Congenital Vaginal Abnormalities

Labial Fusion/Agglutination

Filmy adhesions of the labia can be a common finding in the newborn and are usually left alone. Fusion of the labia is commonly associated with congenital adrenal hyperplasia, and further evaluation and testing may be warranted, especially in the presence of ambiguous genitalia in genetic females. In settings of labial agglutination, topical estrogen is the mainstay therapy. If agglutination or fusion is recalcitrant to conservative therapy, then surgical intervention may be required once maturation has taken place.

Examination under anesthesia is useful in determining the extent of fusion/agglutination ( Fig. 59.1A ) and allows further evaluation of the lower genitourinary tract. A Kelly clamp is inserted in the opening and demonstrates a fused but thin tissue ( Fig. 59.1B ). A midline incision is made with a scalpel or electrosurgery and extended downward until reaching the posterior fourchette. The epithelial edges are approximated with interrupted 3-0 Vicryl sutures ( Fig. 59.1C ). Topical estrogen can be applied, and follow-up is recommended once or twice over the following 6 weeks to assess adequate healing. Dilation is rarely required in our experience.

Imperforate Hymen

A child or adolescent with an imperforate hymen presents with pain and a thin, translucent membrane distended by blood or mucus. An imperforate hymen is often treated in the operating suite with sedation or general anesthesia.

First, an incision is made in the center of the membrane, and the blood and mucus are evacuated. The incision is extended transversely to the lateral margins of the obstructing membrane ( Fig. 59.2A and B ). Next, the membrane is divided anteriorly, then posteriorly, to complete a cruciate incision. Finally, the redundant avascular tissue is excised ( Fig. 59.2C ).

Bleeding should be minimal following resection of the hymenal membrane. Pressure applied with a damp sponge will control most bleeding sites. If the resection has been carried out too far, and the bleeding cannot be controlled with a sparing application of Monsel’s solution (ferric subsulfate) or light pressure, then simple interrupted sutures of 3-0 polyglycolic acid should be placed. A continuous running simple suture should be avoided because this may cause constriction of the hymenal ring. The appropriate result is a capacious introitus that functionally permits comfortable coitus ( Fig. 59.3A ).

Other developmental abnormalities of the hymen, including cribriform ( Fig. 59.3B ) and septate hymens ( Fig. 59.3C ), may require surgical intervention. As with the aforementioned, the goal of surgery is to create a nonconstricting, functional vaginal introitus. A small opening in a septate or cribriform hymen is easily resected with electrosurgery ( Fig. 59.3D ) or dilated with a cervical dilator set. Once the largest dilator has been used, the remaining fragments of the hymen are tied with 4-0 polyglycolic acid suture at the base and resected. If the delicate tissue is torn during suture placement, bleeding usually stops after applying direct pressure for 2 to 5 minutes or with the measures discussed earlier.