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- Simple vs Complex Urethral Diverticulum: Presentation and Outcomes. [Journal Article]
- Urology 2014 Dec; 84(6):1516-20.
To determine whether complex anatomic configurations of urethral diverticula (UD), namely circumferential UD (cUD), present differently or confer a worse prognosis as compared with simple UD (sUD).After institutional review board approval, a retrospective review of patients who underwent transvaginal urethral diverticulectomy at a single institution over an 8-year period was performed. A total of 43 patients were identified, of which 11 were found to have cUD. These lesions were repaired with complete division of the urethra to access the dorsally located portion of the UD, followed by end-to-end anastomosis for urethral reconstruction with a Martius flap and/or autologous fascial pubovaginal sling performed as needed. Presenting symptoms and surgical outcomes were reviewed.Mean age was 50.9 years in the cUD vs 52.7 years in the sUD. Patients with cUD were more likely to present with stress urinary incontinence than those with sUD (90.9% vs 56.3%; P = .04). There was no statistical difference in the rate of preoperative urgency, pelvic pain and/or dyspareunia, postvoid dribbling, and urinary tract infection. Postoperatively, patients with cUD were more likely to have a urinary tract infection (27% vs 3%; P = .2); otherwise, rates of postoperative results were similar.Urethral transection and end-to-end anastomosis for the repair of complex UD is a feasible approach and results in similar clinical outcomes compared with the repair of sUD.
- Clinical and treatment factors associated with vaginal stenosis after definitive chemoradiation for anal canal cancer. [JOURNAL ARTICLE]
- Pract Radiat Oncol 2014 Oct 29.
We sought to evaluate the incidence of vaginal stenosis (VS) and identify clinical and treatment factors that predict for VS in female patients with anal cancer treated with definitive chemoradiation.The cohort included 95 consecutive women receiving definitive chemoradiation between 2003 and 2012. All but 1 received intensity modulated radiation therapy; median primary tumor dose 50.4 Gy (range, 41.4-60). A modified National Cancer Institute Common Terminology Criteria for Adverse Events version 4 was used to score VS based on the medical record description of dyspareunia, pain with dilator use, vaginal dryness, or difficult pelvic examination. Ordered logistic regression was performed to assess VS predictors.Median age was 60.4 years (range, 19-97). With median follow-up of 2.5 years, 70 women (74%) had adequate information to assess VS. Of these, VS grade distribution was 21.4% grade 0, 14.3% grade 1, 27.1% grade 2, and 37.1% grade 3. By multivariable ordered logistic regression, younger age (P = .02), higher tumor dose (P = .06), and earlier treatment year (P = .04) were associated with higher grade of VS.VS is a common late complication in women treated definitively with chemoradiation for anal canal cancer. Younger age, higher tumor dose, and earlier year of treatment were associated with a higher grade of stenosis. Prospective investigation into patient reported outcomes is warranted, including sexual function and VS prevention strategies to better understand its effect on long-term survivorship.
- Effects of ospemifene on the female reproductive and urinary tracts: translation from preclinical models into clinical evidence. [JOURNAL ARTICLE]
- Menopause 2014 Nov 24.
Treatment of menopausal symptoms by compounds with tissue-selective estrogen agonist/antagonist effects, often called selective estrogen receptor modulators, has been researched as an alternative to the use of estrogen therapy. These structurally diverse molecules elicit tissue-dependent responses in hormone-responsive tissues and organs, exhibiting variations in estrogenic activity in preclinical models of postmenopausal reproductive tissues that may improve postmenopausal women's health (eg, prevention and treatment of breast cancer, osteoporosis, and vulvar and vaginal atrophy).This literature review investigates whether preclinical data predicted the clinical effects of ospemifene on female reproductive and urinary tract tissues and compares these findings with the specific vaginal effects of other estrogen receptor agonists/antagonists (tamoxifen, raloxifene, and bazedoxifene) in preclinical and clinical studies. Lasofoxifene, although not currently available, is included because of its unique effects on vaginal tissue.The response of endometrial and vaginal tissues to estrogen receptor agonists/antagonists can be differentiated using transvaginal ultrasound, endometrial histopathology, cytologic examination of vaginal smears, assessment of physical changes in the vagina, and relief of symptoms associated with vulvar and vaginal atrophy (such as dyspareunia).Available evidence indicates that ospemifene has unique effects on tissue, leading to a favorable long-term profile for the relief of vulvar and vaginal atrophy compared with other estrogen receptor agonists/antagonists (eg, tamoxifen, raloxifene, and bazedoxifene) with no short-term concerns about endometrial safety (based on endometrial hyperplasia, carcinoma, endometrial spotting, and endometrial bleeding).This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
- Dyspareunia in HIV-positive and HIV-negative middle-aged women: a cross-sectional study. [Journal Article]
- BMJ Open 2014; 4(11):e004974.
To evaluate whether dyspareunia is associated with HIV status in menopausal women and also to assess which factors are associated with dyspareunia in a group of HIV-positive menopausal women.A cross-sectional study was conducted with 178 HIV-negative and 128 HIV-positive women aged 40-60 years. The Short Personal Experiences Questionnaire (SPEQ) was used to collect data. Sociodemographic, clinical, behavioural and reproductive factors were evaluated, as well as factors related to the HIV infection. Dyspareunia was defined as pain during intercourse. A bivariate analysis and Poisson multiple regression analysis were performed.Overall, 41.4% of the HIV-positive women reported dyspareunia compared with 34.8% of the HIV-negative women (p=0.242). In the HIV-positive women, bivariate analysis revealed an association between dyspareunia and having a steady partner (p=0.047); the woman's partner having undergone HIV testing (p=0.020); vaginal dryness (p<0.001); muscle/joint pain (p=0.021); physical/emotional violence (p=0.049); urinary incontinence (p=0.004); and the use of lamivudine/zidovudine (p=0.048). The Poisson multiple regression analysis found an association between dyspareunia and vaginal dryness (prevalence ratio (PR)=1.96, 95% CI 1.10 to 3.50, p=0.023) and urinary incontinence (PR=1.86, 95% CI 1.06 to 3.27, p=0.031).Dyspareunia was common in this group of HIV-positive women and was associated principally with vaginal dryness and urinary incontinence. The importance of treating dyspareunia within the context of sexual health in this group of women should be emphasised and appropriate management of this issue may reduce the likelihood of lesions on the vaginal wall, which may act as a portal of entry for other infections.
- Safety and efficacy of ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy due to menopause. [REVIEW]
- Clin Interv Aging 2014.:1939-1950.
During the menopausal transition, women experience a number of symptoms due to declining estrogen levels, including vasomotor symptoms and vulvar and vaginal atrophy (VVA). Unlike vasomotor symptoms, vaginal dryness and dyspareunia, the main symptoms of VVA, typically worsen without treatment and can significantly impact the quality of life. Up to 60% of postmenopausal women may be affected by VVA, but many women unfortunately do not seek treatment due to embarrassment or other factors. After 20+ years in development, ospemifene (Osphena™) was approved by the US Food and Drug Administration in 2013 for treatment of moderate-to-severe dyspareunia associated with VVA due to menopause. As the first non-hormonal alternative to estrogen-based products for this indication, the approval of ospemifene represents a significant milestone in postmenopausal women's health. Ospemifene is a non-steroidal estrogen receptor agonist/antagonist, also known as a selective estrogen receptor modulator (SERM), from the same chemical class as the breast cancer drugs tamoxifen and toremifene. Unlike other selective estrogen receptor modulators, ospemifene exerts a strong, nearly full estrogen agonist effect in the vaginal epithelium, making it well suited for the treatment of dyspareunia in postmenopausal women. Results of Phase III clinical trials showed that ospemifene significantly improved the vaginal maturation index (decreased parabasal cells and increased superficial cells), decreased vaginal pH, and decreased severity of the self-identified most bothersome symptom (dyspareunia or vaginal dryness) compared to placebo. Long-term safety studies revealed that 60 mg ospemifene given daily for 52 weeks was well tolerated and was not associated with any endometrium or breast-related safety concerns. This review discusses the preclinical and clinical data supporting the use of ospemifene for the treatment of dyspareunia associated with VVA due to menopause and provides an overview of its clinical safety.
- Effects of female genital cutting on physical health outcomes: a systematic review and meta-analysis. [Journal Article]
- BMJ Open 2014; 4(11):e006316.
Worldwide, an estimated 125 million girls and women live with female genital mutilation/cutting (FGM/C). We aimed to systematically review the evidence for physical health risks associated with FGM/C.We searched 15 databases to identify studies (up to January 2012). Selection criteria were empirical studies reporting physical health outcomes from FGM/C, affecting females with any type of FGM/C, irrespective of ethnicity, nationality and age. Two review authors independently screened titles and abstracts, applied eligibility criteria, assessed methodological study quality and extracted full-text data. To derive overall risk estimates, we combined data from included studies using the Mantel-Haenszel method for unadjusted dichotomous data and the generic inverse-variance method for adjusted data. Outcomes that were sufficiently similar across studies and reasonably resistant to biases were aggregated in meta-analyses. We applied the instrument Grading of Recommendations Assessment, Development and Evaluation to assess the extent to which we have confidence in the effect estimates.Our search returned 5109 results, of which 185 studies (3.17 million women) satisfied the inclusion criteria. The risks of systematic and random errors were variable and we focused on key outcomes from the 57 studies with the best available evidence. The most common immediate complications were excessive bleeding, urine retention and genital tissue swelling. The most valid and statistically significant associations for the physical health sequelae of FGM/C were seen on urinary tract infections (unadjusted RR=3.01), bacterial vaginosis (adjusted OR (AOR)=1.68), dyspareunia (RR=1.53), prolonged labour (AOR=1.49), caesarean section (AOR=1.60), and difficult delivery (AOR=1.88).While the precise estimation of the frequency and risk of immediate, gynaecological, sexual and obstetric complications is not possible, the results weigh against the continuation of FGM/C and support the diagnosis and management of girls and women suffering the physical risks of FGM/C.This study is registered with PROSPERO, number CRD42012003321.
- Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. [Journal Article]
- Obstet Gynecol 2014 Dec; 124(6):1147-56.
To comprehensively review and critically assess the literature on vaginal estrogen and its alternatives for women with genitourinary syndrome of menopause and to provide clinical practice guidelines.MEDLINE and Cochrane databases were searched from inception to April 2013. We included randomized controlled trials and prospective comparative studies. Interventions and comparators included all commercially available vaginal estrogen products. Placebo, no treatment, systemic estrogen (all routes), and nonhormonal moisturizers and lubricants were included as comparators.We double-screened 1,805 abstracts, identifying 44 eligible studies. Discrepancies were adjudicated by a third reviewer. Studies were individually and collectively assessed for methodologic quality and strength of evidence.Studies were extracted for participant, intervention, comparator, and outcomes data, including patient-reported atrophy symptoms (eg, vaginal dryness, dyspareunia, dysuria, urgency, frequency, recurrent urinary tract infection (UTI), and urinary incontinence), objective signs of atrophy, urodynamic measures, endometrial effects, serum estradiol changes, and adverse events. Compared with placebo, vaginal estrogens improved dryness, dyspareunia, urinary urgency, frequency, and stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). Urinary tract infection rates decreased. The various estrogen preparations had similar efficacy and safety; serum estradiol levels remained within postmenopausal norms for all except high-dose conjugated equine estrogen cream. Endometrial hyperplasia and adenocarcinoma were extremely rare among those receiving vaginal estrogen. Comparing vaginal estrogen with nonhormonal moisturizers, patients with two or more symptoms of vulvovaginal atrophy were substantially more improved using vaginal estrogens, but those with one or minor complaints had similar symptom resolution with either estrogen or nonhormonal moisturizer.All commercially available vaginal estrogens effectively relieve common vulvovaginal atrophy-related complaints and have additional utility in patients with urinary urgency, frequency or nocturia, SUI and UUI, and recurrent UTIs. Nonhormonal moisturizers are a beneficial alternative for those with few or minor atrophy-related symptoms and in patients at risk for estrogen-related neoplasia.PROSPERO International prospective register of systematic reviews, http://www.crd.york.ac.uk/PROSPERO/, CRD42013006656.
- Sexual dysfunction in patients with polycystic ovary syndrome and its affected domains. [Journal Article]
- Iran J Reprod Med 2014 Aug; 12(8):539-46.
Polycystic Ovary Syndrome (PCOS) is presented with characteristic complications such as chronic an ovulation, obesity, and hyperandrogenism which can affect sexual function in women of reproductive age.Herein we evaluated the frequency and predisposing factors of sexual dysfunction in infertile PCOS patients.In this cross-sectional study, 130 married women with a definite diagnosis of PCOS who were referred due to infertility were recruited. They were evaluated concerning their sexual function in the domains of desire, arousal, lubrication, orgasm, satisfaction and pain with the female sexual function index (FSFI) questionnaire.The frequency of sexual dysfunction was verified 57.7% in PCOS patients with the domains of desire and arousal being commonly affected in 99.2% and 98.5%of cases respectively. BMI had a significant effect on sexual desire and arousal (p=0.02) while the effect of hirsutism was significant on all domains (p<0.001 for total FSFI score) except for dyspareunia.PCOS patients markedly suffer from sexual dysfunction as comorbidity. It seems appropriate to screen all PCOS patients for sexual function with a simple short questionnaire such as FSFI. Targeted interventions could be considered to help improve their quality of life along with other treatments.
- Sexual Functioning in Women after Surgical Treatment for Endometrial Cancer: A Prospective Controlled Study. [JOURNAL ARTICLE]
- J Sex Med 2014 Nov 17.
Endometrial cancer (EC) can affect sexual functioning based on anatomical, physiological, psychological, and relational mechanisms.The aim of this study was to prospectively investigate sexual adjustment of women with EC during a follow-up period of 2 years after surgical treatment and to compare the results with women who underwent a hysterectomy for a benign gynecological condition and healthy control women.In this prospective controlled study, participants completed the Short Sexual Functioning Scale, Specific Sexual Problems Questionnaire, Beck Depression Inventory Scale, World Health Organization-5 Well-being Scale, and Dyadic Adjustment Scale to assess various aspects of sexual and psychosocial functioning before undergoing a hysterectomy and 6 months, 1 year, and 2 years after surgery.Eighty-four women with EC, 84 women with a benign gynecological condition, and 84 healthy controls completed the survey. In EC survivors, no differences were found in sexual functioning during prospective analyses. In comparison with women with a benign gynecological condition, significantly more EC patients reported entry dyspareunia 1 year after surgical treatment. Moreover, compared with healthy women, pre- and postoperatively, significantly more EC patients reported sexual dysfunctions, including sexual desire dysfunction, arousal dysfunction, entry dyspareunia, and a reduced intensity of orgasm. Furthermore, compared with healthy controls, EC patients reported significantly lower overall well-being 1 year after surgical treatment. Nevertheless, consensus in the partner relationship was significantly higher in EC patients compared with healthy controls. Moreover, before treatment, quality of partner relationship was negatively associated with sexual arousal dysfunction and orgasm dysfunction.In EC patients, no differences were found in sexual functioning when prospectively comparing the situation before surgery with the situation after surgery. However, when compared with healthy controls, EC patients are at high risk for sexual dysfunctions, both before and after surgical treatment. Aerts L, Enzlin P, Verhaeghe J, Poppe W, Vergote I, and Amant F. Sexual functioning in women after surgical treatment for endometrial cancer: A prospective controlled study. J Sex Med **;**:**-**.
- Can Fear, Pain, and Muscle Tension Discriminate Vaginismus from Dyspareunia/Provoked Vestibulodynia? Implications for the New DSM-5 Diagnosis of Genito-Pelvic Pain/Penetration Disorder. [JOURNAL ARTICLE]
- Arch Sex Behav 2014 Nov 15.
Fear has been suggested as the crucial diagnostic variable that may distinguish vaginismus from dyspareunia. Unfortunately, this has not been systematically investigated. The primary purpose of this study, therefore, was to investigate whether fear as evaluated by subjective, behavioral, and psychophysiological measures could differentiate women with vaginismus from those with dyspareunia/provoked vestibulodynia (PVD) and controls. A second aim was to re-examine whether genital pain and pelvic floor muscle tension differed between vaginismus and dyspareunia/PVD sufferers. Fifty women with vaginismus, 50 women with dyspareunia/PVD, and 43 controls participated in an experimental session comprising a structured interview, pain sensitivity testing, a filmed gynecological examination, and several self-report measures. Results demonstrated that fear and vaginal muscle tension were significantly greater in the vaginismus group as compared to the dyspareunia/PVD and no-pain control groups. Moreover, behavioral measures of fear and vaginal muscle tension were found to discriminate the vaginismus group from the dyspareunia/PVD and no-pain control groups. Genital pain did not differ significantly between the vaginismus and dyspareunia/PVD groups; however, genital pain was found to discriminate both clinical groups from controls. Despite significant statistical differences on fear and vaginal muscle tension variables between women suffering from vaginismus and dyspareunia/PVD, a large overlap was observed between these conditions. These findings may explain the great difficulty health professionals experience in attempting to reliably differentiate vaginismus from dyspareunia/PVD. The implications of these data for the new DSM-5 diagnosis of Genito-Pelvic Pain/Penetration Disorder are discussed.