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Here in this study, clinical findings like high up uterus on vaginal examination were found in 242 cases of which some form of endometriosis was found in 156 cases(65%). Among suspected cases of endometriosis following vaginal sonography, 149(61.5%) could be confirmed in laparoscopy. When these two processes considered together confirmation rate went up to 72.7%.
Laparoscopic hysterectomy and pelvic floor reconstruction have recently undergone some degree of evolution. New instrumentation has appeared, such as the vaginal delineator, but overall most of the instruments used have remained basically unchanged. This is related mostly to the need of keeping costs down by limiting the use of disposable instrumentation. For pelvic reconstruction, the laparoscopic approach is now usually considered the optimal approach, as it allows the surgeon to visualize structures that the vaginal surgeon could in the past only palpate.
Lactobacilli play an important role in maintaining the vaginal health of women. The development of suitable bacterial replacement therapies for the treatment of vaginosis requires knowledge of the vaginal lactobacilli species representation. The aim of this study was to identify at the species level vaginal Lactobacillus isolates obtained from Bulgarian women in childbearing age by using different molecular methods. Twenty-two strains of lactobacilli isolated from vaginal samples were identified and grouped according to their genetic relatedness. A combined approach, which included amplified ribosomal DNA restriction analysis (ARDRA), ribotyping and polymerase chain reaction (PCR) with species-specific oligonucleotide primers was applied. All vaginal isolates were grouped into 5 clusters in comparison with a set of 21 reference strains based on the initial ARDRA results, which was then confirmed by ribotyping. Finally, the strains were subjected to PCR analysis with eight different species-specific primer pairs, which allowed most of them to be classified as belonging to one of the following species: Lactobacillus crispatus, Lactobacillus fermentum, Lactobacillus gasseri, Lactobacillus helveticus and Lactobacillus plantarum. In conclusion, this study suggests that the most straightforward identification strategy for vaginal lactobacilli would be grouping by ARDRA or ribotyping, followed by PCR specific primers identification at species level.
Forensic Y-chromosome typing applies Y-chromosomal polymorphisms to the analysis of male/female mixed stains such as vaginal swabs in rape cases. The sensitivity of this approach exceeds that of cytological techniques combined with autosomal DNA typing. Y-chromosome typing is based on the assumption that Y-chromosomal DNA found in tissue or secretions of women must originate from a male individual, usually the perpetrator. Nevertheless, it was shown recently that fetal cells can migrate into the female body during pregnancy and can persist for decades ("persisting fetal microchimerism"). The body of a woman after a pregnancy with a male embryo can thus display a small fraction of fetal cells with Y-chromosomes. Using high sensitivity PCR protocols (reamplification with nested primers and up to 60 PCR cycles) fetal cells were previously identified in a number of maternal tissues including skin, blood, muscle and solid organs. It is, however, not clear at present, whether these cells can occur in vaginal secretions, and whether they are capable of producing false positive results in forensic Y-chromosome typing. To evaluate these questions, 66 blood samples of women with at least one son and nine vaginal swabs of women without sexual intercourse in the last 2 weeks were amplified for a stretch of the SRY gene. Eight thyroid gland tissues with already established male fetal microchimerism were used as positive control samples. Blood samples of 10 young girls without history of pregnancy were used as negative controls. Using a PCR with 10 ng of extracted DNA and 30 PCR cycles ("routine sensitivity assay") none of the samples yielded positive results. However, in a PCR with 200 ng of extracted DNA and 45 PCR cycles ("high sensibility assay"), 14% of the blood samples of mothers and 33% of the vaginal swabs amplified for SRY. Our results thus show that increasing the sensitivity of the PCR method and the amount of template DNA produce positive results while protocols used for routine Y-chromosomal typing with small amounts of DNA (approximately 10 ng of DNA) and with a limited number of PCR cycles (approximately 30) can clearly eliminate this peril.
For any clinician involved in the health care of women, vaginitis remains an unavoidable problem. Vaginitis accounts for an estimated 10 million office visits each year, and it remains the most common reason for patient visits to obstetrician-gynecologists. Despite extensive self-diagnosis and self-treatment for vaginal symptoms in all age groups, important questions persist about the accuracy of such an approach. This article addresses these questions and approaches.
OBJECTIVE: Evaluation of the suitability of total laparoscopic hysterectomy as an adjunctive procedure in the female-to-male transsexual reassignment surgery. Surgical reassignment surgery in the transsexual is not a frequent procedure. The expertise of an gynaecologist in the treatment of the syndrome is necessary as well as the input of other specialists such as psychiatrists, psychologists, plastic and reconstructive surgeons and urologists. The gynaecological surgeon usually performs the hysterectomy and in some cases also colpectomy. SUBJECT: Case report. METHODS: The authors analyse their own surgical experience with the above mentioned syndrom in the patient in whom the surgical reconstruction took place in two phases. In the first phase the Total Laparoscopic Hysterectomy with Bilateral Salpingo Ophorectomy (TLH, BSO) was performed. Of note is that this procedure was chosen due to extremely narrow vaginal canal with no uterine descent. For the second phase of the surgery the patient was referred to the urological surgeon. RESULTS: The duration of the surgery was 54 minutes, the blood loss was not measurable. We have not encountered any per- and postoperative complications and the patient was discharged after 48 hours. CONCLUSION: We conclude that the TLH/BSO approach has enabled to us to preserve the vital structures needed for reconstruction of external genitalia, e.g. inferior epigastric vessels and rectus muscles were not disturbed. This approach is complex and has clear advantages in comparison to vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy or even total abdominal hysterectomy. It does guarantee a smooth removal of both ovaries and it is not dependent on the size of the vagina or uterine descent.
OBJECTIVE: To investigate noninfective, symptomatic, chronic inflammation (CI) of the vaginal mucosa to determine its prevalence and immunologic basis and to initiate an immunologic approach to treatment and assess the response. STUDY DESIGN: A prospective, observational, clinical study of 55 women with dyspareunia and/or discharge of vaginal mucosal origin. Vaginal biopsies and immune investigations were carried out. Treatment was instituted utilizing immune-modifying agents. RESULTS: The prevalence of CI of the vagina in symptom-free women was 0-4.3% and in the symptomatic group, 89%. Systemic immune activation was demonstrated in 43 of the 55, with 21 suffering from an autoimmune disease or a condition in which immune activation plays a part, including endometriosis in 20. Thirty-one were treated; intravaginal hydrocortisone acetate 10% foam was given in 24, giving full relief in 14 and inadequate relief in 10. Hydroxychloroquine, an immune-modifying, antirheumatic drug, was added and largely gave relief in these 10. Hydroxychloroquine alone was given in 4 and was effective in 3. Overall, immune-modifying drugs were successful in 97%. CONCLUSION: CI of the vaginal mucosa stems from local immune activation and is generally associated with evidence of other immune abnormalities, including autoimmune diseases and disorders in which immune activation play a part, including endometriosis. It can be successfully treated by immune modification.
This study adds up to the series of studies on application of factorial designs to analysis of cancer patients medical data. Namely, besides the information regarding his/her disease, each hospitalized cancer patient also provides the variety of data regarding his/her psychological, cultural, social, economical, genetic, constitutional and medical background. The aim of this particular study was to analyze clinical data in patients with primary and metastatic vaginal cancer and to compare them with the results of factor analytic approach in some other gynecological cancers, namely vulvar and cervical cancer. In this particular study the authors have processed the data regarding 25 characteristics of 200 consecutive patients with primary vaginal cancer and 300 consecutive patients with metastatic vaginal cancer treated between 1980 and 1994 at the Department for Gynecological Oncology of the University Hospital for Gynecology and Obstetrics, Zagreb, Croatia. The results revealed numerous repeating clusters of variable correlations across all four factor analyses in patients with cervical, vulvar, primary and metastatic vaginal cancers.
Vaginal agenesis is sometimes found isolated but more frequently as a part of a malformative syndrome, such as the Rokitansky-Küster-Hauser or the Morris syndrome. In our department the technique of choice for surgical creation of a neovagina is that described by Vecchietti. A pelviscopic approach for this technique has recently been described. Two cases of vaginal atresia are described; one with Rokitansky-Küster-Hauser and the other with Morris syndrome, in which the laparoscopic technique was attempted. Due to the aetiopathogenetic and anatomical differences of the two syndromes, the laparoscopic technique resulted easy in the first case but very difficult in the Morris syndrome case, needing laparotomic conversion. We therefore believe that in choosing the surgical approach, a decisive issue is the type of malformation. Indeed in the Morris syndrome, the contiguity between rectum and bladder makes the laparoscopic technique more difficult.
OBJECTIVES: To assess the number of major surgical procedures in gynaecology over a period of eight years in The Netherlands and to detect possible trends. Relevance of the trends and the possible impact on surgical skills and on innovative ability are discussed. DESIGN: Observational study. SETTING: Hospital care in The Netherlands. SAMPLE: Data from a national hospital discharge database, from all 119 hospitals in The Netherlands. METHODS: When a patient is discharged from the hospital. data on the diagnosis and treatment are registered by local medical officers and administrators. Registration of surgical procedures is based on the International Classification of Procedures in Medicine (ICPM, WHO 1978), the so-called WCC-standard. All hospitals but one (a cancer centre) in The Netherlands participate in this registration, resulting in 99.3% of all admissions. Data on gynaccological manpower were obtained from the Dutch College of Obstetricians and Gynaecologists. In order to standardise the frequency numbers per 1,000 women, yearly data of the female population according to age were obtained from the Central Office for Population Statistics. RESULTS: The female population aged 20 years of age and older increased 3% between 1991 and 1998, from 5.8 million to 6.0 million. In the same period the number of gynaecologists grew from 604 to 625, also an increase of 3%. The total number of hysterectomies dropped from 21,433 in 1991 to 16,320 (-24 %) in 1998 (chi2 for trend 1,245.1. P < 0.001) Surgery of the uterine cavity, either performed hysteroscopically or blind, increased from 311 to 1,958 (+ 625%) cases per year (chi2 for trend 2,459.2, P < 0.001). No trend has been detected in the numbers of adnexal operations, including surgical treatment of tubal pregnancy (tubotomy or tubectomy). In 1998, 12% of all ovarian surgery and 28% of all surgery for ectopic pregnancies was performed laparoscopically. Surgery for female urinary incontinence experienced a strong decline of 46% in the studied period. The frequency of vaginal repair decreased with 1354 (-16%) cases. The abdominal prolapse surgery (abdominal sacral colpopexy, obliteration of the Douglas pouch) is steadily increasing, although the absolute numbers are small. In 1998 seven hundred and forty-three women underwent an abdominal approach of their prolapse repair, compared with 7239 that had the vaginal repair. CONCLUSIONS: The declining trend of major gynaecological surgery in combination with the increasing number of gynaecologists will result in more difficulty for gynaecologists to acquire and maintain surgical skills and may therefore affect their ability to innovate within the surgical profession.
OBJECTIVE: The aim of the study was to evaluate the effectiveness of perineal massage during pregnancy for the prevention of perineal trauma at birth. STUDY DESIGN: Pregnant women with (n = 493) and without (n = 1034) a previous vaginal birth from 5 hospitals in the province of Québec, Canada, participated in this single-blind, randomized, controlled trial. All participants received oral and written information on the prevention of perineal trauma. Women in the experimental groups were requested to perform a 10-minute perineal massage daily from the 34th or 35th week of pregnancy until delivery. RESULTS: Among participants without a previous vaginal birth, 24.3% (100/411) from the perineal massage group and 15.1% (63/417) from the control group were delivered vaginally with an intact perineum, for a 9.2% absolute difference (95% confidence interval 3.8%-14.6%). The incidence of delivery with an intact perineum increased with compliance with regular practice of perineal massage (chi2 for trend 13.2, P = 0.0003). Among women with a previous vaginal birth, 34.9% (82/235) and 32.4% (78/241) in the massage and control groups, respectively, were delivered with an intact perineum, for an absolute difference of 2.5% (95% confidence interval -6.0% to 11.0%). There were no differences between the groups in the frequency of sutured vulvar and vaginal tears, women's sense of control, and satisfaction with the delivery experience. CONCLUSION: Perineal massage is an effective approach to increasing the chance of delivery with an intact perineum for women with a first vaginal delivery but not for women with a previous vaginal birth.
Tubular duplication of the recto-sigmoid colon is a rare entity. Associated anomalies including fistulae to the genitourinary tract may be found. A baby girl was found to have duplication of the recto-sigmoid colon, anomalies of sacral vertebra from S1 to S5, and solitary right kidney. The septum of this duplication was divided using staplers. Because of a history of stool coming from the vagina, a meticulous examination perioperatively was performed, but no fistula could be found. Further extensive investigation failed to show any fistula. At the age of 10 she was operated on for a tethered cord. At age 14, she experienced passage of a small amount of liquid stool per vaginum. A recto-vaginal fistula was found. Via a posterior sagittal incision, the fistula was closed by a transrectal approach. She remained asymptomatic for 16 months until the fistula recurred. Using a perineal approach, a very short fistula between the vagina and the rectum was closed. The closure was reinforced by a vaginal flap. Four months later, she remains without signs of recurrence.
OBJECTIVE: To highlight the occurrence of diversion colitis and its effects in colovaginoplasty. Patients and methods The records of 18 children who had undergone colovaginoplasty were reviewed retrospectively. Nine patients had androgen-insensitivity syndrome and three each had congenital adrenal hyperplasia, vaginal agenesis and Mayer-Rokitansky syndrome. Through an abdominoperineal approach a segment of sigmoid colon was isolated on its vascular pedicle and brought to the perineum in the plane between the urethra and rectum, as a blind pouch or as an interposition between the proximal vagina and the perineum. The mean (range) follow-up was 5 (1.5-8) years. RESULTS: There were no major complications during the early follow-up. Three patients developed severe vaginal discharge with bleeding 2-7 years after colovaginoplasty; examination showed erythema, oedema, ulceration and bleeding. Histology confirmed the classic features of diversion colitis in all three patients. One child responded to vaginal irrigation with a solution of short-chain fatty acids, and the other two were treated with steroid enemas and mesalazine after a poor response to short-chain fatty acids. One of these patients has required surgical reduction of an excessively long neovagina. Conclusion Symptomatic diversion colitis can occur after colovaginoplasty. The severity of the symptoms raises concerns about the use of colovaginoplasty in children and alternative techniques of vaginal replacement should be considered in the first instance.
PURPOSE OF REVIEW: Within the last decade we have seen substantial development in the surgical techniques used to treat female stress urinary incontinence. The laparoscopic approach became available and even less invasive methods like the tension-free vaginal tape procedure were introduced. RECENT FINDINGS: These procedures offer quicker recovery and faster return to normal activities after surgery compared with the older procedures. The tension-free vaginal tape technique has been extensively studied and clinical data from a significant number of prospective observational cohort studies have been published. The number of reports on laparoscopic incontinence surgery is more limited. Long-term follow-up results with reassuring cure rates at 5 and 7 years are available for the tension-free vaginal tape procedure. Three-year follow-up results for the laparoscopic colposuspension procedure show reasonable cure rates, though not as good as those reported for the open colposuspension, the 'gold standard'. Both of these techniques are now widely used in everyday clinical practice. Perioperative and immediate postoperative complication rates are low and acceptable. However, data are limited in terms of randomized clinical trials comparing these fairly new techniques. SUMMARY: This review attempts to highlight the recent clinical experience of these two surgical techniques, including cure rates, complications and cost-effectiveness.
AIM: The aim of this work was to evaluate the prevalence of symptomatic vulvo-vaginal infections among the Italian female population and the diagnostic approach of 158 Italian gynaecologists. METHODS: A total of 1644 patients were enrolled in this survey. A presumed diagnosis of vulvovaginal infection was made according to specific clinical and laboratory criteria (pH e sniff test) in 902 (55.4%) cases, whereas a definitive diagnosis was made in 1439 (87.5%) cases. The definitive diagnoses were as follows: 844 (51.3%) vulvovaginal mycosis, 327 (19.9%) bacterial vaginosis, 110 (6.7%) trichomonal infection, 100 (6.1%) aspecific bacterial vaginitis, 58 (3.5%) non-infectious vaginitis. As assessed by typing, mycosis were mainly due to Candida albicans infections in 459 cases (78%). CONCLUSION: From the survey it is possible to infer that: 1) only thanks to the employed microbiological diagnostic tests a definitive diagnosis was made in 702 patients without a previous presumed diagnosis; 2) mycotic infections were underestimated; 3) Candida albicans was the most common species causing female low genital tract mycotic infections. In conclusion, these data underline the importance of laboratory examinations in the diagnosis of low genital tract infections for the ambulatory gynaecological practice.
PURPOSE OF REVIEW: Bacterial vaginosis, a common disorder among young women, is associated with adverse reproductive health outcomes. This review summarizes our current understanding of bacterial vaginosis and where future research should be focused. Recommendations for prevention, diagnosis, and treatment in both nonpregnant and pregnant populations are discussed. RECENT FINDINGS: Little progress has been made in understanding the causal factors. The results of several large prospective studies have shown that racial differences persist for rates of bacterial vaginosis even when other known risk factors are controlled for. Studies of the gene-environment interaction that examine the genetic aspects of immune response may explain racial differences and why some but not all women with bacterial vaginosis experience complications. Trials to prevent preterm birth by the treatment of bacterial vaginosis in pregnancy are disappointing. Resistance to clindamycin by bacterial vaginosis-associated anaerobic organisms has also been documented. New technology to provide rapid point-of-care diagnostic testing for bacterial vaginosis has emerged. SUMMARY: To understand the vaginal ecosystem and its role in reproductive health and disease, we will need to study not only the microflora but also the host-immune response. Currently recommended treatment options for bacterial vaginosis are associated with high rates of recurrence. A new concern is the development of macrolide resistance to vaginal anaerobic flora when clindamycin is used as treatment. Further studies are still needed to determine whether prevention or control of bacterial vaginosis, particularly approaches that rely not on antibiotic treatment but on the maintenance of a healthy vaginal ecosystem, can reduce adverse health outcomes.
OBJECTIVE: To evaluate the performance of a new improved enzyme immunoassay (EIA) kit for the detection of Chlamydia trachomatis in vaginal swab and endocervical swab specimens from female commercial sex workers, in comparison with a conventional EIA test and a polymerase chain reaction (PCR) assay. METHODS: A high risk group of 163 female commercial sex workers who visited a sexually transmitted disease (STD) clinic in order to undergo screening for major STDs, including chlamydial infection, were enrolled. A total of four swab specimens, including two vaginal and two endocervical specimens, were collected from each woman by a clinician. To identify C trachomatis, a new improved EIA kit (IDEIA PCE), a conventional EIA kit (IDEIA), and PCR assay (Amplicor) were used. Discrepancies in the results were resolved using supplementary PCR assay. A female patient was considered to be infected with C trachomatis if the IDEIA PCE test and PCR test for both sample sites (endocervical and vaginal) gave positive results. Following resolution of these discrepancies, relative sensitivity and specificity, confidence intervals, and predictive values for each type of specimen by each assay were calculated. RESULTS: Of the 163 women tested, 35 (21.5%) were shown to be infected with C trachomatis. The relative sensitivities in vaginal swab specimens were 88.8%, 68.6%, and 91.4% using IDEIA PCE, IDEIA, and PCR, respectively. The relative specificities in vaginal swab specimens were 99.2%, 99.2%, and 100%, respectively. The relative sensitivities in endocervical swab specimens were 85.7%, 77.1%, and 91.4% with IDEIA PCE, IDEIA, and PCR, respectively. The relative specificities in endocervical swab specimens were all 100%. CONCLUSIONS: The results obtained in this study suggest that the sensitivity and specificity of IDEIA PCE test on vaginal swab and endocervical swab specimens were similar to those of PCR assay on the two types of specimen. It is concluded that IDEIA PCE test on vaginal swab specimens is an acceptable, sensitive, and less invasive approach for the detection of C trachomatis in commercial sex workers with a high prevalence of C trachomatis infection.
BACKGROUND: Laparoscopic colposuspension is a popular surgical procedure for stress incontinence. To simplify the laparoscopic approach, many physicians have replaced laparoscopic suturing with mesh, secured with staples or tacks. CASES: Two women developed severe, shooting vaginal pain after laparoscopic colposuspension with mesh and tacks. The tacks could be palpated vaginally in both, reproducing the pain. Tack removal relieved their pain, but one had recurrent cystocele. CONCLUSION: Laparoscopic colposuspension with tacks might produce shooting vaginal pain, possibly unique to tacks versus staples or sutures.