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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