A. Imperforate Hymen

Obstruction of female reproductive tract in utero is rare but is most commonly caused by imperforate hymen. This can be detected prenatally where a dilated vagina/uterus is seen as a cystic structure in the pelvis. However, the most common time for diagnosis is in the newborn period where a bulging cystic structure is seen in the posterior introitus, which typically has a whitish appearance with overlying thin membrane. Maternal estradiol exposure is what leads to the vaginal secretions. If the imperforate hymen is missed in the newborn period, the dilation may resolve as the maternal estradiol exposure ends and the patient may come back at puberty with cyclic abdominal pain, amenorrhea, and bluish bulging structure in posterior introitus (Fig. 30-1). Imperforate hymen in newborns is treated by transverse incision of the hymen. Needle aspiration is not recommended due to concerns about causing infection.

B. Labial Adhesions

Labial adhesions are a common finding in young children especially before the age of potty training. The fusion usually starts posteriorly and an opening remains anteriorly (Fig. 30-2). The low estrogen state and possible irritation from urine in diapers is thought to lead to these adhesions. If labial adhesions are asymptomatic, no treatment is needed, as there is a high spontaneous resolution rate. If there are symptoms such as UTI, vaginal pain/itching, or significant parental concern a 4- to 6-week course of topical estrogen or steroid cream is often successful in resolving adhesions. Lysis of adhesions in the clinic after topical anesthetic or lysis of adhesions in the operating room can also be performed. After any successful active intervention for labial adhesions, recurrence is common and therefore a lubricating ointment such as petroleum jelly should be applied after separating labia during diaper changes for several weeks to months to prevent recurrence.

C. Urethral Prolapse

Urethral prolapse often presents with blood in diaper or underwear and reddish bulge in introitus circumferentially around meatus (Fig. 30-3). There may also be complaints of pain. In the pediatric age group, urethral prolapse typically occurs in prepubertal children and is most common in those of black race. As in labial adhesions, urethral prolapse is thought to be due to the low estrogen state before puberty. A 4- to 6-week

course of topical estrogen cream is often successful in treating urethral prolapse, but recurrence is not infrequent. Surgical excision of prolapsed mucosa followed by reapproximation of mucosa with absorbable sutures is sometimes required for recurrent urethral prolapse.

D. Introital Cysts

Cysts in the introitus in children are usually paraurethral cysts, Gartner’s duct cysts, or prolapsed ureterocele.

Paraurethral cysts are dilations of paraurethral glands. These cysts displace the meatus. In the newborn period, paraurethral cysts often resolve with observation. Occasionally, drainage with a small incision or needle may be needed.

Gartner’s duct cysts arise from remnants of the Wolffian ducts. They occur along the anterolateral vaginal wall, typically are benign, and often resolve on their own. There is an association between Gartner’s duct cysts and ectopic ureters to vagina due to embryologic origin of Gartner’s duct cysts. If there is a cyst seen along anterolateral wall of vagina in an infant or child, evaluation with a renal ultrasound for ectopic ureter to that cyst should be considered.