25 Benign conditions of the genital tract Christopher B-Lynch VAGINAL MALFORMATION septum through one of the compartments. If such a defect is detected before pregnancy, a A number of vaginal malformations have CO2 laser excision or other appropriate sur- been described. The vagina may be inacces- gical treatment can remove the septum and sible because of an intact hymen. It also can facilitate creation of a normal functioning vagi- be malformed by a transverse (horizontal) or na. It is usual for women who are preconcep- vertical (longitudinal) septum. In the presence tional to complain if they have this condition, of a transverse septum, menstrual blood may because they experience difficulty in inserting not pass freely and a hematocolpos may also a tampon or dyspareunia when attempting to be present. Vaginal examination should eas- have normal vaginal intercourse. The treat- ily identify the obstruction, and hematocolpos ment results are usually excellent. can be detected either by the presence of a tense fullness behind the septum, or with the aid of an ultrasound examination which will Vaginal atresia further delineate its extent and whether the uterus is itself dilated with further menstrual The vagina develops from the cloacae and is fluid collection. A cruciate incision under gen- usually covered with squamous epithelium. eral anesthesia is generally all that is required Because of its proximity to the anus, which to correct this abnormality. A partial or sub- develops from the same epithelial anlagae, septum can be high or low in the vagina. The similar malformations to those of the anal lower it is the better is the prognosis for preg- canal may occur. Vaginal atresia may be asso- nancy, and complete excision can be achieved. ciated with an absence of rudimentary devel- Excision can also be achieved by using a CO2 opment of the uterus known as the Rokitan- laser. This results in very little surgical trauma sky syndrome, most commonly presenting at and minimal scar tissue is created. The prog- puberty with amenorrhea or cryptomenorrhea nosis for pregnancy is good for a low septum in the presence of normal secondary sexual and much reduced for a high septum. characteristics. If the use of regular vaginal A vertical (longitudinal) septum may be dilators fails, then a variety of surgical tech- present in variable lengths up to a complete niques performed in collaboration with a plas- separation of the vagina creating two cavities. tic surgeon could be beneficial. This can occur as either a high or low septum If the uterus is underdeveloped and has or a complete partition of the vagina. There failed to connect with the vagina then surro- have been instances where normal vaginal gacy would seriously have to be considered as delivery has occurred alongside a longitudinal a childbearing option. 355 PRECONCEPTIONAL MEDICINE Benign conditions of the genital tract UTERINE MALFORMATION surgery can be performed, the benefit of suc- medicine clinics. A common association with anal region. Appropriate blood screening tests cessful and advanced pregnancy is by no means Chlamydia infection is present. Women with could differentiate these various diagnoses. A variety of uterine malformations have been guaranteed. Some forms of bicornuate uterus these conditions experience local irritation of Treatment is not always necessary, as a pro- described varying from a unicornuate uterus may have a redundant horn or a dominant the vulva and vagina as well as marked anxiety. portion of these warty lesions resolve sponta- (Figure 1) to complete division or duplication horn. If pregnancy occurs in the redundant Human papillomavirus (HPV) is the cause of neously5. However, many clinicians will treat all of the uterus, commonly described as a double horn, the chance of ectopic pregnancy or rup- infection and has the associated risk of cervical cases because it is not possible to distinguish uterus with two horns separated in its low ture of the uterus is higher. In some cases a cancer at a later date in some individuals, as those lesions which regress spontaneously. end, along with two tubes and two ovaries1. redundant horn can obstruct the passage of HPV types 16 and 18 are found in most cases These patients are usually asymptomatic but the fetal head into the birth canal from the of cervical cancer. As such, the infection is a may present with fertility problems, recurrent pregnancy that is in the dominant horn. Care- particularly relevant condition for discussion Treatment miscarriage, scanty menstruation and painful ful evaluation is important to understand the in terms of preconceptional medicine. Follow- or heavy periods. They are susceptible to pre- nature and extent of the problem well before ing initial diagnosis, the behavior in pregnancy For mothers who are contemplating and plan- term labor and abnormal presentation of the pregnancy occurs. is unpredictable. Often the pregnant state is ning a pregnancy it is prudent to treat vis- fetus. An ultrasound scan can identify the con- When a septum is discovered within the associated with marked growth of the warts ible lesions before becoming pregnant. No dition well before pregnancy. uterine cavity, it is appropriate to remove it which, if not treated in a timely basis, can treatment modality can be guaranteed to be A unicornuate uterus has a high miscarriage using a hysteroscopic approach, which is com- become problematic in terms of general com- 100% effective and relapses can occur. Treat- and premature labor rate which may lead to monly followed by an immediate insertion fort and, in some instances, locomotion. When ments such as podophyllin and imiquimod can be applied. Long-term toxicity (espe- anything from extreme prematurity to late of an intrauterine contraceptive device of the neglected, obstruction of vaginal delivery is a cially if lesions are large) may mean using an prematurity and immature development of Mirena type for 6 weeks to minimize adhesion possibility. It is probable that the immunosup- alternative such as podophyllotoxin. This is a the fetus. It is commonly acknowledged that formation. pressive effect of pregnancy may opportunisti- cytotoxic agent with the active component of if a unicornuate uterus has carried a pregnancy The numerous varieties of malformation cally charge these viral eruptions to prolifer- podophyllin. It is applied as a cream base and to term the prognosis is good for subsequent make it imperative that during the course of ate. Currently young adolescent women are is effective in young women. Other treatments pregnancies. investigating patients for infertility all clini- offered immunization, but evidence of the such as imiquimod, cryotherapy and trichloro- The well known Strassman’s operation, cians undertake proper physical examination long-term effectiveness of this program is which involves incision at the uterine fundus acetic acid are recommended either in isola- to exclude abnormalities of the genital tract1. awaited. Genital warts can be found anywhere from one horn to the other transversely and tion or in combination6. around the tract of the female genitalia includ- then re-suturing anteriorly and posteriorly to In pregnancy warts tend to grow quite rap- ing the introitus, vulva, vagina and cervix4. create a larger cavity, theoretically may enable idly. Small warts can be treated conservatively; GENITAL WARTS the patient to carry a pregnancy to a more larger warts can be excised even in pregnancy. advanced gestation. Though such corrective Cervical warts should be excised using the Genital warts commonly present in young Diagnosis laser, and when warts are large and invading women, often before they become pregnant. the vagina, serious consideration should be The method of transmission is still unclear, Most cases of genital warts are diagnosed by given to delivery of the baby by cesarean sec- although the causative viral agent is well visual appearance with the individual lesions tion. Transmission from mother to baby can known. The vast majority of cases are man- displaying characteristic warty heads. These occur if lesions are present in the vagina. Pedi- aged in the specialist genitourinary medical are contagious and can be passed onto the atric manifestations of genital wards include clinic; although in many countries manage- male and vice versa. Collaboration with a der- laryngeal polyps of the infant and toddler. ment is in the hands of generalists or obste- matologist is often helpful, because the dif- Treatment with podophyllotoxin should tricians/gynecologists. Some centers provide ferential diagnosis includes uninfectious skin be avoided in pregnancy because of concerns medication for self application at home with lesions including malignancies. It is essential regarding potential toxins. Urethral warts can the inherent pitfalls in managing such a con- not to confuse sexually transmitted diseases be cauterized. In pregnancy, surgical remov- dition effectively (especially when the warts with other genital warts such as molluscum al of localized warts is recommended, but are extensive) by this protocol. Guidelines are contagiosum which are flatter eruptions of recurrence may occur after apparent surgical available from von Krogh et al. and the Health the vulva and contain central cheesy material. clearance. Figure 1 Patient aged 35. Unicornuate uterus Protection Agency2,3. Another consideration should be condyloma Because the chances of greater proliferation with congenital absence of left tube and ovary. In the UK about 71,000 new cases of genital lata of secondary syphilis which are softer more of wart viral changes could be high in patients Copyright Mr C. B-Lynch 2009 warts are reported annually by genitourinary fleshy lesions especially confined to the peri- who are HIV positive and pregnant, these 356 357 PRECONCEPTIONAL MEDICINE Benign conditions of the genital tract individuals should be managed jointly between BENIGN TUMORS OF THE and be flattened like vulval wart infection others. The larger is the surface area of abnor- the sexually transmitted disease unit and the BARTHOLIN’S GLAND but can also appear with indistinct borders.