechanical trauma)  agglutination  Usually < 1cm, may cover vaginal vestibule and rarely urethra  Usually asymptomatic; urine may be trapped  further irritation  extension of adhesion  Treatment, if desired  Estrogen cream BID x 2 wks, then QHS x 1 wk  Zinc oxide-based cream QHS x several months  NO Manual separation (OUCH!!)  Prevent recurrence (remove irritants, tx infections, hygiene)  True adhesions (first few months of life, no response to tx) need further evaluation

2 Genital Tract Obstruction  Imperforate Hymen  Thick membrane just inside the hymenal ring  Hydrocolpos - secondary to vaginal secretions  Midline swelling of lower abdomen that feels cystic  Whitish, bulging membrane at introitus  Hematocolpos  Infancy if neonatal withdrawal bleed/trauma  Late puberty  DDx of amenorrhea  Intermittent lower abdominal/back pain, progresses in severity  Difficulty in urination/defecation  Cystic swelling palpable on rectal exam  Treatment – excision of membrane  Not associated with other GU abnormalities

3 Genital Tract Obstruction  Vaginal atresia or agenesis  Transverse vaginal septum  Androgen insensitivity  Absence of cervix/uterus  Tumors  Obstructing mullerian malformations, with elements of duplication, agenesis, and/or incomplete fusion  Initial imaging with ultrasound, may need MRI

4 Genital Trauma  Prepubescent vs. adolescent/adult  Genital structures and pelvic supporting tissues more rigid and smaller  Increased risk of tearing with blunt or penetrating trauma, and of internal extension of injury

5 Genital Trauma  Superficial Perineal Injuries  Straddle injury – abrasion, contusion, or tear in and around clitorus and anterior labia majora or minora  Minor falls – simple perineal and vulval lacerations  Mild blunt trauma – usually at junction of labia minora and majora; also tears of labia majora or perineal body  Sexual abuse  Tears of posterior portion of hymen, porterior fourchette, or perineal body  Usually scant bleeding, mild discomfort or pain on urination  Management – supportive  Analgesia, topical bacteriostatic/anesthetic, sitz baths

6 Genital Trauma  Moderate blunt trauma  Perineal tears  venous disruption  hematomas (tense, round swellings)  Intense perineal pain; interfere with urination if periurethral  Also submucosal tears of vagina or mucosal separation with vaginal bleeding/hematoma (inspect vaginal orifice)  Moderate penetrating injuries  Result from falls onto sharp objects, rape, auto accidents  Perineal tears that extend into vagina, rectum, or bladder but do not breach peritoneum  May have deceptively minor external injuries

7 Genital Trauma  Indications for OR exploration/repair  Bleeding through vaginal orifice, vaginal hematoma, rectal bleeding/tenderness, abnormal sphincter tone, gross hematuria, inability to urinate  Obviates the need for extensive exam in ED/office

8 Genital Trauma  Severe trauma  Falls from heights on flat surfaces can simulate penetrating injury  Can disrupt pelvic vessels, mesentery, and intestine, w/ or w/out pelvic trauma  If peritoneal extension, patients complain of lower abdominal/perineal pain initially  guarding/rebound  hypovolemia  Prompt hemodynamic stabilization, imaging and surgical exploration and repair

9 Vulvovaginitis  Unestrogenized vaginal epithelium is thin, friable and more easily traumatized  Labia do not fully cover and protect the vaginal vestibule from friction and external irritants

10 Physiologic Leukorrhea  Thin, white, nonodorous discharge without erythema  Treatment - reassurance

11 Prepubertal Vulvovaginitis Noninfectious etiologies  Poor hygeine  May see pieces of stool or toilet paper in perineum; soiled underwear  Sitz baths and careful cleansing after urination/defecation  Poor perineal aeration  Moisture from normal secretions, perspiration, swimming; incontinence  Obesity, tight clothing, nylon underwear  Secondary infection common after maceration; intertrigo  Contact dermatitis, allergic vulvitis  Itching is predominant sx; dysuria from excoriation  Acute - microvesicular papular eruption, erythematous, edematous  Chronic – eczematoid with cracks, fissures, lichenification  Perfumed soaps or toilet paper, poison ivy, OTC/prescribed ointments/creams  Adolescents – feminine hygiene products, cosmetics, spermicides, douches

12 Prepubertal Vulvovaginitis Noninfectious etiologies  Chemical irritants  Bubble bath, soaps, laundry detergents, fabric softeners, perfumed toilet paper  Infrequent diaper changing  Frictional trauma  Tight clothing, sporting activities (gymnastics, running), sand from sandboxes, excessive masturbation, shaving  If chronic, lichenification and atrophic changes

13 Prepubertal vulvovaginitis Noninfectious etiologies  Fistula  Vesicovaginal fistulas, ectopic ureters  Constantly wet perineum  Appendicitis  After rupture and abscess formation of a pelvic appendix, females may develop a purulent vaginal discharge caused by sympathetic inflammation of the vaginal wall.

14 Prepubertal Vulvovaginitis Noninfectious etiologies  Vaginal foreign body  Profuse, foul-smelling, brownish/blood-streaked vaginal discharge  3 to 8 year old, developmental delay, behavioral problems  Result of disturbed behavior or chronic sexual abuse  Toilet tissue, paper, cotton, crayons, small toys  Long latency period for inert materials  Direct vaginoscopy usually required  Under anesthesia or conscious sedation

15 DDx of Vulvovaginitis  Urethral prolapse  Dysuria, perineal pain, bleeding  AA, obese prepubertal girls  Constipation, coughing, crying may contribute  Red/purplish swollen, friable tissue overlying anterior introitus; doughnut shaped; tender  Estrogen cream, analgesics, tx underlying cause

16 DDx of Vulvovaginitis  Lichen sclerosus  Chronic dermatologic disorder involving perineum and perianal area  Etiology unknown  May be preceded by perineal itching or mild watery discharge  Small pink or white, flat-topped papular lesions on cutaneous and mucosal surfaces; coalesce to plaquelike, scaly lesions  May see vesiculation, superficial ulceration/excoriation with erythema, maceration, punctate bleeding (usu from scratching)  Progress to thin, atrophic, hypopigmented epithelium  Wax/wane for several years; resolves around puberty  Tx acute exacerbations with high-potency topical steroids

17 Prepubertal Vulvovaginitis Infectious etiologies  Respiratory/skin pathogens  Result of orodigital transmission  GAS  Abrupt onset of severe burning and dysuria  Sharply demarcated area of intense erythema  Seroanguineous or grayish-white d/c  S.pneumo and H. flu  Purulent d/c, vulvitis, vaginitis  Viral  Varicella, adeno, echovirus, measles, EBV  Folliculitis/impetigo  Poor hygiene, sweating, shaving, mechanical irritation

18 Prepubertal vulvovaginitis Infectious etiologies  GI pathogens  Shigella  No GI sx; 1/3 have diarrhea  Acute/chronic vaginal d/c, otherwise no sx  PE: purulent, blood-streaked d/c, vulvar and vaginal erythema  G-stain: PMN with GNR; pos cx diagnostic  High rate of coinfection with pinworms

19 Prepubertal vulvovaginitis Infectious etiologies  Pinworms  Enterobius vermicularis  May cause vaginal infection and discharge; usually a history of preceding perianal pruritus  Wet mount of vaginal secretions; if neg, do sticky tape test or empiric treatment

20 Prepubertal vulvovaginitis Infectious etiology  Candida  Rare in healthy prepubertal child  Risk factors: recent abx, poor perineal ventilation, DM, immunodeficiency, pregnancy, use of OCP  Pruritus, contact dysuria, dyspareunia  PE: diffuse erythema, thick white d/c; pink/white cobblestone plaques if chronic; satellite lesions  KOH prep-budding yeast; low vaginal pH  Topical azole antifungal cream or oral fluconazole (single dose)  Recurrent  Consider predisposing factor (HIV)  Other fungi (Torulopsis); do fungal culture

21 Prepubertal Vulvovaginitis Evaluation  History  Dysuria, frequency, urgency, perianal pruritus  Duration  Recent respiratory, GI or urinary tract infections  Exposure to irritants  Bowel and bladder habits  Type of clothing worn  Recent activities (daily swimming)  Medications, topical agents  Caretakers (if abuse suspected)  Developmental, behavioral, environmental, medical hx

22 Prepubertal Vulvovaginitis Evaluation  Physical exam  Degree ofpubertal development  Inguinal and abdominal exam  Rectal, perineal, vaginal inspection  Degree of inflammation/excoriation (may appear normal)  Examine underwear  No bathing 12 to 24 hours before exam  Send any vaginal d/c for testing; ua/culture

23 Prepubertal vulvovaginitis Treatment  Noninfectious  Removal of offending agent  Provide sufficient opportunities to urinate  Front-to-back wiping  Regular washing with mild soap; no scrubbing  Avoid skin/vaginal cosmetics, scented pads, bubble bath, fabric softeners, dryer sheets  Wear loose-fitting clothing; white cotton underwear

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