Safety of vaginal oestrogens for genitourinary symptoms in women with breast cancer

BACKGROUND

Oestrogen deprivation is the mainstay of treatment for women with hormone receptor-positive breast cancer, but unfortunately it causes multiple side effects that can significantly impair quality of life. Genitourinary symptoms are very common and although these symptoms can be effectively managed with vaginal oestrogens, concerns about their safety in women with breast cancer limits their use.

OBJECTIVE

The aim of this review is to provide a summary of the data on the safety of vaginal oestrogens in women with breast cancer to help general practitioners advise their patients in this situation.

DISCUSSION

Although there are no large randomised prospective studies to assess safety, the current evidence suggests reassurance can be provided to the majority of women with a history of breast cancer considering vaginal oestrogens. Consultation with the oncology team is advised for women taking aromatase inhibitors, where the safety of vaginal oestrogens is less certain.

A Review on Therapeutic Effects of Labisia pumila on Female Reproductive Diseases

The Labisia pumila (LP) is a traditional plant that is locally known as Kacip Fatimah, Selusuh Fatimah, or Pokok Ringgang by the Malaysian indigenous people. It is believed to facilitate their childbirth, treating their postchild birth and menstrual irregularities. The water extract of LP has shown to contain bioactive compounds such as flavonoids, ascorbic acid, β-carotene, anthocyanin, and phenolic acid, which contribute extensive antioxidant, anti-inflammatory, antimicrobial, and antifungal. The LP ethanolic extract exhibits significant estrogenic effects on human endomentrial adenocarcinoma cell in estrogen-free basal medium and promoting an increase in secretion of alkaline phosphate. Water based has been used for many generations, and studies had reported that it could displace in binding the antibodies and increase the estradiol production making it similar to esterone and estradiol hormone. LP extract poses a potential and beneficial aspect in medical and cosmeceutical applications. This is mainly due to its phytoestrogen properties of the LP. However, there is a specific functionality in the application of LP extract, due to specific functional group in phytoconstituent of LP. Apart from that, the extraction solvent is important in preparing the LP extract as it poses some significant and mild side effects towards consuming the LP extracts. The current situation of women reproductive disease such as postmenopausal syndrome and polycystic ovary syndrome is increasing. Thus, it is important to find ways in alternative treatment for women reproductive disease that is less costly and low side effects. In conclusion, these studies proven that LP has the potential to be an alternative way in treating female reproductive related diseases such as in postmenopausal and polysystic ovarian syndrome women.

Clinical manifestations and evaluation of postmenopausal vulvovaginal atrophy

INTRODUCTION

It is estimated that 50% of women will suffer a severe form of vulvovaginal atrophy (VVA) related to menopause. Equally, young women may temporarily present this clinical problem while receiving various pharmacological or endocrine treatments or radiotherapy.

AIM

To determine clinical and diagnostic exams required to confirm the presence of VVA (also referred to as atrophic vaginitis, urogenital atrophy, or genitourinary syndrome of menopause) and rule out other genital or pelvic clinical conditions.

MATERIALS AND METHODS

Literature review searches were carried out on the main scientific article search engines (PubMed, SciELO, Cochrane) using different clinical terms, treatments or interventions and comorbidity related to VVA.

RESULTS

The development and severity of VVA depend mainly on the duration of hypoestrogenism. Hypoestrogenism causes changes in the urogenital tissue, generating signs and symptoms, such as dryness, burning, soreness, itching, and irritation of the genital skin. The diagnosis can be made through anamnesis (patient history), questionnaires, physical exam, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be completed with the Vaginal Health Index, the Vaginal Maturation Index, or vaginal pH in the absence of infection or semen. The exclusion of other vulvovaginal organic pathology is essential to reach an accurate diagnosis and provide adequate treatment.

CONCLUSIONS

The specialist should be able to identify VVA, rule out other pathologies that make a differential diagnosis and conduct proper management.

At-Home Transvaginal Device Following Fractional Carbon Dioxide Laser Treatment for Genitourinary Syndrome of Menopause

BACKGROUND

Device-based therapeutic approaches have been developed to treat women’s genitourinary post-menopausal symptoms. Fractional carbon dioxide laser resurfacing (FxCO2) has been demonstrated to be safe and effective in the treatment of GSM symptoms, however the results begin to wane by 12-months post-treatment.

OBJECTIVE

This study aims at assessing the application of an at-home transvaginal red and infrared light device as a maintenance treatment commencing 12 months following FxCO2 laser treatment for genitourinary syndrome of menopause (GSM).

STUDY DESIGN

Subjects completing 12-month follow-up after three fractional CO2 laser vulvovaginal treatments received an at-home device and monitored for GSM symptoms with long-term follow-up to 12 months (2 years post-laser).

METHODS

10 post-menopausal subjects completing 12-months follow-up after three FxCO2 vulvovaginal treatments for GSM were treated with an at-home red and infrared LED device. Treatment consisted of intravaginal application three times per week, and subjects were followed to 1, 3, 6, and 12 months. Subjects completed the vaginal assessment scale subject satisfaction, and QUID to assess for vulvovaginal and stress urinary incontinence (SUI) symptoms.

RESULTS

Vulvovaginal symptoms measured by VAS were mean 89% improved at 12-month follow-up after FxCO2 and maintained at 73% improved over baseline (2 years post-laser) following an additional 12 months of at-home transvaginal light therapy (P<0.05). VAS symptoms gradually increased over the 12 months maintenance period by a mean of 17% (P<0.05). Mean subject satisfaction was 0 at baseline, 1.86 at 1 year following FxCO2, and 1.00 after an additional 1 year of at-home light therapy. SUI symptoms as measured by QUID were mean 81% improved at 12-month follow-up after FxCO2and maintained at 38% improved over baseline (2 years post-laser) following an additional 12-months of at-home light therapy (P<0.05). SUI symptoms gradually increased by a mean of 43% over the 12-month maintenance period (P<0.05).

CONCLUSIONS

At-home transvaginal red and near infrared light therapy commencing at 12 months post-FxCO2 vulvovaginal treatment in a post-menopausal population maintained statistically significant improvements in vulvovaginal and SUI symptoms over the additional12-month period (2 years post-laser); however, a gradual return of symptoms suggests that laser re-treatment or combination withhormone therapy may be necessary to maintain optimal outcomes.J Drugs Dermatol. 2020;19(11):1076-1079. doi:10.36849/JDD.2020.1012.

Genitourinary syndrome of menopause

BACKGROUND

Genitourinary syndrome of menopause (GSM) is the new term for vulvovaginal atrophy (VVA). Oestrogen deficiency symptoms in the genitourinary tract are bothersome in more than 50% of women, having an adverse impact on quality of life, social activity and sexual relationships. GSM is a chronic and progressive syndrome that is underdiagnosed and undertreated.

OBJECTIVE

The aim of this article is to increase knowledge and understanding of GSM, improving the ability of healthcare professionals to discuss and obtain an appropriate history sensitively, and treat accordingly.

DISCUSSION

GSM includes conditions of the vagina, vulva, pelvic floor tissues, urinary tract, and sexual dysfunction and loss of libido. Many women are reluctant to report these symptoms to their healthcare professional for many reasons.

The Impact of Abdominal Contouring with Monsplasty on Sexual Function and Urogenital Distress in Women Following Massive Weight Loss

BACKGROUND

Monsplasty treats massive weight loss (MWL) patients with redundant tissues in the mons region. Monsplasty, however, is not a routine component of abdominal contouring.

OBJECTIVES

The goal of this study was to evaluate the changes in urinary and sexual functioning in patients who undergo abdominal contouring with monsplasty vs non-operated controls.

METHODS

A prospective study was performed of patients who underwent abdominal contouring + monsplasty or no surgery. The Urogenital Distress Inventory Short Form (UDI-6) and the Female Sexual Function Index (FSFI) questionnaires were administered to both groups at baseline and then three months later.

RESULTS

The surgical (n = 20) and nonsurgical groups (n = 20) were similar related to patient demographics, body mass index after MWL, parity, relationship status, hormonal status, and baseline UDI-6/FSFI scores (all P values >0.05). After three months, there was a statistically significant decrease in the UDI-6 score for the surgical groups vs the nonsurgical group: median UDI-6 score = -0.01 (interquartile range [IQR], -7.65-5.55) vs 0 (IQR, 0-11.11) (P = .03). There was no change for the Female Sexual Function Index in the surgical vs nonsurgical groups: median FSFI = 0.20 (IQR, -1.20-1.58) vs 0.95 (IQR, 0.08-2.58) (P = .11).

CONCLUSIONS

Urinary dysfunction improved even at the early time point of three months following abdominal contouring procedures including monsplasty. At the early postoperative period of three months, however, there was no significant change in female sexual function. Monsplasty in conjunction with abdominal contouring is recommended in the MWL female patient.

LEVEL OF EVIDENCE

2 Therapeutic.

Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

The objective of this document is to generate a practice guideline for the management and treatment of symptoms of the menopause.

PARTICIPANTS

The Treatment of Symptoms of the Menopause Task Force included six experts, a methodologist, and a medical writer, all appointed by The Endocrine Society.

EVIDENCE

The Task Force developed this evidenced-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned three systematic reviews of published data and considered several other existing meta-analyses and trials.

CONSENSUS PROCESS

Multiple e-mail communications, conference calls, and one face-to-face meeting determined consensus. Committees of The Endocrine Society, representatives from endorsing societies, and members of The Endocrine Society reviewed and commented on the drafts of the guidelines. The Australasian Menopause Society, the British Menopause Society, European Menopause and Andropause Society, the European Society of Endocrinology, and the International Menopause Society (co-sponsors of the guideline) reviewed and commented on the draft.

CONCLUSIONS

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms and other symptoms of the climacteric. Benefits may exceed risks for the majority of symptomatic postmenopausal women who are under age 60 or under 10 years since the onset of menopause. Health care professionals should individualize therapy based on clinical factors and patient preference. They should screen women before initiating MHT for cardiovascular and breast cancer risk and recommend the most appropriate therapy depending on risk/benefit considerations. Current evidence does not justify the use of MHT to prevent coronary heart disease, breast cancer, or dementia. Other options are available for those with vasomotor symptoms who prefer not to use MHT or who have contraindications because these patients should not use MHT. Low-dose vaginal estrogen and ospemifene provide effective therapy for the genitourinary syndrome of menopause, and vaginal moisturizers and lubricants are available for those not choosing hormonal therapy. All postmenopausal women should embrace appropriate lifestyle measures.

Menopause

Women generally spend the last third of their lifetime in menopause, after their reproductive years have ended. During menopause, women experience a variety of predictable symptoms and conditions related to changes in sex hormone levels and aging. The menopausal transition precedes menopause by several years and is usually characterized by irregularity of the menstrual cycle and by hot flashes and night sweats. After menopause, genitourinary symptoms predominate, including vulvovaginal atrophy and dryness and lower urinary tract symptoms, including urinary frequency, urgency, and nocturia. Hormonal treatment is effective for vasomotor and genitourinary symptoms, but the understanding of its impact on cardiovascular disease, cognitive dysfunction, and depression continues to evolve.

Ghrelin and reproductive disorders

Ghrelin is an important factor involved in most of the metabolic and hormonal signals which adapt the reproductive functions in conditions of altered energy balance. Moreover, the coordinated role of leptin and ghrelin appears in fact to have a specific role in the regulation of puberty. Systemic action of ghrelin on the reproductive axis involves the control of the hypothalamic-pituitary-gondal axis. In addition, it has been shown that ghrelin may directly act at a gonadal level in both females and males. Available data also demonstrate that sex steroid hormones and gonadotropins may in turn regulate the gonadal effect of ghrelin, as documented by studies performed in females with the polycystic ovary syndrome and in hypogonadal men. Notably, recent studies also confirm a potentially important role for ghrelin in fetal and neonatal energy balance, and specifically in allowing fetal adaptation to an adverse intrauterine environment.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction

INTRODUCTION

Next to existing terminology of the lower urinary tract, due to its increasing complexity, the terminology for pelvic floor dysfunction in women may be better updated by a female-specific approach and clinically based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two international organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Appropriate core clinical categories and a subclassification were developed to give an alphanumeric coding to each definition. An extensive process of 15 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A terminology report for female pelvic floor dysfunction, encompassing over 250 separate definitions, has been developed. It is clinically based with the six most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific imaging (ultrasound, radiology, and MRI) has been a major addition while appropriate figures have been included to supplement and help clarify the text. Ongoing review is not only anticipated but will be required to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Quality of life impairment among postmenopausal women varies according to race

BACKGROUND

Few studies have addressed the impact of menopausal symptom severity over quality of life (QoL) in Latin American women with different ethnics.

OBJECTIVE

To assess menopausal symptom severity and the QoL among postmenopausal Colombian women with three different ethnicities.

METHOD

Data of healthy naturally occurring postmenopausal Hispanic, indigenous and black women aged 40-59 years who participated in a cross-sectional study filling out the Menopause Rating Scale (MRS) and a general questionnaire was analysed.

RESULTS

A total of 579 women were included, 153 Hispanic, 295 indigenous and 131 Afro-descendent. Hispanic women had an average age of 55.3 +/- 3.3 years. Indigenous and black women were less educated than the Hispanic ones (2.2 +/- 1.8 and 4.6 +/- 4.4 vs. 6.4 +/- 3.5 years, p < 0.0001). Hispanic women displayed lower total MRS scores (better QoL) when compared to indigenous and black women. Urogenital scoring was worse among indigenous women compared to Hispanic and black women. Black women presented higher MRS psychological and somatic scorings than Hispanic and indigenous women. After adjusting for confounding factors, indigenous and black women continued to display a higher risk for impaired QoL, total MRS score > 16 (OR: 3.11, 95% CI: 1.30-7.44 and OR: 5.29, 95% CI: 2.52-11.10, respectively), which was significantly higher among indigenous women due to urogenital symptoms (OR: 102.75, 95% CI: 38.33-275.47) and black women due to psychological (OR: 6.58, 95% CI: 3.27-13.27) and somatic symptoms (OR: 3.88, 95% CI: 1.83-8.22).

CONCLUSION

In this postmenopausal Colombian series, menopausal symptoms in indigenous (urogenital) and black (somatic/psychological) women were more severe (impaired QoL) when compared to Hispanic ones.

Pelvic organ prolapse

Pelvic organ prolapse is downward descent of female pelvic organs, including the bladder, uterus or post-hysterectomy vaginal cuff, and the small or large bowel, resulting in protrusion of the vagina, uterus, or both. Prolapse development is multifactorial, with vaginal child birth, advancing age, and increasing body-mass index as the most consistent risk factors. Vaginal delivery, hysterectomy, chronic straining, normal ageing, and abnormalities of connective tissue or connective-tissue repair predispose some women to disruption, stretching, or dysfunction of the levator ani complex, connective-tissue attachments of the vagina, or both, resulting in prolapse. Patients generally present with several complaints, including bladder, bowel, and pelvic symptoms; however, with the exception of vaginal bulging, none is specific to prolapse. Women with symptoms suggestive of prolapse should undergo a pelvic examination and medical history check. Radiographic assessment is usually unnecessary. Many women with pelvic organ prolapse are asymptomatic and do not need treatment. When prolapse is symptomatic, options include observation, pessary use, and surgery. Surgical strategies for prolapse can be categorised broadly by reconstructive and obliterative techniques. Reconstructive procedures can be done by either an abdominal or vaginal approach. Although no effective prevention strategy for prolapse has been identified, considerations include weight loss, reduction of heavy lifting, treatment of constipation, modification or reduction of obstetric risk factors, and pelvic-floor physical therapy.

The length of menstrual bleeding and the risk of urogenital infections in the context of the activity of hemoglobin-derived microbicidal peptides

OBJECTIVE

Well-known natural unspecific antimicrobial factors acting in the vagina are additionally reinforced during menstrual bleeding by hemocidins--a recently discovered novel class of microbicidal peptides generated proteolytically from hemoglobin. The aim of the presented research was to investigate the relation between the average length of menstrual bleeding and the frequency of urogenital infections. We expected that the shorter menstrual bleeding might increase the risk of urogenital infections because is synonymous with the shorter period of exposition on bactericidal action of hemocidins.

STUDY DESIGN

The study contains statistical analysis of an average declared length of menstrual bleeding in the group of 267 young, sexually active women with the symptoms of urogenital infections. The control group consisted of 300 young healthy women.

RESULTS

The length of menstrual bleeding in the group of patients with urogenital infections (average 4.35 days) was statistically significantly shorter than in the control group (average 4.95 days). The average length of the menstrual cycle was equal and counted ca. 28 days in both groups.

CONCLUSION

The length of menstrual bleeding seems to be a significant factor in the vaginal ecology maintenance.

Number VII Behcet's disease (Adamantiades syndrome)

Behçet's syndrome (BS; Adamantiades syndrome) is the association of the triple symptom complex of recurrent aphthous stomatitis (RAS) with genital ulceration, and eye disease (especially iridocyclitis) though a number of other systemic manifestations may also be seen. BS mainly affects young adult males, and there is an association with HLA-B5 and HLA-B51 (B5101). Features such as arthralgia and leucocytoclastic vasculitis suggest an immune-complex mediated basis, which is supported by finding circulating immune complexes and, although the antigen responsible is unidentified, heat shock proteins have been implicated. An inflammatory disorder, BS is now considered as a systemic vasculitis, characterised by a very wide spectrum of clinical features and by unpredictable exacerbations and remissions.

Urologic manifestations of genetic diseases

Many genetic disorders have genitourinary manifestations in childhood. In order to care for these children, the physician should be aware of such potential manifestations. A succinct overview of the pediatric genetic disorders that have urologic manifestations is presented to assist in the evaluation of patients, counseling of parents and treatment of urologic manifestations of childhood genetic diseases.

The effect of postparturient urogenital diseases on the lifetime reproductive performance of sows

To prove the effect of postparturient swine urogenital disease (SUGD) on reproductive performance, culled sows with SUGD in their previous history (n=1363) were subjected to retrospective lifetime production analysis. The sows were assigned to parity groups 1, 2 to 6, and >6. Bacterial flora of vulval discharges were evaluated. Parity 1 sows had a lower percentage of SUGD than did sows of parity 2 to 6 and parity >6 (P < 0.05 and P < 0.01, respectively). Compared with parity 2 to 6 sows, parity 1 and parity >6 sows had lower (P < 0.001) conception, farrowing and adjusted farrowing rates, lifetime average total born, live-born litter sizes, stillbirth rates, and weaning litter weights compared with animals culled for other reasons than SUGD. The conclusions are that high parity sows have a higher occurrence of postparturient SUGD and that higher parity sows with postparturient SUGD have a lower performance compared with lower parity sows with postparturient SUGD.

The Vicious Cycling: Bicycling Related Urogenital Disorders

PURPOSE

Bicycle riding is one of the most popular means of transportation, recreation, fitness and sports among millions of people of all ages who ride on road and off road, using a variety of bicycle types. It is also a readily available form of aerobic non-impact exercise with established cardiovascular beneficial effects. Bicycles are also a common source of significant injuries. This review focuses upon the specific bicycling related overuse injuries affecting the genitourinary tract.

MATERIALS AND METHODS

MEDLINE search of the literature on bicycling and genitourinary disorders was performed using multiple subject headings and additional keywords. The search yielded overall 62 pertinent articles. We focused primarily on the most prevalent related disorders such as pudendal nerve entrapment, erectile dysfunction and infertility. The potential effect of bicycling on serum PSA level was also discussed in depth in view of its recognized clinical importance. Infrequent disorders, which were reported sporadically, were still addressed, despite their rarity, for the comprehensiveness of this review.

RESULTS

The reported incidence of bicycling related urogenital symptoms varies considerably. The most common bicycling associated urogenital problems are nerve entrapment syndromes presenting as genitalia numbness, which is reported in 50-91% of the cyclists, followed by erectile dysfunction reported in 13-24%. Other less common symptoms include priapism, penile thrombosis, infertility, hematuria, torsion of spermatic cord, prostatitis, perineal nodular induration and elevated serum PSA, which are reported only sporadically.

CONCLUSIONS

Urologists should be aware that bicycling is a potential and not an infrequent cause of a variety of urological and andrological disorders caused by overuse injuries affecting the genitourinary system.

[Autonomic neuropathy in diabetes mellitus]

AIMS

We analyse the different studies conducted on the prevalence, aetiopathology, clinical symptoms and treatment of diabetic autonomic neuropathy (AN), together with its involvement in the mortality of patients.

DEVELOPMENT

AN can affect any part of the nervous system to varying degrees and at different moments in time, and its prevalence is significant in any of the stages of diabetes. The aetiopathogenesis of AN results from a multifactorial process involving metabolic disorders triggered by the activation of the polyolic pathway, microangiopathy and alterations affecting the synthesis of essential fatty acids due to hyperglycemia, which is made worse by a deficient regeneration of nerve tissue. Any of the systems innervated by the autonomous nervous system can be affected; the initial symptoms are insidious and of little cause for concern until the more advanced stages of the disease. The chief dysfunctions affect the cardiovascular, digestive, genitourinary and thermoregulatory systems. How AN courses in time varies from patient to patient and depends on the glycemic control that is carried out. Its presence is a factor that increases the mortality rate in diabetic patients.

CONCLUSIONS

The prevalence of AN is notable, and the symptoms of autonomic dysfunction are usually under-diagnosed owing to its variability, lack of specificity and the wide range of symptoms. It is important to recognise this entity because of its effects on increasing morbidity and mortality, although they can be reduced by means of a strict glycemic control and specific treatment.

[Surgery for urogenital prolapse]

Urogenital prolapse can have a significant impact on quality of life. As the population continues to age, the prevalence of urogenital prolapse is increasing, and the lifetime risk of requiring surgery for urogenital prolapse or incontinence is now approximately 11%. The majority of women presenting with symptomatic prolapse suffer from multiple defects of pelvic support and require comprehensive repair to relieve symptoms. An understanding of normal pelvic support structures provides the basis for the anatomic approach to repair. Many appropriate options exist for surgical correction of urogenital prolapse. Procedures to reestablish apical support include culdoplasty techniques, uterosacral ligament suspension, sacrospinous suspension and colpopexy. Repair of the anterior compartment can be achieved with colporrhaphy and paravaginal repair. Posterior compartment defects are repaired with colporrhaphy, site-specific rectovaginal repair and perineorrhaphy. Most often, surgical correction of urogenital prolapse can be performed vaginally, which avoids the risks associated with laparotomy. Laparoscopic approaches for apical support and paravaginal repair may reduce the risks associated with laparotomy, but long-term follow-up data are not yet available with these techniques. The use of graft reinforcement for anterior and posterior repairs may offer improved success rates, particularly in patients with recurrent prolapse. However, further outcome studies are needed and the risks associated with the use of mesh must be considered.

Urogenital diseases and their effect on reproductive performance in high-parity sows

In a Slowakian indoor pig production unit (2423 sows), from June to December 2002 all culled sows with excessive vulval discharge at culling, and with vulval discharge and periparturient disease in their previous history were subjected to retrospective lifetime production analysis. The sows were assigned to nine groups according to parity (parity 1-9). Average total litter size, average live-born litter size, average stillbirth rate, average mummy rate, and average litter weaning weight were evaluated retrospectively for all births. Non-culled sows represented the control animals. The percentage of animals with periparturient disease and vulval discharge in their history differed between parities. Parity 2, 3, and 4 sows had a significantly lower percentage of vulval discharge and periparturient disease in their history than sows of other parities. Compared to parity 1-6 sows, parity 7-9 sows had significantly lower (P < .001) conception rates, farrowing rates, and adjusted farrowing rates. Compared to parity 1-2 and 7-9 sows, parity 3-6 sows had a significantly larger (P < .001) lifetime average total born and live-born litter size. Compared to parity 1-3 and 7-9 sows, parity 4-6 sows had a significantly lower (P < .001) rate of stillbirths over all parities. No differences in mummy rates were detected between the sows of different parities. Compared to parity 1-2 and 7-9 sows, parity 3-6 sows had significantly higher (P < .001) weaning litter weights over all parities. Sows without a history of vulval discharge and periparturient disease had higher (P < .001) production levels in parity 7-9.

IMPLICATIONS

The present results indicate that parity markedly influences the production level of sows that have a history of periparturient disease and vulval discharge.

The Utility of Urodynamic Testing

The utility of urodynamic testing has been questioned for decades. However, this diagnostic tool has been widely adopted in the evaluation of patients who suffer from urinary incontinence despite the associated costs to society. A review of the literature and the consensus of the authors with regard to the indications of urodynamic testing, its application as a diagnostic and prognostic tool, and its effect on surgical management and outcome are presented here.

Mycoplasma canis and urogenital disease in dogs in Norway

Mycoplasmas identified as Mycoplasma canis were isolated from nine dogs with clinical signs of urogenital disease in Norway over a period of 20 months. Some of the dogs had been treated unsuccessfully with antibiotics, and three were euthanased as a result of severe persistent disease. Seven of the dogs had a urinary tract infection, one had chronic purulent epididymitis and one had chronic prostatitis. Overt haematuria was frequently observed among the dogs with cystitis. M canis was isolated in pure culture from seven of the dogs and in mixed culture from the other two. In three cases the mycoplasma was cultivated only from urinary sediment, and it was typically obtained in smaller numbers than would be considered indicative of a urinary tract infection. In contrast with most mycoplasmas, the M canis isolated from all the dogs grew on ordinary blood agar plates used for routine bacteriological cultivation. Specific mycoplasma media were not used and the presence of other Mycoplasma or Ureaplasma species cannot be excluded.

The relationship of serovar to clinical manifestations of urogenital Chlamydia trachomatis infection

BACKGROUND AND GOAL

Studies assessing the relationship of serovars or genotypes to clinical manifestations of urogenital disease have produced contradictory results. Possible reasons for this include small sample sizes insufficient to reliably detect associations and failure to address potential confounding factors. Utilizing a large dataset and multivariate analysis to address confounding factors, we undertook this study of the relationship of chlamydial serovars to specific clinical manifestations of urogenital disease.

STUDY DESIGN

This was a cross-sectional study of 480 women and 700 heterosexual men with urogenital chlamydial infection attending a sexually transmitted diseases clinic from 1995 to 1999 and a literature review.

RESULTS

Women (89%) and men (86%) were infected predominately with serovars D, E, F, Ia, and J. After controlling for age and race, we found that women who reported abdominal pain and/or dyspareunia were more often infected with serovar F (P= 0.048). An association of specific clinical manifestations with serovars was not detected in men.

CONCLUSION

We conclude that clinical manifestations of urogenital infection are not strongly influenced by the infecting serovar.

Are women with urogenital atrophy symptomatic?

OBJECTIVE

The purpose of this study was to determine the degree of correlation between physical signs of genital atrophy and symptoms that are suggestive of atrophic vaginitis.

STUDY DESIGN

Female volunteers (n = 135; mean age, 69 years) rated the presence and severity (rating, 0-3) of vaginal atrophy symptoms. The presence and severity of vaginal mucosal changes, which included vaginal pH (0-3), were recorded during a pelvic examination. A vaginal cytologic maturation value was performed. Symptoms, signs, pH, and maturation value were correlated by the Spearman rank test.

RESULTS

Symptom scores were low (mean, 0.41; range, 0-2.6). Symptoms were only weakly correlated with physical findings (r = 0.14) and not with maturation value (r = 0.06) or age (r = -0.004). There was a moderate correlation between physical examination score and maturation value (r = -0.48). In women > or =65 years old, symptom score and physical examination score were correlated weakly (r = 0.25). Low pH correlated well with high maturation value (r = -0.52). Women who were undergoing estrogen therapy had higher symptoms scores (P =.0007) and maturation values (P =.0002) than women who were not undergoing therapy.

CONCLUSION

Although urogenital atrophy occurs universally after menopause, most elderly women are minimally symptomatic. Those women on estrogen replacement therapy may be more symptomatic. Symptoms alone should not be used as a guide for the initiation of estrogen therapy.

Evaluation and Treatment of Autonomic Disorders of the Urogenital System

Autonomic pathways are important in the regulation of both lower urinary tract and sexual function, and their interruption in neurological pathologies predictably results in variable urogenital dysfunction, depending mainly on the level of the lesion. A normal neurological examination of a patient with urogenital complaints should exclude an underlying neurological pathology, and the neurologist should become involved in the management of symptoms. Electromyography can be of value in the diagnosis and management of cauda equina lesions and multiple system atrophy, but neurophysiological investigations are of no importance in the diagnosis of neurogenic sexual dysfunction. Urodynamic studies have proven helpful in determining the type and management of lower urinary tract dysfunction. Oral anticholinergics usually combined with clean intermittent catheterizations are the first-line treatment options for neurogenic lower urinary tract dysfunction, with intravesical treatments emerging as the main alternative in intractable incontinence. The availability of effective oral phosphodiesterase inhibitors has revolutionized the management of erectile dysfunction, but treatment of ejaculatory and orgasmic disorders as well as of female sexual dysfunction still remains problematic.

Contractile activity of isolated myometrium from pregnant women with chronic specific urogenital infections

Contractile activity of the isolated myometrium from pregnant women with mycoplasma, chlamydial, and mixed mycoplasma-chlamydial infections of the urogenital system was studied in vitro by pharmacological methods. The amplitude of uterine contractions induced by oxytocin and prostaglandin F2alpha decreased in women with mycoplasma infection, but increased during chlamydial and mixed infections. These data can help to predict pregnancy complications in women with specific urogenital infections.

Quantitative culture of Chlamydia trachomatis: relationship of inclusion-forming units produced in culture to clinical manifestations and acute inflammation in urogenital disease

The relationship of Chlamydia trachomatis inclusion-forming units in quantitative culture to clinical manifestations and inflammation in urogenital disease was assessed in 1179 patients attending a sexually transmitted diseases clinic. In women, greater inclusion-forming unit counts were associated with cervical mucopus (3000 vs. 450 ifu), amount and character of cervical discharge, > or =30 polymorphonuclear cells (PMNL) per high-power field (hpf) on Gram stain (2050 vs. 320 ifu), and diagnoses of mucopurulent cervicitis (MPC; 2550 vs. 300 ifu) and pelvic inflammatory disease (PID; 3000 vs. 578 ifu). In men, greater inclusion-forming unit counts were associated with urethral discharge (85 vs. 44 ifu), amount and character of discharge, and > or =10 PMNL/hpf (95 vs. 50 ifu). These associations persisted on multivariate analysis. Thus, chlamydial replication is associated with MPC and PID in women, urethritis in men, and inflammation in both. Since infections with high inclusion counts may be the most transmissible, identification and treatment of patients with these chlamydia-associated syndromes is important in control programs.

Urogenital atrophy: prevention and treatment

Fifteen percent of premenopausal women, 10-40% of postmenopausal women, and 10-25% of women receiving systemic hormone therapy experience urogenital atrophy. The most common symptoms are dryness, burning, pruritus, irritation, and dyspareunia. Estrogen loss, drugs, and chemical sensitivities are causes. Estrogen or hormone replacement therapy (ERT-HRT) is the treatment of choice in postmenopausal women. Dosages prescribed for menopause symptoms or to prevent osteoporosis (and, potentially, other conditions) can restore the vagina to premenopausal physiology and relieve symptoms. Concomitant progestins are necessary for women with an intact uterus to minimize or eliminate estrogen-induced endometrial cancer. Low-dosage oral and vaginal ERT can relieve urogenital atrophy but might not produce systemic effects. Progestins are not necessary with vaginal rings and vaginal tablets. If ERT is given only to treat urogenital atrophy, estrogen creams 1 or 2 times/week may prevent recurrence after symptoms are resolved. Progestins are not required for occasional estrogen cream use. Vaginal moisturizers provide longer relief by changing the fluid content of endothelium and lowering vaginal pH. Vaginal lubricants provide short-term relief. Women with contraindications to ERT-HRT could use lubricants for intercourse-related dryness or moisturizers for more continuous relief. The lay press promotes agrimony, black cohosh, chaste tree, dong quai, witch hazel, and phytoestrogens for vaginal dryness and dyspareunia; however, no evidence exists to support these specific claims. Pharmacists should be actively involved in identifying, preventing, and treating urogenital atrophy.

Physiological roles for K+ channels and gap junctions in urogenital smooth muscle: implications for improved understanding of urogenital function, disease and therapy

Smooth muscle cells constitute a heterogeneous collection of effector cells that, by virtue of both their constituency in blood vessels and presence as primary parenchymal cells in diverse tissues, affect the function of all organs. Thus, perhaps it is not surprising that alterations in, and/or dysfunction of, smooth muscle cells are quite common, and responsible, at least in part, for the morbidity and mortality associated with a very wide range of human diseases. These facts point to the necessity for improved understanding of the mechanism(s) governing the control of myocyte contractility (i.e., tone). Such understanding has been rapidly forthcoming in recent years, and has indicated that in many smooth muscle cell types intercellular communication through gap junctions acts in concert with nonjunctional (K+) ion channels to make important contributions to the control of myocyte tone and tissue homeostasis in physiologically diverse organs. Intercellular communication through connexin43-derived gap junction channels and K+ flux through the KCa and KATP channel subtypes, in particular, appear to play prominent roles in this process. The goal of this report, therefore, is to review the data concerning junctional and nonjunctional ion channels on the detrusor myocytes of the urinary bladder, as well as on the specialized vascular myocytes of the corpus cavernosum. The choice of an excitable (i.e., bladder detrusor myocytes) and nonexcitable (i.e., corporal smooth muscle) smooth muscle cell type ensures that the discussion will at least encompass consideration of a large portion of the spectrum of physiological possibilities for the participation of junctional and nonjunctional ion channels in the initiation, maintenance and modulation of smooth muscle tone. A central thesis of this communication is that detailed knowledge of the myocyte- and tissue-specific properties of K+ channels and gap junctions will likely lead to the improved understanding and treatment of human smooth muscle diseases/disorders.

[Radionuclide studies of the digestive organ and genitourinary system for general radiologists]

Radionuclide imaging is useful in demonstrating the functional anatomy of target organs and has been used to in routine practices involving the digestive tract and genitourinary system. Such procedures are now limited in number of practices because of the advance of morphological modalities such as CT, MRI, and US. The functional information and data analysis obtained from radionuclide studies may be feasible for CT, MRI, and US. This paper reviews radionuclide studies that are common in clinical practice in Japan.

Genitourinary chlamydial infection: a reappraisal and hypothesis

Our understanding of genitourinary chlamydial infection and disease remains limited. That natural defences and/or apparently adequate treatments leave some patients with latent disease is suspected. There is, however, no consensus as to its nature. Furthermore, many patients, most obviously males, presenting with similar or identical symptoms and signs remain unexplained in microbiological terms; this in spite of many years of dedicated research endeavour. The recent trend towards an impasse has coincided with a growing acquaintance with the immunobiology and immunopathology of chlamydial infections. The time would seem to have arrived for a reappraisal of available clinical and laboratory observations. A hypothesis with research suggestions is presented for discussion.

Sensory-motor and genito-sphincter dysfunctions in multiple sclerosis

Multiple sclerosis is a chronic demyeliniting disease of the central nervous system which is characterized by an extreme multiplicity of clinical features. Multiple sclerosis can have a profound impact on the quality of life of patients. The induced handicap varies from one patient to an other, and depends on the location of the demyeliniting lesions. Among the symptoms, sensory-motor disorders and genito-sphincter dysfunctions are some of the more disabling. Thus, up to 70% of patients suffer from urinary troubles, and 15 years after the onset of the illness, 50% of patients have difficulties for deambulation. A good knowledge of these pathologies is necessary to improve the management of patients suffering from multiple sclerosis.

The use of two estrogen preparations (a combined contraceptive pill versus conjugated estrogen cream) intravaginally to treat urogenital symptoms in postmenopausal Thai women: a comparative study

OBJECTIVE

To determine whether the combined contraceptive pill used intravaginally was as effective as the standard conjugated estrogen cream for the treatment of urogenital symptoms in postmenopausal Thai women.

SUBJECTS AND METHODS

In a randomized clinical trial, 40 postmenopausal women with urogenital symptoms were randomly allocated to two treatment groups for 8 weeks. The first group (n = 20) received a combined contraceptive pill by the vaginal route, one tablet per week at bedtime for 8 weeks. Each tablet contained 250 microg levonorgestrel plus 30 microg ethinyl estradiol. The second group (n = 20) was given 1 gm of an intravaginal conjugated estrogen cream at bedtime, three times in the first week, twice in the second week, and then once a week for the next 6 weeks (1 gram of conjugated estrogen cream contained 0.625 mg conjugated equine estrogens). Subjects were questioned about their urogenital symptoms, and vaginal cytologic smears, vaginal bacterial cultures, and urine cultures were performed before treatment and after 2, 4, and 8 weeks of therapy.

RESULTS

The vaginal pH and the proportion of the fecal type bacteria decreased in both groups, with no statistically significant difference between the groups. The karyopyknotic index and the maturation index were improved during treatment in both groups. An increase in the proportion of lactobacilli were recorded in both groups after therapy, with no significant difference between the two groups. No significant changes were observed in urinary bacteria. The therapy (combined contraceptive pill and estrogen cream) had a marked effect on urogenital symptoms (vaginal dryness, dyspareunia, urinary frequency, and urinary urgency), with impressive improvement comparably in both groups.

CONCLUSIONS

A combined contraceptive tablet administered vaginally once a week can alleviate urogenital symptoms in Thai postmenopausal women as effectively as the vaginal estrogen cream. However, the pills are much less expensive and are easily obtained in developing countries.

[The status of urodynamic examination in urologic evaluation]

Urodynamics encompass a number of functional tests of the lower and occasionally the upper urinary tract. These tests comprise uroflowmetry, cystometry or measurement of bladder pression during bladder filling and voiding, urethral pressure profile, electromyography (EMG) of the external urethral sphincter, pressure-flow studies and video-urodynamics. Alone or in combination these examinations have become essential elements of urological clinical work-up, since they do not only allow to precisely classify a functional disorder but also to establish an adequate therapy. Urodynamics are nowadays standard in any urological department.

The dynias

The "dynias" are a group of chronic, focal pain syndromes with a predilection for the orocervical and urogenital regions. They include glossodynia, carotidynia, vulvodynia, orchidynia, prostatodynia, coccygodynia, and proctodynia. In some cases, the dynias occur secondarily, but more often, despite an exhaustive evaluation, no etiology is found and in these remaining cases, the cause of the pain remains enigmatic. The controversy that surrounds this group of disorders, which ranges from questioning their existence to suggesting that they are purely psychosomatic, is counterbalanced by an extensive literature attesting to their organicity. The approach to the patient begins with acknowledging that the symptom is well described, searching for a secondary cause, and performing a careful psychologic assessment. Treatment is empirical and patients can often be helped with medications used to treat neuropathic pain, all the while providing psychologic support and exercising caution toward invasive and irreversible therapeutic procedures.

Medical and surgical strategies for treating urogynecological disorders

Symptoms and signs of the urogenital estrogen deficiency syndrome occur relatively late in a women's life when endogenous estrogen levels are well below those required to stimulate endometrial growth. At age 60 and above symptoms are common and progress with advancing age. The first and most common complaint is vaginal dryness, but symptoms of lost control of micturition as well as urge incontinence are also frequent. Recurrent infections of the lower urinary tract are common, as well as dyspareunia and a sensation of burning and itching. One third of women above age 60 suffer from urogenital estrogen deficiency syndromes, a figure that rises to two thirds at the age of 75. With a rapid growth of the elderly female population, these symptoms are an increasing burden to the individual as well as to any given health care system. Several clinical trials have repeatedly demonstrated the efficacy in alleviating these symptoms of low daily estrogen doses as exemplified by 8 micrograms/day of vaginally administered estradiol. For reasons not completely understood, the urogenital tissues respond to this low estrogen level but the endometrium does not. Hence, estrogen therapy aiming at mitigating urogenital deficiency symptoms could be given without a progestogen. No side effects have been described for vaginal preparations, and neither absolute nor relative contraindications exist. No protection is offered against cardiovascular disease or osteoporosis, though. In 1991, vaginal low-dose estrogens were declared OTC preparations in Sweden. The costs for the society for this program can be limited to the costs of medication only, for medical monitoring is not compulsory. The clinical efficiency is remarkable, and urogenital symptoms are almost abolished in elderly women receiving this type of treatment, which is practically devoid of side effects.

Manifestations of Chlamydia induced arthritis in patients with silent versus symptomatic urogenital chlamydial infection

OBJECTIVES

To evaluate whether Chlamydia-infected patients with and without urogenital symptoms have similar rheumatological manifestations or whether they belong to distinct clinical groups.

METHODS

In a university-based study, we examined patients with unexplained arthritis in whom other rheumatic diseases had been excluded for urogenital chlamydial infection, and we investigated the clinical and radiological manifestations of the Chlamydia-positive patients.

RESULTS

Sixty of 283 patients (21%) with unexplained arthritis had urogenital chlamydial infection. The infection was asymptomatic in 30%. There was no difference in the pattern of arthritis or immunological and serological characteristics in the patients with and without symptoms of urogenital infection, respectively.

CONCLUSION

The pattern of Chlamydia-induced arthritis is similar in patients with or without symptoms of urogenital chlamydial infection. To recognize CIA, it may be helpful to examine patients with unexplained arthritis for Chlamydia even though they do not have symptoms of urogenital infection.

Primary care for women. Assessment and management of genitourinary tract disorders

This article reviews the basic anatomy and physiology of the genitourinary system and disorders commonly encountered in the primary care setting. The role of the nurse-midwife in the assessment and treatment or referral of complaints of dysuria, hematuria, and incontinence is discussed. The treatment of nonpregnant women with cystitis is addressed; symptoms associated with pelvic relaxation are discussed, and a management scheme for teaching effective pelvic floor exercises is presented.

[Sympathetic skin potentials and neuroperineal disorders. Sixty-eight cases]

Sympathetic pathways can be assessed by using different electrophysiological tests. Sympathetic skin responses (SSR) are elicited with peripheral electrical stimulation of the median nerve. SSR are recorded from the skin of the hand and foot and from the genital skin. SSR were always obtained from normal volunteers with a latency of 1,685 ms. Absence of SSP recorded on the perineum is often the first sign observed in neurogenic perineal disorders.