When a device that later disintegrates is fitted to a patient during surgery, who is responsible for the consequences? What health professionals and hospitals need to know

Management of Bladder Pain Syndrome: Green-top Guideline No. 70.

Vaginal Discharge and Bleeding in Girls Younger Than 6 Years

A Model of Neural Cross-Talk and Irritation in the Pelvis: Implications for the Overlap of Chronic Pelvic Pain Disorders

Medical records of all prepubertal patients who underwent vaginoscopy to rule out vaginal foreign body between 2004 and 2013 were reviewed retrospectively. All patients were evaluated by pediatricians prior to surgical consultation. Vaginoscopy is performed in the operating room under general anesthesia. During the study period, 20 girls with persistent vaginal discharge with a mean age of 6.8 years (1-13 years) underwent vaginoscopy to rule out vaginal foreign body. Six patients had bloody vaginal discharge and 4 had recurrent vaginal bleeding lasting for more than one month. Ten patients had purulent vaginal discharge lasting for 1-7 months. None of vaginal cultures revealed pathological bacteria or candida species. Preoperative imaging techniques revealed vaginal foreign body in one patient only. Vaginoscopy demonstrated vaginal foreign bodies in four patients. Foreign bodies were grass inflorescence, safety pin and undefined brownish particles (n=2), which may be pieces of toilet paper or feces. There was no complication related to vaginoscopy and removal of foreign body. Hymen integrity was preserved in all patients. Persistent or recurrent vaginal discharge in prepubertal girls should raise the suspect of vaginal foreign body. Continuous flow vaginoscopy is mandatory to detect and remove any vaginal foreign body. Early diagnosis would prevent complications secondary to long-standing foreign bodies.

Preface

Chronic pelvic pain (CPP) is a complicated condition that can have a large impact on life. The aetiology of CPP is often unclear and the origin appears to be multifactorial. This study aims to identify risk factors associated with CPP complaint in women. The study is a descriptive case–control study in nature. The study was conducted in one university and one state hospital. Women with CPP (n = 134) composed the case group while those who consulted to the polyclinics with other problems formed the control group (n = 383). The data were collected through a questionnaire which was prepared in light of the related literature and the ‘Pelvic Pain Assessment Form’ developed by the International Pelvic Pain Society. Women in the case and control groups were found to have similar socio-demographical features. This study has detected that CPP is associated with factors such as having a relative with recurrent pelvic pain complaint, having cancer or CPP history, having pain during menstruation, feeling of fullness in the abdominal region and stool consistency, recurrent urinary tract infections, having a diagnosed woman's disease (ovarian cyst, genital tract infection, prolapsus and menstrual irregularity), having had an abdominal operation, taking vaginal showers after sexual intercourse or for any other reason, falling down from height or having an accident that caused back damage, experiencing a sad event during childhood, being exposed to physical violence or forced to sexual intercourse. In Conclusion, this study has found that reproduction, urinary, gastrointestinal, musculoskeletal systems and psychological factors affect women with chronic pelvic pain.

Urologic chronic pelvic pain syndrome (UCPPS) is a condition of unknown etiology characterized by pelvic pain and urinary frequency and/or urgency. As the proximal fluid of this syndrome, urine is an ideal candidate sample matrix for an unbiased study of UCPPS. In this study, a large, discovery-phase, TMT-based quantitative urinary proteomics analysis of 244 participants was performed. The participants included patients with UCPPS (n = 82), healthy controls (HC) (n = 94), and disparate chronic pain diseases, termed positive controls (PC) (n = 68). Using training and testing cohorts, we identified and validated a small and distinct set of proteins that distinguished UCPPS from HC (n = 9) and UCPPS from PC (n = 3). The validated UCPPS: HC proteins were predominantly extracellular matrix/extracellular matrix modifying or immunomodulatory/host defense in nature. Significantly varying proteins in the UCPPS: HC comparison were overrepresented by the members of several dysregulated biological processes including decreased immune cell migration, decreased development of epithelial tissue, and increased bleeding. Comparison with the PC cohort enabled the evaluation of UCPPS-specific upstream regulators, contrasting UCPPS with other conditions that cause chronic pain. Specific to UCPPS were alterations in the predicted signaling of several upstream regulators, including alpha-catenin, interleukin-6, epidermal growth factor, and transforming growth factor beta 1, among others. These findings advance our knowledge of the etiology of UCPPS and inform potential future clinical translation into a diagnostic panel for UCPPS.

Introduction: Biological reagent like PRP having strong anti–inflammatory and healing effect due to large number of growth factors and paracrine action thus plays a crucial role in cell protection, repairing and regeneration of epithelial tissues, curing deep seated inflammation thus protecting patient from long term consequences of chronic inflammation. Adult women worldover are commonly affected by cervicitis, Symptoms of it can be similar to vaginitis with persistent vaginal discharge, itching, heaviness and dysperiunea. It can be ca used by sexually transmitted infection as well as due to trauma, frequent douching and chemical irritants. This chronic in flammation of the cervix has a high recurrence rate due to its complex pathophysiology and leads to long term consequences like pelvic inflammatory disease, infertility, ectopic pregnancy, chronic pelvic pain, increased predisposition to HPV & HIV infection and even it can be a precursor of cervical cancer. Aim: To compare post treatment symptom relief and healing of damaged cervix in patient undergoing either conventional or PRP therapy for chronic cervicitis and erosions. Materials and Methods: This study was a single center, prospective observational study conducted at L N Medical college and research centre Bhopal M.P. A total of 120 patients with CC having similar symptoms were enrolled and out of which 60 randomly selected patients were given conventional treatment and remaining 6 0 were undergone PRP therapy. PRP was prepared from patients own blood in our institutional lab and injected immediately in the targeted areas of cervix at 3- 4 sites and result compared. Result: Better Clinical benefits and healed epithelium were observed o n follow up visits in the PRP treated patient as compared to conventional treatment in addition increased perception of recovery in patients within the prp group compared with the conventional group. No complications were reported in both therapy. Conclu

Foreign body insertion into the vagina has been described across all ages. The presenting symptoms may be persistent vaginal discharge, chronic pelvic pain, post menopausal bleeding. Foreign body as a differential diagnosis is rarely thought of with the above presentations and remains a diagnostic challenge.An unusual case of a foreign body causing vagina l stenosis, haematocolpos and inflammatory adnexal masses leading to diagnostic confusion and difficult surgery is presented.An eighteen year old unmarried woman with chronic pelvic pain of 3 years duration was diagnosed to have bilateral adnexal masses on pelvic USG. On suspicion of genital tuberculosis she received a course of anti tuberculosis treatment with no symptomatic relief or decrease in size of the adnexal mass. A second sonogram four months later suggested presence of vaginal /cervical foreign body surrounded by fluid (haematocolpos?) and she was referred to a gynaecologist. An MRI confirmed the findings. As examination showed what was presumed to be a transverse vaginal septum the patient was posted for examination under anaesthesia. There were dense vaginal adhesions and as the haematocolpos could not be accessed from below a laparotomy was performed, the vagina opened from above and after draining 300ml of chocolate colored fluid a bottle cap was retrieved. The stenosed vagina was successfully opened by vaginal dissection by abdomino-vaginal approach. This case is an unusual presentation of a foreign body causing vaginal stenosis and causing much diagnostic dilemma and difficult surgery.

Epithelial ovarian serous cancer arising in endometrioma is an uncommon phenomenon. Here, we present a case of postmenopausal ovarian high-grade serous carcinoma associated with ovarian endometrioma. A 64-year-old woman attended the clinic with pelvic pain and persistent vaginal discharge. Ultrasonography revealed an endometrial thickness and 37*23 mm left cystic adnexal mass. During the operation, solid pelvic mass grossly located in the cul-de-sac infiltrating rectum and left ovarian cysts were observed. At the intraoperative frozen section, benign left adnexal mass, benign pelvic lymph nodes, and the morphological findings of adenocarcinoma with undetermined-site of the origin were detected in the uterus and rectosigmoid colon. Final pathology revealed a high-grade ovarian serous carcinoma arising in ovarian endometrioma from two microscopic focuses. In sum, when we encounter postmenopausal endometrioma with increased biomarkers, it is crucial to consider the possibility of malignant transformation to ovarian cancer.

MP03-03 TRANSCRIPTOME ANALYSIS IN LUMBOSACRAL DORSAL ROOT GANGLIA REVEALS KEY MOLECULAR CHANGES IN ANIMAL MODELS OF UROLOGICAL CHRONIC PELVIC PAIN SYNDROME (UCPPS)

Dear Editor: Distressing vaginal discharge following conventional proctocolectomy has been reported in up to 50 % of patients. The primary evaluation of such patients includes assessing for the presence of an enterovaginal fistula. We report a case of a patient who presented with distressing vaginal discharge lasting for 2 years after a conventional proctocolectomy. The discharge was found to be a result of the pelvic floor muscle shift and compression of the vagina, with a formation of a fluid reservoir in the upper third of the vagina. A 39-year-old woman with ulcerative colitis (UC) underwent an urgent total colectomy, rectal preservation, and end ileostomy for toxic colitis. The postoperative period was uneventful. Histopathological examination confirmed the diagnosis. Due to persistent rectal mucous discharge and her reluctance to have a completion proctectomy with ileal pouch and anal anastomosis, a perineal proctectomy was performed. The operation and the postoperative period were uneventful. Following the second operation, the patient complained of new onset vaginal discharge. She described recurrent episodes of sudden drainage of copious amount of fluid from the vagina, which was often brown or bloody and had an unpleasant odor. The patient underwent a gynecologic assessment which included repeated vaginal examinations and cultures, without findings. The comprehensive evaluation included transvaginal ultrasonography, computed tomography (CT), gastrografin enema, and magnetic resonance imaging (MRI) for the assessment of an enterovaginal fistula. All of the studies failed to identify a fistula, but the ultrasound, CT, and MRI demonstrated an accumulation of fluid in the upper vagina. An examination under anesthesia was performed, which also failed to diagnose a fistula. Two years after the second procedure, the patient was referred to a vulvovaginal clinic. Detailed history revealed that since analresection, the patient also had dyspareunia and a “phantom” anal pressure sensation. Upon palpation of the levator ani muscle, a ventral migration was noted. Insertion of a speculum was disrupted by a circular narrowing of the upper vagina. Passing the narrowing resulted in the drainage of large amount of fluid. The vagina appeared normal without inflammation, and microscopic evaluation of the discharge was negative. Review of the MRI films confirmed a pelvic floor muscle shift and the compression of the vagina, with the formation of a reservoir offluidintheupper third of the vagina. The patient was referred to pelvic floor physiotherapy, and following pelvic floor muscle relaxation and voluntary emptying of her vaginal contents, she became symptom free.

Recurrent vaginal discharge is a significant health issue for women globally, often leading to discomfort and a reduced quality of life. While normal vaginal discharge helps maintain vaginal health, changes in its composition can signal underlying conditions requiring prompt assessment and treatment. The causes of recurrent vaginal discharge are diverse, including infections, hormonal changes, and anatomical factors. Common infections like bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis are frequently encountered, with studies estimating that up to 75% of women will experience vulvovaginal candidiasis at least once in their lifetime. Non-infectious causes, such as foreign bodies, vaginal atrophy, and cervical or endometrial anomalies, also contribute but are less commonly addressed. Despite its prevalence, diagnosing recurrent vaginal discharge can be challenging, requiring a thorough approach. Cultural taboos and stigma surrounding vaginal health may discourage women from seeking medical help, potentially delaying diagnosis and treatment. This article reports a case of a vaginal foreign body presenting with persistent discharge and emphasizes the importance of a comprehensive approach to diagnosing and managing vaginal discharge.

Urologic chronic pelvic pain syndrome (UCPPS), which encompasses interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome, is characterized by chronic pain in the pelvic region or genitalia that is often accompanied by urinary frequency and urgency. Despite considerable research, no definite aetiological risk factors or effective treatments have been identified. The Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network uses a novel integrated strategy to characterize UCPPS as a systemic disorder that potentially involves multiple aetiologies. The first phase, MAPP I, included >1,000 participants who completed an intensive baseline assessment followed by a 12-month observational follow-up period. MAPP I studies showed that UCPPS pain and urinary symptoms co-vary, with only moderate correlation, and should be evaluated separately and that symptom flares are common and can differ considerably in intensity, duration and influence on quality of life. Longitudinal clinical changes in UCPPS correlated with structural and functional brain changes, and many patients experienced global multisensory hypersensitivity. Additionally, UCPPS symptom profiles were distinguishable by biological correlates, such as immune factors. These findings indicate that patients with UCPPS have objective phenotypic abnormalities and distinct biological characteristics, providing a new foundation for the study and clinical management of UCPPS.

A potential link between isotretinoin and sexual dysfunction has been reported in various studies. However, such an association has not been explored within the context of a literature review until now. To evaluate the methodology and quality of studies investigating this association, and to examine the definitions of sexual dysfunction used. A scoping review approach was used to identify peer-reviewed research articles. The search terms used were 'isotretinoin', 'sexual dysfunction', 'erectile dysfunction', 'ejaculatory disorders', 'decreased libido', 'female sexual interest', 'female arousal disorder', 'libido', 'pelvic pain', 'dyspareunia', 'orgasmic disorder', 'impotence', 'ovaries', 'fertility' and 'menstrual irregularity'. In total, 55 peer-reviewed manuscripts were included, consisting of 8 animal studies and 46 human studies with 2420 patients. Of the studies in humans, there were 18 case reports or case series, 2 case-control studies, 4 cross-sectional studies, 6 longitudinal studies, 3 pharmacovigilance reports and 13 cohort studies. The most frequently observed dose range of isotretinoin was 0.5-1.0 mg kg-1 per day, usually for a duration of 1-6 months. More than half of the studies (54%, n = 25) reported a beneficial or neutral effect of isotretinoin on sexual function. The majority of studies (89%, n = 41) were categorized as Oxford Evidenced-Based Medicine level 4. This scoping review revealed very weak evidence supporting a link between isotretinoin and sexual dysfunction. Notably, the diverse definitions of sexual dysfunction pose a significant challenge for comparative analysis. The authors advocate for a standardized definition of sexual dysfunction and a framework for determining causality in order to contribute to a more comprehensive understanding of the relationship between isotretinoin and sexual dysfunction.