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PubMed1999

Endoscopic management of a case of complete septate uterus with unilateral pyometra.

We report a case with an unusual müllerian anomaly: complete uterine septum and pyometra in the right hemicavity and pyocolpos along with a longitudinal vaginal septum. A patient with recurrent low-grade fever and lower abdominal pain was admitted. Pyometra and pyocolpos were detected in the right uterine hemicavity and in the right hemivagina. The septa were resected, the cavities were irrigated, and the patient was treated with antibiotics. The patient conceived 8 months later. Patients with abnormal vaginal findings should be approached with caution; precise knowledge of urogenital anatomy and urogenital anomalies is necessary in the management of these patients.

Abdominal Pain↗
PubMed1992

Clinical pharmacokinetics of metronidazole and other nitroimidazole anti-infectives.

Metronidazole was first introduced for the treatment of trichomoniasis. Its therapeutic use has subsequently been expanded to include amoebiasis, giardiasis and, more recently, anaerobic infections. Most of the early pharmacokinetic studies employed nonspecific assays such as microbiological and chemical assays. These assays were not able to differentiate the parent drug from the metabolites or other interfering substances. Pharmacokinetic data obtained through the use of specific chromatographic techniques provide the basis for this review of recent pharmacokinetic findings concerning metronidazole and other nitroimidazole antibiotics. When given intravenously or orally at usual recommended doses, metronidazole attains concentrations well above the minimum inhibitory concentrations for most susceptible micro-organisms. The drug has an oral bioavailability approaching 100%. Rectal and vaginal administration results in a smaller amount of drug absorption and lower serum concentrations. Metronidazole has limited plasma protein binding but can attain very favourable tissue distribution, including into the central nervous system. The drug is extensively metabolised by the liver to form 2 primary oxidative metabolites: the hydroxy and acetic acid metabolites. The kidney is responsible for the elimination of only a small amount of the parent drug; however, normal excretion of the 2 metabolites is dependent on the integrity of kidney function. The metabolism of metronidazole was found to vary among patient groups. Preterm and term infants have lower total body clearance (CL) and prolonged elimination half-lives. However, children older than 4 years old were observed to have pharmacokinetic parameters similar to those in adults. Reduced CL was also observed in children who are malnourished. Elderly patients have reduced renal excretion of both the parent drug and hydroxy metabolite. Pharmacokinetic parameters in pregnant patients were not significantly different from those in nonpregnant women; however, the drug is distributed into breastmilk and the infant will be exposed to the drug through the nursing mother. Patients undergoing gastrointestinal surgery or having enteric diseases and those who are hospitalised or critically ill also have altered pharmacokinetics. Metabolism of the drug is reduced in patients with liver dysfunction, giving delayed production of metabolites. In contrast, renal failure has little effect on the elimination of the parent drug, but affects the excretion of the metabolites more significantly. Haemodialysis was found to remove a substantial amount of the metronidazole while the effect of peritoneal dialysis was more limited. Energy and protein deficient diets as well as occupational exposure to gasoline did not alter metronidazole pharmacokinetics. However, the effect of alcohol consumption on metronidazole CL requires further study.(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗
PubMed2001

[A new approach in techniques to treat urinary incontinence: TVT (tension free vaginal tape)].

The indications and the surgical technique of a newly developed operation for the correction of female urinary incontinence (the Tension free Vaginal Tape) are described. This technique is based on a new etiological concept of urinary incontinence and ensures the patient a reduced morbidity (local or regional anaesthesia) and hospital stay (theoretically adapted for a one day clinic). Mid-term results (84% success rate after a median follow up of 3 years) are promising but must be confirmed at the long term. We relate our experience of 30 cases with a success rate of 93% but entached with a high rate of postoperatory urinary urgency. This leads us to emphasise a strict adherence to the indications and an absolute respect of the technique as originally described.

Adult↗
PubMed1991

[Gynecologic urology].

Urinary incontinence, urge symptoms and repeated urinary tract infections are among the most frequent ailments seen in women. Usually, they are easily diagnosed and treated effectively using conservative means. If this treatment fails, a urodynamic investigation should be performed. This includes urethrocystometry and a lateral urethrocystography. The diagnosis made through urodynamic exploration leads to a specific treatment, which usually means, in the case of stress urinary incontinence, a surgical procedure. Subsequently, based on our observations and experiences through urodynamic testing and postoperative follow-ups, we present a concept for the treatment of stress urinary incontinence. Furthermore, the benefits and risks of various vaginal and abdominal surgical approaches, as well as some specific modifications, have been evaluated.

Combined Modality Therapy↗
PubMed1990

Diagnostic and therapeutic technology assessment. Chorionic villus sampling: a reassessment.

The Canadian and National Institute of Child Health and Human Development trials as well as other nonrandomized studies indicate that CVS is both safe and effective. Fetal loss rates have been slightly higher with CVS (6 to 8 more losses per 1000 procedures), but none of these results were statistically significant. Chorionic villus sampling also probably has a slightly higher procedure failure rate than amniocentesis. The DATTA panelists are now confident that the safety of CVS approaches that of amniocentesis and that the higher procedure failure rate is offset by the opportunity of earlier diagnosis with CVS. Transcervical CVS is often preferred by women because it offers an opportunity for early prenatal diagnosis and early intervention if necessary. It is performed as an outpatient procedure and is relatively simple for the patient; however, the practitioner requires special training in CVS. Modifications of the sampling technique are also under investigation. Transabdominal CVS can also be performed early in pregnancy with a fine-bore needle under ultrasonic guidance. It may be used in cases where the placenta is inaccessible to the transcervical approach or there is vaginal infection.

Canada↗
PubMed2006

Concomitant radiotherapy and hyperthermia for primary carcinoma of the vagina: a cohort study.

OBJECTIVE: To evaluate the supplementary value of adding hyperthermia to radiotherapy in patients with primary vaginal cancer. STUDY DESIGN: Cohort of 44 patients diagnosed with primary vaginal cancer between 1990 and 2002 was assessed. Survival rates and median survival of patients with primary vaginal cancer undergoing radiotherapy with and without hyperthermia were compared. Hyperthermia was solely added to radiotherapy in case of a tumor size >4 cm in diameter for FIGO stage III disease. RESULTS: The calculated overall 5-year survival of primary vaginal cancer was 63%. In comparison to histologic high grade tumors, higher survival rates for histologic low grade tumors were calculated. For FIGO stage III of disease, the addition of hyperthermia to radiotherapy for tumors >4 cm in diameter resulted similar survival rates and median survival when compared to those achieved by radiotherapy as monotherapy in tumors of <4 cm in diameter. CONCLUSIONS: The addition of hyperthermia to radiotherapy might result in better survival rates in primary vaginal cancer for tumors >4 cm in diameter. The supplementary effect of hyperthermia to radiotherapy may be a feasible and beneficial approach in the treatment of vaginal cancer.

Adult↗
PubMed2003

[Laparoscopic-vaginal radical hysterectomy in surgical treatment of cervical cancer].

Radical vaginal hysterectomy has been performed in surgical treatment of cervical cancer for over one hundred years. After the term of decrease of popularity of this operation, nowadays we can observe gradual come back to the idea of radical vaginal hysterectomy. Possibility of association of advanced laparoscopic techniques/lymphadenectomy/with vaginal operation have changed the approach to the surgical treatment of cervical cancer. The aim of the study is to present the method of laparoscopic-vaginal radical hysterectomy based on Schauta-Amreich technique. The 51 year old women was admitted to the hospital and cervical cancer FIGO stage IIA was diagnosed according to clinical and histopathological examination. We performed laparoscopic-vaginal radical hysterectomy in general anaesthesia. First after cutting of ligamentum teres uteri and infundibulo-pelvicum, laparoscopic pelvic lymphadenectomy was done. Subsequently vaginal stage of operation was performed. Then we did laparoscopy and controlled operation field again. Combining Schauta operation with laparoscopy allows us to estimate lymph nodes as well as make vaginal phase of operation easier because of mobilization of uterus. We consider that laparoscopic-vaginal radical hysterectomy could be a valuable element in broadening the spectrum of many kinds of operations used in treatment of cervical cancer.

Carcinoma, Squamous Cell↗
PubMed2005

[The surgical treatment of severely injured vagina].

OBJECTIVE: To investigate the surgical methods of treating severely injured vagina. METHODS: A retrospective study was carried out on the clinical materials and results of 7 patients suffered from severe vaginal injury. RESULTS: Different surgical approaches such as trans-suprapubic, transperineal or both approaches were applied according to the position of the atresia, meanwhile, different surgical methods such as skin graft, free flap transplantation, vaginal mucous flap advancement, direct anastomosis of the two ends, "Z" plasty was used to repair the vagina according to the different defect of the vagina, except for 1 case complicated with vaginorectus fistula, all the other cases were achieved satisfactory results. CONCLUSIONS: The accurate judgment of the severity of the vaginal injury and the understanding of the changed anatomy around the injured vagina was the key points to the success of the surgical treatment of traumatic vaginal atresia.

Female↗
PubMed1993

Development of vaginal adenosis following combined 5-fluorouracil and carbon dioxide laser treatments for diffuse vaginal condylomatosis.

BACKGROUND: The management of vaginal human papillomavirus (HPV) lesions may be difficult. We report an unusual long-term consequence of treatment. CASE: A 40-year-old woman presented with vaginal adenosis following treatment of multiple vaginal condylomata by endovaginal applications of 5% 5-fluorouracil cream and vaporization of the remaining subclinical condylomata by CO2 laser. CONCLUSION: The approach to the management of vaginal condylomatosis should take into consideration the possible later occurrence of adenosis.

Adult↗
PubMed2004

Vaginal rings for menopausal symptom relief.

The vagina is an alternative delivery site of sex steroids for menopausal women. New ring technology provides continuous and consistent delivery of steroids for up to 3 months. Rings rest on the pelvic floor muscles in a nearly horizontal position and are usually imperceptible. Steroid is delivered directly into the systemic circulation which may result in less alteration of coagulation/fibrinolysis pathways as seen with transdermal hormone therapy. Fewer adverse effects are noted when progesterone is applied vaginally, possibly due to lower serum levels of metabolites such as alloprenanolone. Women often switch to a ring for the longer dosing interval but also appreciate the reduced messiness. Over 5700 healthy US women who evaluated an unmedicated ring as a drug delivery platform found it very acceptable independent of age or prior use of barrier contraceptives. Marketed rings in the US include: (i) a ring for systemic and vaginal menopausal therapy that provides average serum estradiol levels of 40.6 pg/mL for the 0.05 mg and 76 pg/mL for the 0.1 mg dose; (ii) a ring for urogenital menopausal symptoms only that minimally elevates serum estradiol, usually within the menopausal range, treating atrophic vaginitis and urethritis; and (iii) a ring labelled for contraception that provides ethinyl estradiol 15 microg and etonogestrel 120 microg appropriate for nonsmoking perimenopausal women. A ring for combination hormone therapy and another releasing progesterone for contraception in lactating women have been reported in the literature, but are not yet available commercially. These may offer future options for hormone therapy. Women with a uterus receiving estrogen, even in low doses, should be given progestogen to prevent endometrial hyperplasia or carcinoma. Even women who have had an endometrial ablation are likely to have some endometrial tissue remaining since long-term amenorrhoea is uncommon. Since no marketed combination ring product is available, other forms of progestogen are necessary. Vaginal rings offer a novel approach to menopausal hormone therapy producing consistent serum levels sustained for up to 3 months per unit dose with lower adverse effects than other vaginal products and high acceptability among users.

Administration, Intravaginal↗
PubMed1996

[Vaginal and abdominal hysterectomy: comparison and perspectives. Apropos of 385 consecutive cases].

Hysterectomy is the most common non-pregnancy related surgical procedure. However, given the lack of final guidelines on indications, alternative therapies, surgical approach and outcomes, it is desirable to keep its use under constant monitoring. We reviewed 385 hysterectomies for benign conditions-divided according to surgical approach-performed in the Gynaecological Department of San Daniele del Friuli (Udine-Italy) in 1991-1993, and with one-year follow-up. Traditional approaches, i.e. abdominal (39.2%) and vaginal (60.2%), were used. Colporraphy was performed in 79 cases (33.8% of vaginal hysterectomies); 73.4% of colporraphies were followed by urethral suspension. We reviewed population's patterns, indications and surgical outcomes according to Dicker's suggestions. Vaginal hysterectomy with associated colporraphy concerned a population of patients with average age and parity significantly different from patients who underwent simple vaginal or abdominal hysterectomy. These last two groups, on the other hand, have similar characteristics making them comparable. In abdominal hysterectomy and simple vaginal hysterectomy we reported a complication rate respectively of 21.9% and 7.1%. The advantages of simple vaginal hysterectomy include shorter operating time, reduction in antibiotic drugs usage, earlier hospital discharge and quicker recovery, with obvious cost saving. Our experience therefore supports the view that the balance between abdominal and vaginal hysterectomy could safely be shifted in favour of the last one, the advantages of which could then be made available to a larger number of patients.

Abdomen↗
PubMedDate not supplied

Abdominal versus vaginal hysterectomy: a statistical model for determining physician decision making and patient outcome.

To identify the effects of preoperative assessment and physician practice style on the outcomes of hysterectomy, the authors conducted a small-area analysis of 640 women under-going abdominal or vaginal hysterectomy in a St. Louis, Missouri, hospital. Of these patients, excluding outliers, 115 met the conditions for inclusion in the study. Hysterectomies were performed by the abdominal route in 55 (47.8%) and by the vaginal route in 60 (52.2%) of the 115 patients. A total of 29 physicians performed the hysterectomies. Of these 29, 15 (51.7%) were predisposed toward the abdominal approach, 13 (44.8%) had no appreciable predisposition, and one (3.5%) was predisposed toward the vaginal procedure. Path analysis revealed that physician decision making about the type of hysterectomy procedure performed was primarily influenced by practice style (predisposition) and variables related to physician preoperative assessments (uterine size and uterine mobility), some of which are prone to inaccuracy. Factors that traditionally determine operative approach (such as obesity) did not always act in the expected direction. Furthermore, the decision to perform hysterectomy vaginally had positive outcomes for both cost and length of hospital stay. Shorter hospital stays were associated with physician factors that included selection of the vaginal route, training site, predisposition toward the vaginal procedure, and preoperative assessment of uterine size. Length of hospital stay and duration of surgery were the strongest predictors of cost. Other factors being equal, the mean cost of a vaginal procedure is $224 less than that of an abdominal hysterectomy. Establishing the vaginal approach as the recommended procedure for this specific population should result in cost reductions and shorter hospital stays without negatively impacting quality of care.

Costs and Cost Analysis↗
PubMed1991

Vulvar vestibulitis syndrome: an overview.

Vulvar vestibulitis syndrome is a constellation of symptoms and findings involving and limited to the vulvar vestibule that consists of: (1) severe pain on vestibular touch to attempted vaginal entry, (2) tenderness to pressure localized within the vulvar vestibule, and (3) physical findings confined to vulvar erythema of various degrees. Histopathologic findings are consistent with a chronic, nonspecific inflammatory response that is occasionally associated with metaplasia of the minor vestibular glands. The cause is likely multifactorial, and to date the syndrome has been seen in association with subclinical human papillomavirus, chronic recurrent candidiasis, chronic recurrent bacterial vaginosis, chronic alteration of vaginal pH, and the use of chemical and destructive therapeutic agents. Therapy is directed at elimination of these symptoms. When symptoms are unrelieved, a surgical approach consisting of vestibulectomy with vaginal advancement has a high rate of success.

Chronic Disease↗
PubMed1988

[Treatment and prevention of urinary stress incontinence by the Bologna procedure in prolapse with large cystocele. Surgical technic].

Bologna's procedure allows the curative or preventive treatment for urinary stress incontinence during surgical cure of prolapse with large cystocele (2nd or 3rd degree). An infra-cervical sling is created with 2 vaginal bands dissected from the anterior colpocele, passed through the retropubic space on either side of the bladder neck and fixed to the abdominal wall, after making a suprapubic approach to the aponeurosis of the rectus abdominis muscle. This colposuspension technique, performed via a mixed approach, is generally accompanied by vaginal hysterectomy and colpectomy designed to treat the various elements of the prolapse. This operation is easily reproducible and the postoperative course is generally uneventful. The intermediate term anatomical and functional results are very satisfactory in women over the age of 60 years. There is not sufficient follow-up at the present time to consider this procedure for young women.

Aged↗
PubMed1994

[Delivery conduction in patients with cicatrix of a prior cesarean section. Pilot study].

INTRODUCTION: In the clinical practice there is an increasing number of patients with a previous cesarean section. OBJECTIVE: 1. The description of the evolution of patients with previous cesarean section and the possibility of a vaginal delivery. 2. To compare, in patients in labor, a pharmacological approach (ocitocic conduction and peridural anesthesia) vs a spontaneous evolution. METHOD: -a clinical, random and prospective study. We analyze: age, parity, cause of previous cesarean section, obstetrical conditions at the moment of hospitalization, route of delivery, maternal and neonatal complications and days of hospitalization. ANALYSIS: univariable with single frequency and bivariable with contingency table (chi2) and comparison of means (T test). RESULTS: Incoming to the study of 81 cases. Sixteen per cent were operated on without labor. Eighty four per cent (n-68) were separated randomly into two groups: 26 pharmacologically managed and 42, with a spontaneous approach. Within the first group, 84.6% delivered vaginally; the latter group, 88.1%, delivered vaginally. The only variable with a statistically significant difference was the greater cervical dilatation in the spontaneous grop at the moment of hospitalization. CONCLUSION: The probability of vaginal birth after cesarean section is 72.8%, which increases to 86.7% in labor spontaneously initialized. The active management doesn't differ in this study, which has a 10% of power, of spontaneously management.

Adult↗
PubMed2005

SOGC clinical practice guidelines. The detection and management of vaginal atrophy. Number 145, May 2004.

OBJECTIVE: To support the practitioner in the diagnosis of vaginal atrophy and in the management of the related symptoms. OPTIONS: The modalities of evaluation range from basic pelvic examination, examination of the vulva, and laboratory tests. OUTCOMES: A comprehensive approach to the detection of vaginal atrophy and a discussion of available therapeutic and nontherapeutic options. EVIDENCE: Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. VALUES: The quality of the Force on the Periodic Health Examination. BENEFITS, HARMS AND COSTS: Diagnosis of vaginal atrophy is often a challenge because women are unwilling to report symptoms, which have the potential to significantly decrease their quality of life. Increased clinical suspicion is the first step in the diagnosis of vaginal atrophy, which will prompt the initiation of safe therapies with proven efficacy. RECOMMENDATIONS: (1) Health-care providers should routinely assess postmenopausal women for the symptoms and signs of vaginal atrophy, a common condition that exerts significant negative effects on quality of life. (III-C) (2) Regular sexual activity should be encouraged to maintain vaginal health. (II-2B) (3) Women experiencing recurrent urinary tract infections should be instructed that consumption of pure cranberry-lingonberry juice, rather than cranberry drink, will decrease their risk of urinary infections. (I-A) (4) Vaginal moisturizers applied on a regular basis have an efficacy equivalent to local hormone replacement for the treatment of local urogenital symptoms such as vaginal itching, irritation, and dyspareunia, and should be offered to women wishing to avoid the use of hormone replacement therapy. (I-A) (5) Women experiencing vaginal atrophy can be offered any of the following effective vaginal estrogen replacement therapies: conjugated equine estrogen (CEE) cream (I-A), a sustained-release intravaginal estradiol ring (I-A), or a low-dose estradiol tablet. (I-A) (6) Although systematic absorption of estrogen can occur with local preparations, there is insufficient data to recommend annual endometrial surveillance in asymptomatic women using local estrogens. (III-C) (7) For menopausal women experiencing recurrent urinary tract infections and who have no contraindication to local hormone replacement, vaginal estrogen therapy should be offered. (I-A) VALIDATION: These guidelines have been reviewed by the joint committee of Clinical Practice Gynaecology and Urogynaecology and approved by the Execute and Council of the Society of Obstetricians and Gynaecologists of Canada. SPONSOR: The Society of Obstetricians and Gynaecologists of Canada.

Aging↗
PubMed2004

The detection and management of vaginal atrophy.

OBJECTIVE: To support the practitioner in the diagnosis of vaginal atrophy and in the management of the related symptoms. OPTIONS: The modalities of evaluation range from basic pelvic examination, examination of the vulva, and laboratory tests. OUTCOMES: A comprehensive approach to the detection of vaginal atrophy and a discussion of available therapeutic and nontherapeutic options. EVIDENCE: Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Diagnosis of vaginal atrophy is often a challenge because women are unwilling to report symptoms, which have the potential to significantly decrease their quality of life. Increased clinical suspicion is the first step in the diagnosis of vaginal atrophy, which will prompt the initiation of safe therapies with proven efficacy. RECOMMENDATIONS: 1. Health-care providers should routinely assess postmenopausal women for the symptoms and signs of vaginal atrophy, a common condition that exerts significant negative effects on quality of life. (III-C) 2. Regular sexual activity should be encouraged to maintain vaginal health. (II-2B)3. Women experiencing recurrent urinary tract infections should be instructed that consumption of pure cranberry-lingonberry juice, rather than cranberry drink, will decrease their risk of urinary tract infections. (I-A) 4. Vaginal moisturizers applied on a regular basis have an efficacy equivalent to local hormone replacement for the treatment of local urogenital symptoms such as vaginal itching, irritation, and dyspareunia, and should be offered to women wishing to avoid use of hormone replacement therapy. (I-A) 5. Women experiencing vaginal atrophy can be offered any of the following effective vaginal estrogen replacement therapies: conjugated equine estrogen cream (I-A), a sustained-release intravaginal estradiol ring (I-A), or a low-dose estradiol tablet (I-A). 6. Although systemic absorption of estrogen can occur with local preparations, there is insufficient data to recommend annual endometrial surveillance in asymptomatic women using local estrogens. (III-C) 7. For menopausal women experiencing recurrent urinary tract infections and who have no contraindication to local hormone replacement, vaginal estrogen therapy should be offered. (I-A).

Administration, Intravaginal↗
PubMed1988

Vaginitis: a common malady.

Approximately 90 per cent of all the vaginitides are caused by bacterial vaginosis, candidiasis, or trichomoniasis. Bacterial vaginosis is the most frequent, causing approximately 50 per cent of vaginal infections. As described by Amsel and colleagues, three of four findings indicate bacterial vaginosis: amine odor, pH greater than 4.5, clue cells, and a thin homogeneous discharge. Because G. vaginalis colonizes the vagina, treatment should not be instituted in an asymptomatic woman on the basis of a positive culture. For symptomatic patients, oral metronidazole 500 mg twice daily for 7 days is the treatment currently recommended. Vulvovaginal pruritus should be equated with candidiasis until proven otherwise. Mycelia or spores on 10 per cent KOH preparation are diagnostic of candidiasis in the presence of symptoms. Imidazole creams or suppositories are the treatment of choice. Trichomoniasis is characterized by malodor and mild pruritus. Demonstration of trichomonads on saline preparation or a positive culture provides the diagnosis. A single 2 gm dose of oral metronidazole is the initial treatment. Recurrences should provoke inquiry regarding predisposing factors and investigation of sexual partners. Vaginitis can recur, but if approached properly, these recurrences can be minimized, allowing the patient to proceed with daily life in comfort.

Candidiasis, Vulvovaginal↗