Disorders of the Vagina - Hyperexcision

Last updated: November 11, 2024

Table Of Contents

Overview
Vaginal Foreign Body
Gartner’s Duct Cyst
Atrophic Vaginitis
Vaginal Septum

Overview

The vagina is a cylindrical tube that runs from the cervix to the vulva. Rugae provide a stretching probability which is useful during childbirth.

#1 cause of dyspareunia in a post-menopausal woman
- Post-menopausal atrophic vaginitis

Vaginal Foreign Body

Something in the vagina that is not supposed to be there. Commonly seen in children. The most common culprits are toilet tissue, tampons and sexual devices. Finding a vaginal foreign body warrants a pelvic exam. Sexual abuse should be ruled out.

Signs and symptoms
- Vaginal bleeding
- Foul-smelling vaginal discharge
Differentials for paediatric vaginal bleeding
- Urethral prolapse
- Sexual abuse
- Foreign body
- Accidental trauma
- Epidermal sinus tumors
- Rhabdomyosarcoma
- Hemangioma
Management
- Pelvic exam and rectal exam (with gentle anterior pressure to expel foreign bodies)
- Speculum to inspect for mucosal damage
- Liberal irrigation
- Large or sharp objects may require general anaesthesia

Gartner’s Duct Cyst

It is formed when the wollfian duct does not fully involute. Gartner’s duct cyst is the most common benign cystic lesion of the vagina. Usually asymptomatic and is discovered incidentally on transvaginal ultrasound. Located on the anterolateral wall of the proximal vagina.

Signs and Symptoms
- Dyspareunia
- May cause obstetric complications
- May be associated with Genitourinary anomalies

Other cystic anomalies in the female genital tract

Cystic abnormality	Description
Bartholin’s gland cyst	Asymptomatic or Pelvic pressure. Visualized at 4 or 8 o clock position
Vaginal inclusion cyst	May occur anywhere in the vagina following trauma
Skene’s duct (paraurethral) cyst	Asymptomatic, rarely urinary outflow obstruction
Nabothian cyst	Asymptomatic, raised white-yellow lesions picked up on cervical exam

Atrophic Vaginitis

Thinning of the vaginal epithelium due to decreased estrogen levels. Very common in post-menopausal women. Can occur in those who are functionally post-menopausal (following BSO) or women on anti-estrogens (Endometriosis – Danazol or Leuprolide, Breast cancer – Tamoxifen, Progestin-only contraceptives). Rule out exogenous agents (soap, perfume e.t.c). Consider vulvovaginitis if there is discharge.

Signs and symptoms
- Vaginal or vulvar pruritus
- Dyspareunia
- Dryness
- Burning
- Discharge
Physical exam
- Pale, smooth, shiny vaginal epithelium
- Minor laceration sustained during intercourse or itching
Treatment
- Hormonal Replacement Therapy
- Moisturizers and Lubricants
Contraindications to Hormonal Replacement Therapy ******
- Estrogen-sensitive tumors (Breast, Endometrial, Ovarian)
- End-stage liver disease
- Past Medical History of Estrogen-related thromboembolism
Administration of estrogen replacement therapy
- Intravaginal cream (vagifem)
- Orally
- Transdermal
Other benefits of estrogen replacement therapy
- Reduces bone loss
- Reduces hot flashes
- Reduces stress urinary incontinence
Adverse effects of estrogen replacement therapy
- Breast tenderness
- Acne
- Vaginal bleeding
- Increases risk of endometrial cancer
- Increases risk of VTE
- Can decrease HDL

Vaginal Septum

Transverse vaginal septum: Due to incomplete fusion of the mullerian duct and urogenital sinus. Asymptomatic and noticed on physical exam. Presents as primary amenorrhea (”cryptomenorrhea”) due to uterine outflow obstruction – cyclical lower abdominal pain, amenorrhea, central pelvic mass (hematometra or hematocolpos). Incomplete septa may have oligomenorrhea, dyspareunia or obstetric complications.

Longitudinal vaginal septum: Due to incomplete fusion of the mullerian . Asymptomatic and noticed on physical exam. May be associated with uterine septum or uterine didelphys which causes obstetric complications (miscarriage, abnormal implantation e.t.c due to associated mullerian duct abnormalities)

Treatment
- Excision

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

Overview

Vaginal Foreign Body

Gartner’s Duct Cyst

Atrophic Vaginitis

Vaginal Septum

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