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Mammary duct ectasia in clinical practice
228
NASPAG 18th Annual Clinical Meeting
therapy was begun which included involved field irradiation (modified mantle field and a sub-diaphragmatic inverted Y field) over seven weeks. The patient began having spontaneous menses 16 months after completion of radiation. FSH, LH, and Estradiol levels normalized 20 months post irradiation. She presented 22 months after completing radiation therapy with delayed menses. Positive urine and serum pregnancy tests were documented. She underwent an ultrasound oneweek later, and an intrauterine pregnancy at 8 weeks gestational age was confirmed. Conclusion: Fixation of the ovaries outside of an irradiation field is used to preserve future function. Most early descriptions report lateral fixation to the pelvic brim—“Low Lateral Fixation” when pelvic irradiation alone is required. “Low Lateral Fixation” does not protect the ovaries from radiation exposure when abdominal irradiation is also required. “High Lateral Fixation” to the paracolic gutters has been described in cases requiring pelvic and abdominal irradiation treatment, but this requires transection of the UO ligaments, hence disrupting the ovarian blood supply. “Medial Fixation” of the ovaries behind the uterus may be employed when abdominal and pelvic fields are required, and allows for the possibility of spontaneous conception in the future. We believe our patient is the first adolescent described in the literature to undergo laparoscopic, Medial Fixation of the ovary using a technique to incise the sersosa parallel to the IP ligaments. The procedure allowed the ovaries to be placed behind the uterus without transecting or putting excessive tension on the ovarian blood supply. This technique was associated with a return of ovarian function and spontaneous conception in our patient.
Posterior Sagital Vaginoplasty for Mid-Vaginal Transverse Septum and Mucocolpos, A Novel Approach Eduardo Lara-Torre, MD, Mary E. Fallat, MD, Sari Kives, MD, and S. Paige Hertweck, MD University of Louisville Medical School, Louisville, KY
posterior sagittal approach has been described when rectal and vaginal anomalies are encountered together. We present a case and reviewed the available literature of the repair of this uncommon condition including a posterior sagittal approach. Case: A ten year old premenarcheal female presented to her primary care physician with persistent foul smelling vaginal discharge. After failing initial treatment for vaginitis, a vaginal septum or foreign body were suspected and she was evaluated by a pediatric gynecologist. Her exam revealed Tanner II breasts and Tanner II pubic hair without any signs of estrogenization. A suspected high transverse septum was visualized at 4 cm proximally from the introitus. Imaging studies including an MRI and ultrasound confirmed high vaginal septum and suggested an infected mucocolpos. She had no other associated malformations of the urogenital system and her anus was normal. The diagnosis was confirmed with an exam under anesthesia, and a fistulous tract was suspected as the source of her persistent vaginal infections. A posterior sagittal approach vaginoplasty was performed. The septum and fistulous tract were identified and completely removed. The upper and lower vaginas were then re-approximated to make one single cavity. A Malecot drain was placed in the vagina to maintain patency. The patient had three monthly exams under anesthesia and the drain was removed after patency was confirmed. The patient used small dilators to prevent strictures. At 18 months, the patient has a patent vagina, the cervix is easily visualized with a small Huffman speculum and there is no definitive stricture. Signs of estrogenization are present. Comments: The use of the posterior sagittal approach is a valid technique for the repair of isolated high or mid transverse vaginal septum. Because of the reduced space and difficulty in performing surgery though the vagina in prepubertal patients, this approach may be a valid alternative with easier access and possibly improved results.
Mammary Duct Ectasia in Clinical Practice Monique Regard, MD New York Medical College, Valhalla, NY
Background: Vaginal atresia is an uncommon condition. It generally presents clinically during the peri-pubertal stage. Given the inability of the uterine-cervical contents to be spontaneously drained, it often presents as abdominal pain or a vaginal bulge. Multiple approaches on the repair of a mid vaginal transverse septum have been described in the literature with good results. The repair of cloacal abnormalities using the
Background: Mammary duct ectasia is not often associated with breast disease in girls, but we believe should be considered in the differential of breast masses and nipple discharge in young women. Cases: Two patients were evaluated for breast complaints in a six month period. Both girls had individual findings consistent with mammary duct ectasia. The
NASPAG 18th Annual Clinical Meeting
first child was an eleven month old female who had presented to her pediatrician two months earlier with spontaneous bloody discharge from the right breast for two weeks. She also bled from the right nipple for 3 days one month prior to the visit and for two days one week prior to her visit. The mother could always tell when she was going to bleed, because the underlying breast tissue would turn dark greenish for one to two days before the spontaneous bleeding began. On physical exam the day of her consultation there was no breast discharge or discoloration of the breast tissue. The second girl was a 13 year old healthy menstruating teen complaining of a tender lump just under the right nipple. On the surface there was no induration, erythema, or other skin discoloration and no expressible discharge. On exam there was an irregular firmness about 2 by 2 cm below the nipple that was mildly tender. Ultrasound exam of the right retroareolar region showed two ectatic debris filled ducts with tiny calcifications in the walls. These findings were consistent with mammary duct ectasia. No solid masses, cysts, abnormal shadowings, or textual inhomogeneity were seen on the ultrasound. The patient was offered a trial of antibiotics to see if that would decrease the mass or the tenderness. She and her mother declined once reassurance had been given that this appeared to be a benign condition. The patient was asked to follow up with a repeat ultrasound in two months. Comments: Mammary duct ectasia is usually only included in the differential of breast disorders in older women. Review of the literature shows only two other cases in young females in the last 10 years. In major textbooks it is not included in the differential of breast masses or breast discharge for girls. In young boys the diagnosis has been confirmed by pathologic examination of the surgically excised lesion. If there is a nipple discharge, microbial studies show that the bacteria are usually aerobic and anerobic, implying that infection may be part of the pathogenesis of mammary duct ectasia. Broad spectrum antibiotic treatment is suggested if the condition does not resolve spontaneously. Recognition of this disease entity in young girls is reassuring for the patient and clinician and can avoid immediate invasive evaluation. However, reassurance should always be coupled with close follow-up to document resolution of the process so more serious possibilities can be completely dismissed with time.
Hematocolpos Associated with Chronic Vaginitis and Diagnostic Vaginal Biopsy Stephen M. Scott, MD, and William Schlaff, MD University of Colorado Health Sciences Center, Denver, CO
229
Background: Biopsy of an ulcerative lesion prior to puberty was associated with dense adhesions, vaginal stenosis and hematocolpos at menarche. We recommend avoiding this procedure when bacterial vaginitis is suspected. Case: A Caucasian female presented at 9 1/2 years of age with a complaint of persistent vaginal discharge and bleeding. Eleven months prior she was seen by her primary pediatrician for symptoms of vaginal itching and irritation accompanied by vaginal discharge. Symptoms persisted after two courses of antibiotics. Vaginal cultures grew normal flora. When vaginal spotting occurred she was referred to a gynecologist. Speculum examination under anesthesia revealed ulcerative lesions on the distal vagina and no lesions or bleeding from the cervix. Biopsies of the ulcers were performed to rule out neoplasia. Final histology noted acute and chronic pyogenic granuloma. Recurrent vaginal discharge and bleeding occurred despite repeated antibiotic courses prior to her presentation in our clinic. A vaginoscopy was attempted in our clinic however the distal vaginal canal was completely obliterated. Cystoscopy revealed a normal urethral canal and normal ureters. A pelvic ultrasound and pelvic MRI revealed normal ovaries and normal uterine and vaginal structures. The patient was observed every six months, and by the age of 12 she had Tanner III breast development, Tanner IV pubic hair pattern, and clinical signs of estrogen stimulation of the external genitalia. The vaginal canal spontaneously reopened by this time. However, at age 13 she presented to our Emergency Department with severe abdominal pain. An ultrasound confirmed a large hematocolpos extending to the distal vagina. We initially attempted to open the vaginal stenosis from below but were not successful due to dense adhesions. A laparotomy was performed, and the vaginal canal was identified and reopened by placing a sound into the uterine fundus and extending it through the cervix and into the proximal vagina. The adhesions were removed, and the superior vaginal mucosa was undermined and sutured to the inferior vaginal mucosa. Vaginal patency has been maintained with the use of a vaginal dilator, and one year following surgery the patient reports regular menstrual flow. Conclusion: Vaginal infections prior to puberty are often chronic and recurrent. The lack of endogenous estrogen creates an atrophic environment in the vagina and delays healing of the mucosal surface. This may lead to ulceration and subsequent scar formation. The inflammatory reaction of a vaginal biopsy may have contributed to scar formation in our patient. We would caution against the routine use of vaginal biopsy when prepubertal bacterial vaginitis is suspected. If a biopsy is required, we recommend aggressive treatment with “sitz” baths and possibly topical estrogen application to promote mucosal healing and reduce the risk of dense adhesion formation in the vagina.
NASPAG 18th Annual Clinical Meeting
therapy was begun which included involved field irradiation (modified mantle field and a sub-diaphragmatic inverted Y field) over seven weeks. The patient began having spontaneous menses 16 months after completion of radiation. FSH, LH, and Estradiol levels normalized 20 months post irradiation. She presented 22 months after completing radiation therapy with delayed menses. Positive urine and serum pregnancy tests were documented. She underwent an ultrasound oneweek later, and an intrauterine pregnancy at 8 weeks gestational age was confirmed. Conclusion: Fixation of the ovaries outside of an irradiation field is used to preserve future function. Most early descriptions report lateral fixation to the pelvic brim—“Low Lateral Fixation” when pelvic irradiation alone is required. “Low Lateral Fixation” does not protect the ovaries from radiation exposure when abdominal irradiation is also required. “High Lateral Fixation” to the paracolic gutters has been described in cases requiring pelvic and abdominal irradiation treatment, but this requires transection of the UO ligaments, hence disrupting the ovarian blood supply. “Medial Fixation” of the ovaries behind the uterus may be employed when abdominal and pelvic fields are required, and allows for the possibility of spontaneous conception in the future. We believe our patient is the first adolescent described in the literature to undergo laparoscopic, Medial Fixation of the ovary using a technique to incise the sersosa parallel to the IP ligaments. The procedure allowed the ovaries to be placed behind the uterus without transecting or putting excessive tension on the ovarian blood supply. This technique was associated with a return of ovarian function and spontaneous conception in our patient.
Posterior Sagital Vaginoplasty for Mid-Vaginal Transverse Septum and Mucocolpos, A Novel Approach Eduardo Lara-Torre, MD, Mary E. Fallat, MD, Sari Kives, MD, and S. Paige Hertweck, MD University of Louisville Medical School, Louisville, KY
posterior sagittal approach has been described when rectal and vaginal anomalies are encountered together. We present a case and reviewed the available literature of the repair of this uncommon condition including a posterior sagittal approach. Case: A ten year old premenarcheal female presented to her primary care physician with persistent foul smelling vaginal discharge. After failing initial treatment for vaginitis, a vaginal septum or foreign body were suspected and she was evaluated by a pediatric gynecologist. Her exam revealed Tanner II breasts and Tanner II pubic hair without any signs of estrogenization. A suspected high transverse septum was visualized at 4 cm proximally from the introitus. Imaging studies including an MRI and ultrasound confirmed high vaginal septum and suggested an infected mucocolpos. She had no other associated malformations of the urogenital system and her anus was normal. The diagnosis was confirmed with an exam under anesthesia, and a fistulous tract was suspected as the source of her persistent vaginal infections. A posterior sagittal approach vaginoplasty was performed. The septum and fistulous tract were identified and completely removed. The upper and lower vaginas were then re-approximated to make one single cavity. A Malecot drain was placed in the vagina to maintain patency. The patient had three monthly exams under anesthesia and the drain was removed after patency was confirmed. The patient used small dilators to prevent strictures. At 18 months, the patient has a patent vagina, the cervix is easily visualized with a small Huffman speculum and there is no definitive stricture. Signs of estrogenization are present. Comments: The use of the posterior sagittal approach is a valid technique for the repair of isolated high or mid transverse vaginal septum. Because of the reduced space and difficulty in performing surgery though the vagina in prepubertal patients, this approach may be a valid alternative with easier access and possibly improved results.
Mammary Duct Ectasia in Clinical Practice Monique Regard, MD New York Medical College, Valhalla, NY
Background: Vaginal atresia is an uncommon condition. It generally presents clinically during the peri-pubertal stage. Given the inability of the uterine-cervical contents to be spontaneously drained, it often presents as abdominal pain or a vaginal bulge. Multiple approaches on the repair of a mid vaginal transverse septum have been described in the literature with good results. The repair of cloacal abnormalities using the
Background: Mammary duct ectasia is not often associated with breast disease in girls, but we believe should be considered in the differential of breast masses and nipple discharge in young women. Cases: Two patients were evaluated for breast complaints in a six month period. Both girls had individual findings consistent with mammary duct ectasia. The
NASPAG 18th Annual Clinical Meeting
first child was an eleven month old female who had presented to her pediatrician two months earlier with spontaneous bloody discharge from the right breast for two weeks. She also bled from the right nipple for 3 days one month prior to the visit and for two days one week prior to her visit. The mother could always tell when she was going to bleed, because the underlying breast tissue would turn dark greenish for one to two days before the spontaneous bleeding began. On physical exam the day of her consultation there was no breast discharge or discoloration of the breast tissue. The second girl was a 13 year old healthy menstruating teen complaining of a tender lump just under the right nipple. On the surface there was no induration, erythema, or other skin discoloration and no expressible discharge. On exam there was an irregular firmness about 2 by 2 cm below the nipple that was mildly tender. Ultrasound exam of the right retroareolar region showed two ectatic debris filled ducts with tiny calcifications in the walls. These findings were consistent with mammary duct ectasia. No solid masses, cysts, abnormal shadowings, or textual inhomogeneity were seen on the ultrasound. The patient was offered a trial of antibiotics to see if that would decrease the mass or the tenderness. She and her mother declined once reassurance had been given that this appeared to be a benign condition. The patient was asked to follow up with a repeat ultrasound in two months. Comments: Mammary duct ectasia is usually only included in the differential of breast disorders in older women. Review of the literature shows only two other cases in young females in the last 10 years. In major textbooks it is not included in the differential of breast masses or breast discharge for girls. In young boys the diagnosis has been confirmed by pathologic examination of the surgically excised lesion. If there is a nipple discharge, microbial studies show that the bacteria are usually aerobic and anerobic, implying that infection may be part of the pathogenesis of mammary duct ectasia. Broad spectrum antibiotic treatment is suggested if the condition does not resolve spontaneously. Recognition of this disease entity in young girls is reassuring for the patient and clinician and can avoid immediate invasive evaluation. However, reassurance should always be coupled with close follow-up to document resolution of the process so more serious possibilities can be completely dismissed with time.
Hematocolpos Associated with Chronic Vaginitis and Diagnostic Vaginal Biopsy Stephen M. Scott, MD, and William Schlaff, MD University of Colorado Health Sciences Center, Denver, CO
229
Background: Biopsy of an ulcerative lesion prior to puberty was associated with dense adhesions, vaginal stenosis and hematocolpos at menarche. We recommend avoiding this procedure when bacterial vaginitis is suspected. Case: A Caucasian female presented at 9 1/2 years of age with a complaint of persistent vaginal discharge and bleeding. Eleven months prior she was seen by her primary pediatrician for symptoms of vaginal itching and irritation accompanied by vaginal discharge. Symptoms persisted after two courses of antibiotics. Vaginal cultures grew normal flora. When vaginal spotting occurred she was referred to a gynecologist. Speculum examination under anesthesia revealed ulcerative lesions on the distal vagina and no lesions or bleeding from the cervix. Biopsies of the ulcers were performed to rule out neoplasia. Final histology noted acute and chronic pyogenic granuloma. Recurrent vaginal discharge and bleeding occurred despite repeated antibiotic courses prior to her presentation in our clinic. A vaginoscopy was attempted in our clinic however the distal vaginal canal was completely obliterated. Cystoscopy revealed a normal urethral canal and normal ureters. A pelvic ultrasound and pelvic MRI revealed normal ovaries and normal uterine and vaginal structures. The patient was observed every six months, and by the age of 12 she had Tanner III breast development, Tanner IV pubic hair pattern, and clinical signs of estrogen stimulation of the external genitalia. The vaginal canal spontaneously reopened by this time. However, at age 13 she presented to our Emergency Department with severe abdominal pain. An ultrasound confirmed a large hematocolpos extending to the distal vagina. We initially attempted to open the vaginal stenosis from below but were not successful due to dense adhesions. A laparotomy was performed, and the vaginal canal was identified and reopened by placing a sound into the uterine fundus and extending it through the cervix and into the proximal vagina. The adhesions were removed, and the superior vaginal mucosa was undermined and sutured to the inferior vaginal mucosa. Vaginal patency has been maintained with the use of a vaginal dilator, and one year following surgery the patient reports regular menstrual flow. Conclusion: Vaginal infections prior to puberty are often chronic and recurrent. The lack of endogenous estrogen creates an atrophic environment in the vagina and delays healing of the mucosal surface. This may lead to ulceration and subsequent scar formation. The inflammatory reaction of a vaginal biopsy may have contributed to scar formation in our patient. We would caution against the routine use of vaginal biopsy when prepubertal bacterial vaginitis is suspected. If a biopsy is required, we recommend aggressive treatment with “sitz” baths and possibly topical estrogen application to promote mucosal healing and reduce the risk of dense adhesion formation in the vagina.