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An Abnormal Vaginal Opening in a Two-Twelvemonth-Old

Am Fam Physician. 2008 February 1;77(iii):355-356.

A two-year-old daughter's mother was concerned that her daughter'due south vaginal opening appeared to be closed. The female parent had noticed this a few months earlier when her daughter had astringent diaper rash. The patient did non accept urinary problems or vaginal discharge, and her nascence and development histories were unremarkable. Genital examination revealed a thin vertical raphe over the site of the vaginal opening (run across accompanying figure). The labia majora were intact and separated, although only the upper third of the labia minora was identifiable.

Question

Based on the patient'south history and physical test, which one of the following is the most probable diagnosis?

A. Bartholin cyst.

B. Imperforate hymen.

C. Labial adhesions.

D. Transverse vaginal septum.

Due east. Vaginal atresia.

Discussion

The answer is C: labial adhesions. Labial adhesions are caused abnormalities involving the labia minora, merely not the labia majora. Adhesion is the most mutual interlabial abnormality in kid urology patients.1 The adhesion normally begins at the posterior fourchette and extends to varying degrees superiorly to the clitoris. The abnormality is more often than not discovered between 13 and 23 months of age by the kid's parents or by the doctor during a routine well-child test. Nigh cases occur earlier six years of age.2

Children with labial adhesions usually take a history of a local inflammatory process, such as diaper rash. Most patients are asymptomatic; however, the adhesions occasionally cause local inflammation, recurrent vulvovaginitis, or recurrent urinary tract infections. Adhesions exercise not occur in newborns, presumably because of the protective outcome of circulating maternal estrogens.

Handling of adhesions is nonsurgical and includes application of topical estrogen foam. Estrogen foam applied daily to the affected surface area for one to ii weeks has an effectiveness rate between 49 and 90 per centum.three,4 Occasionally, six to viii weeks of therapy is needed.5

Cleaning the afflicted expanse and keeping the labia separated with curt-term (one to two months) application of a petrolatum-based barrier ointment (e.g., Vaseline) tin aid prevent recurrence. Simple hygienic measures may be sufficient for asymptomatic children considering most adhesions resolve during early puberty.five Topical steroids may also be effective, but they have non been prospectively studied.vi Surgical treatment is reserved for patients with unresponsive cases.

Bartholin's gland is a small-scale vestibular gland located bilaterally between the labia minora and hymen. Occasionally, the duct of the gland becomes obstructed, causing unilateral vulvar swelling. Bartholin'southward gland abnormalities are uncommon in children.

An imperforate hymen is the most common congenital obstructive anomaly of the female person reproductive tract,1 although it may not be diagnosed until adolescence. The labia are intact in afflicted patients. An imperforate hymen should exist suspected in an boyish presenting with principal amenorrhea; circadian intestinal pain; and a bluish, bulging hymen. Newborns with this condition may take a bulge at the posterior introitus, representing retained vaginal fluid. Referral to a pediatric urologist is recommended for surgical repair of the hymen.

A complete transverse vaginal septum may occur at various levels inside the vagina, although most are located in the upper vagina.1 Patients have a vaginal opening, and the labia are intact and separated. Non-fusion or canalization of the urogenital sinus and müllerian ducts cause the abnormality. Children are unremarkably asymptomatic, just they may present with amenorrhea and a distended upper vagina during adolescence. Transperineal ultrasonography and magnetic resonance imaging (MRI) can assistance establish the diagnosis and determine the location and thickness of the transverse septum. Treatment is surgical resection.

Vaginal atresia is suspected when a vaginal opening cannot be identified and, instead, a shallow dimple is seen junior to the urethral opening. Failed germination of the lower portion of the vagina leads to the condition. The labia are intact and the upper vagina, cervix, and uterus are normal. Palpation of a distended vagina on rectal examination may assist to distinguish vaginal atresia from agenesis (failed formation of the upper vagina or testicular feminization). Ultrasonography with or without MRI is necessary to define the aberrant anatomy. Patients should be referred to a pediatric urologist for surgical reconstruction.

Selected Differential Diagnosis of an Abnormal Vaginal Opening in a Child

Condition Characteristics

Imperforate hymen

Labia are intact; vaginal opening is intact, simply obstructed by the hymen; congenital

Labial adhesions

Labia majora are intact; however, labia minora are fused together; vaginal opening is obstructed to varying degrees; not present at birth, merely typically develops between 13 and 23 months of age

Transverse vaginal Septum

Labia are intact; vaginal opening is present, just obstructed by a transverse septum, typically in the upper vagina

Vaginal atresia

Labia are normal; distal vagina is absent-minded; shallow dimple junior to the urethral opening

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Address correspondence to Nikhil Hemady, Dr., FAAFP, at nhemady@nomc.org. Reprints are not bachelor from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

show all references

1. Rink R, Kaefer M. Surgical management of intersexuality, cloacal malformation, and other abnormalities of the genitalia in girls. In: Wein AJ, Kavoussi LR, Novick AC, et al., eds. Campbell-Walsh Urology. 9th ed. St. Louis, Mo.: Saunders; 2007. ...

2. Vulvovaginitis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. St. Louis, Mo.: Saunders; 2004.

3. Muram D. Handling of prepubertal girls with labial adhesions. J Pediatr Adolesc Gynecol. 1999;12(2):67–lxx.

4. Aribarg A. Topical oestrogen therapy for labial adhesions in children. Br J Obstet Gynaecol. 1975;82(v):424–425.

five. Omar HA. Management of labial adhesions in prepubertal girls. J Pediatr Adolesc Gynecol. 2000;13(4):183–185.

6. Myers JB, Sorensen CM, Wisner BP, et al. Betamethasone foam for the treatment of pre-pubertal labial adhesions. J Pediatr Adolesc Gynecol. 2006;nineteen(6):407–411.

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