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Rationale: Embryonal rhabdomyosarcoma (ERMS) is a major subtype of rhabdomyosarcoma, mainly affect children. There is seldom report for perineal ERMS in adults, since its rare location and the age., Patient Concerns: A 20-year old male adult was admitted due to the perineal mass., Diagnoses: Diagnosis by histopathological examination of the biopsy sample was ERMS. Magnetic resonance imaging showed the tumor was found in the perineal region, with metastasis to pelvic cavity, right testis, lymph nodes and bone., Interventions: The patient received Isophosphamide and Epirubicin for 4 cycles, followed by Irinotecan and Vindesine Sulfate for 2 cycles, then cisplatin, Dacarbazine and Apatinib for 3 cycles., Outcome: The patient showed no response to chemotherapy., Lessons: Perineal ERMS in adults is very rare. There is still no standard therapy for adult ERMS. Personalized therapy might be promising treatment for each individual., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: Prostate biopsy is a very commonly performed office procedure leading to the diagnosis of the most prevalent solid-organ malignancy in American men. Although the transrectal technique for prostate biopsy remains the gold standard, there is increasing interest in the transperineal approach as it offers a clean, percutaneous approach that significantly decreases the risk for infection. In this review, we discuss emerging developments in transperineal prostate biopsy that may optimize the way biopsies are performed in clinical practice., Recent Findings: Similarly, to transrectal biopsy, the transperineal approach also allows for the performance of systematic and MRI-targeted biopsy cores. As transperineal biopsy obviates the translocation of rectal bacteria to the prostate or bloodstream, in contrast to transrectal biopsy, it is feasible to forgo peri-procedural antibiotics in accordance with professional guidelines. This may attenuate antimicrobial resistance that may be associated with augmented prophylaxis. In addition, although transperineal biopsy may be traditionally performed under general anesthesia using a template grid, it may also be performed freehand under local anesthesia or sedation. Avoiding prophylactic antibiotics and general anesthesia as well as reducing infections/hospitalizations for transperineal biopsy scaled nationally will likely result in significant healthcare savings., Summary: Transperineal biopsy with combined systematic and MRI-targeted cores, offers several advantages over conventional transrectal biopsy. Transperineal biopsy under local anesthesia and without periprocedural antibiotic is emerging as a promising method for prostate cancer diagnosis and surveillance., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

We report a case of clear cell hidradenoma of the perineum that was initially misinterpreted as a papillary urothelial carcinoma, either metastatic or of Bartholin gland origin, on initial excisional biopsy. The misinterpretation may have been due to the pseudopapillary architecture and GATA3-positivity of the biopsy tissue. Clear cell hidradenomas often show a range of histologic growth patterns and cellular differentiation and are one of many tumors that react immunohistochemically with GATA3. Although rare, these tumors can occur in the genital region and can mimic malignant tumors such as metastatic renal cell carcinoma and carcinomas of the genitourinary tract. This report details the morphologic and immunohistochemical pitfalls that make accurate diagnosis of clear cell hidradenoma in this unusual location challenging., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 by the International Society of Gynecological Pathologists.)

Competing Interests: The authors declare no conflict of interest.

Rationale: Tarlov or perineurial cysts are nerve root lesions often found in the sacral region. Most perineural cysts (PCs) remain asymptomatic throughout a patient's life. While their pathogenesis is still unclear, trauma resulting in hemorrhaging into subarachnoid space has been put forward as a possible cause of these cysts. Recently, we worked with a patient experiencing symptomatic PCs after spontaneous subarachnoid hemorrhage., Patient Concerns: A 45-year-old man had a coil embolization procedure performed after being diagnosed with a subarachnoid hemorrhage from a ruptured anterior communicating artery. His symptoms were relieved after the procedure, but 7 days later he reported worsening pain in the left perineal area. The pain was intermittent at its onset and exacerbated by sitting, walking, and coughing., Diagnoses: Two weeks after the embolization procedure, a lumbar spine MRI revealed 2 PCs at the S1 and S2 level affecting the left S2 root with high signal intensity in T2 and T1 images, suggestive of bleeding within the cyst., Interventions: We operated using a posterior approach. Cyst fenestration was done after S1 laminectomy. We aspirated approximately 1 cc of old blood., Outcomes: His pain was relieved immediately after cyst removal and no neurologic deterioration occurred during the postoperative period., Lessons: Subarachnoid hemorrhage can be the source of the development of pain from asymptomatic PCs, making them symptomatic. Surgical extirpation is 1 treatment option for these symptomatic PCs., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Long regarded as ectopic or supernumerary breast tissue, anogenital mammary-like glands (AGMLG) are now considered a normal constituent of the anogenital area. AGMLG are presumed to be the origin for various benign and malignant lesions. Changes in AGMLG compatible with usual ductal hyperplasia and atypical ductal hyperplasia considered as precursor lesions and its presence in specimens can be explained by their role in the pathogenesis of primary extramammary Paget disease. In this report, we presented four cases of invasive squamous cell carcinoma accompanied by non-neoplastic atypical changes in ductal portions of AGMLG compatible with atypical ductal hyperplasia in breast adjacent to the carcinoma. This is a reactive phenomenon similar to that seen in apocrine/eccrine glands adjacent to squamous cell carcinoma. In a limited biopsy specimen, these areas should not be mistaken for adenocarcinoma., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 by the International Society of Gynecological Pathologists.)

To summarize the clinical features, diagnosis, and treatments of perineal endometriosis (PEM).We retrospectively studied the clinical data of 35 patients with PEM between April 2012 and December 2018 in West China Second Hospital. Patients were divided into the gonadotropins releasing hormone (GnRH) agonist group and non-GnRH agonist group.The main clinical symptom was vulvar painful swellings related to menstrual cycles. Thirty-three patients' lesions (94.29%) were on the episiotomy scar while 1 case was at the opposite side of the scar. We even found 1 nullipara was diagnosed as PEM. Ten patients (28.57%) were found with anal sphincter involvement. All patients received complete excision of PEM. The recurrence rate of GnRH agonist group was 7.69% (1/13), while the rate of non-GnRH agonist group was 18.75% (3/16).Most PEM was associated with episiotomy history, but PEM could also exist in nullipara. Complete excision of PEM was inevitable. The effect of GnRH agonist on recurrence of PEM needs further studies.

Objective: Genital hiatus (Gh) and perineal body (Pb) are part of the Pelvic Organ Prolapse Quantification assessment system, but it is unclear whether measurements should be taken at rest or on Valsalva. This study was designed to assess the predictive value of Gh and Pb measurements obtained at rest and on Valsalva for signs and symptoms of pelvic organ prolapse (POP)., Methods: This is a retrospective study involving 416 women who presented to a tertiary urogynecology unit with symptoms of pelvic floor dysfunction. Genital hiatus and Pb were measured at rest and on maximal Valsalva. The strength of association between binary markers of POP and measurements of Gh/Pb was estimated using logistic regression analysis. Receiver operator characteristic statistics were used to compare predictive values of Gh and Pb measurements obtained at rest and on Valsalva., Results: A total of 451 women were seen during the study period. Thirty-five were excluded owing to missing data, leaving 416. Fifty-four percent (n = 223) complained of POP symptoms. On examination, 80% (n = 332) had significant POP (stage 2+ in anterior or posterior compartments or stage 1+ in the central compartment). On imaging, significant POP was diagnosed in 66% (n = 275). Mean hiatal area was 22 cm (SD, 7; range, 5-49 cm) at rest and 30 cm (SD, 10; range, 11-69 cm) on Valsalva. Genital hiatus and Pb measured on Valsalva were consistently stronger predictors of prolapse symptoms and objective prolapse (by clinician examination and by ultrasound) than at Gh and Pb measured at rest. The corresponding area under the curve values were significantly larger for Gh/Pb measures on Valsalva after adjusting for multiple confounders., Conclusions: Genital hiatus/Pb measured on maximal Valsalva is a superior predictor of symptoms and signs of POP compared with Gh/Pb at rest.

Objective: Ampulla of Vater carcinoma (AVC) has a broad spectrum of different prognoses. As such, new moderators of survival are urgently needed. We aimed at clarifying the prognostic role of perineural invasion in AVC., Methods: Using PubMed and SCOPUS databases, we conducted the first systematic review and meta-analysis on this topic., Results: Analyzing 29 articles for a total of 2379 patients, we found that the presence of perineural invasion increased the risk of all-cause mortality more than 2 times (relative risk [RR], 2.07; 95% confidence interval [CI], 1.78-2.42 [P < 0.0001]; hazard ratio [HR], 2.72; 95% CI, 1.86-3.97 [P < 0.0001]), of cancer-specific mortality more than 6 times (RR, 6.12; 95% CI, 3.25-11.54 [P < 0.0001]; HR, 6.59; 95% CI, 2.29-3.49 [P < 0.0001]), and of recurrence more than 2 times (RR, 2.63; 95% CI, 1.89-3.67 [P < 0.0001]; HR, 2.54; 95% CI, 1.24-5.21 [P = 0.01])., Conclusions: Perineural invasion is strongly associated with a poorer prognosis in AVC, influencing both survival and risk of recurrence. It should be reported in the final pathology report and should be taken into account by future oncologic staging systems, identifying a group of AVC with a more malignant biological behavior.

Objectives: Over the last decade, there has been a notable increase in the incidence of abscesses. Children in the diaper-wearing age group are disproportionately affected, and most of these abscesses occur in the buttock and perineal region. Using case-control methodology, we sought to determine if diaper use itself is an independent risk factor for abscess formation., Methods: Cases were patients, at least 2 years of age but less than 4 years, who presented to the emergency department with a complaint of a buttock or perineal abscess. Age-matched controls presented to the emergency department for unrelated reasons. Caregivers of subjects responded to a survey regarding diaper use (toilet trained, for sleep only, or all day), type and brand of diaper, and diaper hygiene-related factors., Results: We enrolled 465 patients (93 cases, 372 controls). Fully toilet trained children were less likely to have buttock and perineal abscess than their sleep-only and all-day diaper-wearing peers. Limiting diaper use to naptime and overnights (sleep only) did not confer protection against abscesses. Diaper hygiene-related factors did not affect the risk of abscess formation. Female sex was also identified as a strong risk factor for buttock and perineal abscess formation., Conclusions: Diaper use is a potentially modifiable risk factor for buttock and perineal abscess formation in young children.

We present a cadaveric case study of an 88-year-old woman with an unusual posterior perineal hernia containing small bowel, rectum, and mesentery. Dissection revealed several loops of the small bowel occupying the presacral space and displacement of the rectum into a large perineal evagination. The intestinal mucosa appeared to have been healthy at the time of death, and we did not find any indication of rectal prolapse. There was also no evidence of past surgery, suggestive of a primary hernia. We conclude this patient had a posterior enterorectal perineal hernia. Suggestions for surgical repair are described.

To compare the accuracy of magnetic resonance-guided prostate biopsy (MR-GPB) and template-guided transperineal prostate saturation biopsy (TTPSB).A total of 219 patients with elevated prostate-specific antigen, abnormal digital rectal examination or ultrasound findings were enrolled. All patients underwent multiparametric magnetic resonance image (mpMRI). Patients with a Prostate Imaging Reporting and Data System (PI-RADS) score of 3 to 5 underwent MR-GPB using 2 to 5 biopsy cores and then immediately underwent an 11-region TTPSB. Patients with a PI-RADS score of 1 to 2 underwent TTPSB alone. We compared the detection rates for any cancer, clinically significant prostate cancer (csPCA), and the spatial distribution of missed csPCA lesions.Among the 219 cases, 66 (30.1%) had a PI-RADS score of 1 to 2 on mpMRI. The detection rate of TTPSB in these patients was 9.1% (6/66). In total, detection rates for any cancer and csPCA were 48.9% (107/219) and 42.9% (94/219), respectively. Detection rates for any cancer (TTPSB 87/219, 39.7%; MR-GPB76/219, 34.7%, P = .161) and csPCA (TTPSB 76/219, 34.7%; MR-GPB 72/219, 32.9%, P = .636) did not significantly differ between the 2 groups. The csPCA lesions missed by MR-GPB were most commonly located on the left (8.5%, 8/94) and right (9.6%, 9/94) sides of the urethra.MR-GPB can reduce the rate of unnecessary prostate biopsies by approximately 30% and exhibits an efficacy comparable to TTPSB for the detection of any cancer and csPCA. Nevertheless, approximately 1/4 of csPCAs were missed by MR-GPB and were most commonly located on both sides of the urethra.

Purpose of Review: Over the past 20 years, several randomized studies have compared Valsalva and spontaneous pushing techniques during vaginal delivery. This review summarizes current medical knowledge concerning their maternal and fetal consequences, focusing on pelvic and perineal outcomes., Recent Findings: We selected nine randomized controlled trials comparing Valsalva and spontaneous pushing, and a secondary analysis of a randomized controlled trial comparing different methods of perineal protection. Two trials showed that spontaneous pushing reduces the risk of perineal tears, but no firm conclusions can be drawn given the heterogeneity and inconsistent results of these studies. Conflicting results have been reported regarding the duration of the second stage of labor. Pushing technique does not seem to affect episiotomy, instrumental delivery or cesarean rates. Maternal satisfaction seems to be better after spontaneous pushing. Spontaneous pushing appears to have no adverse effects on neonatal well being, and one study showed a significant improvement in prenatal fetal parameters during the expulsive phase., Summary: Valsalva and spontaneous pushing techniques currently appear comparable in terms of duration, pelvic floor, perineal, and neonatal outcomes. In the absence of strong evidence in favor of either technique, the decision should be guided by patient preference and the clinical situation. Additional, well-designed randomized controlled trials are required.

Objectives: This study aimed to describe the relationship between genital hiatus (GH) and perineal body (PB) measurements with increasing pelvic organ prolapse (POP) stage in a large cohort of women referred to Urogynecology clinic for pelvic floor disorders., Methods: Retrospective chart review of all new patients seen in an academic Urogynecology clinic between January 2007 and September 2011 was performed. Data were extracted from a standardized intake form. All patients underwent a Pelvic Organ Prolapse Quantification (POPQ) examination. Descriptive statistics compared the study population. Analysis of variance was used to compare GH and PB measurements by prolapse stage. Fisher least significant differences were used for post hoc comparisons of means between prolapse stages. Pearson correlations were used to evaluate the associations between GH and PB measurements and patient characteristics., Results: A total of 1595 women with POPQ examinations comprised the study population. The mean age was 55.3 ± 14.8 years with a body mass index of 30.3 ± 7.6 kg/m, most women were parous (90%), 40% were Hispanic, and 33% had undergone prior hysterectomy for indications exclusive of POP. Women with any prior prolapse repair were excluded, 6.5% had a prior incontinence procedure. Perineal body measurements were slightly larger for stage 2 POP, but overall did not vary across other prolapse stages (all P > 0.05). In contrast, GH measurements increased through stage 3 POP, GH measurements decreased for stage 4 POP., Conclusions: Mean PB measurements did not demonstrate large changes over prolapse stage, whereas GH measurements increased through stage 3 POP. Genital hiatus serves as an important marker for underlying pelvic muscle damage.

Objective: The aim of this prospective observational study was to obtain a better understanding of the anatomy and to classify the observed different perineal presentations at the time of posterior colporrhaphy and to describe specific surgical techniques used., Methods: To classify the observed perineal findings, the Pelvic Organ Prolapse Quantification System with a newly introduced additional measurement of the perineal ridge (PR) was taken intraoperatively and postoperatively in 121 consecutive women undergoing posterior colporrhaphy. Dependent on the preoperative classification of the perineum as being normal (type 1), deficient (type 2), or with a PR (type 3), a specific surgical repair was performed for each type of perineal presentation., Results: The perineal presentations were categorized into 3 defined groups. Type 1 (normal perineum) was seen in 40%, type 2 (deficient perineum) in 13%, and type 3 (PR) in 47%. A type 1 correlates with prior cesarean section (P = 0.29), a type 2 correlates with prior vaginal delivery (P = 0.05), and type 3 perineum with prior pelvic floor surgery (P < 0.0001). When perineal type-specific surgical techniques were performed, the perineal body length increased postoperatively in type 2 (P < 0.05), decreased in type 3 (P < 0.05), and remained unchanged in those with type 1 defects., Conclusions: This study demonstrates that the perineal region can be clearly defined into 3 categories. The distinct perineal presentation correlates with the previous gynecological history. With a specific perineal repair at the time of posterior colporrhaphy, the perineal anatomy can be restored in the short term.

Purpose of Review: This review discusses the feasibility, recent advances and current status of in-bore MRI-guided interventional techniques for diagnosis and treatment of focal prostate cancer (PCa) and also explores the future applications, highlighting the emerging strategies for the treatment of PCa., Recent Findings: Multiparametric MRI has opened up opportunities for diagnosis and targeted therapeutics to the site of disease within the organ wherein minimizing the incidence of treatment-related toxicity of whole gland therapy. MRI-guided targeted biopsy has a higher detection rate for significant cancer and lower rate of detection of insignificant cancer. In comparison to ultrasound-guided focal therapy, in-bore treatment provides the advantage of real time thermal monitoring during treatment and assessment of treatment coverage by an enhanced scan immediately post-treatment. Preliminary results of ongoing phase I and II in-bore focal PCa treatment trials via transperineal, transrectal and transurethral routes, using different energy modalities for the ablation, have shown promising results., Summary: Advances in multiparametric-MRI has opened up opportunities for in-bore targeted focal treatment of PCa in the correctly selected patient.

Fournier's gangrene is a rare but rapidly progressive necrotizing infection that results from the synergistic action of multiple aerobic and anaerobic organisms colonized on the skin and in the anogenital area. This is a case report of a middle-aged man with late presentation of Fournier's gangrene that was treated aggressively by a team of infectious disease specialists, surgeons, intensivists, and intensive care unit specialty nurses over a 3-week period. Despite heroic efforts by the multidisciplinary team, the patient's condition deteriorated and he died of multisystem failure. The purpose of this article was to alert clinicians to the etiology, pathophysiology, risk factors for invasive necrosis, prognostic indicators, and current diagnostic and treatment recommendations. Fournier's gangrene represents a true medical and surgical emergency and requires early recognition and a team approach to management.

This review discusses multiple cutaneous malignancies that can present on the perineum. Although all of these neoplasms are uncommon, a focus will be on the more common neoplasms including extramammary Paget disease, basal cell carcinoma, squamous cell carcinoma, and melanoma. Other more rare entities discussed are superficial leiomyosarcoma, giant solitary trichoepithelioma, and cutaneous endometriosis.

Introduction: During pancreaticoduodenectomy (PD) for ductal adenocarcinoma, a frozen section (FS) neck margin is typically assessed, and if positive, additional pancreas is removed to achieve an R0 margin. We analyzed the association of this practice with improved overall survival (OS)., Methods: Patients who underwent PD for pancreatic ductal adenocarcinoma from January 2000 to August 2012 at 8 academic centers were classified by neck margin status as negative (R0) or microscopically positive (R1) on the basis of FS and permanent section (PS). Impact on OS of converting an FS-R1-neck margin to a PS-R0-neck margin by additional resection was assessed., Results: A total of 1399 patients had FS neck margins analyzed. Median OS was 19.7 months. On FS, 152 patients (10.9%) were R1, and an additional 51 patients (3.6%) had false-negative FS-R0 margins. PS-R0-neck was achieved in 1196 patients (85.5%), 131 patients (9.3%) remained PS-R1, and 72 patients (5.1%) were converted from FS-R1-to-PS-R0 by additional resection. Median OS for PS-R0-neck patients was 21.1 months versus 13.7 months for PS-R1-neck patients (P < 0.001) and 11.9 months for FS-R1-to-PS-R0 patients (P < 0.001). Both FS-R1-to-PS-R0 and PS-R1-neck patients had larger tumors (P = 0.001), more perineural invasion (P = 0.02), and more node positivity (P = 0.08) than PS-R0-neck patients. On multivariate analysis controlling for adverse pathologic factors, FS-R1-to-PS-R0 conversion remained associated with significantly worse OS compared with PS-R0-neck patients (hazard ratio: 1.55; P = 0.009)., Conclusions: For patients who undergo pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, additional resection to achieve a negative neck margin after positive frozen section is not associated with improved OS.

Unlabelled: Abdominoperineal resections have evolved to the point where increasing amounts of skin and pelvic floor are removed, resulting in extensive defects. Many patients receive neoadjuvant chemoradiotherapy and may require adjuvant treatment; thus, primary wound healing is essential. Existing reconstructive techniques may be inadequate and predispose to postoperative complications including wound breakdown and perineal herniation. The authors have developed a novel innervated gluteal flap reconstruction with significant advantages, including preservation of abdominal wall integrity, prone harvest, reliable vascularity, bulky volume, and tailored inset. This robust technique addresses all components required for successful perineal reconstruction comprising dead space obliteration, reconstruction and maintenance of perineal floor integrity, and importation of nonirradiated skin to facilitate primary wound healing. Indications can be extended to include reconstruction of the posterior vaginal wall and large sarcoma/sacrectomy defects., Clinical Question/level of Evidence: Therapeutic, IV.

Objective: This study aimed to further characterize the epidemiology, clinical manifestations, pathology, immunopathology, outcome from therapy, and associated underlying malignancy in extramammary Paget disease (EMPD)., Materials and Methods: We conducted a retrospective review of patients treated for EMPD in our tertiary care center during a 23-year period ranging from 1985 to 2008., Results: Sixty-four cases of EMPD were diagnosed during this period. Mean age at diagnosis was 66.8 years. Of the patients, 79.7% were female. Tumors were mostly localized on the vulvoperineal region. Associated cancers were found in 30% of the patients and included breast cancer and urogenital cancers. Of the patients, 42% had a least 1 recurrence. The risk of recurrence could only be associated to tumor location on the vulvoperineal region. The limitations of this study include its retrospective nature and sample size., Conclusions: Extramammary Paget disease is more commonly found on the vulva of older women and frequently recurs. Recurrence was not associated to margin status, which would support a more conservative therapeutic approach.

Objective: To evaluate the safety and efficacy of topical cidofovir for treatment of high-grade squamous perianal intraepithelial neoplasia (PAIN) and vulvar intraepithelial neoplasia (VIN) lesions in HIV-positive individuals., Design: Phase IIa prospective multicenter trial conducted at eight clinical sites through the AIDS Malignancy Consortium., Methods: : HIV-positive patients with biopsy-proven high-grade PAIN that was at least 3 cm were enrolled. PAIN biopsy specimens were assessed for human papillomavirus (HPV) using PCR and type-specific HPV probing. Participants applied 1% topical cidofovir to PAIN and VIN (if present) for six 2-week cycles. Results were designated as complete response (CR), partial response (PR) (>50% reduction in size), stable disease, or progressive disease (PD)., Results: Twenty-four men and nine women (eight with high-grade VIN as well) were enrolled. Mean age was 44 years and mean CD4 cell count was 412 cells/μl. HPV DNA (most commonly HPV16) was detected in all pretreatment study specimens. Twenty six (79%) participants completed treatment per protocol: CR, five (15%); PR, 12 (36%), stable disease, seven (21%); PD, two (6%) (one with a superficially invasive cancer and one with new area of high-grade PAIN). Treatment was well tolerated with most common adverse events being mild to moderate affecting lesional skin: pain/burning/irritation (25 patients) and ulceration (13 patients)., Conclusion: Topical cidofovir had 51% efficacy in the short-term treatment of high-grade PAIN and VIN with acceptable toxicity in HIV-positive individuals. Randomized control studies with more prolonged treatment courses and longer follow-up to assess the durability of the response are needed.

We present the case of a 74-year-old woman with a 7-year history of an expanding vulval and perianal erythematous plaque, which failed to respond to topical treatments in the community. Biopsy of the affected skin showed typical features of extramammary Paget disease. No underlying associated malignancy was identified. After 2 months of treatment with 5% topical imiquimod, the patient developed a new tender nodule in the perineal region. Histological examination revealed a mucinous carcinoma, which, after careful clinical assessment, was deemed to be a primary cutaneous mucinous carcinoma. This is the second reported case of a primary cutaneous mucinous carcinoma arising on a background of extramammary Paget disease of the vulva and perineum.

A 55-year-old female equestrian presented with a 3.5 cm painful left perineal mass. Histologic examination of the excised mass showed a poorly circumscribed mesenchymal proliferation involving fibroadipose and fibrous tissue. The lesion consisted of a bland spindle cell proliferation with areas of fat necrosis, hemosiderin-laden macrophages, multinucleated histiocytes, and extracellular hyalinization with degenerative features. Immunohistochemical studies showed vimentin positivity and no staining for actin, desmin, and CD34. On the basis of clinical, morphologic, and immunostaining findings, the lesion was consistent with a diagnosis of perineal nodular induration. This lesion has been described almost exclusively in avid male cyclists with repetitive perineal trauma. A similar etiology of longstanding and repetitive perineal trauma from horseback riding is postulated for this case. Perineal nodular induration should be considered in the differential diagnosis of perineal masses in women with persistent perineal trauma, such as equestrianism, as well as other similar sport activities.

Chorangiocarcinoma is the name designated to a chorangioma with trophoblastic proliferation manifesting increased proliferative activity. Only 3 such cases have been published so far. Other studies challenged this entity by demonstrating that proliferation of the trophoblast around chorangioma is a common phenomenon. We present a case of a unique vascular lesion in a term placenta with a malignant trophoblastic component. Microscopic examination of a well-demarcated placental mass revealed a chorangioma with multiple nodules composed of pleomorphic cells displaying focal multinucleation, large areas of necrosis, and high mitotic activity. Immunohistochemical stains of these cells were strongly positive for pancytokeratin and the beta subunit of human chorionic gonadotropin and focally positive for HSD3B1. There was no invasion of the basement membrane, and no free-floating tumor cells in the intervillous space. No evidence of metastasis was found on follow-up of the mother and newborn. It is concluded that the tumor presented herein, displaying a histologically unequivocal malignant trophoblastic component in a benign chorangioma, is a true chorangiocarcinoma, and should be included within the category of gestational neoplasia as a tumor closely related to choriocarcinoma.

Skydiving is a popular and relatively safe sport. The patterns of injury and mechanisms of death in the rare fatalities resulting from skydiving accidents have been well-documented. In contrast, BASE jumping, that is, jumping from a fixed object using a parachute, is a more dangerous and unregulated sport practiced by few individuals. There are no reports in forensic literature documenting the injuries found in deaths occurring in the practice of BASE jumping. We report the case of the death of an experienced BASE jumper who died after jumping from the antenna of a radio broadcast tower in southwest Florida to illustrate the unique hazards inherent in this sport.

Background: Basal cell carcinoma (BCC) is a rare tumor of the vulva; it accounts for approximately 2% to 4% of vulvar cancer., Case: A 73-year-old woman was referred because of a 2-cm ulcerative lesion on her perineum, near the anus. Punch biopsy showed BCC. She underwent wide local excision of tumor without any damage to the anal sphincter. The postoperative period was uneventful and the cosmetic results were good., Conclusions: BCC most commonly occurs in sun-exposed areas, but it may be seen in rare locations, such as in perineum. In our case, chronic irritation secondary to long-term chronic candidiasis in the presence of diabetes mellitus may have been contributory to the development of vulvar BCC.

Anogenital mammary-like glands, although known to exist (as ectopic breast tissue) as early as 1872, have only recently been thoroughly studied and suggested to be the possible origin for various neoplastic (benign and malignant) and reactive conditions that show a striking homology with lesions in the breast. Reported herein is an unusual benign lesion involving anogenital mammary-like glands in the perineal area of a 41-year-old woman. The lesion is unique in that it does not fully fit into any of the previously recognized conditions affecting anogenital mammary-like glands nor has it an apparent well-defined mammary counterpart. Microscopically, at first glance the lesion appeared as a cluster of extended anogenital mammary-like glands of variable complexity and a lobular architecture, which probably resulted from a compact proliferation of closely situated ducts with small, round lumens (when cut transversally). When cut longitudinally, some of these tiny ducts appeared to bud from larger ductal structures, resembling so-called satellitosis in the breast and this gave a fibroadenomatous appearance to the areas. In addition, there were adenosis-like areas. This lesion extends the spectrum of changes seen in anogenital mammary-like glands.

The authors report two cases of perineal proximal-type epithelioid sarcoma in middle-aged men, age 51 and 43 years old. Both tumors were located in the right side. In the first patient a 7.5-cm, well-encapsulated tumor was completely excised. The second patient was a referral case with incomplete excision, but the computed tomography scan and magnetic resonance imaging showed a 14-cm nonencapsulated tumor involving the soft tissues of the inner thigh and perineum, as well as metastasis in right inguinal and retroperitoneal lymph nodes. Both neoplasms had a predominant solid pattern alternating with occasional discohesive areas. Both were composed of large oval to polygonal cells with vesicular nuclei, conspicuous nucleoli, and amphophilic to eosinophilic cytoplasm. Rhabdoid phenotype was identified in the second case only. The first neoplasm displayed 15% necrosis, 7 mitoses per 10 high-power field, focal vascular invasion, and no extracapsular invasion. The other exhibited 60% necrosis, 12 mitoses per 10 high-power fields, extensive vascular invasion, no distinct capsule, and invasion of the surrounding fatty tissue. Both were positive for vimentin, cytokeratin, epithelial membrane antigen, and CD34. Muscle-specific actin was negative in the first case and focally positive in the second. CD56 was positive in the second case and negative in the first case. Desmin, CD45, CD30, factor VIII, CD31, S100, HMB45, calretinin, and synaptophysin were negative in both. Since proximal-type epithelioid sarcoma can be confused with a number of other soft tissue tumors with epithelioid and/or rhabdoid features, the authors emphasize the immunohistochemical differential diagnosis.

An operating table with the capacity for skeletal traction against a pudendal post is a helpful and commonly used piece of equipment for certain pelvic and acetabular fracture patterns. Perineal soft tissue trauma and urogenital injuries are associated with some pelvic and acetabular fractures. The perineal region is vulnerable to compromise after such injuries. There is little documentation available in the literature that addresses intraoperative complications of the perineum after the use of a traction table for pelvic fractures. We present here a case in which prolonged traction against a pudendal post during operative fixation of complex pelvic and acetabular fractures resulted in massive perineal wound slough. This case should heighten surgeons' awareness of the vulnerability of the perineum to injury with the use of a traction table and should prompt measures to prevent complications.

The aim of this article is to review the magnetic resonance (MR) findings of pelvic floor descent and pelvic organ prolapse in women. In addition, a detailed grading system of pelvic organ prolapse and pelvic floor relaxation based on dynamic MR imaging is presented. The technique described here uses very fast MR sequences, is reproducible and easily learned by radiologists and technologists, is well accepted by patients, and provides as much information as traditional projectional X-ray imaging. Reference points are the pubococcygeal line and puborectalis muscle sling. The grading system is based on degree of organ prolapse through the hiatus and the degree of puborectalis descent and hiatal enlargement.

We present a case of a perineal angiomyofibroblastoma (AMFB) arising in the right perirectal fossa in a middle-aged woman, documented with CT and MRI. Compounding the rarity of the entity, this case is unique as it is the first radiological report illustrating the CT and MR features of this recently clinicopathologically described neoplasm.

Objective: Compare urogenital hiatus size in normal women and women with pelvic organ prolapse., Methods: The sagittal and transverse urogenital hiatus diameters were measured and hiatus area calculated in 300 women whose support was scored using a modified Baden system., Results: In women with normal support and without prior surgery, hiatus area was 5.4 cm2 (+/-1.71 standard deviation [SD], n = 197). In women with uncorrected clinical prolapse (grade 2-3), the area of the hiatus was enlarged (9.6 cm2 +/- 3.97, n = 34, P < .05) and became larger with progressive prolapse (grade 0, 5.4 cm2 +/- 1.71, n = 197; grade 1, 7.3 cm2 +/- 1.91, n = 27; grade 2, 8.3 cm2 +/- 2.45, n = 18; grade 3, 11.0 cm2 +/- 4.90, n = 16). When matched for age and parity, prolapse patients had a larger hiatus than normal women. Women with recurrent prolapse had a larger hiatus than cured women (13.3 cm2 +/- 3.86, n = 8 compared with 8.1 cm2 +/- 2.44, n = 16, P < .05) or women with recurrence after one operation (8.9 cm2 +/- 1.77, n = 18, P < .05). Hiatus size in patients surgically cured (8.3 cm2 +/- 2.44, n = 16) did not return to normal (5.4 cm2 +/- 1.71, n = 197, P < .05). Increasing area of the hiatus was correlated with an increase in anterior-posterior diameter (r2 = 0.9, P < .05), was less attributable to increased transverse diameter (r2 = 0.6, P < .05), and was not related to thickness of the perineal body (r2 = 0.0, P > .05)., Conclusion: Increasing pelvic organ prolapse is associated with increasing urogenital hiatus size; the hiatus is larger after several failed operations than after successful surgery or single failure.

A retrospective study of patients treated from May of 1981 to April of 1994 was conducted. A total of 245 patients with 299 hemangiomas were studied, which represents the largest series reported to date. The study consisted of 173 females and 72 males ranging in age from 1 day to 59 years, with the average age being 4 years and 7 months. Twenty-six were premature neonates (14 females and 12 males). An interesting finding was a 1:1 sex ratio among this group in contrast to the 3:1 female-male ratio frequently reported in the literature. Onset was at birth in 170, within the first month in 43, and after the age of 1 month in 32 patients. Among the 245 patients, 175 hemangiomas were located on the head and neck, 62 on the trunk, 49 on the extremities, and 13 in the perineal area. Five groups of patients were defined based on clinical management. As a result, these groups are not similar. The five groups are as follows: group I (48), observation; group II (9), steroid treatment; group III (27), excision and reconstruction; group IV (88), laser therapy; and group V (73), combined therapy. The involved area of hemangioma was as follows: group 1, 0.5 x 0.5 to 20 x 8 cm; group II, 2 x 2 to 8 x 8 cm; group III, 0.4 x 0.8 to 7 x 7 cm; group IV, 0.5 x 0.5 to 20 x 9 cm; and group V, 1.5 x 1.5 to 25 x 25 cm. The complications of hemangioma seen at the time of consultation were obstruction (28.6 percent), ulceration (20.4 percent), bleeding (14.7 percent), infection (4.9 percent), and pain (0.4 percent). Treatment periods ranged from 1 month to 11 years, with the mean period in each group as follows: group I, 4 years and 9 months; group II, 2 years and 5 months; group III, 1 year and 1 month; group IV, 2 years and 1 month; and group V, 3 years. The outcomes of each patient were evaluated based on improvement of volume, color, and texture by the following scale: 1, poor (0 to 25 percent); 2, fair (26 to 50 percent); 3, good (51 to 75 percent); and 4, excellent (76 to 100 percent). Each of these parameters was summarized for each of the five groups. Statistical analysis by the Irwin-Fisher test was used for analysis and comparison of the final results between groups. Statistically significant differences in outcomes between treatment groups were demonstrated. Laser therapy was shown to be statistically superior to observation with regard to length of treatment and with regard to outcomes of volume and texture (p < 0.05).

Median raphe cysts are uncommon congenital lesions most often found on the penis or scrotum. This report describes an anterior perianal lesion in a 62 yr old male and draws attention to this rarely described location and the unusually late presentation.

Hidradenitis suppurativa is a chronic relapsing infection of the apocrine sweat glands. Its association with penoscrotal lymphedema is not well recognized. A case of massive scrotal elephantiasis associated with chronic hidradenitis of the perineum and scrotum is described. A wide resection of the scrotal mass and perineum was performed, with reconstruction of the perineum and penis carried out using local skin flaps and split-thickness skin grafts. This one-stage treatment yielded an excellent cosmetic and functional outcome.

During January 1978 through May 1989, 232 fine-needle aspirations of palpable lesions of the vulva, vagina, inguinal area, and perineum were performed on 209 women. Five samples were considered inadequate for cytologic evaluation. Eighty-seven (38.3%) aspirates were interpreted as malignant, 80 of which were further classified into specific cell types. Most malignant neoplasms represented metastases from other gynecologic organs. Of the 140 (61.7%) nonmalignant aspirates, only 28 (20%) could be categorized into specific pathologic disorders. The false-positive and false-negative rates were 0 and 4.6%, respectively. We conclude that, because of its safety, simplicity, and accuracy, fine-needle aspiration cytology represents a valuable diagnostic tool in the evaluation of palpable lesions of the lower female genital tract. This technique is particularly helpful in the assessment of primary, metastatic, or recurrent malignant neoplasms of this region.

Rectus abdominis myocutaneous flaps may be transposed through the retroperitoneum to reconstruct defects of the back and perineum. Cadaver dissections and clinical cases are presented to demonstrate the surgical technique and reconstructive possibilities of this flap.

The anogenital region, comprising the cervix, vagina, vulva, perineum, and anus, has the potential for the development of multicentric and multiple primary malignancies. Fifteen patients with 3 or more primary neoplasms in this region are presented. Awareness of the existence of these tumors as a regional disease and the possible long intervals between successive malignancies are emphasized. The presence of a vulvar neoplasm should arouse suspicion of a synchronous primary tumor elsewhere in the region. Conversely, sequential neoplasms occur more commonly after an initial cervical primary neoplasm and should be anticipated.