Surgical Management of OHVIRA and Outcomes.

STUDY OBJECTIVE: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) includes uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal anomaly. Surgical management of this condition relies on accurate diagnosis to excise the obstructed longitudinal vaginal septum (OLVS). Vital considerations involve identifying the side affected, ipsilateral renal anomaly (IRA), thickness of the septum (TS), septal axis (SA), and distance of the septum to perineum (DSP). The study aimed to evaluate the preoperative characteristics, imaging findings, and surgical outcomes of OHVIRA. METHODS: Institutional review board approval was obtained for this retrospective chart review. ICD-10 codes identified OHVIRA cases between 2012 and 2019 at a single children's hospital. Patient demographic characteristics, magnetic resonance imaging findings, surgical management, outcomes, and complications were reviewed. Descriptive statistics were utilized. RESULTS: Twenty-six patients met inclusion criteria. Most were diagnosed at puberty (92%). Abdominal pain (50%) was the most common presenting complaint. The mean age of diagnosis was 13.2 years overall and 11.2 years for those with regular cycles vs 13.4 years for those with irregular cycles. Preoperative imaging showed predominant right-sided OLVS (50%), IRA (77%), and oblique SA (65%). All patients underwent vaginoscopy, septum resection, and vaginoplasty, except 1 who was managed with an abdominal drain as a neonate. Four required postoperative vaginal stent or Foley, with DSP greater than 5 cm in all cases. One intraabdominal abscess complication occurred. No instances of hematocolpos re-accumulation or reoperation were observed during the 3-year follow-up period. CONCLUSION: This study demonstrates that detailed preoperative planning and a systematic surgical approach lead to favorable outcomes in OHVIRA irrespective of the OLVS laterality, TS, SA, or DSP.

Cellular and extracellular vaginal changes following murine ovarian removal.

Loss of estrogen as a result of aging, pelvic cancer therapy, genetics, or eating disorders affects numerous body systems including the reproductive tract. Specifically, a chronic hypoestrogenic state fosters debilitating vaginal symptoms like atrophy, dryness, and dyspareunia. Current treatment options, including vaginal estrogen and hyaluronan (HA), anecdotally improve symptoms, but rectifying mechanisms are largely understudied. In order to study the hypoestrogenic vaginal environment, in particular the extracellular matrix (ECM), as well as understand the mechanisms behind current treatments and develop new therapies, we characterized a reliable and reproducible animal model. Bilateral ovariectomies (OVX) were performed on 9-week-old CD1 mice. After 1 month of estrogen loss due to ovarian removal, a phenotype that is similar to human vaginal tissue in an estrogen reduced state was noted in mice compared to sham-operated controls. The uterine to body weight ratio decreased by 80% and vaginal epithelium was significantly thinner in OVX compared to sham mice. Estrogen signaling was altered in OVX, but submucosal ERα localization did not reach statistical differences. HA localization in the submucosal area was altered and CD44 expression decreased in OVX mice. Collagen turn-over was altered following OVX. The inflammation profile was also disrupted, and submucosal vaginal CD45+ and F4/80+ cell populations were significantly reduced in the OVX mice. These results show altered cellular and molecular changes due to reduced estrogen levels. Developing new treatments for hypoestrogenic vaginal symptoms rely on better understanding of not only the cellular changes, but also the altered vaginal ECM environment. Further studies using this mouse model has the potential to advance women's vaginal health treatments and aid in understanding the interplay between organ systems in both healthy, aged, and diseased states.

Unveiling Vaginal Fibrosis: A Novel Murine Model Using Bleomycin and Epithelial Disruption.

Objective: Develop, validate, and characterize a fibrotic murine vaginal wound healing model using bleomycin instillations and epithelial disruption. Approach: We tested the effect of repeated bleomycin instillations with mucosal layer disruption on induction of vaginal fibrosis. Tissue samples collected at various time points were analyzed for fibrosis-related gene expression changes and collagen content. Results: Low (1.5U/kg) and high-dose (2.5U/kg) bleomycin instillations alone did not induce fibrosis, but when high-dose bleomycin was combined with epithelial disruption, increased pro-fibrotic gene expression and trichrome staining were observed. To evaluate spatial and temporal changes in the ECM structure and gene expression, tissue samples were collected at 1 day, 3 weeks, and 6 weeks after bleomycin and epithelial disruption. Data analyses revealed a significant decrease in matrix metabolizing genes and an increase in pro-fibrotic genes and inhibitors of matrix metabolizing genes in the bleomycin plus epithelial disruption group at 3 weeks. Elevated levels of the profibrotic genes Acta2 , Col1a1 , and Col3a were exclusively detected in this group at 3 weeks, and trichrome staining confirmed increased collagen content after 3 weeks. Hydroxyproline levels showed a tendency towards elevation at 3 weeks (p=0.12) and 6 weeks (p=0.14), indicating fibrosis manifestation at 3 weeks and resolution by 6 weeks post-instillation and epithelial disruption. Innovation: We combined bleomycin instillations with epithelial disruption to induce fibrosis and understand the mechanisms of the vaginal repair process. Conclusions: Epithelial disruption combined with bleomycin induces murine vaginal fibrosis within three weeks, characterized by increased collagen synthesis. Remarkably, the vaginal tissue fully recovers within six weeks, elucidating the regenerative capacity of the vagina.

Mobile interventions targeting common mental disorders among pregnant and postpartum women: An equity-focused systematic review.

INTRODUCTION: Pregnant and postpartum women face major psychological stressors that put them at higher risk of developing common mental disorders, such as depression and anxiety. Yet, their limited access to and uptake of traditional mental health care is inequitable, especially during the COVID-19 pandemic. Mobile interventions emerged as a potential solution to this discontinued healthcare access, but more knowledge is needed about their effectiveness and impact on health equity. This equity-focused systematic review examined the effectiveness and equity impact of mobile interventions targeting common mental disorders among pregnant and postpartum women. METHODS AND RESULTS: We systematically searched MEDLINE, EMBASE, PsychINFO and 3 other databases, from date of database inception and until January 2021, for experimental studies on mobile interventions targeting pregnant and postpartum women. We used pooled and narrative synthesis methods to analyze effectiveness and equity data, critically appraised the methodological rigour of included studies using Cochrane tools, and assessed the certainty of evidence using the GRADE approach. Our search identified 6148 records, of which 18 randomized and non-randomized controlled trials were included. Mobile interventions had a clinically important impact on reducing the occurrence of depression (OR = 0.51 [95% CI 0.41 to 0.64]; absolute risk reduction RD: 7.14% [95% CI 4.92 to 9.36]; p<0.001) and preventing its severity perinatally (MD = -3.07; 95% CI -4.68 to -1.46; p<0.001). Mobile cognitive behavioural therapy (CBT) was effective in managing postpartum depression (MD = -6.87; 95% CI -7.92 to -5.82; p<0.001), whereas other support-based interventions had no added benefit. Results on anxiety outcomes and utilization of care were limited. Our equity-focused analyses showed that ethnicity, age, education, and being primiparous were characteristics of influence to the effectiveness of mobile interventions. CONCLUSION: As the COVID-19 pandemic has increased the need for virtual mental health care, mobile interventions show promise in preventing and managing common mental disorders among pregnant and postpartum women. Such interventions carry the potential to address health inequity but more rigorous research that examines patients' intersecting social identities is needed.

Animal Models and Alternatives in Vaginal Research: a Comparative Review.

While developments in gynecologic health research continue advancing, relatively few groups specifically focus on vaginal tissue research for areas like wound healing, device development, and/or drug toxicity. Currently, there is no standardized animal or tissue model that mimics the full complexity of the human vagina. Certain practical factors such as appropriate size and anatomy, costs, and tissue environment vary across species and moreover fail to emulate all aspects of the human vagina. Thus, investigators are tasked with compromising specific properties of the vaginal environment as it relates to human physiology to suit their particular scientific question. Our review aims to facilitate the appropriate selection of a model aptly addressing a particular study by discussing pertinent vaginal characteristics of conventional animal and tissue models. In this review, we first cover common laboratory animals studied in vaginal research-mouse, rat, rabbit, minipig, and sheep-as well as human, with respect to the estrus cycle and related hormones, basic reproductive anatomy, the composition of vaginal layers, developmental epithelial origin, and microflora. In light of these relevant comparative metrics, we discuss potential selection criteria for choosing an appropriate animal vaginal model. Finally, we allude to the exciting prospects of increasing biomimicry for in vitro applications to provide a framework for investigators to model, interpret, and predict human vaginal health.

Rates of Intrauterine Device Expulsion Among Adolescents and Young Women.

STUDY OBJECTIVE: The objective of our study was to determine the rate of intrauterine device (IUD) expulsion and risk factors for expulsion among adolescents and young adults. DESIGN: Retrospective chart review. SETTING: IUD insertions were performed at a single children's hospital. PARTICIPANTS: Eligible adolescent and young adult patients who underwent IUD insertion between August 2009 and March 2019. INTERVENTIONS: IUD insertion. MAIN OUTCOME MEASURES: Primary outcome was the incidence of IUD expulsion in adolescents and young women. Secondary outcomes were risk factors for IUD expulsion including heavy menstrual bleeding, abnormal uterine bleeding (AUB), anemia, or a bleeding disorder diagnosis. RESULTS: Six hundred forty-two eligible patients underwent IUD insertion. The incidence of first IUD expulsion in this population was 58/642 (9.03%). Among those who chose to have a second IUD placed (n = 29), 8/29 (27.6%) had a second expulsion. Patients who expelled their IUD were more likely to have a history of AUB, heavy menstrual bleeding, anemia, or a bleeding disorder. When controlled for body mass index and age at insertion, history of AUB and anemia remained significant risks for IUD expulsion. CONCLUSION: This study similarly showed a higher risk of primary and secondary IUD expulsion in adolescents and young women. A history of AUB, anemia, bleeding disorder, and elevated body mass index are associated with higher risk for IUD expulsion. This population should be counseled that these conditions might place them at higher risk for expulsion.

An Avant-Garde Model of Injury-Induced Regenerative Vaginal Wound Healing.

Objective: To design and validate a novel murine model of full-thickness (FT) vaginal wound healing that mirrors postinjury tissue repair and underscores the impact of estrogen signaling-driven healing kinetics, inflammation, and neovascularization. Approach: Five-week-old female CD1 mice were subjected to two 1-mm FT wounds. To assess wound healing kinetics, vaginas were harvested at 6, 12, 18, 24, 48, and 72 h and 7 days postinjury. Wounds from all time points were analyzed by hematoxylin and eosin and trichrome to, respectively, assess the rate of wound closure and tissue deposition. Inflammatory leukocyte (CD45), neutrophil (Ly6G), and macrophage (F480 and CD206) infiltration was examined by immunohistochemistry (IHC) and the resulting anti-inflammatory M2 (CD206)/total (F480) macrophage ratio quantified. Neovascularization (CD31) and estrogen receptor-α (ERα) expression levels were similarly determined by IHC. Results: We observed rapid healing with resolution of mucosal integrity by 48 h (p < 0.05), and overall neutrophils and polarized type 2 macrophages (M2) apexed at 12 h and reduced to near control levels by day 7 postinjury. Tissue repair was virtually indistinguishable from the surrounding vagina. CD31+ vessels increased between 12 h and day 7 and ERα trended to decrease at 12 h postinjury and rebound at day 7 to uninjured levels. Innovation: A proof-of-concept murine model to study vaginal wound healing kinetics and postinjury regenerative repair in the vagina was developed and verified. Conclusion: We surmise that murine vaginal mucosal repair is accelerated and potentially regulated by estrogen signaling through the ERα, thus providing a cellular and molecular foundation to understand vaginal healing responses to injury.

Emerging technologies in pediatric gynecology: new paradigms in women's health care.

PURPOSE OF REVIEW: The current review highlights the complexity of the pediatric and adolescent gynecology subspecialty as well as the recent and exciting opportunities for innovation within the field. RECENT FINDINGS: The opportunities for concept, treatment, instrument, and knowledge-transfer innovation to better serve the specific needs of pediatric gynecology patients include novel approaches to neovagina creation using magnets, improving postoperative vaginal wound healing through newly designed and degradable vaginal stents, and complex Mullerian reconstructive surgical planning using virtual reality immersive experiential training. SUMMARY: There is a significant window of opportunity to address the needs of pediatric, adolescent and adult gynecological patients with new innovative concepts and tools.

Tubo-Ovarian Abscesses in Nonsexually Active Adolescent Females: A Large Case Series.

PURPOSE: The aim of the study was to review the incidence, presentation, and management of tubo-ovarian abscesses (TOA) in nonsexually active (NSA) adolescents. METHODS: A retrospective chart review was performed at a single children's hospital. We evaluated self-reported NSA females aged < 21 years diagnosed with TOA. Demographics, presenting symptoms, medical history, laboratory studies, imaging, and treatment were reviewed. RESULTS: Sixteen NSA females met inclusion criteria, with one patient presenting with two separate TOAs. Mean age at diagnosis was 14.6 ± 1.8 years; all were menarchal. Presenting symptoms included abdominal pain (88%), fever (76%), and vomiting (53%). Eleven patients (65%) received transabdominal pelvic ultrasound, 2 (12%) had magnetic resonance imaging of pelvis, and 11 (65%) had computed tomography of abdomen/pelvis. All patients had negative gonorrhea and chlamydia testing. Thirteen (76%) had comorbid disease including obstructed hemivagina ipsilateral renal agenesis, active or recent appendicitis, or genitourinary tract anomalies. Sixteen cases underwent drainage via interventional radiology or surgery. Twelve cases (71%) had TOA fluid cultured; five (29%) grew Escherichia coli species. All cases received intravenous antibiotics, and 88% of cases continued outpatient oral antibiotics. CONCLUSIONS: Although uncommon in NSA females, patients with underlying comorbidities may be at increased risk for TOA formation. Providers should consider the diagnosis of TOA even in NSA females.

Can We Improve Vaginal Tissue Healing Using Customized Devices: 3D Printing and Biomechanical Changes in Vaginal Tissue.

BACKGROUND: Determining biomechanical changes in vaginal tissue with tissue stretch is critical for understanding the role of mechanotransduction on vaginal tissue healing. Noncontact dynamic optical coherence elastography (OCE) can quantify biomechanical changes in vaginal tissues noninvasively. Improved vaginal tissue healing will reduce postoperative complications from vaginal surgery. AIMS: (1) To complete dimensional assessments (DAs) of the vaginal tract. (2) To elucidate biomechanical properties (BMP) of porcine vaginal tissues (PVT). (3) Compare BMPs of piglet and adult PVTs after placement of customized vaginal dilators (VD) by OCE and uniaxial mechanical testing (MT). METHODS: Pilot study using adult nulliparous pig and piglet PVTs (n = 20 each). DA of PVTs was performed using silicone molding. 3D-printed VDs were used to achieve different Relative Diameter Change (RDC) of the PVTs (no dilatation, and -50%, 0%, 50% RDC). Elastographic testing using OCE and MT. RESULTS: Using OCE, no significant differences (SD) were noted between adult and piglet PVT (p = 0.74) or by stretch direction (p = 0.300). SD was noted with increasing RDC (p = 0.023). Using MT, there were SD in tissue stiffness between adult and piglet PVT (p = 0.048), but no SD as a function of RDC (p = 0.750) or stretch direction (p = 0.592). CONCLUSIONS: This study quantified biomechanical changes in PVT with customized stretching by 3D printed VD using both OCE and MT. This work has implications for the mechanotransduction of vaginal wound healing and noninvasive assessment of vaginal diseases.

Noncytotoxic-Related Primary Ovarian Insufficiency in Adolescents: Multicenter Case Series and Review.

STUDY OBJECTIVE: Primary ovarian insufficiency (POI) in adolescents not due to cytotoxic therapy has not been well studied. Causes of POI have been described in adults, but adolescents might represent a unique subset necessitating a targeted approach to diagnosis, workup, and treatment. We sought to better characterize adolescent POI through a descriptive multicenter study. DESIGN: Case series of patients with POI. SETTING: Six tertiary care institutions. PARTICIPANTS: Patients presenting from 2007 to 2014 aged 13-21 years diagnosed with noncytotoxic POI, with exclusions for those who received gonadotoxic therapy, with 46XY gonadal dysgenesis, or lack of evidence of hypergonadotropic hypogonadism on chart review. INTERVENTIONS: Review and data extraction of records identified according to International Classification of Diseases Ninth or Tenth Revision codes. MAIN OUTCOME MEASURES: Data were analyzed for signs and symptoms, workup, and treatments. Complete workup was on the basis of American College of Obstetricians and Gynecologists guidelines. Characteristics of patients with POI who presented with delayed puberty/primary amenorrhea vs secondary amenorrhea were compared. RESULTS: One hundred thirty-five records were identified. Those who had received cytotoxic therapy (n = 52), 46XY gonadal dysgenesis (n = 7), or on review did not have POI (n = 19) were excluded. Of 57 remaining cases, 16 were 45X, 2 had galactosemia, and 4 had X-chromosome abnormalities. Most did not undergo full etiologic evaluation. Girls diagnosed after primary amenorrhea/delayed puberty were less symptomatic and more likely to receive an estrogen patch than those diagnosed after secondary amenorrhea. CONCLUSION: Noncytotoxic POI in adolescents is an uncommon condition with, to our knowledge, only 64 cases in 6 institutions over 7 years. These patients might not undergo complete etiological workup. Aside from 45X, the most common etiologies were X-chromosome abnormalities or galactosemia.

Providers' Experiences with Vaginal Dilator Training for Patients with Vaginal Agenesis.

STUDY OBJECTIVE: To examine providers' experiences with vaginal dilator training for patients with vaginal agenesis. DESIGN AND SETTING: Anonymous electronic survey. PARTICIPANTS: Members of the North American Society for Pediatric and Adolescent Gynecology. INTERVENTIONS AND MAIN OUTCOME MEASURES: How providers learn about vaginal dilator training, common techniques, and methods used for patient training, assessment of patient readiness, common patient complaints, issues leading to early discontinuation. RESULTS: There were a total of 55 completed survey responses of which 31 respondents (56%) had been in practice for more than 10 years. Forty-nine were gynecologists (89%), 20 had completed a fellowship in pediatric and adolescent gynecology (36%), and 6 were reproductive endocrinologists (11%). Thirty-one respondents had first learned about vaginal dilator training through lectures (56%) whereas only 9 through mentorship and fellowship (16%). According to respondents, the most common issue leading to early discontinuation was lack of patient motivation and readiness (n = 42; 76%). The most common complication was pain or discomfort (n = 45; 82%). More than half of respondents determined dilator therapy was successful when patients reported comfortable sexual intercourse (n = 30; 55%) and 65% (n = 35) did not delineate any restrictions to initiation of sexual intercourse. Most respondents (87%) requested further vaginal dilator training at either a clinical meeting (n = 26; 47%) or with a training video (n = 22; 40%). CONCLUSION: Our study in an experienced cohort of pediatric gynecology providers highlights the need for further research and training on vaginal dilation education.

Pediatric medical device development by surgeons via capstone engineering design programs.

BACKGROUND: There is a need for pediatric medical devices that accommodate the unique physiology and anatomy of pediatric patients that is increasingly receiving more attention. However, there is limited literature on the programs within children's hospitals and academia that can support pediatric device development. We describe our experience with pediatric device design utilizing collaborations between a children's hospital and two engineering schools. METHODS: Utilizing the academic year as a timeline, unmet pediatric device needs were identified by surgical faculty and matched with an engineering mentor and a team of students within the Capstone Engineering Design programs at two universities. The final prototypes were showcased at the end of the academic year and if appropriate, provisional patent applications were filed. RESULTS: All twelve teams successfully developed device prototypes, and five teams obtained provisional patents. The prototypes that obtained provisional patents included a non-operative ureteral stent removal system, an evacuation device for small kidney stone fragments, a mechanical leech, an anchoring system of the chorio-amniotic membranes during fetal surgery, and a fetal oxygenation monitor during fetoscopic procedures. CONCLUSIONS: Capstone Engineering Design programs in partnership with surgical faculty at children's hospitals can play an effective role in the prototype development of novel pediatric medical devices. LEVELS OF EVIDENCE: N/A - No clinical subjects or human testing was performed.

Paratubal Cyst Size Correlates With Obesity and Dysregulation of the Wnt Signaling Pathway.

STUDY OBJECTIVE: Paratubal cysts (PTCs) occur in 7%-10% of women, regardless of age. Although common, PTCs often are found incidentally because of the potential for these cysts to be asymptomatic. The specific aims of the study were to determine if PTC number and size correlated with signs of hyperandrogenism and obesity, as well as to investigate the molecular profiles of these PTCs in samples derived from female adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A prospective cohort study was performed in a single children's hospital. Girls 18 years of age or younger who underwent surgery for PTC suspected on the basis of the presence of a persistent adnexal cyst on imaging or a concern for adnexal torsion involving a cyst were consented to participate in the study. RESULTS: Nineteen patients met enrollment criteria with a mean age at menarche of 11.2 ± 1.3 years. Most of the patients (84%; n = 16/19) had adnexal torsion at the time of diagnosis of PTC. Irregular menses and hirsutism was found in 52.6% (n = 10/19) of the patients, among whom 36.8% (n = 7/19) were obese. The mean PTC size was 10.4 ± 4.3 cm with 57.9% (n = 11/19) of the cohort having more than 1 PTC. When patients were compared on the basis of their body mass index, the size of PTCs was significantly larger in the overweight/obese group. The wingless-type (WNT) signaling members catenin beta 1 (CTNBB1) and wingless-type MMTV integration site family, member 7A (WNT7A) were upregulated in 86% (n = 12/14) and 79% (n = 11/14) of the patients, respectively. WNT7A was significantly upregulated in girls with 1 cyst and low body mass index. CONCLUSION: A correlation exists between obesity, cyst size, and hyperandrogenism. Activation of the WNT/CTNBB1 pathway via WNT7A might play a role in PTC development.

Intraoperative Rupture of Ovarian Dermoid Cysts in the Pediatric and Adolescent Population: Should This Change Your Surgical Management?

STUDY OBJECTIVE: (1) To determine the incidence of chemical peritonitis after cystectomy for ovarian dermoid cysts with intraoperative cyst rupture in the pediatric and adolescent population; and (2) to examine the intraoperative and postoperative outcomes of cystectomies performed for ovarian dermoid cysts using laparoscopy and laparotomy, especially those with intraoperative cyst rupture. DESIGN: A retrospective cohort study of female patients who underwent ovarian cystectomy with proven ovarian dermoid pathology between July 2007 and July 2015. SETTING: Texas Children's Hospital, Houston, Texas. PARTICIPANTS: One hundred forty-four patients between the ages of 1 and 21 years who underwent an ovarian cystectomy with proven benign ovarian dermoid histology on the basis of pathology reports. INTERVENTIONS AND MAIN OUTCOME MEASURES: Occurrence of spill of cyst contents, chemical peritonitis, postoperative complications, and hospital readmissions. RESULTS: One hundred forty-four female patients underwent cystectomy (38 laparotomy and 106 laparoscopy) resulting in benign ovarian dermoid histology. Their mean age was 12.4 ± 4.1 years (range, 1-21), mean cyst size was 9.2 ± 6.4 cm (range, 1-30 cm), no patients had elevated tumor markers, 42 (29.1%) presented with torsion, 73 (50.7%) had cyst fluid spill, and there were no cases of chemical peritonitis. Few significant differences were found between cases performed via laparoscopy and laparotomy and those with and without intraoperative cyst rupture resulting in spill of contents. Laparotomy cases were found to have larger mean cyst size (P < .001), estimated blood loss (P = .003), and presence of bilateral cysts (P = .017) compared with laparoscopic cases. Cyst fluid spill occurred in more laparoscopic cases ([67/106] 63.2% vs [6/38] 15.8%; P < .001), and risk increased with cyst size greater than 5 cm (P < .001). In the laparoscopy group, cyst size greater than 5 cm was more likely to present with torsion (P < .001). There was no significant difference in the repeat cystectomy rate between the laparoscopy and laparotomy groups even with cyst rupture (P = .394). Only 5 cases presented to the emergency room postoperatively and 2 were admitted postoperatively for umbilical port site dehiscence and pyelonephritis. CONCLUSION: Laparoscopic cystectomy of ovarian dermoid cysts is associated with greater intraoperative cyst rupture. However, cyst rupture is rarely associated with complications, therefore minimally invasive surgical management of ovarian dermoid cysts is a reasonable surgical approach.

Longitudinal Vaginal Septum Resection Using the Ligasure Device.

BACKGROUND: A longitudinal vaginal septum might present as a nonobstructive or obstructive type. Both can result in dyspareunia, difficult tampon insertion, persistent vaginal bleeding despite tampon placement, and dysmenorrhea. Surgical correction is warranted for symptomatic cases. CASE: We present a 16-year-old female adolescent with a complex cloacal anomaly, uterine didelphys, longitudinal vaginal septum, and other congenital anomalies. The patient was unable to use tampons during menses because of the small caliber on both vaginal canals. We performed a longitudinal vaginal septum resection using the Ligasure (Medtronic, Inc, Doral, FL) device. We were able to resect the vaginal septum without difficulty. SUMMARY AND CONCLUSION: Our case introduces an innovative and safe alternative to the surgical management of a longitudinal vaginal septum, particularly useful in a confined surgical space.

Does an Advanced Pelvic Simulation Curriculum Improve Resident Performance on a Pediatric and Adolescent Gynecology Focused Objective Structured Clinical Examination? A Cohort Study.

STUDY OBJECTIVE: To determine the effect of an advanced pelvic simulation curriculum on resident performance on a pediatric and adolescent gynecology (PAG) focused objective structured clinical examination (OSCE). DESIGN: Obstetrics and gynecology residents in a single academic Canadian center participated in a PAG simulation curriculum. An OSCE on prepubertal vaginal bleeding was administered at the biannual OSCE examination 2 months before the simulation curriculum and again 3 months after the simulation curriculum. SETTING: Academic half-day at the University of Ottawa Skills and Simulation Centre. PARTICIPANTS: Obstetrics and gynecology residents from the University of Ottawa. INTERVENTIONS: Participants completed 4 stations teaching PAG-appropriate history-taking, genital examination, Tanner staging, vaginal sampling and flushing, hymenectomy, vaginoscopy, laparoscopic adnexal detorsion, and approach to the child and/or adolescent. Advanced pelvic models were used for procedure-specific stations. MAIN OUTCOME MEASURES: The primary outcome measure was change in mean score on a prepubertal vaginal bleeding OSCE station. Secondary outcome measures were changes in individual component scores. RESULTS: Fourteen residents completed the simulation curriculum and the PAG OSCE at the 2 separate time points (before and after simulation curriculum). The mean OSCE score before the simulation curriculum was 54.6% (20.5 of 37) and mean score after the curriculum was 78.1% (28.9 of 37; P < .001). Significant score increases were found in history-taking, examination, differential diagnosis, identification of organism, surgical procedures, and identification of foreign body (P < .01 for all). CONCLUSION: This innovative PAG simulation curriculum significantly increased residents' knowledge in PAG history-taking, examination skills, operative procedures, and approach to the child and/or adolescent. Obstetrics and Gynecology Program Directors should consider incorporating PAG simulation training into their curriculum to ensure that residents meet their learning objectives and increase their knowledge and confidence, which will ultimately benefit patient care.

Enhancing postgraduate training in pediatric and adolescent gynecology: evaluation of an advanced pelvic simulation session.

STUDY OBJECTIVE: To describe and evaluate a Canadian simulation session designed to teach pediatric and adolescent gynecology (PAG) history taking, examination and operative skills, and an approach to the child and adolescent. DESIGN: Obstetrics and gynecology residents in a single academic center participated in a PAG simulation session and rated their gain in knowledge on 6 aspects of PAG care. SETTING: Academic half-day at the University of Ottawa Skills and Simulation Centre. PARTICIPANTS: Twenty-four Obstetrics/Gynecology residents at the University of Ottawa. INTERVENTIONS: Participants completed 4 stations teaching PAG-appropriate history taking, genital examination, Tanner staging, vaginal sampling and flushing, hymenectomy, vaginoscopy, laparoscopic adnexal detorsion, and approach to the child/adolescent. Advanced pelvic models were used for procedure specific stations. Participants completed an anonymous evaluation form at the end of the session. MAIN OUTCOME MEASURE: Self-perceived increase in knowledge and PAG specific skills after the simulation session. RESULTS: Twenty-four residents completed the simulation session and post-session evaluation. All residents (100%) agreed that they had gained knowledge in PAG history taking, examination techniques, office procedures, operative skills, approach to child, and approach to the adolescent. Qualitative feedback stressed the excellence of instruction, interaction, immediate feedback, and hands-on experience. All residents (100%) stated the PAG simulation session should continue. CONCLUSIONS: This advanced PAG simulation session increased resident self-perceived knowledge. Other obstetrics/gynecology training programs should consider implementing advanced PAG simulation sessions to increase resident knowledge and confidence in delivering care to the pediatric/adolescent patient.

Best practices to minimize risk of infection with intrauterine device insertion.

BACKGROUND: Intrauterine devices provide an extremely effective, long-term form of contraception that has the benefit of being reversible. Historically, the use of certain intrauterine devices was associated with increased risk of pelvic inflammatory disease. More recent evidence suggests that newer devices do not carry the same threat; however, certain risk factors can increase the possibility of infection. OBJECTIVES: To review the risk of infection with the insertion of intrauterine devices and recommend strategies to prevent infection. OUTCOMES: The outcomes considered were the risk of pelvic inflammatory disease, the impact of screening for bacterial vaginosis and sexually transmitted infections including chlamydia and gonorrhea; and the role of prophylactic antibiotics. EVIDENCE: Published literature was retrieved through searches of PubMed, Embase, and The Cochrane Library on July 21, 2011, using appropriate controlled vocabulary (e.g., intrauterine devices, pelvic inflammatory disease) and key words (e.g., adnexitis, endometritis, IUD). An etiological filter was applied in PubMed. The search was limited to the years 2000 forward. There were no language restrictions. Grey (unpublished) literature was identified through searching the web sites of national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table). Recommendations 1. All women requesting an intrauterine device should be counselled about the small increased risk of pelvic inflammatory disease in the first 20 days after insertion. (II-2A) 2. All women requesting an intrauterine device should be screened by both history and physical examination for their risk of sexually transmitted infection. Women at increased risk should be tested prior to or at the time of insertion; however, it is not necessary to delay insertion until results are returned. (II-2B) 3. Not enough current evidence is available to support routine screening for bacterial vaginosis at the time of insertion of an intrauterine device in asymptomatic women. (II-2C) 4. Routine use of prophylactic antibiotics is not recommended prior to intrauterine device insertion, although it may be used in certain high-risk situations. (I-C) 5. Standard practice includes cleansing the cervix and sterilizing any instruments that will be used prior to and during insertion of an intrauterine device. (III-C) 6. In treating mild to moderate pelvic inflammatory disease, it is not necessary to remove the intrauterine device during treatment unless the patient requests removal or there is no clinical improvement after 72 hours of appropriate antibiotic treatment. In cases of severe pelvic inflammatory disease, consideration can be given to removing the intrauterine device after an appropriate antibiotic regimen has been started. (I-B) 7. An intrauterine device is a safe, effective option for contraception in an HIV-positive woman. (I-B) 8. An intrauterine device can be considered a first-line contraceptive agent in adolescents. (I-A).

Contexte : Les dispositifs intra-utérins constituent un moyen de contraception à long terme extrêmement efficace qui compte l'avantage d'être réversible. Historiquement, l'utilisation de certains dispositifs intra-utérins a été associée à une hausse du risque de syndrome inflammatoire pelvien. Des données plus récentes laissent entendre que cette association ne s'applique pas aux nouveaux dispositifs; toutefois, certains facteurs de risque peuvent accroître la possibilité d'infection. Objectifs : Analyser le risque d'infection associé à l'insertion de dispositifs intra-utérins et recommander des stratégies visant la prévention de l'infection. Issues : Les issues prises en considération ont été le risque de syndrome inflammatoire pelvien, les effets du dépistage de la vaginose bactérienne et des infections transmissibles sexuellement (dont la chlamydiose et la gonorrhée), et le rôle de l'antibioprophylaxie. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées, le 21 juillet 2011, dans PubMed, Embase et The Cochrane Library au moyen d'un vocabulaire contrôlé (p. ex. « intrauterine devices ¼, « pelvic inflammatory disease ¼) et de mots clés (p. ex. « adnexitis ¼, « endometritis ¼, « IUD ¼) appropriés. Un filtre étiologique a été appliqué dans PubMed. Les recherches ont été limitées à la période débutant en l'an 2000. Aucune restriction n'a été appliquée en matière de langue. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Recommandations 1. Toutes les femmes demandant l'insertion d'un dispositif intra-utérin devraient être avisées de la légère hausse du risque de syndrome inflammatoire pelvien qui est constatée au cours des 20 premiers jours suivant l'insertion. (II-2A) 2. Toutes les femmes demandant l'insertion d'un dispositif intra-utérin devraient faire l'objet d'une évaluation (au moyen d'une anamnèse et d'un examen physique) visant à établir leur risque de présenter une infection transmissible sexuellement. Les femmes exposées à un risque accru devraient faire l'objet d'un dépistage avant l'insertion ou au moment de celle-ci; cependant, il n'est pas nécessaire de reporter l'insertion jusqu'à l'obtention des résultats. (II-2B) 3. Nous ne disposons pas actuellement d'assez de données pour soutenir la tenue systématique, chez les femmes asymptomatiques, d'un dépistage de la vaginose bactérienne au moment de l'insertion d'un dispositif intra-utérin. (II-2C) 4. L'utilisation systématique d'une antibioprophylaxie n'est pas recommandée avant l'insertion d'un dispositif intra-utérin; toutefois, l'utilisation d'une telle mesure pourrait être envisagée dans certaines situations comptant des risques élevés. (I-C) 5. Les pratiques standard englobent le nettoyage du col et la stérilisation de tous les instruments qui seront utilisés avant et pendant l'insertion d'un dispositif intra-utérin. (III-C) 6. Dans le cadre de la prise en charge d'un syndrome inflammatoire pelvien allant de bénin à modéré, il n'est pas nécessaire de retirer le dispositif intra-utérin pendant le traitement, sauf lorsque la patiente en fait la demande ou en l'absence d'amélioration clinique après 72 heures de traitement approprié au moyen d'antibiotiques. En présence d'un syndrome inflammatoire pelvien grave, le retrait du dispositif intra-utérin à la suite de la mise en œuvre d'un schéma posologique approprié d'antibiotiques peut être pris en considération. (I-B) 7. L'utilisation d'un dispositif intra-utérin constitue une option sûre et efficace en matière de contraception pour ce qui est des femmes séropositives pour le VIH. (I-B) 8. Les dispositifs intra-utérins peuvent être considérés comme étant des modes de contraception de première intention pour ce qui est des adolescentes. (I-A).