Case 1 -

Normal vaginal 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 Click to view with ImageScope Click to view with a Web-Based Viewer Additional Clinical History (obtained from electronic medical record): Emigrated from Taiwan to U.S. 10 years previously. Prior surgeries: TAH-BSO (Canada) Breast implants (Florida) Colon reduction (Ecuador) Forehead reduction (Ecuador) Physical exam: "pleasant slender woman". labia circumferentially ulcerated very small vaginal introitus no cervix palpable no uterus palpated Cytologic Diagnosis: Benign intestinal epithelium. The findings suggest that the sample was obtained from an intestinal viscus, possibly a neovagina. Diagnosis: Normal vaginal 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. Discussion: 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 included: TAH-BSO (Canada) breast implants (Florida) colon reduction (Ecuador) forehead reduction (Ecuador) 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. 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). References: 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.