Gynecologic concerns in the treatment of teenagers with cloaca
Journal of Pediatric Surgery
Hematocolpos; Hematometra; Hematosalpinx; Hemiuterus; Menstruation; Persistent cloaca; Puberty; Vaginal replacement
Background/Purpose: Gynecologic anomalies are common in patients with persistent cloaca, but, except for hydrocolpos, these patients remain asymptomatic in the neonatal period. Anatomic abnormalities may become manifest in puberty when menses occurs. The authors sought to describe the sequelae of these anatomic defects in the teenage cloaca patient and to determine recommendations for prevention and treatment in the neonatal period. Methods: From a series of 198 patients operated on for persistent cloaca, the authors report a group of 22 patients who have reached puberty. Results: Seven patients are menstruating normally. Six patients have primary amenorrhea because of absent or atretic uteri. Nine patients presented with abdominal pain and cystic abdominal masses and required surgical resection of inflamed collections of old blood in uteri, hemiuteri, tubes, blind vaginas, hemivaginas, or in the peritoneum. The common denominator of this last group was an obstruction of one or more Mullerian structure that interfered with the drainage of menstrual blood. Asymmetric gynecologic anatomy or a vaginal atresia in the neonatal period seemed to correlate with future obstruction to menstrual flow. Conclusions: To prevent future problems, the management of the neonatal cloaca must include the early clarification of the gynecologic anatomy, specifically the patency of Mullerian structures. Unilateral atretic structures and tubes connected to atretic uteri should be resected. Also, clinicians must be suspicious of menstrual problems in teenagers operated on early in life for persistent cloaca.