Practical Vulvar Anatomy Case Presentations - wesley ob/gyn Vulvar... · Practical Vulvar Anatomy...

Practical Vulvar AnatomyCase Presentations

Jed Delmore, MD, FACS. FACOG

Professor of Obstetrics and Gynecology

Division of Gynecologic Oncology

University of Kansas School of Medicine, Wichita

Disclosure

I have no financial relationship with vulvar anatomy other than I make a living there.

Objectives

To review:

-Vulvar embryology

-Vulvar anatomy

-Vulvar innervation

-Vulvar blood supply

-Application of the above

External Anatomy

Case # 1

• 17 year old high school swimmer referred for evaluation of a vulvar mass. She has decided to quit the swim team as she is embarrassed to wear her bathing suit. She and her mother describe a painless, slowly enlarging vulva.

• On exam she is noted to have a smooth, semi-mobile, cystic 5 cm mass in the superior aspect of the right labia majora.

Further evaluation?

Differential Diagnoses?

Labial MassDifferential Diagnoses

• Lipoma

• Fibroma

• Sarcoma

• Inguinal hernia

• Cyst of the Canal of Nuck

Cyst of Canal of Nuck

Processus vaginalisGubernaculumHydrocele of the round ligament

Case # 2

• 29 year old presents to the ED for evaluation. While standing on the porch railing to paint the soffit, she slipped and experienced a straddle injury to the vulva/perineum when landing on the metal railing.

• There is a 9 cm expanding hematoma involving the left vulva, extending to the clitoris.

• You are on EMTALA call and asked to evaluate and treat.

Case # 2

• How will you control the bleeding?

• What is the blood supply to the vulva?

• What anatomic factors determine extent and direction of the hematoma?

Fascial layers

• Superficial fatty layer (Camper’s fascia)

• Membranous fatty layer (Scarpa’s fascia)

• Superficial urogenital diaphragm (Colle’s fascia)

• Limits bleeding to the anterior urogenital triangle.

Blood Supply to the Vulva

• Internal pudendal artery

• Clitoral branch

• Labial branches

• Transverse perineal branch

• External pudendal artery

• Additional supply to the mons and superior vulva

Surgical Approach

• For stable, non-expanding hematoma: Observation.

• Assess serial Hgb., neurological changes, and ischemia

• Expanding hematoma:

• Arteriogram have help, but difficult to interpret. Selective embolization.

• Surgical exploration. Curvilinear, lateral incision. Start mid-vulva.

• Anatomy is distorted and only arterial bleeding is easy to identify and correct.

Case # 2

• What is the risk of residual nerve injury and pain?

• What is the nerve supply to the vulva?

Case # 2

• What is the risk of residual nerve injury and pain?

• What is the nerve supply to the vulva?

• Pudendal nerve (Sacral 2,3,4)

• Passes through the greater sciatic foramen, below the ischial spine, and enters the ischial rectal fossa.

• At the urogenital diaphragm, it divides into the inferior hemorrhoidal, deep perineal and superficial perineal branches.

• Additional innervation

• Ilioinguinal to mons and superior labia

• Genitofemoral to labia majora

• Posterior femoral cutaneous to inferior posterior vulva

Case # 3

• 42 year old with a history of chronic infection of the right Bartholin’s gland and duct. Previous therapy has included antibiotics, I&D and Word catheter placement. Exam reveals a firm 3 cm mass in the 7:00 position, deep to the labia majora.

• She is referred to you for consideration of resection of the right Bartholin’s gland.

Bartholin’s Gland (major vestibular glands)

• Paired glands with duct openings located at 4:00 and 8:00 at the vaginal introitus.

• The glands are lined by cuboidal mucinous cells and the ducts are lined with transitional epithelium.

• The gland is cephalad to the introitus and adjacent to the vagina and above the bulbocavernosus muscles.

Surgical Approach

• Surgical exploration. Curvilinear, lateral incision.

• Dissection is deep to Colle’s fascia, involves resection of part of the vestibular bulb and is deeper than you think.

• Branches of the pudendal artery must be ligated, and secured well, as bleeding can fill the ischial rectal fossa.

Additional Vulvar Anatomy/Structures

• Clitoris

• Bulbocavernosus muscles

• Ischiocaverosus muscles

• Superficial transverse perineal muscles

• External anal sphincter

The End