Genital injuries acute evaluation and management.

Genital trauma may result in external injuries to the labia, vulva or vagina, urethra and anus and internal injuries to the bony pelvis, bladder, bowels and reproductive organs. Worldwide, the most common cause of genital trauma in reproductive age women is injury sustained during childbirth, but in this chapter we will focus on accidental genital injuries as well as those arising from sexual violence, and female genital mutilation. While genital injuries alone rarely result in death; if not properly managed, chronic discomfort, dyspareunia, infertility, or fistula formation may result. Clinicians need to be able to recognize these injuries and provide initial management, and assure that the patient's mental, emotional and physical needs are addressed.

Massive Hydronephrosis from Ureteropelvic Junction Obstruction Masquerading as a Paratubal Cyst in an 11-Year-Old Girl.

BACKGROUND: The differential diagnosis of a cystic pelvic mass in an adolescent girl is broad, and includes gastrointestinal, urologic, and gynecologic conditions. CASE: A premenarchal 11-year-old girl presented with abdominal pain. On transabdominal ultrasonography, abutting the lateral side of the left ovary was a large mass with an appearance compatible with a large paratubal cyst measuring 16.7 × 11.9 cm. On exploratory laparotomy, the patient's uterus, tubes and ovaries were normal and a massively dilated and displaced left kidney due to an ureteropelvic junction obstruction was ultimately diagnosed. SUMMARY AND CONCLUSION: A cystic pelvic mass in an adolescent girl may not always be of ovarian or müllerian origin. Urinary tract obstruction is often silent; an incidental finding of hydronephrosis on ultrasonography may be the first clue of the possibility of ureteropelvic junction obstruction as the underlying diagnosis. It is always best to know which organ system is involved prior to surgery, so that the correct surgical team is present and the correct surgical approach is utilized.

The course of lichen sclerosus diagnosed prior to puberty.

STUDY OBJECTIVE: To help determine the long-term course of girls diagnosed with lichen sclerosus before puberty. DESIGN: Retrospective chart review and follow-up interview. SETTING: Washington University pediatric gynecology and dermatology clinics. PARTICIPANTS: Premenarchal girls diagnosed with lichen sclerosus from 1989-2010. INTERVENTIONS: Telephone interview. MAIN OUTCOME MEASURES: Resolution of symptoms, specifically pain and/or pruritus. RESULTS: Follow-up was available for 36 premenarchal girls. The mean age at lichen sclerosus (LS) diagnosis was 7 years (range: 3-14 years). The mean duration of follow-up was 5.3 years (range: 2 months-15 years). Treatment with topical steroids (primarily 0.05% clobetasol propionate ointment) resulted in improvement in symptoms within an average of 14 weeks (range: 2 weeks-2 years) in 33 girls. Eighty-three percent of patients (n = 30) experienced remission after initial treatment. Sixteen patients reported relapses requiring an average of 3.1 years of intermittent maintenance therapy. The mean length of remission to date was 3.6 years (range 1 months-10 years). 72% of patients reported remission at the time of the phone interview. Of note, 7 out of 9 patients in our study who continue to report symptoms are still premenarchal. One postmenarchal patient was asymptomatic but had signs of LS on physical exam. CONCLUSION: The prognosis and long term course of LS diagnosed prior to puberty is unclear. Although remission may occur prior to menarche in some cases, once children reach menarche with active disease, complete remission may be less likely. Treatment duration of LS in our study had a wide range, but 3 months appears to be adequate for most patients to obtain remission.

The auto-amputated adnexa: a review of findings in a pediatric population.

STUDY OBJECTIVE: To quantify our experience and that of the literature with diagnosis and management of the auto-amputated adnexa in a pediatric population. DESIGN: Case series and literature review. SETTING: Tertiary care medical center. PARTICIPANTS: Case series of pediatric patients (<18 years of age) with surgically documented adnexal auto-amputation collected from our medical center and the literature. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Auto-amputated adnexa. RESULTS: In addition to the 3 cases discussed from our institution, 91 cases of auto-amputated adnexa were identified in the literature dating back to 1943, for a total of 94 cases. Forty-nine percent (46/94) of the cases involved girls in a pediatric population (<18 years of age). Of these, the majority (n = 26) were identified in a subgroup of girls who were diagnosed with an adnexal cyst by antenatal ultrasound. Most of these neonates were asymptomatic at birth or had a palpable abdominal mass (n = 6) and at the time of surgical exploration were found to have an auto-amputated adnexa. 34 out of 46 cases were analyzed in detail. The right adnexa were involved in 56% of the cases. The most common presenting complaint verbalized by the older girls was pain; however, 8 cases were identified in asymptomatic girls undergoing unrelated diagnostic testing. CONCLUSION: The auto-amputated adnexa is a rare finding in the pediatric population, but it must be considered as a possible explanation for the incidental finding of absence of the fallopian tube or ovary in the subgroup of patients who undergo surgery for any reason. Patients with an antecedent history of pelvic pain either chronic or intermittent in nature may be diagnosed with torsion or less frequently auto-amputation of the adnexa. A fetal "pelvic mass" or "ovarian cyst" may predispose the adnexa to torsion and subsequent auto-amputation either in-utero or post-delivery. Many of these antenatally diagnosed cysts and even subsequent auto-amputations are completely asymptomatic, however, and do not compromise fertility assuming the contralateral adnexa are normal. Thus expectant management is appropriate for small (less than 4 cm), asymptomatic simple cysts and even suspected auto-amputated adnexa in an asymptomatic patient.