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Atlas of Vulvar Disorders

Part 1 Unlike in the cervix and vagina, cytology plays little role in the diagnosis of vulvar disease. Because the vulva is clearly visible and easily magnified with the aid of a colposcope, suspicious changes are easily observed as areas that are different from the surrounding normal skin. The diagnosis of vulvar disorders is always confirmed by biopsy. Embryonic Fig. 63.1 shows a rather common finding…

Iatrogenic Vaginal Constriction

Vaginal stricture may occur secondary to inflammatory conditions of the vagina, vaginal surgery, episiotomy repair, or radiotherapy. The surgical approach to the stenosis depends on its anatomic location, underlying cause, and severity. For introital or vaginal stenosis, the procedure can treat both upper and lower vaginal strictures or can correct lower vaginal strictures specifically. Operations that correct upper and lower vaginal strictures include incision of the…

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…

Benign Lesions of the Vaginal Wall

Under normal circumstances, the vagina does not contain any glands. However, when the condition of adenosis exists (i.e., occurs spontaneously or as the result of antenatal diethylstilbestrol [DES] exposure), mucosal and submucosal mucus-secreting glands may be identified ( Fig. 58.1A and B ). These lesions appear as granulation-like tissue, clefts, holes, or cysts ( Fig. 58.2A and B ). Whenever adenosis is suspected, the lesion should…

Avoiding and Managing Synthetic Mesh Complications After Surgeries for Urinary Incontinence and Pelvic Organ Prolapse

In 1998 synthetic midurethral slings became commercially available in the United States. These procedures were robustly compared with suspension procedures, and pubovaginal slings were found to be much less invasive with comparable long-term outcomes. These slings have stood the test of time and would be considered by most to be the “gold standard” for the surgical treatment of stress urinary incontinence (SUI) (see Chapter 55 ).…

Synthetic Midurethral Slings for the Correction of Stress Incontinence

In 1996, Ulmsten and colleagues introduced the first synthetic midurethral sling, which they named the tension-free vaginal tape (TVT) procedure. This procedure introduced the concept of placing a synthetic material (polypropylene) under the midportion of the urethra in a tension-free fashion. The technique quickly gained popularity because it involved minimal vaginal dissection, was easy to learn, and could be performed with the patient under local anesthesia…

Native Tissue Vaginal Repair of Cystocele, Rectocele, and Enterocele

Anterior Vaginal Wall Prolapse Anterior vaginal wall prolapse, or cystocele, is defined as pathologic descent of the anterior vaginal wall and overlying bladder base. The cause of anterior vaginal wall prolapse is not completely understood but is probably multifactorial, with different factors implicated in individual patients. Until recently, two types of anterior vaginal wall prolapse were described: distention and displacement cystocele. Distention cystocele was thought to…

Vaginal Hysterectomy

Simple Vaginal Hysterectomy When hysterectomy is indicated, the most appropriate route of removal of the uterus must be chosen. Hysterectomy can be performed transvaginally, abdominally, laparoscopically, robotically, or with laparoscopic or robotic assistance. The decision to proceed with a vaginal hysterectomy depends on numerous factors. These include the surgeon’s training and comfort level with the procedure, the size and mobility of the uterus, the presence of…