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
