In vitro biomechanical properties of porcine perineal tissues to better understand human perineal tears during delivery.

INTRODUCTION: Data concerning the mechanical properties of the perineum during delivery are very limited. In vivo experiments raise ethical issues. The aim of the study was to describe some of the biomechanical properties of each perineal tissue layer collected from sows in order to better understand perineal tears during childbirth. MATERIAL AND METHODS: Samples of each perineal tissue layer were obtained from the skin, the vagina, the external anal sphincter (EAS), the internal anal sphincter (IAS), and the anal mucosa of fresh dead sows. They were tested in quasi-static uniaxial tension using the testing machine Mach-1®. Tests were performed at a displacement velocity of 0.1 mm·s-1. Stress-strain curves of each perineal tissue layer before the first damage for each sow were obtained and modeled using a hyperelastic Yeoh model described by three coefficients: C1, C2, and C3. Pearson correlation coefficients were calculated to measure the correlation between the C1 hyperelastic coefficient and the duration between the first microfailure and the complete rupture for each perineal tissue layer. Pearson correlation was computed between C1 and the number of microfailures before complete rupture for each tissue. RESULTS: Ten samples of each perineal tissue layer were analyzed. Mean values of C1 and corresponding standard deviations were 46 ± 15, 165 ± 60, 27 ± 10, 19 ± 13, 145 ± 28 kPa for the perineal skin, the vagina, the EAS, the IAS, and the anal mucosa, respectively. According to this same sample order, the first microfailure in the population of 10 sows appeared at an average of 54%, 27%, 70%, 131%, and 22% of strain. A correlation was found between C1 hyperelastic coefficient and the duration between the first microfailure and the complete rupture (r = 0.7, p = 0.02) or the number of microfailures before complete rupture only for the vagina (r = 0.7, p = 0.02). CONCLUSIONS: In this population of fresh dead sow's perineum, the vagina and the anal mucosa were the stiffest tissues. The IAS and EAS were more extensible and less stiff. A significantly positive correlation was found between C1 and the duration between the first microfailure and the complete rupture of the vagina, and the duration between the first microfailure and the complete rupture of the vagina.

Quantitative evaluation of endometrium-expressed mRNAs for the purpose of discriminating between menstruation and traumatic vaginal injury in sexual assault cases.

In sexual assault cases, it is crucial to discriminate between peripheral blood and menstrual blood to provide evidence for vaginal intercourse with traumatic injury. In this study, the menstrual blood mRNA markers progestagen-associated endometrial protein (PAEP), matrix metallopeptidase 7 (MMP7), and left-right determination factor 2 (LEFTY2) were evaluated by quantitative RT-PCR (RT-qPCR) for the discrimination of menstrual blood from peripheral blood and vaginal fluid. As a result, all markers with cutoff delta cycle quantification (ΔCq) values were specifically determined in menstrual blood among forensically relevant body fluids. Even though the changes in the expression levels of each marker differed during the menstrual cycle, all markers were determined to be positive in most of the randomly collected menstrual blood samples that were analyzed. Additionally, the markers with proposed cutoff ΔCq values could discriminate between menstrual blood and peripheral blood-mixed vaginal fluid samples. The determination of positive markers was less affected by storage temperature under dry conditions than under wet conditions, while PAEP was detectable in samples stored below room temperature under wet conditions. The detectability of PAEP was considered to be the result of its higher expression level compared with MMP7 and LEFTY2. In conclusion, menstrual blood markers for the RT-qPCR procedure evaluated in this study were highly specific for menstrual blood. The proposed procedure could be useful for discriminating between menstruation and traumatic bleeding in the female genital tract. In particular, PAEP is expected to be applicable to forensic casework samples because of its high specificity and robustness.

Vaginal Corrosion Due to Insertion of a 9-Volt Battery.

BACKGROUND: Batteries are known to cause damage to mucosal surfaces. Unfortunately, the timing of serious sequelae and recommendations for removal of a vaginally inserted battery in a premenopausal patient are not well characterized. This case report aims to detail the timeline of events and complications after vaginal insertion of a 9-volt alkaline battery and to further clarify the recommendation for urgent removal. CASE: A 24-year-old nulliparous woman with significant psychiatric and trauma history was admitted for ingestion and insertion of multiple foreign objects, including a 9-volt battery that she inserted into her vagina during her hospital admission. Examination under anesthesia was required for removal of the battery, with cervical and vaginal necrosis and partial-thickness burns noted. Removal occurred approximately 5.5 hours after insertion. Management included vaginal irrigation and topical estrogen. CONCLUSION: Given our findings of rapid and severe damage to the vaginal mucosa, urgent removal of a vaginally inserted battery is indicated.

Accidental laceration of the vaginal wall by an intravaginal thermometer as a calving detection device in a Japanese black cow.

An intravaginal thermometer was inserted into a 59-month-old Japanese black cow to predict calving. After calving, the thermometer penetrated the vaginal wall and could not be removed by farm staff. Surgery to remove the thermometer was successful. The cow left the animal hospital without hospitalization. In the follow-up, the cow remained healthy on the farm for more than one year and is now pregnant. No symptoms related to damage to the vagina or infection developed. This is the first case report of a vaginal laceration caused by an intravaginal thermometer in a Japanese black cow. Insertional vaginal devices may cause vaginal lacerations in cattle.

Vaginal distention rodent model for fecal incontinence: a pilot study on the effect on defecation behavior

Objectives: Vaginal balloon inflation simulates the compressive forces on the pelvic floor during the second phase of natural delivery. The foremost use of this animal model of vaginal distention (VD) is to study the mechanisms underlying urinary incontinence. As damage to the pelvic floor during natural birth is a common cause of fecal incontinence, the present paper aimed to investigate the effect of VD on defecation behavior in adult rats. Methods: Vaginal distention was performed in 8 rats for 2 hours, and in 3 rats for 4 hours, and sham inflation was performed in 4 rats. With the use of a latrine box in the rat home-cage and 24/7 video tracking, the defecation behavior was examined. The time spent in and outside the latrine was monitored for two weeks preoperatively and three weeks postoperatively, and a defecation behavior index (DBI; range: 0 [continent] to 1 [incontinent]) was defined. Pelvic floor tissue was collected postmortem and stained with hematoxylin and eosin. Results: Vaginal balloon inflation for 2 hours resulted in fecal incontinence in 29% of the animals (responders) whereas the DBI scores of non-responders (71%) and control animals did not change in the postoperative phase compared with the baseline score. A 4-hour balloon inflation resulted in fecal incontinence in 1 animal and caused a humane endpoint in 2 animals with markedly more tissue damage in the 4-hour responder compared with the 2-hour responders. Conclusions: Vaginal balloon inflation, with an optimum duration between 2 and 4 hours, can be used as a model to study changes in defecation behavior in rats induced by pelvic floor damage. (AU)

Vaginal injuries after consensual sexual intercourse - a survey among office-based gynecologists in Hamburg, Germany.

Studies on the occurrence of injuries following consensual sexual intercourse (CSI) among patients treated by office-based gynecologists are lacking. This survey aimed to assess the presence and medical relevance of vaginal injuries after CSI in gynecological office-based practice, associated risk factors, and their significance for forensic medical assessment practice. All office-based gynecologists in Hamburg, Germany (n = 316), were asked to fill in a one-page questionnaire via a fax survey. The questionnaire covered various aspects such as having observed CSI-related injuries, injury severity, risk factors, and concomitant factors (bleeding, need for surgical care, hospitalization). Response rate was 43.2% (n = 115). Overall, 83.5% of office-based gynecologists reported having observed vaginal injuries after CSI at least once and 59.1% repeatedly. Regarding maximum injury severity, 52.1% observed mucosal erosions, 32.3% mucosa penetrating injuries, and 14.6% injuries penetrating the vagina. Having observed bleeding was reported by 56.3%, 28.1% had to perform surgical suture care, and hospital admission was initiated by 20.8%. Menopause (37.5%), use of objects (19.8%), alcohol, and/or drug use (16.7%) were reported as the most frequently observed associated risk factors. Vaginal injuries after CSI have been observed by the majority of office-based gynecologists in Hamburg involving a wide spectrum of severity, including the necessity of surgical care and hospital admission. Complementing published work in clinical and emergency medicine, these findings are highly relevant to the forensic evaluation of injuries in an allegation of sexual assault, as the severity of a vaginal injury in this setting does not necessarily support a conclusion on the issue of consent.

Sangrado genital por cuerpo extraño en niñas prepuberales: a propósito de un caso / Genital bleeding caused by foreign body in prepubertal girls: a case report

El sangrado genital en niñas prepúberes es un signo poco frecuente y siempre requiere determinar su causa. Se necesitan una detallada anamnesis y examen físico, con el conocimiento adecuado de la anatomía uroginecológica, y, en muchos casos, estudios de imágenes y exámenes complementarios, para arribar al diagnóstico. Se presenta el caso de una niña de 7 años con sangrado genital, cuyo examen físico y estudios complementarios fueron poco concluyentes, y que requirió un procedimiento invasivo para su resolución. (AU)

Genital bleeding in prepubertal girls is a rare sign and always requires determining its cause. A detailed history and physical examination are needed, with adequate knowledge of urogynecological anatomy, and in many cases, imaging studies and complementary tests, to arrive at the diagnosis. We present the case of a 7-year-old girl with genital bleeding, whose physical examination and complementary studies were inconclusive, requiring an invasive procedure for its resolution. (AU)

Maternal and neonatal trauma following operative vaginal delivery.

BACKGROUND: Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume. METHODS: We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression. RESULTS: Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%-25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6-10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%-13.4%) and 9.6 (95% CI 9.0-10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65-1.75) and varied by region, but not by level of obstetric care. INTERPRETATION: In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.

Vaginal Complications after Cystectomy: Results from a Medicare Sample.

PURPOSE: Cystectomy with a vaginal-sparing approach may be associated with unique complications specific to the female population. The objective of this study was to estimate the incidence of vaginal complications (defined to include vaginal prolapse, vaginal fistula, dyspareunia and vaginal cuff dehiscence/evisceration) after cystectomy and to determine risk factors for these complications. MATERIALS AND METHODS: Women 65 years or older undergoing cystectomy for any indication were identified by procedural codes in the Medicare Limited Data Set 5% sample from January 1, 2011 to December 31, 2017. Patients experiencing a vaginal complication after cystectomy were compared to those who did not. Demographic and biological factors that could increase likelihood of complications were identified and time to development of complications determined. Cumulative incidence was calculated using cumulative incidence function. Multivariable cause-specific Cox proportional hazards model assessed risk factors for vaginal complications. RESULTS: In all, 481 women undergoing cystectomy were identified during the study period, and 37.2% were younger than 70 years old. The majority (378, 79%) had bladder cancer, and 401 (83.4%) underwent an incontinent conduit or catheterizable channel diversion. Within 2 years of cystectomy, 93 patients (19.5%) had 1 or more complications on record. Vaginal cuff dehiscence had the highest cumulative incidence, occurring in 49 patients (10.2%). Over the entire study period (2011-2017), 102 women (21.2%) were diagnosed with a vaginal complication, and 27 (5.6%) received an intervention. CONCLUSIONS: Among women who undergo cystectomy, vaginal complications occur at rates higher than expected with over 20% of women experiencing a complication and over a quarter of those diagnosed undergoing intervention.

Design and Validation of an Automated Dilator Prototype for the Treatment of Radiation Induced Vaginal Injury.

Vaginal stenosis (VS) is a common late complication of radiation injury caused by cervical cancer radiotherapy. It is characterized by the narrowing or shortening of the vaginal canal, which is often detrimental to patient quality of life. To address this public health problem, an expandable vaginal dilator was designed for the prevention of VS in cervical cancer survivors. Modeling and benchtop experimentation were used to iteratively characterize the relationship among dilator pressure, expansion, and the load applied to the simulated vaginal wall. Both experimental and simulation results exhibited shared trends relating pressure, dilator expansion, applied load, and resultant displacement of the modeled vaginal walls. Future work will incorporate enhanced Mooney-Rivlin material assumptions and validation of the model with in vivo tests.Clinical Relevance- These results present a design opportunity and treatment paradigm shift to increase patient adherence to VS treatment after cervical cancer radiotherapy. Specifically, gradual expansion of the vaginal dilator increases comfort during the expansion of the vagina, while monitoring the dilator pressure enables the tracking of VS improvement and normalization of vaginal wall compliance.

Traumatic rectovaginal fistula after sexual intercourse following a non-consensual anal penetration: a case report and a review of the literature.

Rectovaginal fistulas are rare genital lesions, often due to obstetric causes. More rarely they are a consequence of sexual intercourse. We present the case of a 36-year-old woman who presented to a gynecological emergency department with pelvic pain and feces coming from the vagina. This symptomatology appeared after non-consensual anal intercourse following consensual penile vaginal penetration. She was treated for a perforation of the rectovaginal septum. On the basis of our results, we reviewed the cases published in the literature, with a summary of the elements that may favor the appearance of this lesion, such as "virginity", obstetrics and gynecological history, or coitus position, its classification by size and localization, and the therapeutic indications (suture repair of the wall or a colostomy). Better knowledge of this type of lesion would improve the practice of forensic pathologists for screening and management.

Obstetric Lacerations: Prevention and Repair.

Obstetric lacerations are a common complication of vaginal delivery. Lacerations can lead to chronic pain and urinary and fecal incontinence. Perineal lacerations are defined by the depth of musculature involved, with fourth-degree lacerations disrupting the anal sphincter and the underlying rectal mucosa and first-degree lacerations having no perineal muscle involvement. Late third-trimester perineal massage can reduce lacerations in primiparous women; perineal support and massage and warm compresses during the second stage of labor can reduce anal sphincter injury. Conservative care of minor hemostatic first- and second-degree lacerations without anatomic distortion reduces pain, analgesia use, and dyspareunia. Minor hemostatic lesions with anatomic disruption can be repaired with surgical glue. Second-degree lacerations are best repaired with a single continuous suture. Lacerations involving the anal sphincter complex require additional expertise, exposure, and lighting; transfer to an operating room should be considered. Limited evidence suggests similar results from overlapping and end-to-end external sphincter repairs. Postdelivery care should focus on controlling pain, preventing constipation, and monitoring for urinary retention. Acetaminophen and nonsteroidal anti-inflammatory drugs should be administered as needed. Opiates should be avoided to decrease risk of constipation; need for opiates suggests infection or problem with the repair. Osmotic laxative use leads to earlier bowel movements and less pain during the first bowel movement. Simulation models are recommended for surgical technique instruction and maintenance, especially for third- and fourth-degree repairs.

Focusing on long-term complications of mid-urethral slings among women with stress urinary incontinence as a patient safety improvement measure: A protocol for systematic review and meta-analysis.

BACKGROUND: There are 3 different types of mid-urethral sling, retropubic, transobturator and single incision performed for women with stress urinary incontinence. Prior studies comparing these three surgeries merely focused on the successful rate or efficacy. But nevertheless, what is more clinically important dwells upon investigating postoperative complications as a safety improvement measure. METHODS: A systematic review via PubMed, Ovid, and the Cochrane Database of Systematic Review and studies were applied based on the contents with clearly identified complications. Selected articles were reviewed in scrutiny by 2 individuals to ascertain whether they fulfilled the inclusion criteria: complications measures were clearly defined; data were extracted on study design, perioperative complications, postoperative lower urinary tract symptoms, postoperative pain, dyspareunia, and other specified late complications. RESULTS: A total of 55 studies were included in the systemic review. Perioperative complications encompassed bladder perforation, vaginal injury, hemorrhage, hematoma, urinary tract infection. There were postoperative lower urinary tract symptoms including urine retention and de novo urgency. Furthermore, postoperative pain, tape erosion/ extrusion, further stress urinary incontinence surgery, and rarely, deep vein thrombosis and injury of inferior epigastric vessels were also reported. CONCLUSIONS: Complications of mid-urethral sling are higher than previously thought and it is important to follow up on their long-term outcomes; future research should not neglect to address this issue as a means to improve patient safety.

[Fractures of the pelvis causing vaginal wound]. / Fractures du bassin occasionnant une plaie du vagin.

Pelvic fractures occur most often in people experiencing a traumatic event. Although they are due to high-velocity injuries, these lesions are rarely associated with vaginal wounds, and data on patients' evolution are scarce. The purpose of our study was to describe anatomoclinic lesions, treatment and progression of these lesions. The study involved five female patients who had had vaginal wounds due to pelvic fracture over the past decade. The patients had a mean age of 23,6 years. Vaginal wounds were mainly due to road accidents. Two patients had linear wounds and three had lacerated wounds. Vaginal suture was performed in all patients. After a mean follow-up period of 2 years, patients' evolution was favorable with healing of vaginal wound and bone. Genital and obstetric functions were not compromised. Although vaginal wounds most often go unnoticed, they should be suspected in female patients with pelvic fracture.

Genital injuries and allegation of digital vaginal penetration - A retrospective examination of forensic case notes.

OBJECTIVE: To determine the prevalence of genital injuries following alleged sexual assault by digital penetration of the vagina in the absence of penile penetration of the vagina or anus in women age 16 and over; and to compare with the prevalence of genital injuries following alleged sexual assault by penile vaginal penetration in the absence of penile penetration of the anus or digital penetration of the vagina and/or anus. POPULATION: 1428 adults and children attending a forensic medical examination between September 2017 and January 2020 at the Haven sexual assault referral center situated in Paddington, London, UK. DESIGN: Retrospective review of forensic notes. METHODS: Eligible cases were identified through the standardized forensic notes and relevant data was extracted. RESULTS: 109 cases of women 16 years and over alleging digital penetration only and 110 cases of women 16 years and over alleging penile vaginal penetration only were included. The 110 cases of penile vaginal penetration only were randomly selected for comparison purposes. 7.6% of Haven attenders fulfilled the digital penetration only category. In this category, the patients mean age was 27.2 years. Thirteen patients (11.9%) sustained genital injuries; of those with genital injuries, eleven (84.6%) sustained one or more abrasions. The most common site of injury was the labia minora (46.2%). There were no significant differences between the 2 groups (digital penetration only and penile vaginal penetration only) in terms of number of patients with genital injuries, type or location of injury. There were differences regarding the relationship between patient and assailant: more stranger assaults in the digital penetration group 27/109 (29%) vs 13/110 (12%) in the penile penetration group. There was one assault by multiple assailants in the digital penetration group and 8 (7.3%) in the penile penetration group. In the digital penetration group there was more alcohol use [71/109 (65.1%) vs 62/110 (56.4%)] but less drug use [21/109 (19.3%) vs 30/110 (27.3%)] than in the penile vaginal penetration group. CONCLUSION: The majority of patients examined following an allegation of digital vaginal penetration without penile penetration sustained no injuries. Of those who did, abrasions were the most common type of injury, with the inner labia minora being the most common location for injury. There were no significant differences with the injuries seen in the penile vaginal penetration group in terms of number of patients with genital injuries, type or location of injury.

Beef Tongue Surgical Simulation Model for Posterior Vaginal Repair.

BACKGROUND: This surgical simulation model for vaginal posterior repair is designed to enhance vaginal surgical training. METHODS: A beef tongue simulation model was previously described and validated to practice the repair of obstetric laceration. The model was modified for surgical simulation of vaginal posterior repair. Chicken skin was used to simulate the anal canal. The model was secured in a PVC (polyvinyl chloride) pipe attached to a wooden base to simulate operating within the vaginal canal. EXPERIENCE: Materials can be obtained from the local supermarket and hardware store. The total cost of the model is $35.47 for initial setup and $7.11 per use. Residents performing on the model felt it was realistic and useful for practicing the steps and skills for this procedure. CONCLUSION: The beef tongue simulation model of vaginal posterior repair is realistic, easy to construct, and affordable. It can be incorporated into a vaginal surgery curriculum to augment resident surgical education.

Surgical repair of an obstetric cloaca with review of the literature.

A complete perineal wound breakdown of a fourth degree laceration leading to a cloaca is a rare but devastating complication of vaginal childbirth. A 32-year-old primiparous woman presented with an obstetric cloaca 4 months following delivery. She underwent preoperative evaluation and, following extensive counselling, elected to proceed with operative repair. The procedure is presented in 15 well-defined steps with photos. The repair was performed in standard fashion with three supplementary steps. These included: (1) division of the rectovaginal tissue into three distinct layers; (2) attachment of these layers individually to the reconstructed perineal body and sphincter and (3) incorporation of the levator muscles into the repair. The wound healed well within 6 weeks of repair. Now 3½ years postoperatively, the patient has no faecal incontinence or sexual dysfunction and only minimal defecatory dysfunction. The discussion describes our surgical approach in the context of a review of the literature.

Clinical Presentation, Treatment, and Challenges in the Management of Child Sexual Assault at a Tertiary Care Referral Center in India.

BACKGROUND: Child Sexual Assault (CSA) is not an uncommon but an under-reported crime. Along with social and psychological critical issues, there are multiple challenges faced by the surgical team for the treatment of complex perineal injuries associated with CSA. This study was conducted to find clinical presentation and management of CSA along with its problems and challenges encountered by the pediatric surgical team. MATERIALS AND METHODS: This was a retrospective study from 2010 to 2019, conducted in the department of pediatric surgery at a tertiary referral center. All-female patients with a definitive history of sexual assault were included in the study. RESULTS: Seven patients fulfilled the inclusion criteria and the mean age was 5.3 years. After a primary survey, all patients were taken up for examination under anesthesia (EUA). Three patients were managed by the primary repair of the wound and did well during follow-up. Four patients had grade 4 perineal injury and required stage reconstruction. As a first stage, repair of rectal tear, vaginal tear, and the perineal body reconstruction was done along with diversion colostomy. One patient required redo repair of the perineal body and one had developed a rectovaginal fistula. Three patients completed all stages and they are fully continent. CONCLUSION: The spectrum of injuries varies widely in CSA and more chances of high-grade perineal injuries in children due to distinctive local anatomy. EUA is crucial to assess the extent of the injury and to decide the course of management. Meticulous anatomical repair and diversion stoma is the key for successful complex repair and excellent long-term outcomes in terms of continence for the severe grade of perineal injuries.