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Background: Postpartum women often experience stress urinary incontinence (SUI) and vaginal microbial dysbiosis, which seriously affect women's physical and mental health. Understanding the relationship between SUI and vaginal microbiota composition may help to prevent vaginal diseases, but research on the potential association between these conditions is limited., Results: This study employed 16S rRNA gene sequencing to explore the association between SUI and vaginal dysbiosis. In terms of the vaginal microbiota, both species richness and evenness were significantly higher in the SUI group. Additionally, the results of NMDS and species composition indicated that there were differences in the composition of the vaginal microbiota between the two groups. Specifically, compared to postpartum women without SUI (Non-SUI), the relative abundance of bacteria associated with bacterial dysbiosis, such as Streptococcus, Prevotella, Dialister, and Veillonella, showed an increase, while the relative abundance of Lactobacillus decreased in SUI patients. Furthermore, the vaginal microbial co-occurrence network of SUI patients displayed higher connectivity, complexity, and clustering., Conclusion: The study highlights the role of Lactobacillus in maintaining vaginal microbial homeostasis. It found a correlation between SUI and vaginal microbiota, indicating an increased risk of vaginal dysbiosis. The findings could enhance our understanding of the relationship between SUI and vaginal dysbiosis in postpartum women, providing valuable insights for preventing bacterial vaginal diseases and improving women's health., (© 2024. The Author(s).)

Background: The purpose of this study was to evaluate the vaginal microecology and the distribution of human papillomavirus (HPV) subtypes in patients with uterine adhesions and explore the correlation between HPV infection and vaginal microecology imbalance and the occurrence of intrauterine adhesion (IUA)., Methods: A total of 479 women were enrolled in the study, including 259 in the normal group and 220 in the IUA group. Vaginal microecological and HPV analyses were performed on all participants. Significant differences between the two groups were analyzed, and Spearman correlation analysis was performed., Results: The incidence of IUA in patients between 31 and 40 years of age was high. The I-II degree of vaginal cleanliness in the IUA group was significantly lower than that in the normal group, and the number of III-IV degree was significantly higher than that in the normal group. Moreover, the incidences of VVC (vulvovaginal candidiasis) and vaginal disorders and infections with HPV 16 and HPV 52 subtypes were significantly higher in the IUA group than in the normal group. The incidence of high-risk HPV infection combined with vaginal disorders in the IUA group was higher than that in the normal group. Correlation analysis showed that the occurrence of IUAs was positively correlated with HPV infection and negatively correlated with PH and vaginal microecological imbalance., Conclusion: The HPV infection rate and vaginal microecology disorders affect the occurrence of IUAs. For patients with IUAs, control of the HPV infection rate and the prevention of vaginal microecological disorders should be improved., (© 2023. The Author(s).)

Background: Batteries are known to cause damage to mucosal surfaces. Unfortunately, the timing of serious sequelae and recommendations for removal of a vaginally inserted battery in a premenopausal patient are not well characterized. This case report aims to detail the timeline of events and complications after vaginal insertion of a 9-volt alkaline battery and to further clarify the recommendation for urgent removal., Case: A 24-year-old nulliparous woman with significant psychiatric and trauma history was admitted for ingestion and insertion of multiple foreign objects, including a 9-volt battery that she inserted into her vagina during her hospital admission. Examination under anesthesia was required for removal of the battery, with cervical and vaginal necrosis and partial-thickness burns noted. Removal occurred approximately 5.5 hours after insertion. Management included vaginal irrigation and topical estrogen., Conclusion: Given our findings of rapid and severe damage to the vaginal mucosa, urgent removal of a vaginally inserted battery is indicated., Competing Interests: Financial Disclosure Diane Christopher owns shares of Illumina stock. The other authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This prospective pilot study aimed to evaluate the effects of a modified vaginal erbium laser (VEL) protocol, using the hyperstack mode on the vaginal vestibulum and introitus to treat superficial dyspareunia in postmenopausal breast cancer survivors suffering from the genitourinary syndrome of menopause., Methods: In this pilot, prospective, randomized study, two groups of postmenopausal women suffering from superficial dyspareunia were included: 34 women (VEL group) were treated with erbium laser crystal yttrium-aluminum-garnet (XS Fotona SMOOTH; Fotona, Ljubljana, Slovenia) with a wavelength of 2,940 nm; for the other 34 (hyperstack group), a modified second step of the VEL protocol for the treatment of vestibulum and introitus was used, with hyperstacked (repeating a number of) subablative, long pulses with very low fluences. For each group, three laser applications at 30-day intervals were performed. Symptoms were assessed before, after each application, and after 1 and 3 months from the last laser application, using the visual analog scale score for superficial dyspareunia., Results: Superficial dyspareunia improved in both groups over time (P < 0.001), regardless of age and years since menopause status. The reduction in visual analog scale score after the third laser application was 58% in VEL versus 73.5% in hyperstack. The hyperstack group, since the first laser application, showed a greater (P < 0.001) and persistent improvement of superficial dyspareunia., Conclusions: The hyperstack treatment of the introitus and vestibulum in breast cancer survivors leads to a more significant improvement in superficial dyspareunia than the VEL alone., Competing Interests: Financial disclosure/conflicts of interest: None reported., (Copyright © 2022 by The North American Menopause Society.)

Introduction and Hypothesis: Evidence and recommendations for the use of intravaginal estrogen for prevention of bacterial vaginosis and pessary-related complications are limited and controversial. We hypothesized that adding intravaginal estrogen to pessary use would decrease the incidence of bacterial vaginosis and other pessary-related complications., Methods: A single-center, open-label, randomized, parallel study was conducted between April 2018 and August 2020. Participants were randomized to either receive intravaginal estriol 0.03 mg plus Lactobacillus acidophilus 100 million viable cell vaginal tablets or have no treatment. The Amsel criteria, normal flora index, visual analog scale, Thai version of the ICIQ-VS (International Consultation on Incontinence Questionnaire-Vaginal symptoms) questionnaire, vaginal abrasions and vaginal bleeding were evaluated at entry and at 2- and 14-week follow-up., Results: Seventy-eight women were included and randomized to two groups (39 women per group). At 2-week follow-up, one participant in the intervention group and two participants in the control group were diagnosed with bacterial vaginosis (2.7% vs. 5.7%, p = 0.609). At 14-week follow-up, two participants in the intervention group and two participants in the control group were diagnosed with bacterial vaginosis (5.7% vs. 6.2%, p = 0.926). Normal flora index was significantly different at 2-week follow-up [8 (6.3) vs. 5 (6.0), p = 0.032]. There was no significant difference in the visual analog scale, Thai version of the ICIQ-VS, vaginal abrasions and vaginal bleeding between the 2- and 14-week follow-ups., Conclusions: This study shows no benefit of intravaginal estrogen in reducing bacterial vaginosis, vaginal abrasions, vaginal bleeding and pain in postmenopausal women using a vaginal pessary for pelvic organ prolapse treatment., (© 2021. The International Urogynecological Association.)

Aim: To investigate the effects of isolated posterior vaginal compartment prolapse to lower urinary tract symptoms (LUTS)., Materials-Methods: Patients who were admitted with any kind of LUTS and diagnosed with posterior compartment defects were retrospectively analyzed at urogynecology units of 2 different tertiary referral centers. Patients were included in the analysis if they had isolated posterior vaginal compartment defects with no clinically significant anterior and apical compartment defects. The control group consisted of patients with no pelvic organ prolapse (POP). All pelvic examinations were performed by the same 2 specialists. The responses to a detailed LUTS questionnaire in the unit were assessed., Results: Of the 340 women with posterior POP, 280 were excluded from the analysis due to combined anterior and/or apical POP with posterior POP and stage 4 POP. When we compared the symptoms between the control group and the remaining 60 patients with isolated posterior POP, there was a statistically significant difference in urge, frequency, nocturia, abnormal emptying, vaginal winding, difficult stool passage (p = 0.031, p < 0.001, p < 0.001, p = 0.022, p = 0.041, and p = 0.039, respectively)., Conclusion: Women with posterior POP should be carefully examined not only for anorectal or bulging symptoms but also for LUTS., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Studies in the adjuvant setting have shown that endocrine therapy related side effects predict breast cancer recurrence risk. Here, we assess the relationship between early reported side effects and incidence of breast cancer in women randomised to tamoxifen for cancer prevention in the International Breast Intervention Study (IBIS)-I trial., Methods: Women randomised to tamoxifen in the IBIS-I trial and for whom side effect status was known at the 6-month follow-up visit were included in this analysis. Side effects included in this analysis were hot flushes, vaginal discharge, and vaginal dryness. The primary endpoint was all breast cancer and secondary endpoint was oestrogen receptor (ER) positive breast cancer. Cox proportional hazard models were used to investigate breast cancer incidence in the tamoxifen group with and without side effects reported within 6 months of randomisation., Results: Women randomised to tamoxifen and reporting hot flushes at the 6-month follow-up visit had a non-statistically significant increase in breast cancer compared to those without hot flushes (HR = 1.26 (0.98-1.62), P = 0.08). A significant higher breast cancer risk was observed for postmenopausal women who reported hot flushes at the 6-month follow-up visit compared to those without hot flushes (HR = 1.59 (1.12-2.26), P = 0.01). A higher risk was observed for ER-positive breast cancer in postmenopausal women (HR = 1.81 (1.19-2.74), P = 0.01). No significant associations between gynaecological side effects and breast cancer occurrence was observed., Conclusions: Overall, no association between side effects reported at 6 months and subsequent breast cancer occurrence was observed. Some side effects might be useful markers for breast cancer occurrence in postmenopausal women., Competing Interests: Declaration of competing interest JC has received research grants from AstraZeneca, all other authors declare no conflict of interest., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To assess independent risk factors for surgical failure and worsening pelvic floor symptoms within 5 years after vaginal prolapse surgery., Methods: This secondary analysis includes OPTIMAL (Operations and Pelvic Muscle Training in the Management of Apical Support Loss) (n=374) and E-OPTIMAL (Extended) (n=285) trial participants. Surgical failure was defined as apical descent greater than one third of the total vaginal length, anterior or posterior vaginal wall past the hymen, subsequent surgery or bothersome vaginal bulge. Worsening pelvic floor symptoms were defined as increases from baseline as large as the minimally important difference for subscale scores of the Pelvic Floor Distress Inventory: 11 for the Urinary Distress Inventory and Colorectal-Anal Distress Inventory and 34.3 for the Pelvic Organ Prolapse Distress Inventory. Outcomes were measured at 6 months then 1, 2, 3, 4, and 5 years. Chi-square and t test results from bivariate models and clinical relevance were used to inform final models., Results: Baseline risk factors for surgical failure were Hispanic ethnicity (adjusted odds ratio [aOR] 1.92, 95% CI 1.17-3.15), perineal body (aOR 1.34, 95% CI 1.09-1.63), and pretreatment Pelvic Organ Prolapse Distress Inventory score (aOR 1.16, 95% CI 1.05-1.28). Risk factors for worsening of pelvic floor symptoms were pretreatment Pelvic Organ Prolapse Distress Inventory score (aOR 0.75, 95% CI 0.60-0.94) for worsening Pelvic Organ Prolapse Distress Inventory score, vaginal deliveries (aOR 1.26, 95% CI 1.10-1.44) and pretreatment Urinary Distress Inventory score (aOR 0.86, 95% CI 0.80-0.93) for worsening Urinary Distress Inventory score, and age (aOR 1.03, 95% CI 1.01-1.05) and pretreatment Colorectal-Anal Distress Inventory score (aOR 0.95, 95% CI 0.92-0.98) for worsening Colorectal-Anal Distress Inventory score., Conclusions: Hispanic ethnicity, larger preoperative perineal body, and higher pretreatment Pelvic Organ Prolapse Distress Inventory scores were risk factors for surgical failure up to 5 years after vaginal prolapse repair. Participants with higher baseline Pelvic Floor Distress Inventory scores were less likely to worsen. Risk factors for worsening Urinary Distress Inventory and Colorectal-Anal Distress Inventory scores included more vaginal deliveries and increased age, respectively., Clinical Trial Registration: NCT00597935, NCT01166373.

Objective: Breastfeeding-related hypoestrogenic state has been reported as a possible risk factor for postpartum dyspareunia. This study aimed to evaluate the prevalence and characteristics of postpartum vulvovaginal atrophy according to 3 different diagnostic methods and to estimate its association with postpartum dyspareunia and daily vulvovaginal symptoms., Methods: This is a prospective cohort study of puerperal women attending a routine postpartum checkup. Participants completed a questionnaire and underwent a gynecological examination. Atrophy was diagnosed separately according to gynecologist impression, vaginal pH measurement (≥5.1), and cytologic vaginal maturation index. Patients were followed up with a telephone survey 2-3 months later, inquiring about symptoms possibly associated with atrophy., Results: Of 117 participants, vaginal atrophy was diagnosed in 48% by gynecological examination, 62% by a pH level of 5.1 or greater, and 40.2% had cytological atrophy. Of the 35.9% of women who had resumed sexual intercourse (42/117), 69% reported dyspareunia. No significant association was found between dyspareunia and atrophy parameters. There was no difference in the rates of dyspareunia among women who were exclusively breastfeeding (21/27 = 78%), partially breastfeeding (4/7 = 57%), or not breastfeeding (4/8, 50%). Atrophy was more common in breastfeeding women according to the 3 criteria (gynecological examination: 57.6% vs 16.7%, p = .006; pH: 70% vs 22%, p < .001; vaginal maturation index: 51.1% vs 0%, p < .001). Of the 117 participants, 47% reported daily vulvovaginal symptoms. Those with daily symptoms reported more dyspareunia as compared with those without daily symptoms (85% vs 52%, p = .025)., Conclusions: A high prevalence of atrophy was observed in puerperal women in association with breastfeeding. There was no significant association between atrophy and dyspareunia or daily vulvovaginal symptoms.

Transverse vaginal septum is one of the variants of Mullerian duct anomaly, caused as a result of defective fusion or recanalisation of vaginal and Mullerian organs. At an early age, it commonly presents as primary amenorrhea along with cyclical abdominal pain while later on usually it presents as dyspareunia and infertility. Our 22-year-old patient presented with secondary amenorrhea. It is very unusual for a transverse vaginal septum to cause secondary amenorrhea. MRI and clinical examination raised the suspicion of transverse vaginal septum causing secondary amenorrhea. She attained regular menstrual cycle after septum excision. The proposed theory behind it is obliteration of microperforated transverse vaginal septum because of menstrual blood and cell debris. Thus, a rare possibility of transverse vaginal septum should also be considered as a differential diagnosis of secondary amenorrhea., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/objectives: Several exposures during pregnancy are associated with offspring body mass index (BMI). The objective of this study was to evaluate whether third trimester antibiotic use and vaginal infections are associated with BMI in preschool children., Subjects/methods: The study population included singletons from the NINFEA birth cohort with available anthropometric measurements at the age of 4 (3151 born with vaginal and 1111 born with caesarean delivery). Self-reported use of antibiotics and the presence of vaginal infection in the third trimester were analysed in association with the child's BMI, classified into three categories: thinness, normal and overweight/obesity, using both the International Obesity Task Force (IOTF) and the World Health Organization (WHO) recommended cut-offs., Results: Maternal vaginal infections in the third trimester of pregnancy were associated with higher relative risk ratios (RRR) for overweight/obesity at age of four in children delivered vaginally: 1.92 (95% confidence interval [CI]: 1.37 to 2.70). This association appeared stronger for children born to women with pre-pregnancy BMI >25 kg/m 2 (RRR: 4.78; 95% CI 2.45 to 9.35), and was robust when different obesity cut-offs were used. The results regarding third trimester antibiotic use in vaginal deliveries were less conclusive (RRRs for overweight/obesity: 1.43 (0.92 to 2.21) and 1.11 (0.57 to 2.20), for the IOTF and WHO cut-offs, respectively). Third trimester vaginal infections were not associated with BMI in children delivered by caesarean section., Conclusions: Maternal third trimester vaginal infections are associated with an increased overweight/obesity risk in children born by vaginal delivery, and especially in children of mothers with pre-pregnancy overweight/obesity., (© 2020 The Authors. Pediatric Obesity published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

In thisarticle, we present the case of a 14-year-old girl withcyclicalabdominalpainand a palpablemass in thelower abdomen duetoanimperforate hymen.

Vulvovaginal atrophy (VVA) has an impact on the quality of life (QoL) of women. This post hoc analysis of the EVES study provides an overview of the QoL in postmenopausal Italian women in relation with VVA severity. We included 1066 women attending menopause/gynaecologic centres. A face-to-face survey (including QoL and sexual life questionnaires), joining an objective gynaecological examination to confirm VVA, were performed. The 65.5% of the participants presented severe vaginal, vulvar and/or urinary symptoms; an 86.9% had an objective confirmed VVA. Women with severe symptoms presented with significantly worse QoL scores than the women without. We found there were moderately significant correlations between vaginal and vulvar symptoms' severity and lower overall DIVA QoL scores (p<.0005, in both cases). Women with a confirmed VVA presented worse QoL scores than women without confirmation. Our data suggest a clear relationship between VVA severity and a decrease in QoL in postmenopausal Italian women.IMPACT STATEMENT What is already known on this subject? Vulvovaginal atrophy (VVA) appears as a common chronic disorder in postmenopausal women that, as soon as the oestrogen levels decrease, becomes a severe condition affecting their quality of life (QoL). What do the results of this study add? We provide new insight about QoL related to VVA severity in Italian postmenopausal women. Our local data demonstrates that QoL in Italian women suffering from menopause is directly related to the severity of vaginal and vulvar symptoms. The same correlation exists for urinary symptoms. QoL is also reduced in patients with an objectively confirmed VVA diagnosis. What are the implications of these findings for clinical practice and/or further research? The implications of our findings involve the need for a better management, not only of the physical aspects of VVA, but also of the non-physical dimensions. Clinicians should ask for the impact of VVA on QoL aspects, making postmenopausal women aware about the possible affected spheres. Medical personnel should conduct future campaigns in the Italian general population, not only in those asking for medical help, to make all women conscious about this silent disorder affecting physical and non-physical dimensions and in order to treat it at early stages.

Objective: To estimate the impact of vulvovaginal atrophy (VVA) on sexual function in a clinical population of postmenopausal women., Methods: Women 45 to 75 years old and more than 12 months after the last menstruation, who attended menopausal/gynecological centers in Italy and Spain, were included. Women with at least one VVA symptom completed the following questionnaires: Day-to-Day Impact of Vaginal Aging (DIVA), Female Sexual Function Index (FSFI), and Female Sexual Distress Scale revised (FSDS-R). A physical gynecological examination was performed to confirm the VVA diagnosis. Data were analyzed by chi-square and Student's t tests., Results: In all, 2,160 evaluable women were included in the study. VVA was confirmed in 90% of the included participants. The negative impact on sexual function was significantly higher in women with than in women without confirmed VVA, as evaluated with the sexual function component (DIVA-C) of the DIVA questionnaire (P = 0.013). Statistically significant differences (P < 0.0005) were also detected in the scores of overall FSDS-R, the overall FSFI, and of all the FSFI subdomains (desire, arousal, lubrication, orgasm, satisfaction, and pain)., Conclusion: For postmenopausal women with at least one VVA symptom, the presence of physician-confirmed VVA is associated with significant impaired sexual function, as shown by unadjusted analyses. Given the impact on quality of life and the prevalence of VVA, further research to improve and reduce VVA is warranted.

Study Objective: To demonstrate the application of the so-called reverse technique to approach deep infiltrating endometriosis nodules affecting the retrocervical area, the posterior vaginal fornix, and the anterior rectal wall. In Video 1, the authors describe the complete procedure in 10 steps in order to standardize it and facilitate the comprehension and the reproduction of such a procedure in a simple and safe way., Design: A case report., Setting: A private hospital in Curitiba, Paraná, Brazil., Patient: A 32-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 2.4-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the muscularis 10 cm far from the anal verge., Interventions: Not applicable., Measurements and Main Results: Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veress needle placed at the umbilicus. Four trocars were placed according to the French technique as follows: a 10-mm trocar at the umbilicus for the 0 degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions (step 1). The implants located at the ovarian fossae were completely removed (step 2). The ureters were identified bilaterally, and both pararectal fossae were dissected, preserving the hypogastric nerves (step 3). The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum (step 4). The lesion was shaved off the anterior rectal wall using a harmonic scalpel (step 5). The anterior rectal wall was closed using X-shaped stitches of 3-0 polydioxanone suture in 2 layers (step 6). The specimen was extracted through the vagina (step 7). The posterior vaginal fornix was reattached to the retrocervical area using X-shaped sutures of 0 poliglecaprone 25 (step 8). A pneumatic test was performed to check the integrity of the suture (step 9). At the end of the procedure, hemostasis was controlled, and the abdominal cavity was irrigated using Lactate ringer solution (step10)., Conclusion: The laparoscopic reverse technique is an alternative approach to face retrocervical or rectovaginal nodules infiltrating the anterior rectal wall. In this technique, the separation of the nodule from the rectal wall is performed at the end of the surgery and not at the beginning as performed within the traditional technique. This enables the surgeon to perform a more precise dissection of the endometriotic nodule from the rectal wall because of the increased mobility of the bowel. The wider range of movements serves as an ergonomic advantage for the subsequent dissection of the lesion from the rectum, allowing the surgeon to decide the best technique to apply for the treatment of the bowel disease (rectal shaving or discoid or segmental resection)., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: It has previously been suggested in the literature that ultrasound measurement of total vaginal wall thickness (TVT) differs significantly between pre- and postmenopausal women, indicating that it may be a useful and noninvasive objective assessment to correlate the degree of vaginal atrophy to patient-reported symptoms., Aim: The purpose of this cross-sectional pilot study was to determine whether TVT in postmenopausal women, as measured with transabdominal ultrasound, is associated with patient-reported dyspareunia and symptoms related to genitourinary symptomatology., Methods: Postmenopausal women presenting for pelvic ultrasound had TVT and total mucosal thickness (TMT) measured via transabdominal ultrasound. A questionnaire also was administered assessing menopausal status, relevant medical history, and self-report of dyspareunia and other symptoms related to the genitourinary syndrome of menopause (GSM). This questionnaire was derived from the Vulvovaginal Symptom Questionnaire, which has been validated in the literature., Main Outcome Measure: The main outcome measures included the average TVT and TMT for postmenopausal women reporting any symptom of GSM and average TVT and TMT of women reporting no symptoms of GSM., Results: Data from 44 postmenopausal women showed no significant association between transabdominal ultrasound-measured TVT or TMT and patient report of dyspareunia or other genitourinary symptoms. Data were stratified by individual GSM symptoms, sexual symptoms as an aggregate, and individual sexual symptoms. Neither of these subgroups showed a statistically significant difference in TVT or TMT between symptomatic and asymptomatic women., Clinical Implications: Although no statistically significant data were derived from this study, we propose that future studies investigating the longitudinal relationship between TVT and GSM symptomatology may show an association between total vaginal thickness measurement change over time as determined by ultrasound with the presence of patient-reported dyspareunia and other GSM symptoms., Strengths & Limitations: This study is limited by its small sample size as well as the patient population, which was restricted to postmenopausal women with a clinical indication for ultrasound. A major strength of this investigation is that it is the first study to look at the relationship between sexual pain and other GSM symptoms and TVT using transabdominal ultrasound, which is a readily available, non-invasive tool in most clinical settings., Conclusion: Based on the results of this small pilot study, transabdominal pelvic ultrasound cannot be used at this time to objectively quantify the presence of sexual pain or other GSM symptoms; however, future studies should continue to investigate the longitudinal relationship between these 2 variables. Balica AC, Cooper AM, McKevitt MK, et al. Dyspareunia Related to GSM: Association of Total Vaginal Thickness via Transabdominal Ultrasound. J Sex Med 2019; 16:2038-2042., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to determine the most used methods for assessing genitourinary syndrome of menopause by the latest studies on the subject, and to critically assess their differences and comparability., Methods: A narrative review of the literature was conducted, employing the terms genitourinary syndrome, vaginal atrophy, urogenital atrophy, and atrophic vaginitis, to analyze methods used to assess treatment efficacy. Only controlled randomized clinical trials assessing improvement of genitourinary syndrome of menopause, conducted in the last 5 years, and considering all types of treatment, were selected., Results: Of the 37 studies included, 24 combined both objective and subjective methods thereby ensuring reproducibility and efficacy of symptom relief of the treatment analyzed. The vaginal maturation index was the most used objective method, followed by vaginal pH. One study used histological and immunohistochemistry tests. Regarding subjective methods, the "Most bothering Symptom" and other questionnaires as the Female Sexual Function Index for sex life, the Verbal Rating Scale, among others, were used., Conclusions: Despite the heterogeneity observed, particularly for subjective assessment of symptoms, there was a tendency to standardize methods and to use an objective method together with a subjective, which seems to be fundamental to guarantee reproducibility and comparability of results of each treatment analyzed. Histological and immunohistochemistry tests may be an option as an objective method in further studies, to better assess thickness, vascularization, among other parameters.

Objective: The softgel 17β-estradiol (E2) vaginal inserts (4 and 10 μg; Imvexxy; TherapeuticsMD, Boca Raton, FL) are FDA approved for treating moderate to severe dyspareunia associated with postmenopausal vulvar and vaginal atrophy (VVA). The objective here was to determine responder rates at week 2 and whether week-2 findings predicted week-12 responders in the REJOICE trial., Methods: Postmenopausal women received E2 vaginal inserts 4, 10, or 25 μg, or placebo for 12 weeks. Proportion of responders (having ≥2 of the following: vaginal superficial cells >5%, vaginal pH <5.0, or dyspareunia improvement of ≥1 category) were calculated. Odds ratios (ORs) for positive response at week 12 given a positive response at week 2 were determined in the efficacy evaluable (EE) population., Results: The responder rate (in EE population [n = 695]) was 74% to 82% with E2 inserts versus 24% with placebo at week 2, and 72% to 80% versus 33% at week 12. Positive treatment responses were 9- to 14-fold higher with vaginal E2 than with placebo at week 2, and 5- to 8-fold higher at week 12. Response at week 2 predicted response at week 12 in the total population (OR 13.1; 95% CI, 8.8-19.7) and with active treatment only (OR 7.9; 95% CI, 4.7-13.2)., Conclusions: A high percentage of postmenopausal women with moderate to severe dyspareunia responded with the E2 softgel vaginal insert at week 2, and a positive response at week 2 predicted a positive response at week 12.

Objectives: To assess the effects of vaginal erbium laser treatment on the vaginal health and sexual function of postmenopausal women with a history of breast cancer., Methods: An open, prospective, therapeutic intervention study was conducted with 24 postmenopausal women with a history of breast cancer and vaginal dryness, and/or dyspareunia, who had not used vaginal hormone therapy for at least 6 months. The women were treated using a 2,940-nm Erbium: YAG laser (Etherea-MX, Athena, São Carlos, São Paulo, Brazil), with 90 and 360 scanning scopes, between August, 2017 and October, 2017 in a private clinic in a city of southeastern Brazil. Vaginal erbium laser treatment was performed at three sessions with a 30-day interval between each session. Sexual function was assessed before and 1 month after treatment using the Short Personal Experiences Questionnaire. Questions related to genitourinary symptoms were also applied. Vaginal health was assessed before each laser session using the Vaginal Health Index Score., Results: Mean age was 53.7 years. Vaginal health improved, as shown by an increased overall score (P < 0.001). The effect size was large between pretreatment and post-treatment scores for vaginal elasticity, fluid volume, epithelial integrity, and moisture. The effect size was also significant for the overall sexual function score and for the score in the dyspareunia domain between pretreatment and 1 month after the final treatment session., Conclusion: Vaginal erbium laser may represent a novel therapeutic option for improving vaginal health and sexual function in postmenopausal women with a history of breast cancer.

Background: The Mirena levonorgestrel intrauterine system (IUS; Bayer HealthCare Pharmaceuticals) is frequently used for menstrual suppression in adolescents with special needs. However, the presence of a uterine anomaly is generally considered a contraindication to IUS insertion, thereby excluding a potentially highly effective option for this patient population., Case: A Mirena IUS was used in a medically and surgically complex special needs 14-year-old adolescent with a didelphys uterus and obstructed hemivagina. With the IUS inserted into the unobstructed uterus, she achieved amenorrhea and significant reduction in pain, with interval reduction in hematometra in the contralateral obstructed uterus., Summary and Conclusion: We report the successful use of the Mirena IUS in a patient with a Müllerian anomaly, supporting the use of this device in carefully selected patients., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Introduction: The management of posterior deep endometriosis is not consensual. This is due to a great heterogeneity of data from the literature. Many series were small and overall, predictors of pregnancy were not all included and analyzed by multivariate analysis. We conducted this study to evaluate the factors associated with pregnancy during the first two in vitro fertilization (IVF) attempts in infertile women with posterior deep endometriosis., Material and Methods: 230 women were included in this retrospective observational study, between January 1st, 2007 and September 30th, 2013, at the University Hospital of Lille. A large set of variables were recorded and their association with the chance of pregnancy was analyzed by multivariate analysis (MVA), including patients' features, endometriosis items, surgery procedures and IVF data., Results: After 2 IVF attempts, 48.7% of the 230 women achieved a pregnancy, including 39.1% of ongoing pregnancies. Logistic regression analysis retained five variables significantly associated to the chance of pregnancy: oocyte retrieval number (OR=0.468 (0.296-0.739) p=0.001), age (OR=0.888 (0.811-0.974) p=0.011), single embryo transfer number (OR=1.494 (1.036-2.153) p=0.031), presence of a recto-uterine nodule (OR=0.454 (0.235-0.877) p=0.019) and IVF technique (OR=0.509 (0.272-0.951) p=0.034)., Conclusion: The presence of a recto uterine nodule is associated with a lower chance of pregnancy after IVF. It has to be checked by prospective studies whether the finding of a recto-uterine nodule whose pejorative effect has not been reported so far should encourage to perform surgery before IVF in patients with deep endometriosis., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objective: Evaluate the efficacy and safety of a non-hormonal intravaginal moisturizer on reducing the symptoms arising from vaginal dryness and sexual dysfunction., Study Design: A total of 37 postmenopausal women used a non-hormonal intravaginal Moisturizer (polycarbophil, butyl ester of a copolymer of methyl vinyl ether/ copolymer PVM/MA, 50% sodium lactate solution, and Carbopol) twice a week for 12 weeks. The vaginal moisture levels, volume of fluid, elasticity, and epithelium integrity were assessed using the Vaginal Health Index. Sexual function was measured using the Female Sexual Function Index questionnaire. All women were evaluated before starting treatment and at the 4th, 8th and 12th weeks of the study. At the end of the study, the patients analysed the treatment regarding to their satisfaction with the product, and its application system, their sense of well-being after using it as well as their perception bout the discharge of the moisturizer (if it run or was held by the vaginal mucosa)., Results: There was a significant improvement in the vaginal moisture, fluid volume, elasticity and epithelial integrity (p < 0.001). Sexual function improved in the total score and in all six domains (p < 0.001). More than 50% of all patients reported being very satisfied with the treatment and product application. The sense of well-being was considered very good by 51.4% of the participants and most (91.9%) indicated that the product did not leak and did not stick to the vaginal mucosa. No severe adverse events were reported., Conclusion: Our study suggests that treatment with the non-hormonal intravaginal moisturizer is a safe and efficient therapeutic option for the improvement of vaginal dryness with encouraging benefits for the sexual function of postmenopausal women., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Chlamydia trachomatis can lead to a persistent infection in the lower gastrointestinal tract, suggesting a potential role of autoinoculation of cervical chlamydial infection from the rectal site, contributing to repeat infections. Moreover, around 75% of women with urogenital C. trachomatis have concurrent anorectal infection. Current treatment guidelines for urogenital C. trachomatis infection recommend either a single 1 g dose of azithromycin or doxycycline 100 mg twice daily for 7 days. Doxycycline appears to be more effective in treating anorectal infections as suggested in a population of men who have sex with men, but no randomized controlled trial (RCT) had directly compared azithromycin with doxycycline for the treatment of rectal infections. We propose an open-label RCT to compare the microbial cure obtained with a single 1 g dose of azithromycin versus 100 mg of doxycycline twice daily for 7 days, for the treatment of anorectal C. trachomatis infection concurrent to urogenital infection in women., Methods and Study Design: A total of 460 women with C. trachomatis urogenital infection will be enrolled in the study. Women will be asked to provide self-collected anorectal swabs and will be randomized to receive either a 1 g single dose of azithromycin or doxycycline 100 mg twice daily for 7 days. Clinical and biological data will be collected and patients will complete questionnaires about their sexual behavior. The primary outcome is the microbial cure rate, defined as a C. trachomatis negative nucleic acid amplification test (NAAT) result in the anorectal specimens 6 weeks after treatment initiation among women with a C. trachomatis positive urogenital and anorectal NAAT result at the baseline. The secondary outcome is autoinoculation from the rectum to the vagina, which will be evaluated based on the number of women with the same C. trachomatis genotype profile that will be identified in an anorectal-positive specimen obtained 6 weeks after treatment initiation and in a vaginal-positive specimen obtained four months after treatment., Discussion: The results of this trial will establish which treatment is more efficacious against anorectal infection and could affect recommendations for the treatment of urogenital C. trachomatis infection, taking into account concurrent anorectal infection., Trial Registration Numbers: EudraCT number: 2017-002595-15. CLINICALTRIALS., Gov Identifier: NCT03532464. Date of registration: May 31, 2018., World Health Organisation International Clinical Trials Registry: NTC03532464. Secondary ID: CHUBX 2016/26. Date of registration: May 09, 2018.

Context: Intravaginal testosterone (IVT) is a potential treatment of vulvovaginal atrophy (VVA) associated with aromatase inhibitor (AI) use., Objective: To investigate the effects of IVT on sexual satisfaction, vaginal symptoms, and urinary incontinence (UI) associated with AI use., Design: Double-blind, randomized, placebo-controlled trial., Setting: Academic clinical research center., Participants: Postmenopausal women taking an AI with VVA symptoms., Intervention: IVT cream (300 μg per dose) or identical placebo, self-administered daily for 2 weeks and then thrice weekly for 24 weeks., Main Outcomes and Measures: The primary outcome was the change in the sexual satisfaction score on the Female Sexual Function Index (FSFI). Secondary outcomes included vaginal symptoms and responses to the Profile of Female Sexual Function, the Female Sexual Distress Scale-Revised (FSDS-R), and the Questionnaire for UI Diagnosis. Serum sex steroids were measured., Results: A total of 44 women were randomly assigned and 37 provided evaluable data, (mean age 56.4 years, SD 8.8 years). At 26 weeks, the mean between-group difference in the baseline-adjusted change in FSFI satisfaction scores was significantly greater for the IVT group than the placebo group (mean difference 0.73 units; 95% CI, 0.02 to 1.43; P = 0.043). IVT cream resulted in significant improvements, compared with placebo, in FSDS-R scores (P = 0.02), sexual concerns (P < 0.001), sexual responsiveness (P < 0.001), vaginal dryness (P = 0.009), and dyspareunia (P = 0.014). Serum sex steroid levels did not change. Few women had UI symptoms, with no treatment effect., Conclusion: IVT significantly improved sexual satisfaction and reduced dyspareunia in postmenopausal women on AI therapy. The low reporting of UI among women on AI therapy merits further investigation.

Introduction: Vaginal laxity is increasingly recognized as an important condition, although little is known regarding its prevalence and associated symptoms., Aim: To report the prevalence of self-reported vaginal laxity in women attending a urogynecology clinic and investigate its association with pelvic floor symptoms and female sexual dysfunction., Method: Data were analyzed from 2,621 women who completed the electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF)., Main Outcome Measure: Response data from ePAQ-PF questionairre., Results: Vaginal laxity was self-reported by 38% of women and significantly associated with parity, symptoms of prolapse, stress urinary incontinence, overactive bladder, reduced vaginal sensation during intercourse, and worse general sex life (P < .0005)., Clinical Implications: Clinicians should be aware that vaginal laxity is prevalent and has an associated influence and impact on sexual function., Strength & Limitations: The main strength of this study is the analysis of prospectively collected data from a large cohort of women using a validated questionnaire. The main limitation is lack of objective data to measure pelvic organ prolapse., Conclusion: Vaginal laxity is a highly prevalent condition that impacts significantly on a woman's sexual health and quality of life. Campbell P, Krychman M, Gray T, et al. Self-reported vaginal laxity-Prevalence, impact, and associated symptoms in women attending a urogynecology clinic. J Sex Med 2018;15:1515-1517., (Copyright © 2018 International Society for Sexual Medicine. All rights reserved.)

Background: Transvaginal bowel evisceration is an exceptionally rare event. Most reported cases are of small bowel evisceration in postmenopausal women who have undergone hysterectomy., Case: Here, we report an isolated case of complete procidentia and spontaneous sigmoid colon evisceration leading to sepsis in an 89-year-old woman with no surgical history., Conclusions: We highlight the risk factors, clinical presentation, and treatment options for this unique multidisciplinary emergency.

Competing Interests: Competing interests: None declared.

The aim of this study was to assess the effectiveness of ospemifene in the improvement of sexual function in postmenopausal women with vulvovaginal atrophy (VVA) affected by overactive bladder syndrome (OAB) or urge urinary incontinence (UUI). One hundred five postmenopausal patients with VVA affected by OAB and/or UUI were enrolled for the study. All patients received ospemifene 60 mg for 12 weeks. Clinical examination, 3-d voiding diary and the vaginal health index (VHI) were performed at baseline and at 12 weeks. Patients completed the OAB-Q SF, FSFI, FSDS, and SF-36 questionnaires. The patient's satisfaction was also calculated. After 12 weeks, the reduction of urinary symptoms was observed. The OAB-Q symptoms, OAB-Q (HRQL) score were (55.34 ± 13.54 vs. 23.22 ± 9.76; p < .0001) and (22.45 ± 9.78 vs. 70.56 ± 15.49; p < .0001), before and after treatment. SF-36 questionnaire showed a significant improvement (p < .0001). VHI score increased and the women who regularly practice sexual activity increased after treatment. The total FSFI score increased significantly and the FSDS score changed after 12 weeks (p < .0001). The PGI-I after 12 weeks showed a total success rate of 90.5%. Ospemifene is an effective potential therapy for postmenopausal women with VVA affected by OAB or UUI improving sexual function and quality of life.

Acute retention of urine in pregnancy is an emergency, since it can lead to loss of pregnancy besides other dire complications. Gartner's abscess is an extremely rare cause for this condition. We present a case of a 23-year-old primigravida woman who presented to us at 24 weeks of pregnancy with acute retention of urine. After clinical and radiological evaluation, a large Gartner's abscess was found to be the cause. Per vaginal drainage of the abscess was not attempted because insertion of transvaginal probe was extremely painful for the patient, and the abscess was located high up in the anterior fornix. Transabdominal approach under sonographic guidance was used for the drainage of the abscess. Careful aspiration of the abscess, avoiding injury to the placenta, fetus and maternal bladder, revealed 60 cc of frank pus. The patient was given injection hydroxyprogesterone caproate and antibiotics in the preprocedure period. Antibiotics were continued in the postprocedure period, and she was discharged at 26 weeks of pregnancy in satisfactory condition., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: First evaluation of dual-phase vaginal Er:YAG laser to omit hormonal treatment for atrophy-related symptoms in post-menopausal breast cancer survivors following prolapse surgery., Methods: Patients with a history of breast cancer at the time of surgery for pelvic organ prolapse were offered non-hormonal vaginal Er:YAG laser treatment when complaining of atrophy-related genitourinary syndrome of menopause. A single 10-min course of dual-phase protocol of pulsed Er:YAG laser (2940 nm, fractional ablative and thermal mode, fluence according to tissue thickness). Follow-up included subjective satisfaction, vaginal pH, vaginal health index (VHI), and complications after 6 weeks., Results: A total of 16 breast cancer survivors (age 71 years, SD 7) had been seeking treatment for pelvic floor symptoms related to vaginal atrophy at follow-up visits after prolapse surgery. All ablative vaginal Er:YAG laser outpatient procedures were successfully completed, all patients returned to daily activities without a need for analgetic medication. Evaluation was performed after 8.3 (SD 2.5) weeks. Pre-laser VHI scored 16 (SD 4.6) and post-laser VHI 20 (SD 3) with p = 0.01. Patients were satisfied in 94% (n = 15) regarding symptom relief., Conclusions: Breast cancer survivors with atrophy-related complaints after pelvic floor surgery may benefit from vaginal application of this innovative dual protocol of Er:YAG laser technology as a non-hormonal treatment approach.

Introduction and Hypothesis: Pelvic organ prolapse (POP) is defined as the coexistence of anatomical POP and relevant symptoms. Vaginal bulge is the symptom most closely associated with the anatomical condition in nonpregnant women. Even if childbearing is a major risk factor for the development of POP, there is scant knowledge on the prevalence of specific POP symptoms, and how these symptoms relate to anatomical POP during pregnancy and postpartum. The aim of this study was to explore whether vaginal bulge symptoms were associated with anatomical POP in pregnancy and postpartum, and to present the prevalence of vaginal bulge symptoms throughout this period., Methods: A prospective observational study was carried out following 300 nulliparous pregnant women with repeat assessments from mid-pregnancy until 1 year postpartum. Symptoms of vaginal bulge defined as the sensation of a vaginal bulge inside and/or outside the vagina were assessed by electronic questionnaires. Anatomical POP defined as pelvic organ prolapse quantification system (POP-Q) stage ≥2 has been presented in a previous publication and showed a range of 1-9%. The association between the symptom vaginal bulge and anatomical POP at the various visits was analyzed using Fisher's exact test., Results: Prevalence of vaginal bulge ranged between 16 and 23%. At 6 weeks postpartum the symptom was associated with anatomical POP; otherwise, these two features were unrelated., Conclusions: The symptom vaginal bulge was barely associated with anatomical POP, and cannot identify anatomical POP in pregnancy or postpartum.

Tokgöz Y, Erdem AO, Özbey BC, Terlemez S. A rare reason in a child with feeding intolerance: Intravaginal struvite stone. Turk J Pediatr 2018; 60: 86-88. Vaginal stones are rarely seen in childhood; they are categorized as primary and secondary whether they are a foreign object focus (nidus) or not. Urethrovaginal fistula is the most common etiological cause; other etiologies are considerably rarely reported. Primary vaginal stones are formed as a result of urinary salt accumulate. A 14-year-old girl, suffering from an unidentified neurodegenerative disease, was admitted with complaints of cough, poor feeding and vomiting. Abdominal X-ray showed a large calcific mass; further evaluation revealed a vaginal struvite stone, and it was removed surgically. No anatomical reason was determined for the formation of stone and it was accepted as primary vaginal stone.

Introduction and Hypothesis: Pelvic organ prolapse (POP) surgery is a common gynecological procedure. Our aim was to assess the influence of obesity and other risk factors on the outcome of anterior and posterior colporrhaphy with and without mesh., Methods: Data were retrieved from the Swedish National Register for Gynecological Surgery on 18,554 women undergoing primary and repeat POP surgery without concomitant urinary incontinence (UI) surgery between 2006 and 2015. Multivariate logistic regression analyses were used to identify independent risk factors for a sensation of a vaginal bulge, de novo UI, and residual UI 1 year after surgery., Results: The overall subjective cure rate 1 year after surgery was 80% (with mesh 86.4% vs 77.3% without mesh, p < 0.001). The complication rate was low, but was more frequent in repeat surgery that were mainly mesh related. The use of mesh was also associated with more frequent de novo UI, but patient satisfaction and cure rates were higher compared with surgery without mesh. Preoperative sensation of a vaginal bulge, severe postoperative complications, anterior colporrhaphy, prior hysterectomy, postoperative infections, local anesthesia, and body mass index (BMI) ≥30 were risk factors for sensation of a vaginal bulge 1 year postsurgery. Obesity had no effect on complication rates but was associated increased urinary incontinence (UI) after primary surgery. Obesity had no influence on cure or voiding status in women undergoing repeat surgery., Conclusions: Obesity had an impact on the sensation of a vaginal bulge and the presence of UI after primary surgery but not on complications.

Defining whether medical therapy is effective in women with deep rectovaginal endometriosis and in which circumstances it can be considered an alternative to surgery is important for patients and physicians. Numerous observational and some randomized controlled studies demonstrated that different hormonal drugs improved pain and other symptoms in approximately two-thirds of women with deep rectovaginal endometriosis. Because major differences in the effect size of various compounds were not observed, much importance should be given to safety, tolerability, and cost of medications when counseling patients. Progestins seem to offer the best therapeutic balance when long-term treatments are planned. Women should be informed that hormonal drugs control but do not cure endometriosis and that, to avoid surgery, they should be used for years. Medical therapy is not an alternative to surgery in women with hydronephrosis, severe subocclusive bowel symptoms, and in those wishing a natural conception. A progestin should systematically be chosen as a comparator in future randomized trials on novel medications for deep endometriosis. In the meantime, the use of existing drugs should be optimized, and medical and surgical treatments could be viewed as subsequent stages of a stepwise approach. In general, there is no absolute "best" choice, and women must be thoroughly informed of potential benefits, potential harms, and costs of different therapeutic options and allowed to choose what they deem is better for them., (Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To estimate the prevalence of painful sex among women in Britain, and to explore associated sexual, relationship and health factors that should be considered in assessment., Design: Multi-stage, clustered and stratified population probability sample survey, using computer-assisted self-interview. Sample frame was the British Postcode Address File., Setting: Participants interviewed at home between 2010 and 2012., Sample: A total of 15 162 adults aged 16-74 years (8869 women). Data reported from 6669 sexually active women., Methods: Age-adjusted logistic regressions to examine associations between painful sex and indicators of sexual, relational, mental and physical health., Main Outcome Measure: Physical pain as a result of sex for ≥3 months in the past year, plus measures of symptom severity., Results: Painful sex was reported by 7.5% (95% CI 6.7-8.3) of sexually active women, of whom one-quarter experienced symptoms very often or always, for ≥6 months, and causing distress. Reporting painful sex was strongly associated with other sexual function problems, notably vaginal dryness (age adjusted odds ratio 7.9; 6.17-10.12), anxiety about sex (6.34; 4.76-8.46) and lacking enjoyment in sex (6.12; 4.81-7.79). It was associated with sexual relationship factors [such as not sharing same level of interest in sex (2.56; 1.97-3.33)], as well as with adverse experiences such as non-volitional sex (2.17; 1.68-2.80). Associations were also found with measures of psychological and physical health, including depressive symptoms (1.68; 1.28-2.21)., Conclusion: Painful sex is reported by a sizeable minority of women in Britain. Health professionals should be supported to undertake holistic assessment and treatment which takes account of the sexual, relationship and health context of symptoms., Tweetable Abstract: Painful sex-reported by 7.5% of women in Britain-is linked to poorer sexual, physical, relational and mental health., (© 2017 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Study Objective: To demonstrate the technique of laparoscopic approach in a rare case of rectovaginal splenosis with severe dyspareunia and dyschesia., Design: A step-by-step explanation of the patient's condition, diagnosis, surgical technique, and postoperative results (Canadian Task Force classification II-3)., Setting: Splenosis consists of ectopic functioning splenic tissue that can be located anywhere within the abdomen or pelvis. Fragments are often multiple and range in diameter from a few millimeters to a few centimeters. They are reddish-blue and are sessile or pedunculated. Their appearance can mimic that of neoplasms or endometriosis, which are the main differential diagnoses. Trauma and subsequent splenectomy is the cause in most cases. Splenosis is a benign condition usually found incidentally and is usually asymptomatic. The need for therapy is controversial, and treatment is suggested only in symptomatic cases, primarily those related to pelvic or abdominal lesions, as in our patient. The diagnosis of splenosis in a woman complaining of pelvic pain may present diagnostic difficulties. The splenic tissue has the macroscopic appearance of endometriosis, and its position in the pelvis also may suggest this diagnosis. Where excision of splenosis is considered necessary, the approach should be laparoscopic, unless this is considered too risky owing to the proximity of vital structures., Intervention: A 40-year-old woman was referred to our department for severe dyspareunia and dyschezia. The gynecologic examination revealed a painfull nodularity on the posterior vaginal cul de sac. Further evaluation with 2- and 3-dimensional ultrasound and magnetic resonance imaging revealed several soft tissue nodules in the pouch of Douglas (POD), which were enhanced on contrast administration. She had undergone a splenectomy 15 years earlier after a car accident. A laparoscopic approach to a rectovaginal nodularity was performed. Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her legs in abduction. Pneumoperitoneum was achieved using a Veres needle placed at the umbilicus. Four trocars were placed: a 10-mm trocar at the umbilicus for the 0-degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions. In the pelvis, hypervascular and bluish nodules were visible with extension from the POD into the deep rectovaginal space. The macroscopic appearance was atypical for endometriotic implants. The nodularities were carefully dissected and excised, and histological assessment revealed splenic tissue. At the time of this report, the patient had been asymptomatic for 6 months after surgery., Conclusion: Rectovaginal splenosis may mimic endometriosis. The laparoscopic approach to rectovaginal splenosis avoids an abdominal incision, with its associated pain and possible adhesion formation. It also provides a better view for dissection. In this patient, the splenosis was removed by laparoscopy, with no postoperative dyspareunia or dyschesia., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: Endometriosis is associated with an increased risk of dyspareunia, therefore this chronic gynecologic disease should be considered as a major cause of sexual dysfunctions. The aims of this study were to review the literature on the effects of surgical and pharmacological treatments for endometriosis on female sexual functioning, and to provide suggestions for future treatment strategies., Material and Methods: We followed the PRISMA guidelines to conduct this systematic review, which involved an electronic database search of studies on the association between endometriosis and sexuality published between 2000 and 2016., Results: As a result of the screening process, 22 studies were included in this systematic review. The 22 studies included were divided into two categories: (a) surgical intervention studies (n = 17), examining postoperative sexual outcomes of surgery for endometriosis; (b) pharmacological intervention studies (n = 5), evaluating the effects of pharmacological endometriosis treatments on sexual functioning. The studies considered showed that overall surgical and pharmacological interventions for endometriosis can lead to medium-/long-term improvement, but not necessarily to a definitive resolution of female sexual dysfunctions due to endometriosis., Conclusions: Sexual functioning is a multidimensional phenomenon and the ideal treatment for endometriosis-related sexual dysfunctions should be conducted by a multidisciplinary team that involves not only gynecologists, but also sexologists and psychologists/psychotherapists. Improving global sexual functioning, and not just reducing pain at intercourse, should be considered as a major clinical goal of endometriosis treatment., (© 2016 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To investigate spontaneous pregnancy rate (SPRs) of women with rectovaginal endometriosis (RV) with/without ovarian endometrioma (OMA) and treated with the use of expectant or surgical management., Design: Retrospective study., Setting: University hospital., Patient(s): The study included patients with RV with or without OMA who tried to conceive spontaneously for 1 year either without undergoing surgery (group E; n = 284) or after surgery (group S; n = 221). The study population was further divided into four subgroups: women with RV without OMA who directly tried to conceive (group eRV; n = 121) or tried to conceive after surgery (group sRV; n = 96), and women with RV with OMA who directly tried to conceive (group eOMA; n = 163) or tried to conceive after surgery (group sOMA; n = 125)., Interventions(s): Expectant or surgical management., Main Outcome Measure(s): Crude and cumulative SPRs., Result(s): At 1 year, crude and cumulative SPRs were lower in group E (17.3% and 23.8%, respectively) than in group S (35.7% and 39.5%). Similarly, crude and cumulative SPRs were lower in group eRV (24.8% and 30.6%) than in group sRV (42.7% and 45.7%, respectively) and in group eOMA (11.7% and 18.0%) than group sOMA (30.4% and 34.5%). At 1 year, crude and cumulative SPRs were higher in group eRV (24.8% and 30.6%) than in group eOMA (11.7% and 18.0%), and in group sRV (42.7% and 45.7%) than in group sOMA (30.4% and 34.5%)., Conclusion(s): Crude and cumulative SPRs are lower in women treated with the use of expectant rather than surgical management. The presence of OMAs decreases SPRs independently from the treatment modality adopted., (Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To study outcomes and complications during pregnancy and at delivery in women with a posterior deep infiltrating endometriosis (DIE) nodule persisting after surgery and diagnosed at transvaginal sonography (TVS) in comparison with a control group of women without endometriosis., Design: Multicenter observational and cohort study., Setting: University hospital., Patient(s): Women (n = 200) with a posterior DIE nodule equal or more than 2 cm centimeters in size who desired a pregnancy and a control group of women (n = 300) with no previous recorded diagnosis of endometriosis who delivered in our clinic during the same time period., Intervention(s): Patient data collected from medical charts and by phone interviews., Main Outcome Measure(s): Evaluation of complications during pregnancy and delivery., Result(s): Of the 101 women with a posterior DIE nodule, 52 become pregnant among whom 25 used assisted reproductive technology. Of these 52 pregnancies, 11 ended in an early abortion, and 41 delivered a baby; 13 (31.7%) had a premature delivery, 7 (17.8%) a placenta praevia, and 28 (68.2%) had a cesarean delivery. When compared with the control group, the women with endometriosis had a higher risk of pregnancy complicated by preterm birth, placenta previa, placental abruption, and hypertension. Cesarean delivery and complications during surgery (hysterectomy, hemoperitoneum, and bladder injuries) were statistically significantly more frequent in women with endometriosis than in controls., Conclusion(s): Women with an incomplete removal of posterior DIE have a high complications rate during pregnancy and delivery., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the risk for preterm deliveries <37 week of gestation and associated prevalence of vaginal infection in a rural setting after the tsunami in Banda Aceh, Indonesia., Methods: Wet mount microscopy, vaginal pH and vaginal swabs for microbiological culture were collected in pregnant women during the 2nd trimester from February to June of 2005 in four temporary outpatient clinics and the patients were followed up until delivery., Results: One hundred and fifty-nine pregnant patients were screened. Sixty-two could be followed up until delivery. Thirty-nine (62.9%) delivered at term and 23 (37.1%) delivered prematurely. Significant risk factors for preterm delivery were a history of preterm delivery and group B streptococcus infection. Increased vaginal pH alone had no significant influence on preterm delivery, although there was a trend., Conclusion: The rate of preterm delivery was high in this cohort. We suggest risk stratification for preterm delivery in rural conditions by performing a vaginal pH and wet mount microscopy. If either is suspect we suggest collecting a vaginal swab for microbiological culture for targeted treatment. Patients with a history of preterm delivery are at increased risk and should be monitored closely.

Objective: Vulvovaginal atrophy (VVA), caused by decreased levels of estrogen, is a common problem in aging women. Main symptoms of VVA are vaginal dryness and dyspareunia. First-line treatment consists of the application of local estrogen therapy (ET) or vaginal moisturizer. In some cases however, symptoms and signs persist despite those interventions. This case study describes a 77-year-old woman with severe VVA symptoms despite use of local ET and the addition of pelvic floor muscle (PFM) training to her treatment., Methods: A patient with stress urinary incontinence and VVA was referred to a randomized clinical trial on PFM training. On pretreatment evaluation while on local ET, she showed VVA symptoms on the ICIQ Vaginal Symptoms questionnaire and the ICIQ-Female Sexual Matters associated with lower urinary tract Symptoms questionnaire, and also showed VVA signs during the physical and dynamometric evaluation of the PFM. She was treated with a 12-week PFM training program., Results: The patient reported a reduction in vaginal dryness and dyspareunia symptoms, as well as a better quality of sexual life after 12 weeks of PFM training. On posttreatment physical evaluation, the PFMs' tone and elasticity were improved, although some other VVA signs remained unchanged., Conclusions: Pelvic floor muscle training may improve some VVA symptoms and signs in women taking local ET. Further study is needed to investigate and confirm the present case findings and to explore mechanisms of action of this intervention for VVA.

Müllerianosis is the term used to designate lesions composed of an admixture of two or three types of müllerian-derivation glands in heterotopic location. In this report, we describe a case of incidental vaginal müllerianosis in a 59-year-old woman who underwent rectosigmoidectomy for rectal adenocarcinoma. In the vaginal cuff removed for neoplastic invasion, a separate multilocular mass measuring 1.5cm was found. The microscopic examination of the vaginal wall revealed endosalpingeal, endocervical and endometrial dilated or cystic glands with predominance of the endosalpingeal epithelium. Müllerian epithelium showed positivity for cytokeratins 7 and 8/18, high molecular weight cytokeratin, estrogen receptor alpha, and androgen receptor. The periglandular stroma was condensed and reactive for smooth-muscle actin, h-caldesmon, and CD10. To the best of our knowledge, a case of vaginal müllerianosis has not been previously reported. This lesion should be differentiated form vaginal adenosis and primary well-differentiated vaginal adenocarcinoma. The vagina should be added to the list of locations in which müllerianosis can be observed., (Copyright © 2016 Elsevier GmbH. All rights reserved.)

Vaginal calculi are extremely rare and are most commonly encountered in the setting of an urethrovaginal or vesicovaginal fistula. We present a case of a 72-year-old woman with mixed urinary incontinence and vaginal mesh exposure incidentally found to have a large vaginal calculus. We removed the calculus surgically and analyzed the components. Results demonstrated the presence of ammonium-magnesium phosphate hexahydrate and carbonate apatite.

Posterior vaginal wall prolapse is one of the most common prolapses encountered by gynecological surgeons. What appears to be a straightforward condition to diagnose and treat surgically for physicians has proven to be frustratingly unpredictable with regard to symptom relief for patients. Functional disorders such as dyssynergic defecation and constipation are often attributed to posterior vaginal wall prolapse. Little scientific evidence supports this assumption, emphasizing that structure and function are not synonymous when treating posterior vaginal wall prolapse. Rectoceles, enteroceles, sigmoidoceles, peritoneoceles, rectal and intraanal intussusception, rectal prolapse, and descending perineal syndrome are all conditions that have an impact on the posterior vaginal wall. All too often these different anatomic conditions are treated with the same surgical approach, addressing a posterior vaginal wall bulge with a traditional posterior colporrhaphy. Studies that examine the correlation between stage of posterior wall prolapse and patient symptoms have failed to reliably do so. Surgical outcomes measured by prolapse staging appear successful, yet patient expectations are often not met. As increasing attention is being placed on patient satisfaction outcomes concerning surgical treatments, this fact will need to be addressed. Surgeons will have to clearly communicate what can and what cannot be expected with surgical repair of posterior vaginal wall prolapse., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Imperforate hymen typically presents in adolescence with pain, hematocolpometra and primary amenorrhea. This case documents a previously unreported etiology for an atypical presentation with a history of recent menstruation., Case: A female adolescent presented with symptoms of urinary retention and leg pain. She reported a history of irregular, painful menses. Clinical examination revealed a pelvic mass and imperforate hymen. Sonography was consistent with hematocolpometra. Before a planned hymenectomy, the patient began to pass dark blood through a fistulous opening in her vulva. Hymenectomy resulted in complete resolution of the pain and hematocolpometra., Summary and Conclusion: Identification of the fistulous tract explained the patient's history of menstrual bleeding despite an imperforate hymen. Spontaneous rupture of hematocolpometra through a fistulous tract to the vulva is a previously unreported atypical presentation of imperforate hymen in a "menstruating" adolescent with pain and a pelvic mass., (Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)