PERI-URETHRAL AND PERINEAL-VAGINAL MASSES: HOW TO DEAL WITH IT ?

Periurethral, perineal or vaginal  masses are masses or swelling around the urethral meatus, vaginal area or the perineal region. The incidence is less than 4%. The main presentation is feeling a swelling or mass around the meatus, vagina & vulva, difficulty in passing urine, urethral discharge and pain on sexual intercouse. There is limited information / literature on the exact incidence, diagnosis and management for this conditions.

periurethral mass

The differential diagnosis of suchs  massess include;

• Urethral Diverticulum ( 84%)
• Peri-urethral leiomyoma (7%)
• Periurethal vagianl cyst/ Gartner's cyst (6%) or remnant of mullerian duct cyst
• Skene's gland cyst or abcess
• Retention cyst
• Urethral Prolapse
• Urethral Caruncle
• Ectopic Ureterocele 
• Inguinal/Femoral Hernia
• Benign tumours- angiomyoblastoma, fibromas, warts
• Malignancies

The diagnosis is usually clinical, and some case we may need to do some imaging studies to see the nature & extent of the lesions. The suggested imaging studies include perineal Ultrasound, Ct Scan/ MRI, Urethroscopy/cystoscopy, micturating cystogram and double balloon urethrogram.

The management options will depends on the diagnosis. If small & asymptomatic, usually can be managed as conservatively. Aspiration of the cyst content can be done , but usually the cyst reoccurs. The suggested surgery include endoscopic re-roofing, trans-urethral incision, Marsupialization of the diverticulum or cyst, cystectomy of the cyst wall in cases of gartner's or skene gland cyst. Diverticulectomy in case of urethral diverticulum with grafting in some case. In some case excision of the lesions

Below are some of my personal collection of cases & how l managed them:

Case 1. 36 year old Para 2 with urinary incontinence & passing pus discharge urethral meatus. on examination noted tender, fluctuant mass, below urethral meatus. On pressing/milking the mass, pus & urine discharge noted coming from the urethral meatus. The diagnosis of Urethral Diverticulum was made. Marsupialization was carried out. This will create a small suburethral  fistula and allow the secretion to escape & thus facilitates the closure & healing of the fistula tract that communicates into the urethra. Based on my experience, this is very effective & simple operation.

suburethral abscess

Case 2. 32 year old patient presented with periurethral mass for 3 months. Initially the mass was small 3x 2 cm. Over few mass it become 8x8 cm. It was infected & rubbery in nature. Patient also had difficulty in passing urine. EUA & excision of the mass was carried out. The histology was consistent with para-urethral angiomyofibroblastoma. This case was published in Australia & New Zealand Continence Journal Vol 10, No 1, March 2004. The patient recovered very will with no recurrence. This condition is Benign tumour. 

Case 3. 29 year old Para1, noted cystic swelling around urethral meatus after delivery. On examination there was a cystic, transparent mass around 6 o clock below the urethral meatus. It was non tender mass. Mobile & cystic in nature. The options for such cases are neddle aspiration (but the recurrence rates are high), cystectomy, & marsupialization. In this case complete cystectomy was done. paraurethral or vaginal cyst develop as result of local irritation, inflammation or sequential blockage of vaginal or paraurethral glands. If infected the develop into abscess.

Case 4. 56 year old para 5 lady, presented with progressively enlarging mass on the left side of vagina. On examination the was 18 x 12 cm cystic mass noted. The mass was multiloculated & cystic. CT Scan showed cystic mass with no intra pelvic extension. A dignosis of  vagianl cyst/ Gartner's cyst or remnant of mullerian duct cyst was made. EUA and drainage was carried out. Serous like material removed and complete cystectomy and labioplasty was carried out. Vaginal wall cyst/ Gartner/ Mullerian remnant cyst occurs in 0.5-1% of patients. Mostly asymptomatic & unreported. An evaluation should include upper genito-urinary tract assessment to rule out any extension of the mass/cyst and other genito-urinary tract abnormalities. US/CT scan/MRI is the imaging modality of choice. If the is no concomitant abnormality of extension, than a cystectomy or marsupialization is surfice.

Case 5. 44 year old para 5 presented with recurrent left side tender vaginal mass. The mass typically present during pregnancy & subside after delivery. After the last childbirth, the mass persisted and become very tender & painful. Transabdominal ultrasound revealed a longitudinal mass from left vaginal wall extending to pouch of douglas. The mass was mixed in echogenicity. CT scan of abdomen reported as cystic mass anterior to the sacrum extending to lower part of vagina with possible differential diagnosis as (rectal duplication cyst or cystic sacrococcygeal teratoma or ischiorectal cystic lesion/abscess.). A diagnostic laparoscopy was carried out, which revealed left ischiorectal fossa abscess Therefore, 300cc of pus and caseous material drained through vagina. Pus culture and sensitivity grew B-hemolytic non A/B steptococcus. Otherwise, swab AFB, all other infective screening were negative. The fasting blood sugar was 4.8mmol/l. Sigmoidoscopy and Colonoscopy was essentially normal. This time a large marsupialization was done & the abscess was drained. Since than the mass/abscess did recurred. She remain asymptomatic until now.

Case 6. 68 year old patient postmenapausal for 20 year, presented with painful micturition and vaginal soreness. On assessment, there was a growth at the external urethral meatus. The common diagnosis for such conditions are Caruncle or urethral prolapse. In this case this patient had a urethral prolapse. Treatment for caruncle or prolapse is usually topical estrogen application. In some case caruncle/prolapse can be infected. in such cases antibiotics may be indicated. Surgical options includes cauterization for the caruncle or prolapse.  In some cases of prolapse, circumferential excision of the prolapse and approximation of the urethro-vagina margins can be carried out.

Case 7. 58 year old, presented with urinary obstruction & pv bleeding. 

On Examination, noted friable mass periurethrally. Biosy was consistent with sq cell ca stage 4. Patient was referred for radiotherapy. Malignancy at peri- urethral region is very rare. Prognosis is usually poor.

Case 8. This is a 15 year old girl, presented with continuous urine leakage from young. No proper previous evaluation. On examination, there was continuous leakage & wetness at periurethral region. CTU was carried out, revealed an ectopic ureter from right kidney extending to the periurethral region. Patient was referred to our paediatric surgeon, who subsequently ligated the ectopic ureter. Patient was symptom free after this procedure.

Case 9. A 6 year old child presented with difficulty in pass urine & para peri-urethrally. The mass was firm in consistency & non tender. It was reducible. An inguinal hernia was suspected. This patient referred to paediatric surgeons. The finding confirm reducible inguinal hernia with omentum

Case 10. A 58 year old patient presented with large mass, protruding from the vulval region. It was there for nearly 20 year. it was slow growing mass. On examination there was a firm & pedunculated mass on the left labia. It was non tender and mobile. US & CT scan did not show any extension or pelvic mass, Uterus & ovaries was normal, Labial Fibroma was diagnosed. Patient underwent excision with much problem. Histology was consistent with fibroma

Case 11. 65 year old para 5 presented with right side periurethral mass. the mas was firm & tender on pressure. Patient also had voiding difficulty. On examination there was a firm mass in the right upper labia and extending to lower abdomen. it was not reducible. A CT scan revealed a possible ovarian mass with omentum. A diagnosis of ovarian hernia was diagnosed. EUA & exploration was carried out, It turn of as ovarian fibroma prolapsing through the inguinal canal. Right Salphingo-oopherectomy & hernia repair was carried together with surgical team. Patient recovered well. Histology consistent with ovarian fibroma.

Other Mass that I have seen in my practice:

Recurrent mass at upper left labial. First excision biopsy was leiomyoma. came back again after 5 years, the second Excision Biopsy can as Leiomyosarcoma. She was subsequently referred for wider excision and chemotherapy with gynae-oncologist.

This patient presented as fungating grown & wary lesions. Biopsy & excision of the warty growth reveal Hyperkeratosis. Manged with local & systemic steroids. No under dermatology.

Hypertrophic clitoris. Patient planned for clitroplasty

 Genital Wart. Excision & cauterization of the wart carried out. Followed by application of  imiquimod cream.

Chronic Ulceration & necrotic mass. Biopsy revealed sq cell ca, Wide excision & radiotherapy carried out.

 Recurrent Paget's Disease . Now on remission & intermittent Imiquimod cream treatment.

Excessive Lichen sclerosis. Excision biopsy and local Steroid treatment given, recover very well.

 A baby with Ambiguous genitalia. given to paediatric surgeon to manage

 Case of Vulva Varicosity before & after ligation of the feeding vessels ( by Plastic Surgeon) newer modality is sclerotherapy and embolization technique by Interventional radiologist.

In Summary, In most case proper history & examination is sufficient to make a diagnosis. In some case we may want to take a biopsy before treatment or we can do an excision biopsy which is diagnostic and therapeutic, in which the lesion is removed at the same setting. We also may need some imaging modality like US/CT Scan or MRI or CTU / cystoscopy to assess the extend of peri-urethral, perineal or vaginal masses. These imaging will give us some idea about the relationship of such mass with the surrounding areas. This information is important to plan our definitive surgical plan.

All the photos were taken and displayed with patients permission.

Like to thank the owners of the drawings/ pictures as these photos were taken taken from google images. They were displayed here purely for teaching purpose only. 

Malaysian Urogynaecology Mission to Vientiane, Laos

A team of Malaysian urogynaecologists participated in a mission to Vientiane, Laos on the invitation of the officials from the Ministry of Health, Laos & The Obstetrics & Gynaecology society Of LOAS  . This team comprised Dato Dr Aruku Naidu ( Team Leader  from Hospital Raja Permaisuri Bainun, Ipoh), Dr Ng Poh Yin (Senior consultant urogynaecologist of Hospital Kuala Lumpur), Prof Lim Pei Shan (consultant urogynaecologist  from Hospital Universiti Kebangsaan Malaysia), Dr Ida Liliwaty Latar (consultant urogynaecologist from Pusat Perubatan Universiti Malaya), Dr Tan Gaik Imm (urogynaecology fellow from Hospital Pulau Pinang), Sr Tan Lee Khan (Hospital Kuala Lumpur) Sr Lee Fong Hoo (Hospital Kuala Lumpur). This mission was partially sponsored by the Obstetrics and Gynaecology Society Malaysia (OGSM), with the support of The Malaysian Urogynaecology Society (MUGS). 

       

 The team arrived in Vientiane on 28^th October and proceeded to work soon after arriving. The mission was held at the Women and Neonate Hospital Vientiane. This was the first and only Maternal & New born Hospital in Laos.  After a quick tour of the hospital premises and facilities, the team proceeded to assess women with urogynaecological problems, who had been screened beforehand by the local hospital doctors. Out of 10 women was reviewed, but only 3 patients were identified for surgical intervention, including 2 women with advanced Stage 4 pelvic organ prolapse and 1 patient with  3^rd degree tear repair with bad wound dehiscence.

The following day, the Malaysian team conducted the Obstetric Anal Sphincter Injury (OASIS) Workshop for the benefit of the local obstetric specialist and registrars. This workshop was attended by 60 participants. They were junior doctors and specialist from all over Laos. The workshop comprised lectures delivered by the mission urogynaecologists. The topics discussed include pelvic and anal sphincter anatomy, risk factors and prevention of OASIS, and methods of repair of OASIS. The lectures were delivered with the help of a local translator. The afternoon was spent on a hands-on workshop using life animal models & life porcine specimen. The participants had the invaluable opportunity to practise their skills in the repair of the anal sphincter tears on sow perineum.

On the 31 October 2017, the team performed pelvic reconstructive surgeries on the 3 patients who had been identified and prepared for surgery. Two teams of Dr Ng/ Dr Ida and Dr Aruku/ Dr Lim performed the surgeries which included vaginal hysterectomy, pelvic floor repair, McCall culdoplasty and perineal body reconstruction. The aim of the surgical workshop was not only to offer symptom relief to the patients but also to demonstrate surgical techniques and train the Laotian doctors in repair methods, and this was aptly demonstrated by the team. The nursing team of Sr Tan and Sr Hoo were also able to educate the local nurses on the proper technique to safely assist and sterilize equipment for the operation.

 

On the final day of the mission, the team visited the hospital to conduct a post operative ward round to ensure that the patients were on the road to an uncomplicated recovery. We found that the 3 patients were nursed in the recovery area of the operating theatre. Although somewhat uncomfortable for the patients, this enabled them to have better monitoring in the critical post operative period due to logistic reasons in the local setting. All 3 patients were recovering well, and we educated the local registrars about post operative management for urogynecology patients, which included pain relief, prevention of thromboembolism, catheter care and the trial of void protocol and follow up. As with the common problems with mission such as this, the importance of post operative care cannot be overemphasized as the team cannot be present onsite throughout the entire recovery period and also to assess patients in the immediate and short term post operative period, which would be the ideal situation. We however ensured that the local doctors would be able to contact the operating team for advice should the need arise so as not to compromise patient care.

Overall it was a very successful inaugural mission to Vientiane for both the Malaysian and Laotian teams. We were able to build networks and learn from one another. It was enlightening to experience working in a different country’s settings with challenging logistics, manpower, experience and equipment. We hope to assist our foreign counterparts in setting up and running an organized urogynaecology service by periodical missions over the coming years and hope to foster goodwill and better friendships for future collaboration within the Asia-Pacific region.

Last but not least, the Malaysian urogynaecology Mission Team likes to thank all the team players for their valuable support either morally or physically. A very big thanks to OGSM for the timely partial financial support to make this event a successful event.  

Prevention of Vault prolapse during hysterectomy (PHVP)

Prevention of vault prolapsed, needs some understanding on pelvic organ support system.  De Lancey’s 3 Levels of Pelvic Support ( Delancey JOL: Am J Obstet Gynecol 166: 1717, 1992 ) is one of the essential components in preventing PHVP.  The method & techniques’ for prevention depends on the type of hysterectomy carried out ( Abdominal as well as Vaginal). If the Abdominal Hysterectomy, one can Re-anchor uterosacral ligament pedicles to vaginal vault during vault closure / pelvic peritonisation or pericervical tissues ( Level B evidence),  Moscowitz sutures (Circumferential sutures to obliterate a deep cul-de-sac) & Halban cul-de-sac closure are some other procedures to prevent PHVP. When doing vaginal hysterectomy, one can do peritoneal closure of the cul-de-sac, a vaginal Moschowitz operation, McCall’s culdoplasty. However The authors found significantly fewer cases of posterior-apical vaginal prolapse (stage 2) at three years following  the McCall’s culdoplasty 2/32 (6%) than with either peritoneal closure 13/33 (39%) or the vaginal  Moschowitz procedure 10/33 (30%)  (p=.004)* (Stephen H Cruikshank, Am J 427 Obstet Gynecol 1999;180:859-65). Therefore McCall Culdoplasty at the time of vaginal hysterectomy is effective in preventing subsequent PHVP (Level B evidence). Sacrospinous ligament fixation (SSF) & abdominal sacral colpopexy are not recommended for the prevention of prolapse at the time of hysterectomy for non-related disease (Level C). SSF can be added to a post vaginal hysterectomy and McCall culdoplasty if the cuff (point C) is ≥ Stage 2 to prevent vault prolapse. Subtotal hysterectomy is not recommended for the prevention of PHVP (Level A). In cases of total Laparoscopic hysterectomy (TLH). The only study evaluating 22 laparoscopic uterosacral ligament suspension in comparison to 96 vaginal uterosacral ligament suspension retrospectively found no significant difference in recurrent apical prolapse (6% in the vaginal group vs 0% in the laparoscopic group. This study identified no statistical significance in the  ureteral compromise recognized intraoperatively 4% in the vaginal group, 0% in the laparoscopic group (Rardin CR, Erekson EA, Sung VW, Ward RM, Myers DL. Comparison of laparoscopic and vaginal.Uterosacral colpopexy at the time of vaginal hysterectomy's J Reprod Med 2009: 54: 273-80). Of course there are other confounding factors involved in the success in preventing the PHVP which include surgeon factor, patient factors, materials & techniques used.

Below is AN technique which is the modification of Mc Culdoplasty to address vault prolapse after Vaginal Hysterectomy. 

DE LANCEY'S 3 LEVEL  PELVIC SUPPORTS

                                                  METHODS OF PREVENTION OF PHVP

                                                          Abdominal Hysterectomy

• Peritonisation of pelvis- transfixing anterior leaf of peritoneum, round ligament, ovarian ligaments, uterosacral ligaments and vaginal wall of vault. This is repeated on both sides.

• Richardson's cuff angle closure, in-cooperating broad ligaments, uterosacral ligament & vaginal vault ( most gynaecologist do this during abdominal hysterectomy)

• Moschowitz Suturing ( usually done if there concurrent enterocele)

• Halbans Cul do sac closure ( Done if there is concurrent enterocele)

Abdominal / Total Laparoscopic Hysterectomy

• Pericervical And Uterosacral plication ( most laparoscopic surgeons do this technique at the time of TLH

Vaginal Hysterectomy / LAVH

• Mc Call Culdoplasty ( very effective operation, has small risk of ureteric injury esp with regards to high suture placement)

• Vaginal approach Moschowitz ( most vaginal surgeon like this technique, in cooperating all the ligaments-round, ovarian and  uterosacral ligaments and in-cooperating them as purse string closure )

• AN (Aruku Naidu) modified Mc Call ( In-cooperation of low-mid uterosacral and anchored to vaginal vault ipsilaterally and brought to centre) = provide goo vault support & reduce post vaginal skin bleeding

          

The above are some of the technique, which can be used to prevent vault prolapse during hysterectomy after abdominal, laparoscopic or vaginal approach.

Credits to all the authors of the pictures, which was taken from internet/ google images.

Consent has been obtained for the video clip on AN technique from the patient

The above picture & video are purely for teaching junior doctors.

REPAIR OF VAGINAL APICAL SUPPORT DEFECTS

Apical support defects can occur alone but usually one or more of the following segmental prolapses coexist:

      ·        Uterine prolapse when a uterus is in place

·      vaginal vault prolapse is reserved to apical support defect when a hysterectomy was performed previously

·       Cystocele

·        Rectocele

·        Enterocele

These defects should be recognized prior to surgery and their repair carried out at the same time.

Several surgical procedures have been described for the correction of apical support defects. The repair can be performed transvaginally, transabdominally, or laparoscopically. Surgical procedures available include as day care procedure include:

Abdominal Appraoch

 Abdominal sacral colpopexy (Open/  laparoscopic)

This approach is usually preferred when a preservation of cervical length to allow sexual intercourse is desired or when vaginal approach failed. The bladder, rectum and ureters can be directly visualized; hence the chances of injury to these structures is minimized. This procedure aims at supporting the vaginal apex to the sacral promontory using a synthetic or facial bridge.

Procedure:

 ·         The patient is in frog-leg like position with a foley catheter inside the bladder.

 ·         Three port or single port technique can be employed.

 ·         The peritoneal cavity is entered and the bowel is displaced out of the field.

 ·         A sponge stick introduced into the vagina is helpful in identification of the vagina. The peritoneum overlying the vagina is then dissected of the vaginal wall.

 ·      A synthetic graft polypropelene mesh are used are sutured to the vaginal apex using permanent suture material using 3/0 daflon or prolene sutures. 

 ·         The peritoneum covering over the sacrum is opened from the sacral promontory to the level of S3. Permanent sutures are passed through the periosteum of the sacral promontory, alternatively protex tagger/ bone anchors can be used to fix the free end of the graft.

 ·      Once the sutures are tied, the vaginal apex is approximated to the sacral promontory. The graft material should be tension free. 

 ·         The peritoneum is then closed with absorbable suture material.

Complications

·         Injuries to bowels, bladder, ureter, and vessels

·         Bleeding

·         Infection

·         Mesh related complication like erosion, irritations to bowels

·         Chronic pelvic pain, defecation pain

·         Herniation

Vaginal Apparoach

Vaginal sacrospinous fixation ( TVSSF)

This procedure aims at suspension of vaginal apex to the sacrospinous ligament (SSL) or the coccygeous-sacrospinous ligament that extend from the ischial spine to the lower portion of the sacrum and coccyx.

The surgeon should be aware of the close proximity of the pudendal nerve and vessels running directly posterior to the ischial spine and the sciatic nerve that runs superior and laterally to the ligament.

Procedure:

·       The patient is put in the dorsal lithotomy position. 

·       The ischial spine and sacrospinous ligament should be identified by palpation before surgery begins.

·      The apex of the vagina is grasped and fully retracted out of the vagina to evaluate the extent of the defect. Stay sutures are put to mark the apex of the vagina and then the apex is reduced to verify its relationship to the SSL. At times, the vagina is too short to reach the SSL so that the fixation is dependant on the sutures connecting the two structures (vaginal apex and SSL).

·      Cystocele repair, +/- bladder neck suspension or a sling procedure, if needed, is usually performed at this point. 

·         A midline longitudinal posterior vaginal wall incision is performed from the vaginal intoitus to 2cm caudal to the vaginal apex previously marked.

·    An enterocele sac, when present, should be dissected free from the posterior vaginal wall and reduced as discussed separately (see enterocele repair).

·       The plane between rectocele and posterior vaginal wall is developed as in any rectocele repair, this dissection is extended, however, usually on the right side of the patient, to the perirectal space. 

·       The perirectal space at the level of the ischial spine is entered by blunt and sharp dissection of the fibroareolar tissue medial to the rectum until the SSL can be palpated. 

·     The SSL is further dissected clean. Briesky-Navratil retractors (long straight retractors) are used by the assistant to allow easy approach to the deeply situated SSL and medial retraction of the rectum. A Deschamps ligature carrier and a nerve hook or a Miya hook ligature carrier are traditionally used to pass 2 sutures through the SSL 3-4 cm medial to the ischial spine, 1 cm apart. Passing the sutures more laterally can cause injury to the underlying pudendal nerve and internal pudendal vessels which course posteriorly to the ischial spine. Other commercially available kits ( Capio applicators) for passing the sutures are also available. An Allis or a Babcock clamp can be used to hold the SSL, during this sometimes difficult to perform step. 

·      The sutures are then passed through vaginal apex. A pulley stitch can be used so that the knot is buried between the vaginal wall and the SSL. 

·      The vaginal apex incision is closed. Only then, the stitches passed through the SSL and the vaginal apex are tied so that the vaginal apex is approximated to the SSL. Tying these sutures beforehand will cause difficulty in closing the vaginal apex. 

·      The posterior vaginal wall is closed as in posterior colporraphy.

·        Check cystoscopy & PR are performed to exclude any injuries to the bladder or bowels

This are two main appoach to support in my practice, there are other options like Uterosacral ligament plication and others 

 

 

 The above are perrecatal dissection & placement of sutures to SSL and vault

 Consent Has been Taken from Patient to publish this Pictures ( For Teaching Purpose)