Diagnostic Cytopathology: Something for Everyone
Moderator: Dr. Celeste N. Powers
Case 1 -
smear of a neovagina
Dr. Ed Cibas
Clinical History (provided with specimen):
35 year old woman status post hysterectomy. (Vaginal smear)
Case 1 - Slide 1
Additional Clinical History (obtained from electronic medical record):
Emigrated from Taiwan to U.S. 10 years previously.
- TAH-BSO (Canada)
- Breast implants (Florida)
- Colon reduction (Ecuador)
- Forehead reduction (Ecuador)
- "pleasant slender woman".
- labia circumferentially ulcerated
- very small vaginal introitus
- no cervix palpable
- no uterus palpated
Benign intestinal epithelium.
The findings suggest that the sample was obtained from an intestinal viscus, possibly a
smear of a neovagina
Follow-up Visit Note:
"Her vaginal vault smear came back consistent with cells of GI origin. As it turns out, Ms. X has had
a sex change, which makes all her operations and social history clearer."
She is alive and well 8 years later.
This remarkable "vaginal" smear, which showed normal colonic mucosa, was very puzzling to us at the
time we first reviewed it because we did not know that the patient was transgendered. As it turned out,
neither did her (female) physician, who was seeing her for the first time. The patient had not
volunteered this information.
In an attempt to make sense of the findings, we searched the electronic medical record for additional
clinical history. The office visit note was ultimately very helpful, although at first the mystery only
deepened. The patient had emigrated to the U.S. from Taiwan 10 years previously. Her prior surgeries
The physical examination revealed a "pleasant slender woman". Her labia was circumferentially
ulcerated, with a very small vaginal introitus. Neither cervix nor uterus was palpable.
- TAH-BSO (Canada)
- breast implants (Florida)
- colon reduction (Ecuador)
- forehead reduction (Ecuador)
Ultimately, it was the multiplicity of surgeries in this relatively young woman, particularly the
forehead reduction surgery (in South America) that suggested to us that she might be a male-to-female
transsexual. The "TAH-BSO", in this context, was a fiction created by the patient to explain the absence
of a palpable uterus or cervix.
We reported the findings as "Benign intestinal epithelium", with a note suggesting that the sample
might have been obtained from a neovagina. We telephoned the physician to convey this unusual
interpretation. The next office visit note had this statement: "Her vaginal vault smear came back
consistent with cells of GI origin. As it turns out, Ms. X has had a sex change, which makes all her
operations and social history clearer."
Cytology of The Neovagina
A neovagina can be created during male-to-female gender reassignment surgery from
squamous-lined (either genital or non-genital skin) or intestinal epithelial-lined (often sigmoid) tissue
(Karim et al).
The normal cytology of a neovagina of colonic origin has been nicely described and illustrated by
DeMay. Possible long-term complications in patients with neovaginas of colonic origin include diversion
colitis, involvement by ulcerative colitis, stenosis, diverticulitis, perforation, and malignancy
(adenocarcinoma). Not surprisingly, cytologic methods can be used to detect malignancies this setting
(Hiroi et al).
The normal cytology of neovaginas of squamous origin (commonly used in women with congenital vaginal
agenesis) has been nicely described and illustrated by Belleannee et al and Lelle et al. Cytologic
smears resemble normal vaginal smears, with normal vaginal-type flora. The degree of hyperkeratinization
can vary widely. Neovaginas of squamous origin can develop condylomata, squamous intraepithelial
lesions, squamous cell carcinoma (Harder et al), and even adenocarcinoma (Munkarah et al).
- Belleannee G, Brun JL, Trouette H et al. Cytologic findings in a neovagina created with Vecchietti's technique for treating vaginal aplasia. Acta Cytol 1998; 42: 945-8.
- DeMay RM. The Art and Science of Cytopathology. ASCP Press, Chicago, 1996, pp. 138, 170.
- Harder Y, Erni D, Banic A. Squamous cell carcinoma of the penile skin in a neovagina 20 years after male-to-female reassignment. Br J Plast Surg 2002; 55: 449-51.
- Hiroi H, Yasuga T, Matsumoto K et al. Mucinous adenocarcinoma arising in a neovagina using the sigmoid colon thirty years after operation: a case report. J Surg Oncol 2001; 77: 61-64.
- Karim RB, Hage JJ, Mulder JW. Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility. Ann Plast Surg 1996; 37: 669-675.
- Lelle RJ, Heidenreich W, Schneider J. Cytologic findings after construction of a neovagina using two surgical procedures. Surg Gynecol Obstet 1990; 170: 21-24.
- Malka D, Anquetil C, Ruszniewski P. Ulcerative colitis in a sigmoid neovagina (letter). NEJM 2000; 343:369.
- Munkarah A, Malone JM, Budev HD, Evans TN. Mucinous adenocarcinoma arising in a neovagina. Gynecol Oncol 1994; 52: 272-275.
- Schouten van der Velden AP, de Hingh Ihjt, Schijf CP, Bonenkamp HJ, Wobbes T. Metachronous colorectal malignancies: "don't forget the neovagina". A case report. Gynecol Oncol 2005; 97: 279-281.
- Steiner E, Woernle F, Kuhn W et al. Carcinoma of the neovagina: case report and review of the literature. Gynecol Oncol 2002; 84: 171-175.
- Toolenaar TAM, Freundt I, Huikeshoven FJM et al. The occurrence of diversion colitis in patients with a sigmoid neovagina. Hum Pathol 1993; 24: 846-849.