Comparison
The vaginal wall anatomical and histological descriptions are
well-studied, and the findings are
noncontroversial.8-17 Therefore, this type of study on
the vaginal wall was not performed in the current experimental
investigation. However, the medical literature does not describe the
vaginal outlet wall anatomy and histology. The vaginal introitus,
vaginal vestibule, and vaginal orifice are often used for the vaginal
outlet. The present cadaveric gross-topographic anatomy investigation
shows that the vaginal outlet wall is a different structure than the
vaginal wall, vaginal introitus, vaginal vestibule, or vaginal orifice
because the hymeneal ring layer (intermedial stratum) of the vaginal
outlet wall consists of a white cartilage structure Fig. 1B. The gross
vaginal anatomy consists of four walls that create a canal (the
anterior, posterior, and two lateral walls). The vaginal outlet
comprises only one circular wall surrounding the vaginal wall’s distal
edges. The anterior vaginal wall fuses with the posterior urethral wall
and the based of the urinary bladder, the vaginal outlet
anterior-superior part fuses with the inferior border of the membraneous
urethral sphincter, and the free margin of the vaginal outlet wall hangs
over the vaginal lumen. The topographical position of the vaginal wall
is in a horizontal orientation, and the vaginal outlet is in a vertical
position. The vaginal sagittal dissection reveals three vaginal layers:
the mucosa, muscular, and adventitia (surgical fascia). The sagittal
dissections of the vaginal outlet present different layers: the
membraneous soft tissue — the thin mucosa (hymeneal membrane),
flexible but rigid tissue — hymeneal ring (hymeneal cartilage), soft,
muscular, and elastic tissue — hymeneal plate.
The educational textbooks of histology and atlas also provide an
uncontroversial description of the vaginal wall mucosal epithelium,
histologically described as a stratified squamous epithelium with a
small degree of keratinization. The vaginal outlet wall membrane layer
consists of a stratified non-keratinized squamous epithelium. In the
vaginal wall below the epithelium is a thick and loosely organized layer
of dense connective tissue containing blood vessels and nerves ending.
The vaginal mucosa is thicker (up to 10-roses of the epithelium squamous
cells) than the vaginal outlet wall (3-rose). There is no corresponding
vaginal histology to the cartilage of the hymeneal ring. Documentation
The digital photographic documentation of the anatomy and
histology of the vaginal outlet wall proves that this structure is fused
with the vaginal walls; however, it is not an identical anatomical
extension of the vaginal walls. Moreover, the present study’s findings
can assist obstetricians, general practitioners, midwives, and surgeons
in better understanding this vital anatomical structure. Finally, this
study confirmed the accuracy of the existing clinical classification of
vaginal introitus.9 Future Research
The present study laid the foundation for basic and clinical research.
Determining the cartilage, type of collagens, and elastin distribution
within the vaginal outlet wall was beyond the scope of the present
investigation; therefore, it creates an additional essential medical
study option.
The current study findings showed that the vaginal outlet wall could
play a significant role in developing a new episiotomy procedure
(vaginal outlectomy) and, by doing so, eliminating the incisions of the
posterior perineal musculature postpartum posterior perineal pain.
Clinical-scientific research will answer that traditional episiotomy
techniques should be changed to a new episiotomy (vaginal outlectomy).
Future studies on a new episiotomy can revolutionize our current
obstetrical practice.
The present study suggests that superficial dyspareunia can be caused by
vaginal outlet wall stenosis or other aberrations. Additionally, vulvar
vestibulitis syndrome (vulvodynia) can be associated with the
abnormality of the vaginal outlet wall because the vaginal entry severe
pain is dominant in vulvodynia. This characteristic-induced pain
suggests that the vaginal outlet can play a significant role in
vulvodynia and superficial dyspareunia, and vaginal wall prolapse,
Fig. 3A and Fig. 3C. Conclusion
The vaginal outlet wall is an anatomical structure that consists of the
hymeneal membrane, hymeneal ring (cartilage), and hymeneal plate. This
structure is in vertical topographic orientation. Anatomically and
histologically, it differs from the vaginal wall, which fuses with the
deep layer-hymeneal plate.