Post void residue in women with pelvic organ prolapse: a prospective observational study

Background: The objective of the present study was to observe the post void residual volume (PVRV) in women with pelvic organ prolapse (POP) pre and postoperatively and to correlate stage of prolapse with lower urinary tract symptoms and quality of life in women with pelvic organ prolapse.Methods: This is a prospective observational cohort study of 100 women with symptomatic pelvic organ prolapse of stage II or greater. Patients were admitted for Vaginal hysterectomy with pelvic floor repair for pelvic organ prolapse in Gynaecology Department at Christian Medical College Hospital, Vellore, India over one year were recruited. This study was approved by the institutional review board and ethical committee of the hospital. Pre- and post-operative PVR were measured. The statistical analysis was done by using SPSS version 21 and P value < 0.05 was considered as statistically significant.Results: In this study 100 patients were recruited and 11% of women had pre-operative high post void residual volume of more than 100 ml. Stages of POP did not correlate with severity of LUTS and QOL. Pre-operative elevated PVR resolved post operatively in 91%, the P value <0.000 which was highly significant.Conclusions: 11% of women had preoperative high PVR. Stages of POP did not correlate with severity of lower urinary tract symptoms (LUTS) and quality of life(QOL). Pre-operative elevated PVR resolved post operatively in 91%, the P value < 0.000 which was highly significant. Majority of the patient with severe pelvic organ prolapse had elevated pre-op PVR which resolved post- operatively after surgical correction

Prevalence of voiding and defecatory dysfunction in postmenopausal women with pelvic organ prolapse: a prospective observational study

Background: Primary objective of this work was to study the prevalence of voiding and defecatory dysfunction in women with pelvic organ prolapse and correlate the stage and compartment of prolapse with voiding and defecatory dysfunction. The secondary objective was to correlate stage of prolapse with flow rate and post void residue and to study the voiding dysfunction in pelvic organ prolapse.Methods: A prospective observational cohort study in 120 post-menopausal women scheduled for vaginal hysterectomy pelvic floor repair. Short form of pelvic floor distress inventory (PFDI-20) and International prostate symptom questionnaire I-PSS score for Lower urinary tract symptoms (LUTS)was employed.Results: The prevalence of voiding dysfunction in this study was 78% and defecatory dysfunction was 77%. Higher stage of prolapse had significant correlation with voiding dysfunction. (P value was 0.028). Women with posterior compartment defect had more voiding dysfunction with the significant P value (p value was 0.04). Pre-operative voiding dysfunction resolved post operatively in 86%, the p<0.000 which was highly significant.Conclusions: Women with pelvic organ prolapse had high prevalence of voiding and defecatory dysfunction. Stages of prolapse have positive correlation with voiding dysfunction. Pre-operative voiding dysfunction resolved after vaginal hysterectomy and pelvic floor repair

Impact of premature ovarian insufficiency on cardiovascular health

Background: The objectives of the study were to identify the causes of premature ovarian insufficiency (POI) and to assess the severity of menopausal symptoms as well as the impact on cardiovascular health in these patients.Methods: Authors did a cross sectional case control study with 100 cases and 100 age matched controls. Women 4months and FSH >25mIU/ml were identified with POI. Women <40years with normal cycles were the controls. Causes were identified from medical records and menopausal symptoms were categorized using menopause rating score questionnaire. Hypercholesterolemia (≥200mg/dl), hypoalbuminemia (<3.5g/dl) and high sensitive C reactive protein (HS-CRP ≥3mg/dl) were assessed as the early markers of coronary artery disease. Statistical methods included Chi square test and logistic regression analysis. P value <0.05 was considered significant.Results: 64% of the patients were between 31-40 years. 66% of them were into menopause for <5 years. The cause was idiopathic in 62%. 91% had no or minimal menopausal symptoms. Hypoalbuminemia (6 versus 1, 95% CI 1.8-2.4, OR 2.1, p=0.01) and hypercholesterolemia (75 versus 51, 95%CI 2.5-3.1, OR 2.8, p= 0.001) were significantly high in cases. HS-CRP was not found to be different between the groups (59 versus 49, OR 1.5, 95%CI 0.8-2.6, p=0.2).Conclusions: In majority with POI the cause is idiopathic and menopausal symptoms are minimal. Hypoalbuminemia and hypercholesterolemia, markers of coronary artery disease, were significantly elevated in POI. Early screening for these variables within 5 years of menopause would reduce the cardiovascular mortality in these patients

Pelvic reconstructive surgery in geriatric urogynaecology: an uphill task

Female ageing “Geripause” is receiving much attention from the health care community due to worldwide increase in proportion of elderly population as a result of improved health services and awareness. Pelvic floor disorder such as urinary incontinence, faecal incontinence and pelvic organ prolapse disproportionately affect geriatric population and undermines the quality of life. Surgery remains an important and effective therapeutic option for many women with pelvic floor disorders. Operative outcome can be adversely affected in elderly because of physiologic changes associated with aging and the increased number of comorbidities. To present date there is limited information on morbidity and mortality following urogynaecology surgery in geriatric patients. A retrospective analysis was performed on all patients of age more than 60 years old who underwent urogynaecologic surgery in urogynaecology unit from January 2011 to December 2014. Total 551 patients of all age underwent pelvic reconstructive surgery and Out of 121 patients were of age more than 60 years. Overall in our series 66% patients had one or more than one risk factors and 23% of patients had one or more than one perioperative complications. Intraoperative and postoperative complications rate was 4.9% and 18.1% respectively. Elderly women can undergo urogynecologic surgery with an acceptable rate of complications and should not be excluded from interventions that may improve their quality of life. 

Pelvic actinomycosis: unrelated to prior intrauterine device use

Actinomycosis is a chronic, suppurative, granulomatous disease which is typically seen in the cervicofacial and thoracic regions and less commonly abdominopelvic (10-20%). It is caused by an anaerobic, filamentous gram positive bacterium which is a normal commensal of the oropharynx, gastrointestinal tract and genital tract. Pelvic actinomycosis is almost always associated with the current or prior use of an intrauterine contraceptive device. Clinical diagnosis is difficult owing to the close resemblance to an ovarian tumour. Definitive diagnosis is usually made only after histopathological correlation. Reported here is a patient with pelvic actinomycosis unrelated to the use of an intrauterine contraceptive device. This patient presented with clinical features suggestive of chronic pelvic inflammatory disease with a possible benign ovarian tumour. Operative findings were consistent with pelvic inflammatory disease. The typical histopathological features of the Splendor Hoeppli phenomenon with sulphur granules and isolation of the actinomyces organism (which is rare) revealed the diagnosis of actinomycosis of the fallopian tubes. Pelvic actinomycosis is a rare condition and seldom described in the absence of an intrauterine device. High dose, long term antibiotic therapy is the key to successful resolution with surgery reserved for refractory cases. This patient showed good clinical and radiological response

Levonorgestrel intrauterine system: A first line medical therapy for idiopathic heavy menstrual bleeding

Heavy menstrual bleeding or menorrhagia is a common menstrual disorder. Currently, both medical and surgical treatment options are available for the management of heavy menstrual bleeding. Hysterectomy, one of the surgical treatment options is associated with risks and is a costly procedure. Medical treatment may be preferred for the management of heavy menstrual bleeding. Oral medical treatments have various limitations for their use. For instance, cost is a limiting factor for tranexamic acid. Limited data is available to support the effectiveness of oral contraceptives. Poor patient compliance and intolerable adverse events are some other limitations especially in long term use. Levonorgestrel intrauterine system (LNG-IUS) is one of the common medical modalities in the management of heavy menstrual bleeding. LNG-IUS has been compared with other medical options like tranexamic acid, mefenamic acid, combined estrogen-progestogen, or progesterone alone, cyclic oral medroxyprogesterone acetate (MPA) oral norethisterone and low-dose combined oral contraceptive. LNG-IUS is more effective than usual medical treatment and also reduces the effect of heavy menstrual bleeding on quality of life. Similarly, it has shown similar therapeutic effects compared to endometrial ablation. Based on its efficacy, convenience and cost of therapy, it can be considered as the first line medical therapy for the management of heavy menstrual bleeding

Hydroureteronephrosis in women with pelvic organ prolapse: a prospective cohort study

Background: Pelvic organ prolapses (POP) is a common problem in women. The prevalence of POP increase with age. The true prevalence and risk factor for developing hydroureteronephrosis (HUN) in women with pelvic organ prolapse is still unclear due to lack of prospective studies on sufficiently large cohorts. This prospective study was done to study the prevalence of HUN in women with POP and to identify the risk factors for developing HUN.Methods: In this prospective observational study 219 patients were recruited for surgical repair for pelvic organ prolapse for 2 years.  Preoperatively, all patients had transabdominal scan to assess the uterus, adnexa and to look for Hydroureteronephrosis (HUN). Women with presence of HUN were followed postoperatively look for the resolution of HUN.Results: The prevalence of bilateral HUN was 6.85%. The mean age of women with HUN ranged from 51-69 years. Diabetes and hypertension were significant risk factor for development of HUN (OR 4.70, 95% CI -1.59-13.88 and OR 3.72, 95% CI- 1.23-11.1 respectively). There was a statistically significant correlation between chronic kidney disease and HUN. (OR 1 with 95%: CI 9.49-30.42). The correlation between stage of pelvic organ prolapse and HUN was not statistically significant (p = 0.062). There was a statistically significant correlation between the duration (2years -15 years) of POP to HUN. (OR 0.233, 95%0.13-0.419). Patients were followed up post operatively for resolution of HUN. HUN resolved in 9 women (60%) and persisted in 6 (40%).Conclusions: The prevalence of bilateral HUN in women with pelvic organ prolapse was 6.8%. Presence of hypertension, diabetes and chronic kidney disease was a risk factor for HUN. HUN resolved in 60% of women after pelvic reconstructive surgery

Abdominal wall endometriosis: accuracy of the diagnostic triad

Background: Endometriosis is the presence of endometrial glands and stroma outside the uterine cavity and musculature. The objectives were to study the prevalence, the clinic-pathological presentation and the accuracy of the criteria for diagnosis of abdominal wall endometriosis.Methods: This is a retrospective observational study done at a tertiary hospital. The study was approved by the ethics committee and the IRB. Data was retrieved from computer generated medical records. Specificity, sensitivity and likelihood ratio along with univariate and multivariable penalized logistic regression analysis of each presenting symptom were done.Results: Of the 493 cases with genital endometriosis, 45 cases had AWE diagnosed clinically giving a prevalence of 8.3%. Histological diagnosis of AWE was made in 41, while 4 had suture granuloma. Pain, swelling and previous LSCS had sensitivity of 71%, specificity of 100% and the likelihood ratio was 0.29. The presentation was within 6 years after the index surgery of Caesarean section, with the odds ratio of having endometriosis of 19 (95% CI 1.7- 1595) and the P value of 0.016.Conclusions: The diagnostic triad of previous caesarian section with swelling and pain at the scar site should prompt the possibility of AWE. However, previous LSCS was the only factor that contributed to the presence of abdominal wall endometriosis.

Is hysterectomy a risk factor for urinary incontinence?

Background: Hysterectomy is the most common gynecological surgery performed. There are few studies evaluating hysterectomy as a risk factor for urinary incontinence. If hysterectomy is found to be a risk factor for developing urinary incontinence, women undergoing hysterectomy can be well informed prior to the procedure regarding the same. The objective of the present study was to study the prevalence of urinary incontinence in post-menopausal women and its relationship to hysterectomy. To evaluate the association of metabolic syndrome, to urinary incontinence.Methods: This study was a prospective cohort study done in Christian Medical College and Hospital, Vellore, Tamil Nadu between December 2016- December 2017. Postmenopausal women both with natural and surgical menopause, were enrolled into the study after an informed consent. The UDI-6 questionnaire was used to assess urinary incontinence. The categorical variables were presented using frequencies and percentages. The comparison of categorical variables was done using Fisher's exact test. The odds ratio and confidence interval were calculated for the prevalence. P value < 0.05 was considered to be statistically significant.Results: A total of 600 women were enrolled into the study with 300 women having attained natural menopause and 300 women with a surgical menopause. The prevalence of urinary incontinence among these post-menopausal women was 46.24%. The prevalence of urinary incontinence amongst the women with natural menopause was 47.3% and amongst the women with surgical menopause was 45% (p = 0.566). Women with metabolic syndrome suffered from urinary incontinence more than their counterparts without metabolic syndrome (55.8% vs. 36%, p <0.0001).Conclusions: The prevalence of urinary incontinence in the natural menopause and surgical menopause groups was similar, thus proving that hysterectomy is not a risk factor for developing urinary incontinence. However, metabolic syndrome was found to be associated with urinary incontinence.

Association of metabolic syndrome and lower urinary tract symptoms amongst South Indian postmenopausal women

Background: Women spend one third of their life in menopause. The age related anatomical and physiological changes predispose them to MetS and lower urinary tract symptoms (LUTS). The aim was to study the prevalence of metabolic syndrome (MetS) and lower urinary tract symptoms in postmenopausal women attending menopause clinic, to study the correlation of LUTS and body composition among women with MetS.Methods: 154 post-menopausal women who attended menopause clinic at the Christian Medical College Hospital Vellore, were recruited. MetS was diagnosed using IDF criteria. LUTS were assessed BFLUTS questionnaires. Blood was taken to assess serum fasting glucose and lipid profile. DEXA was performed to assess the whole-body composition.Results: Of 154 postmenopausal women, 64% had MetS and 43% of women had a total LUTS score > 5. 90% of women had filling symptoms,57% had incontinence,17% had voiding symptoms,14 % had quality of life issues and 6 % had sexual symptoms. However, there was no statistical significant difference between two groups in correlating the variables of MetS with LUTS (P >0.05). The percentage of total body fat by DEXA scan was significantly greater (P=0.006) in women with MetS (37.32±5.04) when compared to the women without MetS (34.629±3.65).Conclusions: Prevalence of MetS among the study population was 64 %. LUTS were observed in 43% of the patients. There was no significant difference in LUTS in women with MetS and without Mets. However, there was a significant difference in body composition among women with and without MetS