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Background: A suburethral diverticulum is a herniation of the urethra into the potential space between the anterior vaginal wall and the periurethral fascia. We report a case of an unusual-appearing suburethral diverticulum that resulted from repetitive self-induced trauma., Case: A 43-year-old, mentally handicapped woman presented to our clinic for evaluation of a papillary mass projecting from her anterior vaginal wall. Her caretakers reported that the woman traumatized herself periodically to induce vaginal bleeding. After evaluation the mass was excised in the operating room, and the diagnosis of a suburethral diverticulum was confirmed., Conclusion: Self-induced trauma as an etiology of suburethral diverticula should be considered in patients with atypical-appearing masses of the anterior vaginal wall.

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.

Background: Vaginal cuff dehiscence is an uncommon but serious complication of hysterectomy. It has not previously been described in the setting of systemic lupus erythematosus (SLE) and total laparoscopic hysterectomy (TLH)., Case: A 43-year-old woman with SLE presented to the emergency department >7 weeks after TLH with severe abdominal pain resulting from a postoperative intercourse attempt. Examination under anesthesia revealed complete separation of the anterior and posterior vaginal cuff edges., Conclusion: A patient's medical profile, including comorbidities that affect wound healing, plays a role in vaginal cuff integrity after hysterectomy. For patients with SLE undergoing TLH, temporarily stopping immunosuppressive medications for several weeks preoperatively and postoperatively and allowing prolonged recovery with pelvic rest may improve postoperative outcomes.

Background: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become a curative treatment modality for many patients with malignant hematologic diseases. Despite impressive advances in the management of allo-HSCT, graft vs. host disease (GvHD) is a frequent complication that significantly contributes to the morbidity and mortality associated with transplantation and is a significant obstacle to overcome., Case: An unusual case of hematocolpometra secondary to vaginal stenosis occurred as a manifestation of chronic GvHD., Conclusion: Management of vaginal stenosis and stricture formation as a manifestation of chronic GvHD consists of surgery with lysis of adhesions. Return of anatomic distortion to normal is followed by vaginal dilatation. Later, local estrogen cream and sexual activity help to avoid further adhesion formation.

Objective: To analyze the clinical trends of gestational trophoblastic neoplasia (GTN) at the Department of Obstetrics and Gynecology, Hospital Universitario de Caracas (HUC)., Study Design: A medical record review was performed of epidemiologic, clinical and diagnostic features of 25 cases of GTN at HUC from 1997 to 2004., Results: During the study period, 35,300 deliveries occurred, and 25 patients were diagnosed with GTN; the prevalence was 0.70:1,000 deliveries. The mean age was 29.2 years. Fifty-six percent were posthydatidiform mole (HM), 36% postchoriocarcinoma (CC), 4% postinvasive mole and 4% postabortion with abundant intermediate trophoblast. Vaginal bleeding was the main symptom in patients with CC. Two cases resembled ectopic pregnancy, and another resembled a vaginal endometrioma. Fifty-two percent of cases were at stage Ib; 76% received single-agent chemotherapy. Hysterectomy was performed in 6 cases. Twenty-one patients achieved remission, 2 showed regression and 2 died., Conclusion: GTN had a high prevalence because HUC is a reference center. The most common presentation was post-HM GTN. Vaginal bleeding is frequent in CC and can mimic other gynecologic diseases. Chemotherapy is helpful, and hysterectomy can be performed in selected cases at early stages or with severe vaginal bleed-with a good ing. GTN has a good prognosis, and early diagnosis is possible.

Background: Bone marrow transplantation is used in the treatment of a variety of malignancies. One common sequela is graft-versus-host disease (GvHD.), Case: A case of vaginal GvHD in a postmenopausal woman manifested as a 2-cm, cystic, paracervical mass. The patient was followed with consecutive pelvic ultrasounds and pelvic examinations until 27 months after transplantation, when the mass increased in size to 4 x 3 cm. Exploratory laparotomy with total abdominal hysterectomy revealed a 3 x 3-cm phlegmon within the proximal part of the vagina. Presumably, this resulted from vaginal GvHD, causing a midvaginal stricture with obstruction of cervical/uterine effluent., Conclusion: An awareness of the gynecologic manifestations of GvHD is critical for clinicians caring for women undergoing bone marrow transplantation.

Background: Arteriovenous malformations are composed of large, tortuous arteries and misshapen, veinlike structures. They are extremely uncommon in the genital tract., Case: An arteriovenous malformation in a Bartholin gland presented as intermittent vaginal bleeding in a 43-year-old woman., Conclusion: Persistent unexplained bleeding from Bartholin's gland requires surgical excision.

Objective: To evaluate the incidence of vulvar lesions during the acute and healing periods in toxic epidermal necrolysis (TEN), to describe the clinical aspects and functional consequences, and to evaluate surgical treatment., Study Design: During the acute period in 40 patients, cutaneous and mucous lesions were described on the day of hospitalization and daily thereafter. To evaluate the healing period, a questionnaire was sent to the same 40 patients to obtain information on symptomatology after the acute period, anatomic modifications, and the quality of sexual and other genital activity., Results: During the acute period, genital lesions were present in 28 of the 40 patients studied (70%). In 24/28 (89%) the lesions were vulvar only, and in 3/28 (11%) they were vulvovaginal. In one case vaginal involvement could not be proven because the patient was a virgin. During the healing period, sequelae occurred in 5 of the 40 patients (12.5%): four cases were known since the patients had visited the Department of Gynecology because of secondary effects, and one case was detected by the questionnaire. The symptoms occurred during hospitalization in 1 case, at the end of the second month in 2, at the 12th month in 1 and unknown in 1. The site was the vulva in all five cases and was the vulva and vagina in three. Again, the virgin could not be examined. The average interval between secondary effects and the original gynecologic visit was 7 months (3-12). The sequelae were treated surgically in two of the five affected patients: on the vulva, nymphoplasty, posthectomy and median perineotomy; in the vagina, sharp and blunt dissection, with use of a soft mold. The first patient had a recurrence six months after surgery, and the second had no recurrence but has been unable to engage in intercourse., Conclusion: From our study of the involvement of the vulva and vagina during TEN and the sequelae, it is clear that detection from the questionnaire was insufficient. Some women can have synechiae without functional sequelae, and others can have minor involvement with important psychological repercussions. A prospective study with systematic examination of the vulvovaginal area and systematic follow-up for at least one year is needed. For therapy, a lubricant gel (perhaps topical steroids) could be useful. Placing a soft mold in the vagina as soon as possible, though difficult, and keeping it there until complete healing occurs can lead to infection. It is not clear that use of a mold would promote healing or be tolerated. Intercourse immediately after the acute period would be helpful but probably would not be welcome to the patients. However useful, a prospective survey would be difficult because it would entail many years of study.

Women members of the newly formed Ehlers-Danlos National Foundation (EDNF) were surveyed with a very detailed questionnaire with 50 questions concerning family history and inheritance, past medical history, and obstetric and gynecologic problems. They entailed the largest extant database on Ehlers-Danlos Syndrome (EDS) patients. The mean age of the 68 women who responded to the survey was 42 years; most had EDS types I, III, IV and unknown. Forty-three women had 138 pregnancies; 13 women never married. The stillbirth rate was 3.15% (3/95); the preterm delivery rate was 23.1% (22/95), and the spontaneous abortion rate was 28.9% (40/138). There was a cesarean delivery rate of 8.4%, with 14.7% having perinatal bleeding problems. One woman (EDS type IV) had congestive heart failure. Common gynecologic problems were recurrent anovulation (41.3%), recurrent vaginal infections (53%), abnormal cytologic smears (19%), sexual dysfunction (61%), irregular menses (28%), endometriosis (15.8%), vaginal dryness (25%) and a need for hysterectomy (19.1%). In this largest series of pregnancies with EDS, we found relatively high rates of abortion, preterm delivery, pregnancy-related bleeding and stillbirth. Women with EDS also seem to have high frequency of anovulation, vaginal infections, abnormal cytologic smears and dyspareunia.

Despite the fact that vaginal douching is practiced regularly by approximately 20 million American women, little is known about who douches, why or its associated risks or benefits. Recent studies of douching collectively suggest a possible association with ectopic pregnancy and pelvic inflammatory disease. These findings, however, are difficult to interpret because of the small number of studies, conflicting findings and methodologic weaknesses, reflecting both the early stage of interest and difficulties inherent to studies of intimate behaviors. Further information is needed to differentiate between douching as a causal factor or as an indicator for behaviors that increase the risk of sexually transmitted diseases and their complications. The central issue is whether other risk factors and/or markers for sexually transmitted diseases, which are more common among women who douche, have been reasonably excluded as a source of bias. Few, if any, criteria for establishing a causal link between douching and adverse outcomes are satisfied, but this reflects a paucity of data rather than data that refute such a conclusion.

During a 15-month period, September 1984 through January 1986, 10 women who were treated in the Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania, developed vaginal or vulvar adenosis after CO2 laser vaporization. The indications for therapy were condylomata of the cervix, vagina and vulva refractory to conservative management in 3 patients, vulvar intraepithelial neoplasia in 3, lichen sclerosus in 1 and cervical intraepithelial neoplasia with condylomata on the cervix and vagina in 3. All the patients underwent treatment of the vagina. Most underwent treatment of the cervix, and some underwent treatment of the vulva at various degrees of intensity and depth. During the posttreatment colposcopic follow-up examination, all the patients demonstrated lesions colposcopically consistent with adenosis of the vagina or vulva within the area treated with the CO2 laser. Biopsies of the lesions were performed, adenosis was confirmed histologically, and endometriosis was ruled out histologically. This entity has not been previously associated with CO2 laser vaporization, and its clinical significance is undetermined. Further follow-up is indicated.

Prospective and retrospective experience with physical complaints of 112 oral contraceptive and 67 intrauterine device Black family planning patients with sickle cell trait was evaluated by comparing their cumulative complaint rates with a randomly selected control group of non-sickle cell trait family planning patients having the same method, age and parity distribution as the sickle cell trait patients. Physical complaints considered are: dysmenorrhea, mental depression, vaginal discharge, fatigue, headaches, and nausea-vomiting. No evidence of a significant difference at level .05 is found between cumulative complaint rates of sickle cell trait and control patients for either oral or intrauterine device users for any of the complaint types. Further clinical research may be desirable in this area for dysmenorrhea and mental depression.

All women referred to the Department of Obstetrics and Gynecology, School of Medicine, State University of New York at Stony Brook, for evaluation of vulvar condylomata were reviewed to identify concurrent cervical and vaginal pathology. Over the five-year period 1981-1985, referrals to our colposcopy clinic for vulvar condylomata increased from 7.8% to 29.2%. All patients underwent a thorough history, physical examination and colposcopic evaluation of the cervix, vulva and vagina. Of the patients with vulvar condylomata, 68% had biopsy-proven cervical and vaginal pathology. While 50% of patients with cervical disease had human papillomavirus infection alone, the other 50% had concurrent cervical intraepithelial neoplasia (CIN) or CIN only. Proper evaluation of patients with vulvar condylomata must include colposcopy of the cervix and vagina.

Eleven patients developed a delayed reaction to the Dacron buttress used in Stamey urethropexy. The reaction was characterized by pain, dyspareunia, vaginal discharge and/or bleeding, induration of the abdominal incision, vaginal granulation tissue and draining abdominal or vaginal sinus tracts. This complication occurred in 5% of the 163 patients we treated with the Stamey procedure for stress urinary incontinence. Treatment consisted of removal of the nylon suture and Dacron buttress. None of the 11 patients developed recurrent incontinence. The subjective cure rate for stress urinary incontinence was 92% using the Stamey procedure.

Between Jan 1, 1985, and Dec 31, 1987, 26 women were treated for vaginal intraepithelial neoplasia (VAIN). Twenty-two of them had undergone hysterectomy, 15 for a cervical intraepithelial neoplasia or cancer. Five patients were identified whose management was complicated by the presence of the neoplastic process within vaginal cuff inclusion cysts (or sinuses). All five patients ultimately underwent upper vaginectomy as part of their treatment, and two of them were found to have an invasive squamous cell carcinoma of the vagina. Women who are found to have an abnormal Papanicolaou smear or VAIN in the upper vagina following hysterectomy should be examined carefully for vaginal cuff abnormalities. Those with nodularity or distortion of the cuff are best managed with surgical excision for both treatment of VAIN and discovery of an occult invasive cancer.

Foreign bodies present in the vagina for long periods of time are infrequent but potentially serious findings in adult women. Significant injury can occur to bowel, bladder or other pelvic structures. Repair of fistulae is delayed following removal of the foreign bodies until the chronic inflammation produced by the objects has resolved. Coexisting psychiatric illness or physical abuse may complicate the evaluation and treatment of some women with long-standing vaginal foreign bodies.