Search

Examination of the female external genitalia to assess for sexual abuse is performed in living individuals, and the interpretation of the findings is based on evidence-based studies. However, in the deceased, no such studies are available, and postmortem changes could present as suspicious findings that can be mistaken for trauma. Patches of discoloration in the hymen were reported previously in one case as hypostasis (i.e., livor and lividity), and based on this finding, it was listed as a finding that is not associated with trauma. This was a retrospective study that was conducted in the Center of Forensic and Legal Medicine in Dammam, Saudi Arabia over a 4-year period. The study included 30 deceased women in whom photographic documentation of their external genitalia was assessed for postmortem changes. The postmortem interval ranged from less than 24 h to more than 100 days, and the ages of these deceased women were in the 20-40 year-old age group. In cases where the hymen, vagina, and/or fossa navicularis were clearly visible, none of these areas showed any hypostatic discoloration. A comparison between antemortem and postmortem appearance of the hymen in one case clearly showed the absence of hypostatic changes in the hymen. In conclusion, any discoloration of the external genitalia that is detected in a female decedent requires serious consideration.

Introduction and hypothesis There has been a great deal of discussion about mesh complications in urogynecology in recent years. However, awareness of other doctors who are not urogynecologists is unknown. This study was aimed at determining the level of awareness of mesh discussions among medical doctors whose specialty is not urology or gynecology. Methods A survey study was administered, and all medical doctors, except gynecologists and urologists, were invited. Respondent doctors were classified into four groups: King's College Hospital (KCH), UK; Uludag University Hospital (UUH), Turkey; the United States (USA); and the world (WORLD). The primary outcome was the awareness of mesh discussion in urogynecology, and the secondary outcome was the social media awareness of the mesh discussion. Results 1231 doctors responded to the survey. The awareness of the current mesh problems among the respondent doctors was 15.8% in KCH, 15.4% in UUH, 26.9% in the USA, and 16.2% in WORLD. The social media awareness about mesh problems was 20.8% in KCH, 20.3% in UUH, 32.8% in the USA, and 20.6% in WORLD. Although there were no differences among three of the groups with regard to primary and secondary outcomes, the USA group score was statistically significantly higher than the others. Conclusions Social media can influence doctors' thinking on controversial academic issues. In this survey study, non-urogynecologist doctors in the USA cohort have higher awareness levels and a higher social media awareness level than other groups.

The aim was to compare objective and subjective cure rates between Uphold™ hysteropexy (HP) and vaginal hysterectomy (VH) with uterosacral suspension. A sample size of 49 in each arm would be required to detect a clinical difference of 20% between the groups. Owing to delayed recruitment, this originally planned randomised controlled trial was changed to a patient preference study after randomising initial 6 participants. Women with symptomatic stage ≥2 uterine descent wishing a surgical solution were included. Routine follow-up was scheduled at 6 weeks, 6 months, 12 months, and annually thereafter. Primary outcome was absence of stage ≥2 apical prolapse. Secondary outcomes included a composite cure of no leading edge beyond the hymen, absence of bulge symptoms and no retreatment; patient-reported outcomes were based on quality-of-life questionnaires (PFDI-20, PFIQ-7, PISQ-12, PGI-I, EQ5D and a health score). We recruited 50 patients undergoing VH between 2011 and 2013 and 51 patients undergoing HP between 2011 and 2016. Participants were followed up for a median of 25 months (23–96). Five women from the VH (10%) and 7 from the HP (14%) group were lost to follow-up. Combined anatomical and symptomatic outcomes were available for 41 (82%) VH and 39 (76%) in the HP group. There was no difference in objective apical outcomes; the incidence of stage 2 prolapse was 0% in the VH group and 2% in HP group (p = 0.50). We found no difference in the composite cure rate (78% VH vs 85% HP, 0.45) between the groups. There was no significant difference in surgical complications (p = 0.33), assessed using Clavien–Dindo classification. There was a 2% surgery rate for mesh exposure in the HP group. Uphold™ uterine suspension and VH appear to have similar objective and subjective cure at 25 months, with no significant difference in surgical complications.

Aim: To present ‘bilateral iliococcygeal fixation of the pubocervical fascia’ as an alternative vaginal surgical technique for anterior compartment repair with native tissue and the surgical outcomes of 30 cases. Materials-Methods: The consecutive 30 cases who admitted to urogynecology clinic with anterior vaginal prolapse/cystocele and underwent anterior compartment repair by bilateral iliococcgeal fixation of the pubocervical fascia by native tissue were included to the study. All cases attended to the postoperative follow-up visits at the sixth and the twelfth months. Results: There were no major or minor intraoperative complications. Overall, in 28 (93.3 %) patients surgical success was achieved at the postoperative 12th month when it was defined as the maximum descent of the anterior segment was proximal to the hymen. During the study period, none of the patients requested or admitted for re-treatment for anterior compartment prolapse. Subjective cure that was assessed by the absence of bulge symptoms was achieved in 29 cases (96.7 %) at first year follow-up. Lower urinary tract symptoms (LUTS) were found to be significantly lower at the first-year postoperative visit compared to pre-operative evaluation. A clinically significant improvement in the quality of life parameters were also noted (mean PFIQ-7 scores = 8.5, 5.6 and 50.8, respectively). Conclusion: Bilateral iliococcygeal fixation of the pubocervical fascia seems to be effective in surgical correction of anterior vaginal prolapse according to our post-operative follow-up results. It is an easy to learn procedure with low complication rates and associated with high patient satisfaction. © 2020 Elsevier Masson SAS

IntroductionTransvaginal reconstructive surgery is the mainstay of treatment for symptomatic pelvic organ prolapse. Although adequate support for the vaginal apex is considered essential for durable surgical repair, the optimal management of anterior and posterior vaginal wall prolapse in women undergoing transvaginal apical suspension remains unclear. The objective of this trial is to compare surgical outcomes of pelvic organ prolapse quantification (POPQ)-based surgery with outcomes of simulated apical support-based surgery for anterior or posterior vaginal wall prolapse at the time of transvaginal apical suspension.Methods and analysisThis is a randomised, multicentre, non-inferiority trial. While women who are assigned to the POPQ-based surgery group will undergo anterior or posterior colporrhaphy for all stage 2 or greater anterior or posterior vaginal prolapse, those assigned to simulated apical support-based surgery will receive anterior or posterior colporrhaphy only for the prolapse unresolved under simulated apical support. The primary outcome measure is the composite surgical success, defined as the absence of anatomical (anterior or posterior vaginal descent beyond the hymen or descent of the vaginal apex beyond the half-way point of vagina) or symptomatic (the presence of vaginal bulge symptoms) recurrence or retreatment for prolapse by either surgery or pessary, at 2 years after surgery. Secondary outcomes include the rates of anterior or posterior colporrhaphy, the changes in anatomical outcomes, condition-specific quality of life and sexual function, perioperative outcomes and adverse events.Ethics and disseminationThis study was approved by the institutional review board of each participating centre (Seoul National University College of Medicine/Seoul National University Hospital, Chonnam National University Hospital, Seoul St. Mary’s Hospital, International St. Mary’s Hospital). The results of the study will be published in peer-reviewed journals, and the findings will be presented at scientific meetings.Trial registration numberNCT03187054

Absolute uterine factor infertility (AUFI) was considered untreatable until recently, when uterus transplantation (UTx) proved its potential as an effective treatment (Brannstrom et al., Lancet 385:607–616, 2015). In 2014, live births were reported after transplantation, using an altruistic living donor (Brannstrom et al., Lancet 385:607–616, 2015) and a recipient’s mother (Brannstrom et al., Fertil Steril 107:261–266, 2016) as the uterus donors. Women with AUFI have either absence of a uterus (congenital/surgical) or abnormalities (anatomic/functional) that prevent embryo implantation or further pregnancy. The uterine absence can occur from birth as part of the Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, affecting around 1:4000 girls (Oppelt et al., Hum Reprod 21:792–797, 2006). This is the predominant group where UTx attempts have been performed but represent less than 3% of women with AUFI. The MRKH girls have an absence of the vagina above the hymen and absence of a uterus. The uterus may be replaced by rudimentary tissue above the vaginal dimple and bilaterally on the pelvic sidewalls by two small buds of myometrial tissue.

This chapter discusses the history of hysteroscopy, emerging technology, and potential applications in adolescent gynecology, including both diagnosis and for therapeutic procedures, with approaches that preserve the hymen. Hysteroscopy is safe and with rare complications, particularly when performed with a narrow diameter hysteroscope. Potential vaginal, cervical, and endometrial pathologies that are closely associated with endometriosis are also described, demonstrating the utility of hysteroscopy when assessing endometriosis. Hysteroscopy is also useful for evaluating and treating dysfunctional bleeding, dysmenorrhea, recurrent discharge, abnormal imaging of the genital tract, genital tract anomalies, adenomyosis, polyps, and myomas.

Although there is no scientific proof of a breakable membrane in the vagina, virginity controls are causing great suffering to women worldwide, and hymen (re) constructions are carried out in many countries. The hymen is called mödomshinna 'virginity membrane' in Swedish, which can reinforce the idea of a breakable membrane. In their work against female sexual oppression the Swedish Association for Sexuality Education launched a new term, vaginal corona. The aim of our study is to evaluate this initiative. By conducting a survey directed at youths and health professionals at youth clinics in Stockholm, we were able to show that knowledge of the new word had spread and that changes in the oppressive cultural beliefs connected to virginity and female sexuality in part can be connected to the word. The study thus supports the claim that initiatives aimed at changing vocabulary can be effective in changing cultural concepts. Feminist language activism initiatives are thus usable as part of feminist political work to promote women’s sexual rights and gender equality.

Background: This study aimed to investigate the prevalence and characteristics of trauma in sexual assault victims aged 15 years and less referred to legal medicine centers of Fars Province, Iran. Methods: This descriptive cross-sectional was carried out on all female victims of sexual assault aged 15 years old and less referred to legal medicine centers of Fars, Iran, during 2006 - 2012. The study population consisted of 3140 victims that was reduced to 2113 due to incomplete records of some cases. To analyze the data, descriptive statistics and Chi-square test were used in SPSS, version 16. Results: The prevalence of teenage victims was 32.01%. The highest frequency was reported in 2006 and the next highest rate was reported in 2011. The ordinal place of the victims in family was between 4 and 6 in 79% of the cases. All the crimes happened in cities. In 6.4% of the cases, victims had experienced sexual assault. In 90.1% of the cases, criminals were aged 16 - 25 years old, and in 40.3% of the cases, they were familiar and had familial relationship with the victim. Sexual traumas in 57.1% of the cases were hymen tear and in 11.8% cases anal tear. Conclusions: Most adolescent sexual assaults remain hidden from the law because of fear of exclusion from the family and society. Therefore, community awareness regarding the prevalence of rape should be raised, and the necessary steps should be taken by the authorities and families to control this crime. Enforcing severe punishments for offenders can be considered as a preventive measure.

The study aimed to determine the prevalence and pattern of genital injuries among the female adolescents alleged to have been raped that presented at the Enugu State University Teaching Hospital (ESUTH) from January 1 2013 to August 31 2014. All of the adolescents alleged to have been raped that presented within the study period were studied, and the relevant data were extracted from their records. The data were analysed using the Epi info statistical software, Version 7. There were 78 adolescents alleged to have been raped within the study period. They were all female, with a mean age of 14.12 ± 5.6 years. The majority of them were virgins (n = 47, 60.3%). Five of them (6.4%) had multiple perpetrators. The prevalence of genital injuries was 44.9%, while the genital injury frequency rate was 1.2. Laceration was the commonest injury type, while the hymen was the most affected site (n = 15; 35.7%). Being a virgin at the time of the rape was significantly associated with the presence of genital injury (p < .001). This suggests that the absence of genital injury is not sufficient evidence to rule out the possibility of rape. Impact Statement What is already known on this subject? Rape is a global problem with a severe negative impact on the victim. Apart from the associated psychological and emotional trauma, a genital injury could result. However, it appears that so much emphasis are usually placed on the presence of a genital injury in establishing an incident of rape in the developing world. Genital injuries seem to be the main substantive evidence of rape in the developing world including Nigeria. Convicting the perpetrator of rape in law court is usually difficult in the absence of genital injuries after medical examination. What the results of this study add? The result of this study shows that a genital injury is not be found in all cases of an alleged rape, especially among the adolescents. In fact, more than half of the rape survivors had no genital injury. What the implications are of these findings for clinical practice and/or further research? The absence of a genital injury does not exclude the possibility of a rape, neither does its presence confirm a rape, as genital injuries can occur even in consensual sex. Adopting a modern method of establishing a rape case is very important for the provision of concrete evidence in court that will enable the proper and sound dispensation of justice.

Background: Imperforated hymen is a rare condition usually diagnosed at puberty due to amenorrhea accompanied by cyclic pelvic pain and sometimes other significant complications such as hematometra...

Vaginally assisted laparoscopic sacrocolpopexy (VALS) is a combined vaginal and laparoscopic surgical approach that has been described for the treatment of women with a uterus who suffer from severe multicompartmental pelvic organ prolapse (POP). The aim of this study is to evaluate the long-term anatomical and functional outcomes and report the long-term mesh-related complications. This was a single-center prospective study of women with advanced POP who underwent VALS with at least 3 years of follow-up. The primary outcome was “composite surgical success” defined as: (1) no descent of the vaginal apex (point C) more than one-third into the vaginal canal and no anterior or posterior vaginal wall beyond the hymen (Ba and Bp

A two finger test or virginity test is the procedure of determining laxity of vaginal wall i.e. whether she had engaged in sexual intercourse. The concept of virginity testing is not new; it has been practiced for thousands of years by cultures all over the world. In many countries like South Africa, Zimbabwe it is performed as a ritual. There is various legislation relating to twofinger test worldwide. The test is performed by a doctor usually on sexual assault victims. In fact, this test is absolutely not necessary, since forensic evidence can be collected without performing the two-finger test. The word “Two finger test” should be abandon because of its negative connotation and we should instead use the more accurate term “per vaginal examination” as it is more scientific.

INTRODUCTION AND HYPOTHESIS: Uterosacral ligament suspension (USLS) is a common procedure for apical pelvic organ prolapse. The procedure has been described using only permanent suture, only absorbable suture and a combination of permanent and absorbable suture. We hypothesized that the use of absorbable suture is not inferior to the use of permanent suture. METHODS: All women undergoing USLS between October 2016 and November 2017 were approached. Subjects were randomized to permanent or absorbable suture. The primary outcome was POP-Q point C 12 months after surgery (non-inferiority limit = 2 cm). A composite outcome of success at 12 months was defined as no apical prolapse ≥1/2 TVL, no prolapse beyond the hymen, no prolapse retreatment and no bulge symptoms. RESULTS: Forty-four subjects with mean (SD) age 62.9 (12.0) years and body mass index 29.1 (5.4) kg/m(2) were enrolled and underwent USLS. 15 (34.1%) had POP-Q stage II and 29 (65.9%) stage III prolapse. 22 were randomized to permanent and 22 to absorbable suture. 40 (90.9%) completed 12 months follow-up. Median (IQR) POP-Q point C at 12 months was −7 (−10,−6) for permanent and −7 (−9,−5.5) for absorbable suture groups (p=0.65, non-inferiority p

Aims Anogenital distance (AGD) has been proposed as a marker of the prenatal hormonal milieu and potential environmental insults. The measures of the Pelvic Organ Prolapse-Questionnaire (POP-Q) system is being widely used in the evaluation of the perineum in women with POP pathologies. Genital hiatus (GH) and perineal body (PB) lengths have been related to both prolapse incidence and recurrence and for pessary treatment failure. The use of AGD in female human studies is now emerging and its comparability with other anthropometric measurements could be relevant. The aim of the study was to compare AGD and POP-Q system in adult females. Methods The study included 155 pregnant women in the first stage of labor. Perineal measurements were performed on women in the lithotomy position: AGD from the anus to the clitoris (AGDAC ); AGD from the anus to the fourchette (AGDAF ); GH from the external urethral meatus to the posterior midline hymen, and length of the PB from the posterior midline hymen to the mid-anal opening. Coefficients of variations (CV) were calculated. Intraclass correlation coefficients (ICC) and Bland-Altman graphs were used to compare both set of measurements. Results CV were below 15% for AGDAC and GH + PB, though higher for AGDAF and PB (20% and 17%, respectively). ICCs for each pair of measurements were above 80%, (excellent agreement between methods). Concordance between measurements was confirmed by Bland-Altman graphs. Conclusions Comparable measurements were obtained using AGDs and POP-Q system. Further studies are needed to explore clinical and epidemiological implications of these findings.

Author(s): Jelovsek, J Eric; Chagin, Kevin; Lukacz, Emily S; Nolen, Tracy L; Shepherd, Jonathan P; Barber, Matthew D; Sung, Vivian; Brubaker, Linda; Norton, Peggy A; Rahn, David D; Smith, Ariana L; Ballard, Alicia; Jeppson, Peter; Meikle, Susan F; Kattan, Michael W; NICHD Pelvic Floor Disorders Network | Abstract: ObjectiveTo develop statistical models predicting recurrent pelvic organ prolapse, surgical complications, and change in health status 12 months after apical prolapse surgery.MethodsLogistic regression models were developed using a combined cohort from three randomized trials and two prospective cohort studies from 1,301 participants enrolled in surgical studies conducted by the Pelvic Floor Disorders Network. Composite recurrent prolapse was defined as prolapse beyond the hymen; the presence of bothersome bulge symptoms; or prolapse reoperation or retreatment within 12 months after surgery. Complications were defined as any serious adverse event or Dindo grade III complication within 12 months of surgery. Significant change in health status was defined as a minimum important change of SF-6D utility score (±0.035 points) from baseline. Thirty-two candidate risk factors were considered for each model and model accuracy was measured using concordance indices. All indices were internally validated using 1,000 bootstrap resamples to correct for bias.ResultsThe models accurately predicted composite recurrent prolapse (concordance index=0.72, 95% CI 0.69-0.76), bothersome vaginal bulge (concordance index=0.73, 95% CI 0.68-0.77), prolapse beyond the hymen (concordance index=0.74, 95% CI 0.70-0.77), serious adverse event (concordance index=0.60, 95% CI 0.56-0.64), Dindo grade III or greater complication (concordance index=0.62, 95% CI 0.58-0.66), and health status improvement (concordance index=0.64, 95% CI 0.62-0.67) or worsening (concordance index=0.63, 95% CI 0.60-0.67). Calibration curves demonstrated all models were accurate through clinically useful predicted probabilities.ConclusionThese prediction models are able to provide accurate and discriminating estimates of prolapse recurrence, complications, and health status 12 months after prolapse surgery.

A 13-year-old prepubertal girl had with primary amenorrhea and severe lower abdominal pain. Pelvic ultrasound showed double uterine cavity and a fluid collection in left uterine cavity with diffuse low level internal echoes, which appeared contiguous with the endocervix. Hymen could not be evaluated because the patient could not be taken to the gynecological table the patient was initially diagnosed as imperforate hymen, gynecologic examination was performed with sedation, and hymen has a normal patency. Magnetic resonance imaging (MRI) revealed two uterus and two cervix, normal right endometrial cavity and 17 mm fluid in the left endometrial cavity and compatible with hematometra. Hematocolpos was observed in the left half of the vagina. There was no left kidney and the right kidney was normal. Based on these findings, the patient was diagnosed as Herlyn-Werner-Wunderlich syndrome and vaginal septum resection was performed as treatment. Evaluation of the genital tract by means of MRI scanning or ultrasonography should be recommended in all girls with known renal abnormalities before the onset of menstruation.

An indication is used to increase the judge's confidence that the accused is guilty or not. Instructions obtained from witness statements, letters and from the defendant's statement were put together, then put together and will make a clue that can strengthen the judge's conviction that the defendant is guilty or not. Not only that, evidence such as sperm found around the victim's vagina, damage to the blood membrane (hymen) and the victim's panties are also tools to strengthen evidence to prove that the victim has raped herself. It is unlikely that reports of rape will occur after a few days after the incident, because it is feared that the necessary evidence will be weak or no longer visible, making it difficult for the judge to believe that rape has occurred. This writing uses normative juridical legal research methods (normative research) with descriptive analytical research specifications that use secondary data. The procedure of data collection is in the form of documentation of notes or quotations, search of legal literature, books and others related to the identification of problems both offline and online, which are then analyzed through the content analysis method (content analysis method) with a focus on issues about how the legal basis the use of evidence from the Public Prosecutor as a means of proving the case of molestation of children, how is the process of using evidence from the Public Prosecutor as a means of proof of sexual abuse cases against children.

Few studies have compared the different approaches of mesh surgery in patients with severe pelvic organ prolapse (POP). In addition to laparoscopic sacrocolpopexy/cervicopexy (LSC-Cx), anterior vaginal mesh (AVM) may be an effective approach for correcting anterior vaginal wall associated with apical POP in women with advanced POP. A randomised controlled trial (RCT; January 2011 to March 2016) including 120 patients (60/group) with advanced symptomatic POP, with a predominant anterior vaginal wall descent stage III or greater in combination with a stage II or III apical defect (uterus or vaginal vault). Patients underwent four visits: baseline, 3, 6 and12 months after surgery. The main outcome was anatomical success defined as anterior and posterior vaginal wall not descending beyond the hymen and vaginal apex descent no more than one third into the vagina. Secondary variables: PFDI, ICIQ-UI-SF, intraoperative variables, postoperative morbidity and complications. Anatomical success was achieved with LSC-Cx in 79% and with AVM in 76% (NS). No statistically significant differences were found among POP-Q anterior vaginal wall points between groups, whereas better results were obtained with LSC-Cx in posterior vaginal wall points and total vaginal length. Intraoperative outcomes were similar in the two groups, except for operating time (78.05 min LSC-Cx vs 44.28 min AVM). There were no statistically significant differences related to de novo stress urinary incontinence and dyspareunia. Worse results were found in the CRADI-8 in the LSC-Cx group, owing to constipation. Late postoperative complications and reinterventions were similar in the two groups. No differences were found in the anatomical correction of anterior and apical POP. The LSC-Cx group presented better correction of posterior vaginal wall defects and a longer total vaginal length.

The Roman de la Rose ends with an allegory of foreplay and intercourse: Amant first venerates relics that figuratively represent testicles and then penetrates his beloved only to find entry hampered by a barrier signifying the hymen. The hermaphroditism of the body here penetrated incarnates a hermaphroditic hermeneutics. The reader must engage the body of the beloved with an attention to detail that is at least as rapt as the adoring gaze of the lover and must, in the process, attempt to separate the literal and figurative registers of the text. The task is frustrated, however, by the fact that the body in question is both literally male and figuratively female. Frustration, nonetheless, brings a pleasure of its own, the delight that accrues for the very act of interpretation.

INTRODUCTION AND HYPOTHESIS: To compare treatment success and adverse events between women undergoing open sacrocolpopexy (ASC) versus vaginal repair (VAR) using data from women enrolled in one of three multicenter trials. We hypothesized that ASC would result in better outcomes than VAR. METHODS: Participants underwent apical repair of stage 2–4 prolapse. Vaginal repair included uterosacral, sacrospinous, and illiococcygeal suspensions; sacrocolpopexies were via laparotomy. Success was defined as no bothersome bulge symptoms, no prolapse beyond the hymen and no retreatment up to 24 months. Adverse events were collected at multiple time-points. Outcomes were analyzed using longitudinal mixed effects models to obtain valid outcome estimates at specific visit times, accounting for data missing at random. Comparisons were controlled for center, age, BMI, initial POPQ stage, baseline scores, prior prolapse repair and concurrent repairs. RESULTS: Of women who met inclusion criteria (1022 women included /1159 eligbile); 701 underwent vaginal repair. The sacrocolpopexy group (n=321) was older, more likely White, had prior prolapse repairs, and Stage 4 prolapse (all p

OBJECTIVE The aim of this study was to compare anatomic results after vaginal uterosacral ligament suspension with absorbable versus permanent suture. METHODS We performed a retrospective cohort study of women who underwent vaginal uterosacral ligament suspension, from 2006 to 2015. We compared 2 groups: (1) absorbable suspension suture and (2) permanent suspension suture (even if accompanied by absorbable suture). Our primary outcome was composite anatomic failure defined as (1) recurrent prolapse in any compartment past the hymen or (2) retreatment for prolapse. Continuous variables were analyzed using the Student t test or Mann-Whitney U test, and categorical variables were analyzed using χ or Fisher exact test. Multivariable logistic regression analysis was performed to control for confounders. P < 0.05 was considered significant. RESULTS Of the 242 patients with medium-term follow-up (3 months to 2 years after surgery), 188 underwent vaginal uterosacral ligament suspension with only absorbable suture, and 54 underwent suspension with permanent suture. Compared with the absorbable suture cohort, the permanent suture cohort was more likely to have had advanced preoperative prolapse (P = 0.01), less likely to have had a prior hysterectomy (P = 0.01), and less likely to have undergone a concomitant posterior colporrhaphy/perineoplasty (P < 0.01). Overall, there were no differences in composite anatomic failure between the absorbable and permanent suture groups (17.0% vs 20.4%, P = 0.41). In multivariable logistic regression analyses, when controlling for covariates, there remained no difference in composite anatomic failure between permanent and absorbable suture groups. CONCLUSIONS Completion of vaginal uterosacral ligament suspension using only absorbable suture affords similar anatomic outcomes in the medium term as compared with suspension with additional permanent suture.

This study aims to highlight three types of femicide in Jordan – so-called ‘honour killings’, fatal intimate partner violence (IPV), and domestic violence committed by male family members other than the husband (DV) – and to compare them with the killing of women in non-gender related situations such as during a robbery. The autopsy reports of 100 adult female homicide victims dealt with at Jordan University Hospital in Amman during a 10-year period from 2006 to 2015 were reviewed. Based on information contained in the police reports they were assigned to one of four categories. Of the 100 deaths, 52% were classed as honour killings, 33% as fatal IPV and 5% as DV crimes, with non-gender related murders making up the remaining 10%. The majority (76%) occurred in the woman's home. The commonest cause of death was gunshot injuries, the severity of violence as judged by the largest number of major injuries was greatest in the honour killings, and 14 victims had defence wounds, again the majority in the honour cases. The hymen was found to be intact in 38% of the honour victims, while 33% in this category were pregnant at the time of death, compared to only 3% of fatal IPV victims. Conclusions Most female murders in Jordan are committed by an assailant who is either a partner or a family member, the home becoming the most dangerous place to be for a threatened woman. With extra-marital pregnancy being one of the strongest motivators for honour killings, and old injuries a potential sign of ongoing intimate partner violence, forensic doctors can assist in recognizing these risk factors and thereby help potential victims. It is thus important to highlight some of the characteristic features of femicide.

Stabilization of the vaginal apex (level 1) is an important component of operations to correct pelvic organ prolapse (POP). We report functional and anatomical results and patient-reported outcomes of our technique of vaginal vault fixation at the time of vaginal hysterectomy. One hundred and nine patients—mean 69 years, range 50.4–83.8; body mass index (BMI) 26.3, range 17.7–39.5—with symptomatic stage 2–3 uterine prolapse combined with stage 3–4 cystocele underwent vaginal hysterectomy with anterior vaginal wall repair; the apex was formed with high closure of the peritoneum and incorporation of the uterosacral and round ligaments. Only absorbable sutures were used. Follow-up included clinical examination with Pelvic Organ Prolapse Quantification system (POP-Q) scoring, introital ultrasonography, quality of life (QoL) Likert scale, and the German Pelvic Floor Questionnaire. Seventy patients (64%) were available for a follow-up after a mean of 2.8 years (range, 1.6–4.2). At follow-up, point C was stage 0 in 55 (78.6%) women and stage 1 in 15 (21.4%). The anterior vaginal wall was stage 0 or 1 in 35 (50%), stage 2 (no cystocele beyond the hymen) in 34 (49%), and stage 3 in 1 (1.4%). Vaginal length (VL) was 9 cm. Four women (4%) were reoperated for prolapse: two for recurrent anterior compartment prolapse and two for de novo rectocele. Postvoid residuals >150 ml were seen in 21(30%) patients preoperatively and resolved postoperatively in 20. Urgency occurred in nine (13%), stress urinary incontinence (SUI) in ten (14%), and nocturia in 19 (27%). No patient had discomfort at the vaginal vault and 62 patients (87%) reported improved QoL, which did not correlate with anatomical results. Cystocele ≥ 2° at follow-up was associated with BMI >25 (p = 0.03). Our surgical technique without permanent material offers good apical support and functional and subjective results. Anatomical improvement was achieved in all cases of cystocele repair. Recurrent cystoceles are often asymptomatic.

OBJECTIVE The primary objective is to describe the long-term anatomic and subjective outcomes in women undergoing ventral rectopexy with sacrocolpo- or hysteropexy. The secondary objective is to describe the perioperative adverse events. METHODS This is a retrospective cohort of women who underwent ventral rectopexy with either concurrent sacrocolpo- or hysteropexy at a tertiary care center between 2009 and 2015. A composite outcome for recurrent pelvic organ prolapse and rectal prolapse was defined as subjective failure (vaginal or rectal prolapse symptoms), objective failure (prolapse to or beyond the hymen or full thickness rectal prolapse), or any retreatment for prolapse. Patient's Global Impression of Change was recorded at baseline and at all follow-up visits. Perioperative adverse events were defined a priori and collected up to 6 weeks after surgery. RESULT A total of 59 patients underwent a ventral rectopexy, either a sacrocolpopexy (48/59, 81.3%) or sacrohysteropexy (11/59, 18.6%). The median follow-up after surgery for all patients was 17 months (range, 1-76) with a composite success rate for both pelvic organ prolapse and rectal prolapse (estimated by Kaplan-Meier method) of 57.4%. Forty (91%) of 44 patients reported a Patient's Global Impression of Change score of 6 or 7, indicating significant improvement after surgery. Of the patients, 15 (25.4%) experienced a perioperative adverse event. Use of biologic graft was associated with a higher rate of adverse event (40.0% [95% confidence interval, 24.6-57.5] vs 10.3% [95% confidence interval, 3.6-26.3]; P < 0.01). CONCLUSIONS Ventral rectopexy with sacrocolpo- or hysteropexy is associated with significant improvement in anatomic and subjective outcomes. One in 4 women experienced a perioperative adverse event.

Background: Hysterosalpingogram (HSG) and Laparoscopy and dye tests for tubal assessment for a virgin who places high premium on her virginity could be challenging. Routine HSG may result in loss or damage to the hymen and loss of virginity. Aim: The aim of the procedure of retrograde dye test was explored to see the possibility of assessing tubal patency during laparotomy. Case Presentation: At laparotomy and after myomectomy in a 32 year old virgin, a moderate sized Wilkinson’s cannula was gently inserted at the fimbrial end of the both tubes and 50mls of dilute Methylene-Blue solution was injected in each tube at a time to see whether the dye will appear at the vagina introitus. There was no resistance to flow of the dye in both tubes. Inspection of the vaginal introitus revealed a gush of dye flowing through it as the dye was introduced through each tube confirming the patency of both tubes. Conclusion: Retrograde dye test at the time of abdominal procedures like myomectomy, pelvic adhesiolysis and excision of endometriotic cyst can be cost effective. This procedure is also useful in assessing tubal patency for women who undergo laparotomy and also wish to preserve their virginity.

OBJECTIVES The aim of this study was to determine anatomical and clinical cure, as well as patient satisfaction in uterine-preserving laparoscopic uterosacral ligament suspension (LUSLS) in women with anterior and apical prolapse. METHODS This was a retrospective cohort study including all women who underwent LUSLS for anterior and apical prolapse between January 2012 and December 2015 at a tertiary-care university hospital. All women had LUSLS hysteropexy and anterior colporrhaphy. Pre- and postoperative pelvic organ prolapse quantification (POP-Q) measurements were taken. Prolapse symptoms were queried via standardized history. Patient satisfaction was measured by the Patient Global Impression of Improvement (PGI-I). RESULTS Fifty-three women underwent the procedure during the study period. Follow-up data were available for 48 women. The mean preoperative POP-Q Ba point was 2.7 ± 1.6 and C point was -0.8 ± 2.8. At a mean follow-up of 17.5 ± 16.0 months with a median of 12 months (range, 1-54 months), there was a significant improvement of POP-Q points Ba, C, and Bp (P < 0.001 for all comparisons). Anatomical cure, defined as no prolapse of any POP-Q point at or below 1 cm above the hymen (-1), was 85.4%. Clinical cure, defined as a composite outcome of no prolapse outside the hymen, C point above total vaginal length/2, no prolapse symptoms, and no need for further treatment, was 95.8%. At a mean of 22.2 ± 12.4 months postoperatively, patient satisfaction was high, with 95.5% stating their condition was very much better (PGI-I-A) or much better (PGI-I-B). CONCLUSION Laparoscopic uterosacral ligament suspension is a valid uterine-preserving option for women with anterior and apical prolapse, with high anatomical and clinical cure rates and patient satisfaction.

Background Untreated symptomatic imperforate hymens at birth can result in renal complications and ascending infection. Although guidelines recommend incision and drainage, little is discussed regarding postoperative management and surveillance. Case A 2-day-old infant with symptomatic imperforate hymen (hydrometrocolpos and hydronephrosis) underwent incision and drainage using sterile technique. On postoperative day 19 she developed hymen reclosure, fluid reaccumulation, and concern for sepsis. After stabilization, redrainage was performed in the operating room with interrupted suture placement around an annular incision. She rapidly improved. Serial postoperative follow-up was performed to ensure ongoing patency of the hymen during healing. Summary and Conclusion Neonatal hymenotomies can have postoperative complications. We recommend consideration of annular suture placement and close follow-up, because of risk for reclosure and rapid deterioration from infection in this age range.

Background Prolapse recurrence after transvaginal surgical repair is common; however, its mechanisms are ill-defined. A thorough understanding of how and why prolapse repairs fail is needed to address their high rate of anatomic recurrence and to develop novel therapies to overcome defined deficiencies. Objective This study aimed to identify mechanisms and contributors of anatomic recurrence after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair) vs transvaginal mesh (VM) hysteropexy surgery for uterovaginal prolapse. Study Design This multicenter study was conducted in a subset of participants in a randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Overall, 94 women with uterovaginal prolapse treated via native tissue repair (n=48) or VM hysteropexy (n=46) underwent pelvic magnetic resonance imaging at rest, maximal strain, and poststrain rest (recovery) 30 to 42 months after surgery. Participants who desired reoperation before 30 to 42 months were imaged earlier to assess the impact of the index surgery. Using a novel 3-dimensional pelvic coordinate system, coregistered midsagittal images were obtained to assess study outcomes. Magnetic resonance imaging–based anatomic recurrence (failure) was defined as prolapse beyond the hymen. The primary outcome was the mechanism of failure (apical descent vs anterior vaginal wall elongation), including the frequency and site of failure. Secondary outcomes included displacement of the vaginal apex and perineal body and change in the length of the anterior wall, posterior wall, vaginal perimeter, and introitus of the vagina from rest to strain and rest to recovery. Group differences in the mechanism, frequency, and site of failure were assessed using the Fisher exact tests, and secondary outcomes were compared using Wilcoxon rank-sum tests. Results Of the 88 participants analyzed, 37 (42%) had recurrent prolapse (VM hysteropexy, 13 of 45 [29%]; native tissue repair, 24 of 43 [56%]). The most common site of failure was the anterior compartment (VM hysteropexy, 38%; native tissue repair, 92%). The primary mechanism of recurrence was apical descent (VM hysteropexy, 85%; native tissue repair, 67%). From rest to strain, failures (vs successes) had greater inferior displacement of the vaginal apex (difference, −12 mm; 95% confidence interval, −19 to −6) and perineal body (difference, −7 mm; 95% confidence interval, −11 to −4) and elongation of the anterior vaginal wall (difference, 12 mm; 95% confidence interval, 8–16) and vaginal introitus (difference, 11 mm; 95% confidence interval, 7–15). Conclusion The primary mechanism of prolapse recurrence following vaginal hysterectomy with uterosacral ligament suspension or VM hysteropexy was apical descent. In addition, greater inferior descent of the vaginal apex and perineal body, lengthening of the anterior vaginal wall, and increased size of the vaginal introitus with strain were associated with anatomic failure. Further studies are needed to provide additional insight into the mechanism by which these factors contribute to anatomic failure.

To investigate the clinical course and management of congenital vaginal atresia. This retro-spective analysis included patients with congenital vaginal atresia treated from March 2004 to August 2014 at the Obstetrics and Gynecology Hospital of Fudan University. Thirty-nine patients were included in this study. Their average age was 16.87±2.2 years when they came to our hospital. Totally, 51% of the patients had isolated congenital vaginal atresia with a normal cervix, whereas the others had either cervical atresia or imperforate hymen. The primary presenting signs and symptoms included primary amenorrhea (71.8%), periodic abdominalgia (41.0%), abdominal pain (36.0%), dyspareunia (10.3%), menstrual disorders (5.1%), and pelvic mass (5.1%). Ultrasound and magnetic resonance imaging (MRI) were effective inspection methods for the screening of urogenital tract-associated anomalies. Vagi-noplasty mainly included simple vagina reconstruction with insertion of a mold (n=22) and split-thickness skin grafting (n=4). In 64% of surgical patients, normal menstrual bleeding was achieved. Four of the patients subsequently became pregnant and delivered at term. Primary amenorrhea, periodic abdominalgia and abdominal pain are the main reasons for the post pubertal patients to visit doctors. Surgical methods can successfully provide these patients an opportunity for subsequent conservative management, can result in normal menstrual bleeding, resolve cyclic pelvic pain, and provide some po-tential for fertility.

Symptomatic imperforate hymen is very rare in infants. Here we report a neonate who presented with imperforate hymen with abdominal distension, fever and loose stool. Imaging study showed large thick walled cystic lesion extending from pelvis to abdomen upto epigastric region with bilateral mild hydroureteronephrosis and lower part in between urinary bladder and rectum suggesting hydrometrocolpos. There was spontaneous rupture leading to flow of collection. It leads to spontaneous resolution of the mass which was confirmed with pelvic ultrasound and computed tomography.Keywords: Hydrometrocolpos; hydroureteronephrosis; imperforate hymen

The Royal College of Obstetricians and Gynaecologists (RCOG) has urged the government to introduce a ban on virginity testing and hymenoplasty in the UK. In a policy statement published on 16 August, the college said there is no medical reason why virginity testing, hymenoplasty, or any other procedure under a different name that seeks to reconstruct or repair the hymen would need to be carried out. It said such procedures were harmful as they create and exacerbate social, cultural, and political beliefs that a woman’s value is based on whether or not she is a virgin before marriage. The college noted that the scale of the …

Objective To describe the unique presentation and surgical management of a complete uterovaginal septum. Design Video case report. Setting Tertiary care academic medical center. Patient(s) A 25-year-old woman, gravida 2, para 0-0-2-0, referred for evaluation after imaging and clinical examination revealed conflicting information. She was initially seen by her local provider for menorrhagia. Locally an ultrasound revealed a septate uterus, and examination under anesthesia with hysteroscopy noted a single vagina and cervix with a unicornuate uterus. Due to incongruous findings, she was referred for evaluation. Intervention(s) Magnetic resonance imaging (MRI), examination under anesthesia, vaginal surgery, and operative hysteroscopy. Main Outcomes and Measure(s) The MRI identified a complete uterovaginal septum with a single septate cervix. Vaginal gel was used to define vaginal anatomy, and the gel was noted to fill the right hemivagina with none noted on the left. Examination under anesthesia revealed an imperforate hymen with a small opening on the left as the cause for confusion in the clinical presentation. A hymenectomy was performed followed by guided surgical management of a complete uterovaginal septum, unicollis. Result(s) The patient was discharged home the same day of surgery. Conclusion(s) Presentation of mullerian anomalies are often complex, and anatomic variations in commonly described anomalies make misdiagnoses common. Advanced imaging with use of MRI with vaginal gel or three-dimensional ultrasonography and detailed examination are often helpful. Differentiating between unicollis and bicollis presentations in complete uterovaginal septum cases is an important distinction during surgical management.

We report a case of acute urinary retention in an adolescent female secondary to hematocolpos. A 13-year-old female presented to the emergency department with acute urinary retention and suprapubic abdominal pain for 24 hours. She denied menstruation or sexual history. Bedside bladder ultrasound scan revealed 1.2 L of retained urine and a Foley catheter was placed. A formal renal ultrasound detected a debris-filled structure in the abdomino-pelvic cavity. Follow-up computed tomography of the abdomen and pelvis revealed an 8.5 cm × 9.3 cm × 12.1 cm mass-like structure in the pelvis. No formal pelvic exam was completed and the patient was taken to the operating room for exploratory laparotomy due to concern for large pelvic mass versus tubo-ovarian abscess. However, upon entering the abdominal cavity, no mass was found. At that point, an external genital exam was performed, revealing an imperforate hymen. Hymenotomy resulted in the evacuation of 2.5 L of clotted blood from the vagina and uterus. Hematocolpos resulting in acute urinary retention is exceedingly rare; however, it is an important differential diagnosis that can be ruled in or out by physical exam findings. Although it may be uncomfortable for adolescent patients and physicians, external genital exams should be conducted in young females with acute urinary retention and amenorrhea to evaluate for imperforate hymen. This can ensure appropriate treatment and avoidance of unnecessary invasive procedures.

Study Objective To present a pediatric case with nonspecific vaginal symptoms where exam under anesthesia and vaginoscopy were indicated as a diagnostic and therapeutic measure. To review the strengths of vaginoscopy in this specific population. To describe vaginoscopy instrumentation and techniques given the infrequent use of this modality in gynecologic practice. Design Case Report. Setting Academic Hospital. Patients or Participants A 5-year-old pre-pubertal female presented with persistent vaginal discharge and spotting for four months. Prior workup and treatment included empiric antibiotics given for urinary tract infection and wet prep and vaginal cultures that were unrevealing. Interventions Vaginoscopy was performed in the operating room under general anesthesia using a 6mm 0-degree operative hysteroscope and distension of the vaginal cavity using saline media. Measurements and Main Results Visualization of the vaginal cavity demonstrated multiple foreign bodies including nine 1-cm rubber-bands, one 3-cm LEGO toy, and multiple fragments of toilet paper. The foreign bodies were removed using flexible graspers without complications. Visualization of the vaginal cavity and cervix thereafter ensured complete removal of all foreign objects (photos available). Care was taken to document examination of the external genitalia and hymen preceding vaginoscopy in the event that further investigation for sexual abuse was warranted. Conclusion Vaginoscopy is a minimally invasive tool critical in the diagnosis and management of pediatric vaginal symptoms including evaluation for presence of foreign bodies. A multitude of hystero- or cystoscopes can be used for evaluation of vagina, however an operative channel is required in case there is a need for a biopsy or removal of a foreign body. Zero-degree optics are preferable. Benefits include preservation of hymenal integrity, enhanced visualization of the vaginal cavity, and increased flexibility in obtaining samples and removing foreign bodies.