Pediatric general surgeons and urologists are frequently called upon to evaluate the young girl with a vaginal abnormality, including congenital anomalies, tumors, injuries, and foreign bodies. Imperforate hymen presents as hydrocolpos in young girls or hydrometrocolpos in pubescent females. The vagina can become quite large, sometimes palpable above the pubis as a mass. The diagnosis should be suspected in girls with abdominal pain and amenorrhea and is confirmed with a simple bedside examination in which the hymen is seen to be bulging and tense. Ultrasound is also frequently performed. The treatment is a cruciate incision (or excision) of the hymen in the operating room, in which case a large amount of dark brown fluid is often evacuated. The vagina will usually return to a normal size over time. After opening the hymen, one should examine the vagina carefully, as it is not uncommon to find a double vagina in which one hymen is patent and the other is imperforate. The longitudinal septum should be excised and the subsequent incisions on the anterior and posterior walls oversewn with absorbable suture. Most also have a duplicated uterus (two cervices) and eventually need to have an MRI or diagnostic laparoscopy to characterize their internal anatomy for fertility counseling purposes.
Sarcoma botryoides of the vagina presents as a fungating polypoid lesion and if stage I generally has a very good prognosis with chemotherapy alone. The surgeon’s role is limited to biopsy to confirm the diagnosis and to exclude the rare endodermal sinus tumor. Further surgery is rarely indicated. Urethral prolapse is sometimes confused for a tumor and though there are numerous reports recommending surgical excision, as long as urinary flow is not obstructed, most can be treated with topical application of estrogen cream. Sarcoma of the uterus or cervix is also sometimes seen but is extremely rare. Vaginal foreign bodies usually consist of tissue paper or toys. It should be suspected in girls with vaginal bleeding, discharge, or itching. The history is almost never helpful. The mass can sometimes be identified on rectal examination but examination under anesthesia is usually warranted. MRI has also proven useful but if the child needs general anesthesia for the study, EAU might be more practical. In the operating room, examination of a prepubescent girl with a standard speculum is impossible. One can sometimes adequately assess the entire vagina using a nasal speculum and good lighting, but the best approach is to perform vaginoscopy using a small bronchoscope. This provides an excellent view and allows the hymen to remain intact, which is enormously important to some parents.
Perineal lacerations after straddling injuries are quite common. Most will heal without intervention. Indications for surgical repair under general anesthesia include bleeding, pain, urinary retention, obvious severe injury, or inability to fully assess the extent of injury in the office or ED. A careful examination under moderate sedation might save everyone a trip to the OR. Even moderate to severe injuries that involve the perineal body or rectal sphincter can usually be repaired primarily in layers with absorbable sutures. Colostomy should never be considered except perhaps in the rare case of severe rectal injury with devitalized tissue, gross fecal contamination, or delayed presentation. If there is any question of sexual abuse, a rape kit should be employed and the injuries should be carefully documented and photos taken.
Crohn’s disease can sometimes affect the vulva and vagina with a spectrum of lesions from ulcers to fistulae or frank tissue destruction. Treatment is with anti-inflammatory drugs although fecal diversion is sometimes necessary. Severe acute herpetic lesions are sometimes seen and the possibility of sexual abuse must be investigated. Likewise, perivulvar condylomata acuminata often require surgical excision and certainly warrant investigation of inappropriate sexual contact.