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Genital Tract Obstruction

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Presentation on theme: "Genital Tract Obstruction"— 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 Topical estrogen may cause transient hyperpigmentation of labia and areolae and increase in breast tissue; estrogen withdrawal bleed occasionally occurs Further evaluation for abnormalities in gender differentiation or androgen production

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 Frequently missed on newborn exam because of redundancy of hymenal folds;evident by 8-12 weeks old on careful inspection Hymens are not of mullerian origin, so not assoc with other gu abn

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 Usually due to mild, blunt force; Superficial injuries may go unnoticed until pt cries w/urination or blood noticed in underwear Straddle injury – crushing of perineal soft tissues between pubis and object Apply cream b/f urinating; urinate in tub of water; if urinary retention, use topical anesthetic for a few days; deeper tears of labia majora need to control bleeding and suture under anesthesia

6 Genital Trauma Moderate blunt trauma Moderate penetrating injuries
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 Vaginal hematoma – external injury may be deceptively small; pain usu can be referred to rectum/buttocks; bluish swelling involviing wall of vagina Extensive tears may produce little pain if no hematoma; may have little bleeding

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 Get detailed behavioral history and family psychosocial history; may be chronic

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 Increased intra-abdominal pressure; Encircles the urethral meatus

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 Unknown etiology; hour-glass or figure 8 appearance Mistaken for abuse – failure to heal rapidly, pattern and distribution of lesions

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 GAS – sometimes w/out respiratory sx; however throat culture is often positive Down syndrome, young women with increased androgens, children with familial predisposition to keratosis pilaris Also staph, neisseria species

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 ;d/c often bloodstreaked d/c may clinically indistinguishable from vag foreign body Must use enteric specific transport and culture media Also e. coli and yersinia species

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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