A proposed classification of vaginal anomalies and their surgical correction.

A classification of vaginal anomalies has been derived, which permits logical operative decisions. This tool allows the assignment of increasingly involved reconstructive operations to progressively more complex vaginal anatomies. The outcome of this approach in 49 vaginal reconstructions performed in 36 patients over a 25-year period has been analyzed. The cause was found to be congenital adrenal hyperplasia in 21 patients, gonadal dysgenesis in four, and cloaca in two; nine children had other causes. Based on the following anatomic classification and the authors' clinical experience, the following approaches to reconstruction can be recommended. Eight infants with labial fusion (type I) underwent simple introitoplasty. Fourteen patients with distal urogenital sinus (type II) underwent flap vaginoplasty using labioscrotal tissue and/or a posteriorly based flap. Pull-through vaginoplasty was used in 10 children with distal vaginal atresia and proximal urethrovaginal fistula (type III). Four patients with absence of the vagina (type IV) required segmental colon vaginoplasty. Thirteen revisions have been required in nine patients thus far. The follow-up period is 1 to 17 years, and despite the need for reoperation, all but two patients have excellent or satisfactory results based on anatomic and functional considerations. The choice for and timing of vaginal reconstruction rests on precise anatomic evaluation. The complexity of vaginal reconstruction in the growing child and the essentiality of psychosocial adjustment to appropriate sexual identity and function mandate long-term comprehensive follow-up. Optimal care for each patient requires experience and continuity to take the child through diagnosis, surgical reconstruction, stressful adolescence, and into adulthood with full attention to anatomic, physiological, and psychological support.