Safety and efficacy of non-ablative CO2 laser treatment of vulvo-vaginal atrophy in women with history of breast cancer

PURPOSE

Breast cancer survivors (BCS) suffer severe vulvo-vaginal atrophy (VVA) and some of the most effective therapies are contraindicated. In literature we have no data about the non-ablative CO2 laser on these women. The aim of this study was to examine its efficacy, safety and acceptability in BCS.

MATERIALS AND METHODS

The enrolled women underwent 3 sessions of laser therapy (t0, t1, t2) and a one-month follow up examination (t3). At each time point we measured objective signs of VVA via VHI (Vaginal Health Index) and VuHI (Vulvar Health Index) and subjective parameters (Dryness, Burning, Itching, Dysuria) via visual analog scales (VAS). In sexually active women we evaluated the sexual function with FSFI (Female Sexual Function Index), FSDS (Female Sexual Distress Score) scores and MENQOL (menopause quality of life questionnaire).

RESULTS

We enrolled 26 BCS. The mean VHI, VuVHI, dryness and burning VAS scores improved significantly and this improvement was not influenced by the initial VVA grade. MENQOL sexual domain, Lubrication, Orgasm and Pain domains and FSFI total score improved significantly, while Desire, Arousal and Satisfaction domains of FSFI and FSDS did not. At t0 women using Aromatase Inhibitors suffered more severe vaginal dryness than women using Tamoxifen or no therapy, but the three subgroups improved without differences. No adverse event and minimum discomfort were reported.

CONCLUSIONS

The non-ablative CO2 laser is a safe and effective treatment of VVA and has positive effects on sexual function in BCS regardless the use of adjuvant therapies and the initial grade of VVA.

Lower Urinary Tract Symptoms in Greek Women After Menopause: The LADY Study

INTRODUCTION AND HYPOTHESIS

The genitourinary syndrome of menopause (GSM), apart from symptoms related to vulvovaginal atrophy (VVA), also consists of lower urinary tract symptoms (LUTS). Based on the common embryological origin of the genital and lower urinary system, the presence of estrogen receptors, and the high prevalence of VVA and LUTS in the menopausal population, the two conditions can coexist. This study is aimed at investigating the prevalence and risk factors of LUTS in a sample of Greek peri- and postmenopausal women.

METHODS

Four hundred and fifty (450) women, aged 40-70 years, attending three outpatient gynecology clinics for routine examination, completed a structured interview and responded to a validated questionnaire (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms, ICIQ-FLUTS).

RESULTS

Urinary urgency or frequency affected 51.6% and dysuria 43.6% of the participants. Mild urgency or frequency was described by 25.6%, moderate by 14.4%, and severe by 11.6% of the women. Mild dysuria was reported by 26.26%, moderate by 5.8%, and severe by 11.6%. Age, weight, BMI, and number of pregnancies and abortions correlated with a higher ICIQ-FLUTS score. Women with moderate/severe symptoms of VVA, such as irritation, a burning sensation, and pruritus of the vulva or vagina, had a higher ICIQ-FLUTS score than women without such symptoms (beta coefficient 2.42, CI 1.204, 3.635, p < 0.001).

CONCLUSIONS

Lower urinary tract symptoms are very common among peri- and postmenopausal women and are linked to symptoms of VVA. Our data support the need for prompt evaluation of women transitioning to menopause, as these symptoms compromise the quality of life.

Vaginal foreign bodies in children: a single-center retrospective 10-year analysis

OBJECTIVE

To evaluate the clinical features and outcome in girls with a vaginal foreign body.

METHODS

The clinical data of 97 girls with a vaginal foreign body were collected between 2010 and 2020. The descriptive analysis was used to summarize the clinical characteristics.

RESULTS

The patients were aged between 1.5 and 14.8 years, and the age of peak incidence was shown to be 3-10 years, which accounted for 88% of the cases. Blood-stained vaginal discharge or vaginal bleeding was the most common symptom (48%). The most common foreign bodies were small hard objects (57%), followed by bits of cloth or toilet tissue (22%). The patient whose foreign object was a disk battery had the most severe symptoms. When an injury of the vaginal mucosal was suspected, antibiotics were used to prevent infection, with full recovery of all patients without any additional treatment after removal of the foreign object.

CONCLUSION

If there is no damage to the vaginal mucosa, no additional treatment is needed after the foreign body is removed. When a vaginal foreign body is suspected to be a battery, emergency surgery is needed to prevent further damage.

Vaginal dilator use to promote sexual wellbeing after radiotherapy in gynecological cancer survivors

This study investigated the efficacy of a vaginal dilator (VD) for the treatment of radiation-induced vaginal stenosis (VS) and the effect of a VD on sexual quality of life.Fifty three patients with endometrial or cervical cancers participated in this prospective observational study. All participants were treated with radical or adjuvant external beam radiotherapy and/or brachytherapy. They were routinely examined 4 times after radiotherapy (RT) and were also asked to complete a validated sexual function-vaginal changes questionnaire. SPSS version 20 and Minitab version 16 were used for the statistical analysis. The statistical significance was set at P < .05.The VS grading score decreased and the comfortably insertable VD size gradually increased throughout a year of VD use; all patients with initial grade 3 showed a VS of grade 2 after 12 months of VD use and 65.8% of the patients with initial grade 2 demonstrated a final VS of grade 1, while 77.8% of the participants who started with the first size of VD reached the third size after 12 months. Starting VD therapy ≤3 months after the end of RT was associated with a significant decrease in VS. A total of 60.9% of participants reported that they did not feel their vaginas were too small during intercourse after 12 months of dilation, whereas only 11.5% gave the same answer before starting dilation. Furthermore, 47.17% rated their satisfaction with their sexual life 5 out of 7 and only 3.77% gave a score of 3 after 12 months of dilation.Endometrial and cervical cancer survivors are encouraged to use VD to treat VS and for sexual rehabilitation after RT. This study recommends starting vaginal dilation no more than 3 months after treatment at least 2 to 3 times a week for 10 to 15 minutes over 12 months. However, larger, well-designed randomized clinical trials should be conducted to develop specific guidelines for VD use and efficacy in VS and sexual sexual quality of life after RT.

Importance of Doppler ultrasound in vaginal foreign body: case report and review of the literature

The aim of this paper is to describe the distinctive ultrasound findings of a case of vaginal bleeding caused by the presence of a foreign body. We present the case of an infant who consulted for vaginal bleeding and foul-smelling discharge. The ultrasound revealed signs of vaginal distension due to heterogeneous-hematic contents and parietal thickening. At Doppler examination, a striking finding of increased vascularization limited to the upper two-thirds of the vaginal wall was found, which was initially interpreted as a sign of local inflammation suggesting the presence of an underlying foreign body. At direct vaginoscopic examination remains of toilet paper in the vaginal fundus were found. The presence of a foreign body in the vagina is an uncommon cause of discharge and vaginal bleeding in pediatrics, therefore, this etiology should be kept in mind when the adequate clinical context arises. Doppler ultrasound represents a first-line complementary method when this entity is suspected.

Interventions Preventing Vaginitis, Vaginal Atrophy after Brachytherapy or Radiotherapy Due to Malignant Tumors of the Female Reproductive Organs-A Systematic Review

BACKGROUND

Radiotherapy, as a method of treatment of cervical and uterine cancers, may induce severe late-onset vaginal side effects. Unfortunately, little evidence on the management of adverse effects has been presented. This study aimed to evaluate the available interventions which reduce symptoms of vaginitis and vaginal atrophy by improving dyspareunia, mucosal inflammation, vaginal pH and vaginal dryness in women who have undergone brachytherapy or radiotherapy due to uterine or cervical malignancies.

MATERIALS AND METHODS

A comprehensive literature search was performed following PRISMA guidelines. The systematic search was conducted using electronic databases, namely Scopus, Web of Science and PubMed, between October and November 2020 to identify randomized controlled trials (RCT) and, prospective randomized studies (PRS).

RESULTS

The analyzed population consists of 376 patients with uterine or cervical cancer, treated with hyaluronic acid, vitamin A, vitamin E, alpha-tocopherol acetate and dienestrol. Intervention with HA along with vitamin A and vitamin E revealed advantage in endpoints such as reduced dyspareunia, vaginal mucosal inflammation, vaginal dryness, bleeding, fibrosis and cellular atypia. Administration of alpha-tocopherol acetate reduced vaginal mucosal inflammation and improved vaginal acanthosis, whereas dienestrol resulted in reduced dyspareunia, vaginal caliber and bleeding.

CONCLUSIONS

Vaginal suppositories were found to be clinically effective at the management of late-onset vulvovaginal side effects after radiotherapy.

Metabolic syndrome is the key determinant of impaired vaginal lubrication in women with chronic spinal cord injury

PURPOSE

Spinal cord injury (SCI) affects sexual health of both male and female, but little attention has been given to sexuality of SCI women. Similar to penile erection, vaginal lubrication represents a neurovascular event and then both denervation and vascular damage might contribute to its impairment. Nevertheless, the relative weight of lesion location/degree and vascular risk factors in determining hypolubrication in women with SCI has not yet been investigated. The aim of this study was to recognize among putative determinants of poor sexual arousal in women with SCI, neurogenic and vascular/metabolic independent predictors of vaginal hypolubrication.

METHODS

Twenty-eight consecutive female patients admitted to a rehabilitation program because of chronic SCI (≥ 1 year) underwent clinical and biochemical evaluations, including assessment of vaginal lubrication by the Female Sexual Function Index (FSFI). As, in people with SCI, waist circumference overestimates visceral fat mass due to abdominal muscle paralysis, metabolic syndrome (MetS) was defined according to specific criteria proposed for SCI population: BMI ≥ 22 kg/m² and two or more of the following: triglycerides ≥ 150 mg/dL (or actual treatment), HDL < 50 mg/dL, hypertension (or actual treatment), fasting glucose ≥ 100 mg/dL or diabetes mellitus type 2.

RESULTS

A FSFI lubrication sub-score < 3.6, suggestive for impaired vaginal lubrication, was exhibited by 53.7% of the study population. When compared to the group with normal lubrication, a significantly higher proportion of these women had paraplegia (93.3% vs 38.5%, p = 0.003) and met the SCI-specific criteria for MetS (73.4% vs 7.6%, p = 0.0006), whereas, no significant differences were found between the two groups in the proportion of women exhibiting the single components of MetS. At the multiple logistic regression analysis, only the presence of MetS exhibited a significant independent association with impaired vaginal lubrication (OR = 3.1, 95% CI 1.2, 5.8, p = 0.01).

CONCLUSIONS

In women with SCI, a clustering of modifiable vascular/metabolic risk factors, constituting the MetS, could contribute to sexual dysfunctions by affecting the vaginal lubrication, independently of the level of the spinal cord lesion.

[Acquired vaginal stenosis: about a case and literature review]

Vaginal stenosis or gynatresia is a congenital disease and it is part of Mayer-Rokitansky-Kustner-Hauser syndrome. Acquired vaginal stenosis is a rare complication of vaginal delivery and may be caused by an infection, charlatans, birth injury or postpartum hypoestrogeny. We report a case of postpartum complete vaginal stenosis secondary to vaginal injuries as a result of medical negligence. The study involved a 19 year old patient, who had had dead child born vaginally at home, presenting with a two-year history of secondary amenorrhea associated with chronic pelvic pain. The patient reported the occurrence of multiple not sutured vaginal tears. Pelvic MRI showed complete extended vaginal stenosis of about 25mm with upstream haematological retention and bilateral hematosalpinx. The patient underwent release of vaginal adhesions followed by regular vaginal dilation. Only two cases have been reported in the literature. Pain and dyspareunia were the most common symptoms. All cases were treated by a release of the synechias and vaginal dilation.

Vaginal stones caused by urethrovaginal fistula: A case report

RATIONALE

Vaginal stone is a rare condition that is often misdiagnosed due to its low incidence. It can be divided into 2 types, primary vaginal and secondary vaginal, based on the etiology of the disease. Vaginal stones involve pathologic calcification. The formation of vaginal stones is mainly due to stasis and urine infection. We describe a procedure for the safe extraction of vaginal stones.

PATIENT CONCERNS

We report a case of a 25-year-old female patient with congenital genitourinary malformation and urethrovaginal fistula. A urogenital tract malformation repair operation was performed before she was 21 years old. Frequency of urination occurred before and after menstruation for 9 years, and dyspareunia occurred for 1 year.

DIAGNOSES

B ultrasound examination showed a 59 × 55 × 23 mm fusiform region of increased signal intensity in the vagina followed by a sound shadow. We performed a gynecologic examination and found that the long diameter of the vaginal opening was 20 mm. A brown substance observed in her vagina had a hard texture and felt like a stone, and a palpation hand test revealed the size was approximately 60 × 50 mm. A cystoscope was inserted into the urethra and revealed that the broken end of the urethra was connected to the vagina. The proximal broken end of the urethra was 20 mm from the distal end.

INTERVENTIONS

The purpose of this operation was to make a definite diagnosis and remove the stones. We performed vaginal stone removal surgery and cystoscopy under anesthesia.

OUTCOMES

We removed the stone successfully. The patient was discharged from the hospital after a smooth recovery without any complications. Follow-up was conducted 1 month after the operation and then every 3 months.

LESSONS

Although vaginal stones are rare, we must pay attention to this disease, especially in patients with congenital genitourinary malformations and urethrovaginal or vesicovaginal fistulas. Obstruction of urine discharge combined with repeated urinary tract infection is the main cause of vaginal stone formation. For these patients, follow-up every 3 months, including a physical examination, B-mode ultrasonography of the urinary system and cystoscopy if necessary, can avoid the occurrence of the disease.

Long-Term Follow-Up of Sexual Dysfunction in Women Following Allogeneic Hematopoietic Stem Cell Transplantation

Chronic graft-versus-host disease is the most common late complication following allogeneic hematopoietic stem cell transplantation. The aim of this study was to present the outcomes of two successful vaginal reconstructions. Patient 1 received chemotherapy for leukemia and underwent bone marrow transplantation (BMT). The patient was sexually inactive for 9 years. In 2012, she was diagnosed with complete vaginal obliteration and underwent vaginal reconstruction. Patient 2 underwent chemotherapy (myeloablative therapy), was sexually inactive for 3 years and was then diagnosed with complete vaginal obliteration. In January 2013, she had vaginal reconstruction with cervical dilatation. Hormonal replacement therapy was administered to both patients. The results of dedicated questionnaires revealed decent quality-of-life and normal sexual functioning and continence status after surgery. Obliteration of the vagina after BMT can be prevented, but if it occurs, vaginal reconstruction surgery should be offered to any patients suffering from obliteration. Our results show that this therapy enables patients to have normal sexual lives without compromising their continence status.

Acute and sub acute toxicity study and randomized clinical trial of polyherbal coded drug candicure in the management of acute vulvo-vaginal candidiasis

Vulvo-Vaginal Candidiasis is common gynecological disorder. Clinical trials are designed to evaluate the effect of medical intervention with allopathic and herbal medicine to treat vulvo-vaginal candidiasis. The toxicity index and the safety profile of test drug were assessed on animals' model. Toxicity study of polyherbal formulation was done in order to consider it safe before use. In acute toxicity study, a single dose of 2000 mg/kg was given to Swiss Albino mice and in sub-acute toxicity study three different doses were given to Wistar rats. Randomized Controlled Clinical Trials was conducted. Inclusion and exclusion criteria and informed consent from the patients were to be monitored. In acute toxicity study no morbidity and mortality noticed on single administration of dose 2000mg/kg/day. In sub -acute toxicity study no significant changes were observed in consumption of food and water, body weight, hematological parameters, Liver function test, renal function parameters and lipid profile. The statistical analysis showed C. albican was eradicated in 59 participants (78%) out of 75 participants by the use of Candicure (Test drug) and in 56 participants (74%) out of 75 participants by the use of Fluconazole therapy (Control drug). Chi-square test was applied and p-value was calculated 0.3101 which is greater than 0.05 showed that Candicure therapy and Fluconazole therapy is equally significant in eradication of C. albican. The acute and sub-acute toxicity study of polyherbal formulation on experimental animals is safe at a dose of 2000mg/kg/day. The clinical findings of randomized controlled trial revealed that the effect was almost comparable to control drug in eradicating the micro-organism.

Spontaneous vaginal cuff dehiscence and evisceration of multiple organs: A case report

RATIONALE

Vaginal cuff dehiscence and evisceration constitute a rare but potentially life-threatening event that usually occurs in postmenopausal patients who have undergone hysterectomy. This is a valuable case of spontaneous transvaginal evisceration without pelvic surgery history.

PATIENT CONCERNS

A 74-year-old postmenopausal woman with an obstetric history of 7 full term vaginal deliveries, experienced sudden evisceration when she attempted to defecate.

DIAGNOSES

Spontaneous vaginal cuff dehiscence and multiorgan evisceration.

INTERVENTIONS

After physical examination and fluid resuscitation, the patient had underwent the Hartmann's procedure, total hysterosalpingo-oophorectomy, sacrocolpopexy, and posterior colporrhaphy.

OUTCOMES

The patient recovered well and the constipation symptoms have significantly improved. One-year follow-ups examination revealed complete healing of the vaginal cuff, and there was no evidence of prolapse.

LESSONS

We report a case of spontaneous vaginal cuff evisceration without pelvic surgery history but with constipation and redundant sigmoid colon. After resecting the necrotic sigmoid colon, the patient's constipation symptoms significantly improved. It is reasonable to speculate that the etiology was related to severe sigmoidocoele.

Incidence of vaginal erosion with different synthetic materials for suburethral sling in the treatment of Stress Urinary Incontinence: A systematic review

INTRODUCTION

The aim of this systematic review is to compare the vaginal erosion rates in different synthetic materials used in suburethral slings in Tension Free Vaginal Tape (TVT-O /TOT) procedures in management of female stress urinary incontinence.

METHODS

PRISMA 2009 framework was adopted for study design. Scholarly literature search was done using MEDLINE, EMBASE, the Cochrane Library and Clinical Trials.gov using selected keywords. Five articles fulfilled the inclusion and exclusion criteria. Our main outcome of interest is to review the ideal properties of the suburethral sling, procedure of insertion and post-surgical complication following the sling insertion primarily vaginal erosion. Results were compared using one way-ANOVA test and independent T- test.

RESULTS

Total of 1725 subjects were available for analysis in the five studies. Monofilament polypropylene constituted 92.5% of the total sample size from one study alone. Polyester (n= 16/51) causes higher incidence rate of vaginal erosion compared to monofilament polypropylene (31.4 vs., 4.7; p = 0.01). There was no difference in the vaginal erosion rate between monofilament polypropylene and multifilament polypropylene (4.7 vs, 14.1; p=0.055) as well as between multifilament polypropylene and polyester (14.1 vs, 31.4; p=0.068). Although there was a marginally lower rate of vaginal erosion in TVT-O over TVT, the difference was not significant. (5.6 vs., 6.4, p=0.468). Common presentations of vaginal erosion were vaginal discharge, perineal pain and dyspareunia.

CONCLUSION

Given the limited sample size, polyester sling material appears to cause higher rates of vaginal erosion. No difference in erosion rate was seen between TVT and TVT-O.

Imperforate Hymen and Vaginal Atresia and their Associated Anomalies

The presenting features and associated abnormalities of imperforate hymen and vaginal atresia were studied in 24 girls under the age of 16 years. Hydrocolpos or hydrometrocolpos occurred in 8 infants, 13 older girls developed haematocolpos, but 3 of the girls had no distension of the genital tract. Seven of the older girls were diagnosed as having appendicitis. Anorectal anomalies were present in 9 of the children. Intravenous pyelography was performed on 16 girls and was normal in only one. Urinary tract investigations are indicated in all girls with vaginal outlet obstruction, and the vaginal orifice should be inspected in all girls with anorectal abnormalities.

Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal survey

OBJECTIVE

To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress.

DESIGN

Longitudinal survey.

SETTING

Two hospital-based colposcopy clinics.

POPULATION

Women with abnormal cytology who underwent colposcopy (±related procedures).

METHODS

Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables.

MAIN OUTCOME MEASURES

Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress.

RESULTS

Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up.

CONCLUSIONS

The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress.

TWEETABLE ABSTRACT

Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.

Efficacy and tolerability of a plant-based, multi-component cream (Ginetrox®) in vulvovaginal disorders of the genitourinary syndrome during menopause

BACKGROUND

Genitourinary syndrome of menopause (GSM) is a symptomatic condition including vaginal dryness, irritation, dyspareunia and recurrent urinary tract infections which affects 40-54% of post-menopausal women. Although several estrogen-based therapies are available, it is generally preferable to avoid hormonal therapy, particularly in women with mild symptoms or at risk for estrogen-responsive neoplasia. Therefore, the most common treatment options are over-the-counter vaginal creams for symptomatic relief.

METHODS

Thirty-three postmenopausal women suffering from GSM were enrolled in this observational study. A multi-component cream (Ginetrox®, Indena, Milan, Italy) was applied on the vestibular area of the vagina for three months. The primary endpoints were: vaginal burning and/or pain, assessed by Visual Analog Scale and dyspareunia, assessed using the Marinoff Score. As a secondary endpoint, vestibular health was evaluated through a four-point scale. Side effects and adherence to treatment were also recorded.

RESULTS

Statistically significant improvement was observed in pain scores and dyspareunia at the end of the treatment compared to baseline values. The vestibular health index significantly decreased after 3 months. Tolerability was acceptable.

CONCLUSIONS

This preliminary study suggests that the plant-based, multi-component cream Ginetrox® could be effective and safe in counteracting menopause-related vaginal discomfort symptoms.

New options for menopausal symptoms after 15 years of WHI Study

Menopausal symptoms include vasomotor symptoms (VMS), vulvar-vaginal atrophy, and loss of bone mass associated with an increased risk of fracture. Treatment of VMS consists of lifestyle changes, hormone treatment (estrogens with and without progestogens, tissue selective estrogens complex or conjugated estrogens and bazedoxifene [CE/BZA], progestogens, and tibolone), and nonhormonal treatments. Genitourinary symptoms due to vulvar-vaginal atrophy are treated with systemic and local hormones, moisturizer creams and gels, CE/BZA, and a selective estrogen receptor modulator (ospemifene). In addition to lifestyle changes, treatments for the risk of fragility fracture include calcium and vitamin D, hormone treatment, selective estrogen receptor modulators (raloxifene, BZA), bisphosphonates, strontium ranelate, denosumab, and teriparatide. This article reviews treatment options and provides treatment algorithms for women with menopausal symptoms.

Endometriosis and Glanzmann’s thrombasthenia

Glanzmann’s thrombasthenia (GT) is a rare bleeding syndrome characterized by deficiency or defect of platelet aggregation complex. The pathogenesis of endometriosis is controversial but the strongest evidence leans towards retrograde menstruation. GT probably predisposes to endometriosis. The management of women affected by this disease can be difficult due to the risk of bleeding complications, especially during surgical treatment. We describe the cases of three sisters affected by endometriosis and GT, referred to our Department, who received different therapeutic management.

Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction

We present the British Association for Sexual Health and HIV (BASHH) Special Interest Group for Sexual Dysfunction recommendations for the management of vaginismus. The recommendations outline the history, prevalence, aetiological factors, patient assessment and management for this sexual problem. Treatment strategies are discussed along with general recommendations and auditable outcomes.

Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis

IMPORTANCE

Between 40% and 50% of women in Western countries use complementary therapies to manage menopausal symptoms.

OBJECTIVE

To determine the association of plant-based therapies with menopausal symptoms, including hot flashes, night sweats, and vaginal dryness.

DATA SOURCES

The electronic databases Ovid MEDLINE, EMBASE, and Cochrane Central were systematically searched to identify eligible studies published before March 27, 2016. Reference lists of the included studies were searched for further identification of relevant studies.

STUDY SELECTION

Randomized clinical trials that assessed plant-based therapies and the presence of hot flashes, night sweats, and vaginal dryness.

DATA EXTRACTION

Data were extracted by 2 independent reviewers using a predesigned data collection form.

MAIN OUTCOMES AND MEASURES

Hot flashes, night sweats, and vaginal dryness.

RESULTS

In total, 62 studies were identified, including 6653 individual women. Use of phytoestrogens was associated with a decrease in the number of daily hot flashes (pooled mean difference of changes, -1.31 [95% CI, -2.02 to -0.61]) and vaginal dryness score (pooled mean difference of changes, -0.31 [95% CI, -0.52 to -0.10]) between the treatment groups but not in the number of night sweats (pooled mean difference of changes, -2.14 [95% CI, -5.57 to 1.29]). Individual phytoestrogen interventions such as dietary and supplemental soy isoflavones were associated with improvement in daily hot flashes (pooled mean difference of changes, -0.79 [-1.35 to -0.23]) and vaginal dryness score (pooled mean difference of changes, -0.26 [-0.48 to -0.04]). Several herbal remedies, but not Chinese medicinal herbs, were associated with an overall decrease in the frequency of vasomotor symptoms. There was substantial heterogeneity in quality across the available studies, and 46 (74%) of the included randomized clinical trials demonstrated a high risk of bias within 3 or more areas of study quality.

CONCLUSIONS AND RELEVANCE

This meta-analysis of clinical trials suggests that composite and specific phytoestrogen supplementations were associated with modest reductions in the frequency of hot flashes and vaginal dryness but no significant reduction in night sweats. However, because of general suboptimal quality and the heterogeneous nature of the current evidence, further rigorous studies are needed to determine the association of plant-based and natural therapies with menopausal health.

Surgical management of vulvovaginal agglutination due to lichen planus

Lichen planus is a rare dermatological disorder that is often associated with painful and disfiguring vulvovaginal effects. At the University of Michigan Center for Vulvar Diseases, we see many women with vulvovaginal lichen planus each year, with marked scarring and vulvovaginal agglutination that precludes vaginal intercourse and causes difficulty with urination. Through our experience, we developed a protocol for the operative management and postoperative care for severe vulvovaginal agglutination. Our objective is to share this protocol with a wider audience so that providers who see patients with these devastating effects of lichen planus can benefit from our experience to better serve this patient population. The figure represents a case of erosive lichen planus with early vaginal agglutination. The video reviews the pathophysiology and presentation of lichen planus. We then present a case of scarring and agglutination in a young woman, including our surgical management and postoperative care recommendations.

Hyaluronic acid and vitamins are effective in reducing vaginal atrophy in women receiving radiotherapy

AIM

During the last decades, therapies targeting cervical cancer have been considerably improved. Surgery and radiotherapy (RT) represent the main common therapeutic approach in cervical cancer. In order to minimize the side effects of radiotherapy approach, several protocols have been developed such as brachytherapy (BRT). Among the side effects associated with RT, the vaginal atrophy is the most important and common one. Vaginal atrophy, in turn, leads to additional alterations like inflammation, associated to relevant symptoms such as itching, burning and dyspareunia. All these alterations heavily affect the quality of women's life. The aim of our study was to evaluate the toxicity induced by RT on vaginal mucosa, and the adjuvant action of a product containing LMWHA, vitamin A, and Vitamin E (Santes®, Lo.Li. Pharma, Rome, Italy). The introduction of adjuvant therapies may have likely had a relevant place in providing that result.

METHODS

A prospective randomized study was designed. From October 2006 to October 2008, 45 women with a mean age 38 ± 6 years were enrolled. After surgery, all patients were treated with 4 weeks of RT and 4 weeks of BRT, concomitantly with chemiotherapy. They were randomly assigned in two groups: 23 women were treated with two suppositories (Santes®) per day for 4 months. For the first two months the preventive treatment was simultaneous to RT and BRT. Instead the control groups for composed by 22 patients and they did not undergo any treatment during RT. To evaluate the efficacy of Santes® treatment three biopsies were performed.

RESULTS

At the second biopsy, after the BRT therapy, the treated group showed a statistically significant improvement (P<0.05 vs. control) on inflammation, cell atypia, fibrosis, mucositis and bleeding. At the third biopsy, two months after BRT, further statistically improvement were observed for all RT/BRT associated side effects. The treatment showed an efficacy also in terms of pain severity.

CONCLUSION

Our data suggest that low molecular weight HA shows good performances in treating RT-damaged tissue and plays a key role in all steps of the healing process. Indeed the results shows that women exposed to RT treatments and simultaneously treated with Santes®, had an optimal resolution of vaginal atrophy and related symptoms.

Does vaginal estrogen treatment with support pessaries in vaginal prolapse reduce complications?

OBJECTIVE

Pelvic organ prolapse is often co-existant with atrophy of the genital tract in older women who tend to prefer vaginal pessaries for prolapse. Vaginal estrogen therapy is used by some along with a support pessary for prolapse with no robust evidence to back this practice. We aimed to evaluate differences in complications of support pessaries for vaginal prolapse in postmenopausal women, with and without vaginal estrogen use.

STUDY DESIGN

We prospectively assessed postmenopausal women attending the urogynaecology clinic for a pessary change. We asked them about the level of discomfort during pessary change (visual analogue scale for pain), discharge, bleeding and infection. Ethics approval was not required as this was a service evaluation project. Statistical analysis for relative risk was performed, including sub-group analysis for 'ring pessary' and 'non-ring group' (Shelf, Gellhorn, Shaatz).

RESULTS

Between July 2013 and December 2014, we assessed 120 postmenopausal women using support pessaries for prolapse. The mean age was 70 years; 45% of the patients used vaginal estrogen. There were no statistically significant differences in complications with or without vaginal estrogen use, although the trend was higher amongst non-users. The 'non-ring' sub-group not using vaginal estrogen had a higher risk of vaginal ulceration, bleeding and discharge.

CONCLUSION

Postmenopausal women may have lesser complications when using vaginal estrogen with a support pessary for prolapse, particularly with pessaries other than the ring. An adequately powered randomised controlled trial is needed to assess conclusively whether vaginal estrogen enhances comfort and reduces complications of support pessaries for prolapse.

Common vaginal and vulvar disorders

Vaginal and vulvar disorders are among the leading causes for women to visit a health care professional. Therefore, it is important to have a basic understanding of these diseases. Although rarely life threatening, these disorders can impact significantly a woman's sexual function and sense of well-being.

Short-term effect of vaginal erbium laser on the genitourinary syndrome of menopause

AIM

In this study we evaluated the short term effects of vaginal erbium laser (VEL) in the treatment of postmenopausal women (PMW) suffering from genitourinary syndrome of menopause (GSM).

METHODS

Sixty-five PMW were evaluated before and after VEL treatment (1 treatment every 30 days, for 3 months). GSM symptoms were evaluated either with subjective (Visual Analog Scale, VAS) and objective (Vaginal Health Index Score, VHIS) measures. In addition, in 21 of these PMW suffering from mild-moderate stress urinary incontinence (SUI), the degree of incontinence was evaluated with the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) before and after VEL treatments.

RESULTS

VEL treatment induced a significant decrease of VAS of both vaginal dryness, dyspareunia (P<0.01) and a significant (P<0.01) increase of VHIS). In addition, VEL treatment induced a significant (P<0.01) improvement of ICIQ-SF scores in PMW suffering from SUI. VEL was well tolerated with less than 2 % of patients discontinuing treatment due to adverse events.

CONCLUSION

VEL treatment significantly improves vaginal dryness, dyspareunia and mild-moderate SUI. Larger and long-term studies are needed to investigate the role of laser treatments in the management of GSM.

[Obstructed hemivagina and ipsilateral renal anomaly: unusual cause of piocolpos. Report a case and review of literature ]

OHVIRA (Obstructed hemivagina and ipsilateral renal anomaly) by acronym and abbreviations in English or Herlyn Werner Wunderlich syndrome is a rare congenital malformation caused by an alteration in the Mullerian ducts and Wolffian Ducts. Which is characterized by a triad: uterus didelphys, obstructed and ipsilateral renal agenesis hemivagina still uncertain etiology. Patients are usually asymptomatic until menarche where the most common clinical presentation is pelvic pain, followed by a vaginal or abdominal mass, normal menstrual periods, infertility, and vaginal discharge rarely appears. The case of a female patient of 15 years, nubile with chronic fetid vaginal discharge, initially diagnosed and treated as pelvic inflammatory disease occurs, however because it is an exceptional condition with the background of the patient, by complementary studies were conducted where pelvic ultrasound revealed pyocolpos and absence of left kidney, uterus didelphys, blind hemivagina by other imaging studies, where we could integrate Herlyn-Werner-Wunderlich syndrome. In conclusion, abnormalities in the development of the Miillerian ducts are difficult to diagnose early, so you must have the embryological knowledge, conduct thorough clinical assessment and detailed picture in whom the coridition is suspected to identify malformations coexisting urinary tract and vaginal defects with the importance of preserving reproductive success through appropriate planning of surgical approach, given that the fertility rate in these patients is comparable to the average.

An alternative approach for the treatment of vaginal atrophy

AIM

The aim of this study was to determine the efficacy of a new topic non-hormonal treatment for postmenopausal women complaining of symptoms of vaginal atrophy.

METHODS

Patients included in the study were prescribed Sinecol gel (AM PHARMA Srl, Vimercate, Monza and Brianza, Italy) application once a day for 20 consecutive days. Sinecol gel is a topic compound for vaginal atrophy containing hyaluronic acid, that is known to improve vaginal elasticity, lactoperoxidase, Xantham gum and glucose oxidase, which have protective and antibacterial action. We evaluated each patient before and after treatment, both subjectively with the "Visual Analogical Scale" (VAS) and objectively with the "Vaginal Health Index" (VHI).

RESULTS

We observed a significant clinical improvement of the subjective and objective assessment of symptoms severity with a p value <0.001 at the end of the treatment compared to baseline.

CONCLUSION

Sinecol gel appears to be an effective and valid non-hormonal alternative to the estrogen therapy for vaginal atrophy.

An unusual-appearing suburethral diverticulum resulting from trauma: a case report

BACKGROUND

A suburethral diverticulum is a herniation of the urethra into the potential space between the anterior vaginal wall and the periurethral fascia. We report a case of an unusual-appearing suburethral diverticulum that resulted from repetitive self-induced trauma.

CASE

A 43-year-old, mentally handicapped woman presented to our clinic for evaluation of a papillary mass projecting from her anterior vaginal wall. Her caretakers reported that the woman traumatized herself periodically to induce vaginal bleeding. After evaluation the mass was excised in the operating room, and the diagnosis of a suburethral diverticulum was confirmed.

CONCLUSION

Self-induced trauma as an etiology of suburethral diverticula should be considered in patients with atypical-appearing masses of the anterior vaginal wall.

Severe gynecologic sequelae of Stevens-Johnson syndrome and toxic epidermal necrolysis caused by ibuprofen: a case report

BACKGROUND

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a serious, drug-induced, life-threatening condition characterized by an epidermal blistering rash with necrosis, desquamation and mucosal surface involvement. This patient represents the youngest and most significant case report in the literature of gynecologic damage due to TEN.

CASE

A 31/2-year-old girl developed TEN involving 90% of her body surface area after exposure to pediatric ibuprofen. After onset of puberty she required surgery to treat vulvar, vaginal and cervical adhesions, stenosis and hematometra.

CONCLUSION

While delaying evaluation and treatment of the extremely young child with this disorder until puberty has been the standard, consideration should be given to earlier evaluation and intervention.

Vaginal cuff dehiscence after hysterectomy

OBJECTIVE

To determine the incidence of vaginal cuff dehiscence (VCD) among women undergoing hysterectomy according to clinico-surgical factors including surgical route, and to describe patient characteristics associated with VCD.

METHODS

In a retrospective study, the medical records of all women who underwent hysterectomy between January 2005 and March 2011 at a university teaching hospital in Seoul, Republic of Korea, were reviewed. The incidence of VCD was determined in relation to the following factors: patient age, hysterectomy route, indication for hysterectomy, and extent of resection (either simple or radical hysterectomy).

RESULTS

Among 9973 hysterectomies, 37 (0.37%) cases of VCD were identified. The incidence of VCD was significantly higher after abdominal hysterectomy (0.6%) than after laparoscopic (0.2%) or vaginal (0.4%) hysterectomy (P=0.016). Compared with laparoscopic approaches, abdominal hysterectomy was associated with a higher risk of VCD (odds ratio, 2.735; 95% confidence interval, 1.380-5.420). However, there was no significant difference in the incidence of VCD according to surgical indication or extent of resection.

CONCLUSION

Laparoscopic hysterectomy was found to be associated with a lower risk of VCD compared with abdominal hysterectomy. The lower risk is probably related to the different techniques used for colpotomy and cuff closure.

A multi-omic systems-based approach reveals metabolic markers of bacterial vaginosis and insight into the disease

BACKGROUND

Bacterial vaginosis (BV) is the most common vaginal disorder of reproductive-age women. Yet the cause of BV has not been established. To uncover key determinants of BV, we employed a multi-omic, systems-biology approach, including both deep 16S rRNA gene-based sequencing and metabolomics of lavage samples from 36 women. These women varied demographically, behaviorally, and in terms of health status and symptoms.

PRINCIPAL FINDINGS

16S rRNA gene-based community composition profiles reflected Nugent scores, but not Amsel criteria. In contrast, metabolomic profiles were markedly more concordant with Amsel criteria. Metabolomic profiles revealed two distinct symptomatic BV types (SBVI and SBVII) with similar characteristics that indicated disruption of epithelial integrity, but each type was correlated to the presence of different microbial taxa and metabolites, as well as to different host behaviors. The characteristic odor associated with BV was linked to increases in putrescine and cadaverine, which were both linked to Dialister spp. Additional correlations were seen with the presence of discharge, 2-methyl-2-hydroxybutanoic acid, and Mobiluncus spp., and with pain, diethylene glycol and Gardnerella spp.

CONCLUSIONS

The results not only provide useful diagnostic biomarkers, but also may ultimately provide much needed insight into the determinants of BV.

An overview of chronic vaginal atrophy and options for symptom management

During the menopausal transition and after menopause, up to 45 percent of women will develop vaginal atrophy as a consequence of decreased levels of circulating estrogen. Symptoms include vaginal dryness, itching, soreness, bleeding, increased susceptibility to infection and pain with sexual intercourse. Treatments are often underused because of patient and clinician lack of knowledge of available treatments, embarrassment about initiating a discussion of symptoms and reluctance to initiate hormonal therapy. Methods of symptom management include self-care with over-the-counter agents and prescription treatment with various forms of localized estrogen. Clinicians should consider each woman's unique situation and health history before recommending a management strategy.

Management of vaginal dryness and dyspareunia in estrogen sensitive cancer patients

Cancer patients suffer from vaginal dryness and dyspareunia earlier and longer than the general population, with more severe and distressing symptoms. Life-style advices are the first step and vaginal lubricants can be tried, but they can't completely relieve atrophic symptoms. The most effective therapy is use of vaginal estrogens, but compliance and management are particularly difficult in estrogen sensitive cancer patients because of their systemic absorption. Compliance can be improved if they are begun at a very low dose and gradually increased until the lowest effective dose is reached. Promestriene only possesses an intramucosal effect, it can be used at very low doses in cancer patients suffering from urogenital symptoms.

Vaginally inserted herbs causing vesico-vaginal fistula and vaginal stenosis

A 32-year-old woman developed a vesico-vaginal fistula and vaginal stenosis following insertion of herbs into her vagina by a traditional doctor to "melt" her uterine myomata. She underwent successful trans-abdominal repair of her fistula and passive dilatation of her vagina was recommended for the vaginal stenosis. The emerging importance of traditional treatments as a cause of vesico-vaginal fistula is highlighted. The role of quality improvement through research and strict regulation to maximise the benefits of traditional treatment and minimise complications is also emphasised.

[Cerebral venous thrombosis in Behçet's disease]

Behçet's disease (BD) is a chronic relapsing inflammatory disorder of unknown aetiology with involvement of multiple organs. The incidence of BD is highest in the countries along the ancient Silk Route. In approximately 9% of the BD patients there is involvement of the central nervous system (CNS). We present a case of a 32 year-old Lebanese woman with severe headache and papilloedema due to a cerebral venous thrombosis and secondary intracranial hypertension. During follow-up she was diagnosed with bilateral uveitis and a history of recidivating oral and genital ulcerations was disclosed. BD with CNS affection is an important diagnosis to keep in mind in case of cerebral venous thrombosis.

[Tethered vagina syndrome after classical anterior colporrhaphy]

We presented etiology symptomatology and diagnosis of the tethered vagina syndrome. Detailed information concerning pharmacological and surgical treatment was given. Surgical method of vaginal anatomy restoration using Martius flap technique was described in patients with tethered vagina syndrome after classical anterior colporrhaphy. We paid special attention to a particular type of genital fibrosis such as labial fusion in girls.

Pain at Midlife

Although menopause is a normal developmental milestone through which all women pass, the transition has been long associated with chronic pain conditions that may be more accurately viewed as secondary to aging. Clinicians need to understand management of pain problems women may experience. This article examines pain syndromes including headache, back pain, osteoarthritis, pelvic pain, vulvo-vaginal pain, and burning mouth syndrome.

[Analysis of prevalence and risk factors of pelvic organ prolapse of women underwent gynecologic health care in Peking Union Medical College Hospital]

OBJECTIVE

To investigate prevalence and risk factors of pelvic organ prolapse in women underwent routine gynecologic health care in Peking Union Medical College Hospital (PUMCH).

METHODS

From Jan. 2008 to Aug. 2009, 972 women underwent gynecological health care in PUMCH were enrolled in this study. Questionnaires and pelvic examinations were given. The pelvic organ prolapse quantitive examination (POP-Q) system was used as the assessment tool.

RESULTS

(1) Among all participants, the mean ages were (42 ± 10) years (range 22 to 78 years), the mean height were (162 ± 5) cm (range 142 to 180 cm), and the mean weight were (59 ± 8) kg (range 42 to 91 kg). 83.8% (815/972) of women were multipara. The mean total vaginal length (TVL) of 972 women was 8.20 cm. No women met the standard of pelvic organ prolapse, while 35.5% (345/972) of women presented mild posterior vaginal descent and 96.7% (940/972) presented mild anterior vaginal descent, all of them were asymptomatic. (2) The length of genital hiatus (gh), TVL and C, D proximal to the hymen in nullipara were (2.26 ± 0.32), (8.08 ± 0.30), (-7.08 ± 0.24) and (-8.08 ± 0.30) cm, which were significantly less than (2.33 ± 0.39), (8.22 ± 0.35), (-7.14 ± 0.28) and (-8.22 ± 0.35) cm in multipara (P < 0.05). Ap and Pb proximal to the hymen of (-2.87 ± 0.22) and (-2.87 ± 0.22) cm in nullipara were significantly larger than (-2.81 ± 0.25) and (-2.81 ± 0.25) cm in multipara (P < 0.05). When compared with nullipara, the incidence of posterior and anterior vaginal wall protrusion were increased (OR = 1.819). (3) The index of POP-P were compared among women at groups of 22 - 34 years, 35 - 49 years and more than 50 years (P < 0.05). Those index did not show statistical difference between women at group of 22 - 34 years and group of 35 - 49 years (P > 0.05). However, those in women at group of 22 - 34 years and 35 - 49 years showed statistical difference when compared with women at group of more than 50 years (P < 0.05). When compared with women at group of 22 - 34 years, the incidence of posterior and anterior vaginal wall protrusion were increased (OR = 1.713, 3.765). (4) Menopause status was associated with severities of all kinds of descent (P < 0.05) and presence of posterior vaginal protrusion (OR = 3.354).

CONCLUSIONS

Mild anterior and posterior vaginal descent by POP-Q were common among women in China. The risk of anterior vaginal descent is relatively higher than posterior vaginal descent. However, most of the women with descent are asymptomatic and need no treatment. The most important factors associated with the severity and detectable ratio of descent is parity and age.

Vulvovaginal atrophy

Vulvovaginal atrophy (VVA) is a common and underreported condition associated with decreased estrogenization of the vaginal tissue. Symptoms include dryness, irritation, soreness, and dyspareunia with urinary frequency, urgency, and urge incontinence. It can occur at any time in a woman's life cycle, although more commonly in the postmenopausal phase, during which the prevalence is close to 50%. Clinical findings include the presence of pale and dry vulvovaginal mucosa with petechiae. Vaginal rugae disappear, and the cervix may become flush with the vaginal wall. A vaginal pH of 4.6 or more supports the diagnosis of VVA. Even while taking systemic estrogen, 10% to 20% of women may still have residual VVA symptoms. Breast cancer treatment increases the prevalence of VVA because the surgical, endocrine, and chemotherapeutic agents used in its treatment can cause or exacerbate VVA. Local estrogen treatment for this group of women remains controversial.

Severe vaginal chronic graft-versus-host disease (GVHD): two cases with late onset and literature review

Female genital graft-versus-host disease (GVHD) occurs after allogenic stem cell transplantation (SCT) in 25% of long-term survivors. To date, 28 severe cases with hematocolpos requiring surgery have been documented. We report two cases of severe gynecological GVHD. Although most of the vaginal GVH disease cases occurred within two years after oncologic treatment, our two cases highlight the possibility of a very long onset. We also confirmed that hormonal replacement therapy does not protect against synechia and that corticoid treatment has a good therapeutic value in recurrence after surgery. In conclusion, women with SCT experience a high risk of vaginal GVHD that could impair quality of life and sexual function. These cases pinpointed the importance of very long-term gynecological follow-up in order to diagnose early symptoms. To date, only early therapy with local corticoid application might reduce symptoms and development of severe genital GVHD. We support systematic use of topical corticoid therapy in severe cases even after surgery because of the high incidence of recurrence.

Undertreatment of menopausal symptoms and novel options for comprehensive management

OBJECTIVE

There is currently a gap in treatment options for menopausal symptoms and a need for comprehensive therapies that are safe and effective for postmenopausal women. This review discusses challenges in the management of menopausal symptoms and the effect of the Women's Health Initiative (WHI) study findings on current treatment patterns. It also examines present and future therapies.

RESEARCH DESIGN AND METHODS

A literature search was conducted using Medline, the Cochrane Database, and the National Heart Lung and Blood Institute WHI website with the following search terms: primary care, menopause, vasomotor symptoms, hormone therapy, osteoporosis, and vaginal atrophy. Searches were limited to articles published between 1995 and 2009.

RESULTS

Comprehensive therapies that target several aspects of menopause, such as vasomotor symptoms and chronic disease prevention, are currently hormone based. These hormone-based approaches are considered more effective than currently available nonhormonal therapies for the relief of menopausal symptoms. However, hormone therapy is not recommended for women at high risk for venous thromboembolic events, cardiovascular disease, and/or breast cancer. A need exists for novel therapies that mitigate menopausal symptoms, provide protection from osteoporosis, and encourage patient compliance without promoting cancer, heart disease, or stroke. Emerging modalities and strategies, such as the tissue selective estrogen complex (TSEC), Org 50081, MF101, and desvenlafaxine, may provide improved options for postmenopausal women.

CONCLUSIONS

Several new menopausal therapies that may help to address the ongoing unmet need for safe and effective therapies for postmenopausal women are currently in development. In particular, the TSEC, which provides the benefits of both a selective estrogen receptor modulator and conjugated estrogens with an improved tolerability profile, may offer advantages over currently available treatment options. Limitations of this review include the narrow search criteria and limited search period.

The pathophysiology of an enterocele and its management

This paper describes 130 patients with enteroceles and their treatment. It includes analysis of all cases with enterocele over a 17-month period in a pelvic floor dysfunction database. Procedures performed included the Moschcowitz procedure with suspension of the vaginal vault to the sacrum in 13 patients (10%), colposacrosuspension (CSS) (mesh from the upper posterior half of the vagina to the sacrum with mobilisation and fixation of the rectum to the mesh) in 39 patients (30%), perineocolposacrosuspension (PCSS) (similar to CSS, but the mesh is inserted further down to the perineum) in 48 patients (37%) and perineopubo-colposacrosuspension (PPCSS) (as PCSS, but with a second mesh between the bladder and vagina extending to the sacrum) in 30 patients (23%). An additional modified Burch colposuspension was performed in 87 patients (67%). A failure was defined as a recurrent vaginal prolapse of Grade II or more, or urinary incontinence requiring surgical correction. The patients' mean age was 60.5 years, their mean parity 3.3 and 92.3% were white. Preoperatively, 33.8% of the patients complained of constipation, 33.1% of difficulty in defaecation and 77% had bladder symptoms, suggesting urinary stress incontinence or detrusor instability. In 74.6% of the patients part of the vagina protruded through the vaginal introitus. The mean period of follow-up was 7.4 months (range 1-26) with only 13 patients (10%) not followed. Only two patients (1.5%) developed Grade II vaginal prolapse (both cystoceles and both from the PCSS group). Urinary stress incontinence in need of further treatment developed in 13 patients (10%). The failure rate, therefore, was 11.5%. In six patients (4.6%) the mesh had to be removed due to mesh reaction. In all cases the mesh was unabsorbable. Vaginal suspension procedures with mobilisation of the rectum provided satisfactory results for severe enterocele over the short term.