infertility resulting from pelvic adhesions. In addition, every effort should be made to conserve ovarian tissue. In the presence of a malignant unilateral ovarian mass, management may include unilateral oophorectomy rather than more radical surgery, even if the ovarian tumor metastasized (see Chapter 37). Analysis of frozen sections may not be reliable. In general, conservative surgery is appropriate; further surgery can be performed, if necessary, after an adequate histologic evaluation of the ovarian tumor.
When symptoms persist in a patient with the clinical diagnosis of PID or tubo-ovarian abscess, laparoscopy should be considered to confirm the diagnosis. A clinical diagnosis may be incorrect in as many as one-third of patients (118). The surgical management of inﬂammatory masses is rarely necessary in adolescents, except to treat rupture of tuboovarian abscess or failure of medical management with broad-spectrum antibiotics (see Chapter 18). Some surgeons advocated laparoscopy to perform irrigation, lysis of adhesions, drainage of unilateral or bilateral pyosalpinx or tubo-ovarian abscess, or extirpation of significant disease (126). If surgical management is required because of failed medical therapy, conservative, unilateral adnexectomy usually can be performed in these situations, rather than a pelvic clean-out, thereby maintaining reproductive potential. Percutaneous drainage, transvaginal ultrasonographic drainage, and laparoscopic management of tubo-ovarian abscesses are being done more often, although evidence supporting this approach is sparse. As with the laparoscopic management of ovarian masses, the surgeon’s skill and experience with this procedure are critical, and prospective studies on its effectiveness are lacking (127). Laparoscopic management is associated with a risk of major complications, including bowel obstruction and bowel or vessel injury (128).
Disorders of sex development may cause genital ambiguity, typically noted at birth, although virilization may occur at puberty (29). Adolescents with gonadal dysgenesis or androgen insensitivity may have abnormal pubertal development and primary amenorrhea (see Chapters 29 and 30). Various developmental anomalies—vaginal agenesis, imperforate hymen, transverse and longitudinal vaginal septa, vaginal and uterine duplications, hymenal bands, and septa—most frequently are diagnosed in early adolescents with amenorrhea (for the obstructing abnormalities) or with concerns such as inability to use tampons (for hymenal and vaginal bands and septa). These developmental abnormalities must be evaluated carefully to determine both external and internal anatomy.
Figure 14.16 Hymenal band.
A tight hymenal ring may be discovered when the patient seeks care because of concerns about the inability to use tampons or have intercourse. Both manual dilation and small relaxing incisions at 6 o’clock and 8 o’clock in the hymenal ring can be effective. This procedure can sometimes be done in the office using local anesthesia but may require conduction or general anesthesia in the operating room. Hymenal bands are not rare and lead to difficulty in using tampons; they usually can be incised in the office using local anesthetic (Fig. 14.16). Hypertrophy of the labia minora may be considered a variant of normal, and reassurance rather than a cosmetic surgical reduction is appropriate as the primary therapy. Surgical management is described, although the procedure could be considered to be esthetic rather than medically mandated. Genital ulcerations may occur in girls with leukemia or other cancers requiring chemotherapy (129,130). Vulvar ulcerations in the absence of sexual activity or infectious etiology are described as vulvar aphthosis (46) (Fig. 14.10). The possibility of sexual abuse, incest, or involuntary intercourse should be considered for young adolescents with vulvovaginal symptoms, STDs, or pregnancy.