Genital Symptoms Research Articles

High prevalence and little awareness in patients with chronic inflammatory skin diseases and genital involvement.

Genital involvement in patients with chronic inflammatory skin diseases is frequent, yet insufficiently acknowledged. To evaluate the prevalence of genital symptoms in psoriasis and chronic urticaria patients, effects on quality of life, physician-patient relations and disease management. 100 patients with psoriasis and 100 with chronic urticaria from our outpatient clinic, as well as 50 healthy controls were included. Data was collected using questionnaires developed by dermatological experts. Out of 250 subjects, 74% had already experienced genital symptoms - 70% of psoriasis patients and 58% of urticaria patients. Seven out of ten even complained about recurrent genital involvement. 50% of psoriasis and 41% of urticaria patients reported an impact on quality of life. 41% identified genital pruritus as the main symptom, with one out of three expecting a better management for this specific problem. Furthermore, 74% complained about a lack of awareness among physicians: 79% of urticaria patients and 58% of psoriasis patients reported never having been questioned about genital symptoms by their physicians. The majority of patients with psoriasis and chronic urticaria suffer from genital involvement and an impaired quality of life. Patient and physician reported outcomes should include genital symptoms as an influencing factor for quality of life.

Comprehensive management of patients with pelvis organ prolapse and metabolic syndrome

Background. Genital prolapse (GP) and stress urinary incontinence (SUI) are characterized by a failure of connective tissue skeleton of the pelvic floor structures, and there are many risk factors in their pathogenesis. Metabolic syndrome (MS), which includes obesity and abnormalities in the lipid and carbohydrate profile, contributes to the initiation of pelvic organ prolapse (POP) due to increased intra-abdominal pressure and the presence of comorbidities. Endothelial dysfunction associated with MS aggravates the existing metabolic disorders, resulting in the formation of a vicious circle and an increase in the likelihood of recurrence of genital prolapse symptoms and НМ during tension in the postoperative period. Aim. The search for rational algorithms for the comprehensive management of patients with POP and MS. Materials and methods. A comparative analysis of effectiveness of treatment with the use of surgical method or drugs which affect the metabolic profile in patients with GP and SUI was carried out. Results. Drugs which contribute the restoration of lipid and carbohydrate profiles, and microcirculatory vasculature normalization, attenuate negative effects of MS components on the integrity of pelvic floor structures. Comprehensive management of patients with POP and MS with surgical correction of GP and SUI, as well as the use of drugs affecting metabolism, is highly effective and predictive in regard to POP severity and the risk of recurrence of clinical symptoms in the postoperative period. Conclusion. Adequate restoration of the endothelial layer in patients with pelvic floor muscle incompetence and endothelial dysfunction reduces the likelihood of developing mesh-associated complications after the surgical stage of treatment.

Clinical Pattern Of Sexually Transmitted Infections And Sexual Behavior In Patients With Genital Symptoms- A Cross Sectional Descriptive Study”

Background: Sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), continue to present major health, social, and economic problems in the developing world, leading to considerable morbidity, mortality, and stigma. Despite the availability of effective treatment and preventive measures, incidence of STIs is increasing even in developed countries. STIs, acting as a facilitator for the spread of HIV have become a globally important issue at present context. Objectives: To determine the pattern of sexually transmitted infections along with their sexual behaviour in patients presenting with genital symptoms. Material and Methods: A cross sectional, descriptive study was carried out in the department of Dermato-venereology, Medical College for Women & Hospital (MCW&H), Uttara, Dhaka, Bangladesh. During one year period, a total of 130 consecutive cases were enrolled in this study. The diagnosis of infections was made clinically with relevant laboratory investigations and they were interviewed for their sexual behaviour after taking consent and assuring confidentiality. Results: The average age of this population was 27.84 years. Majority belonged to age group 15-24 years, with male to female ratio of 3.19:1. Many (52.3%) were married. The most common infection was condyloma acuminate (29.2%). The mean age of sex debut was 18.95 years and majority (50.8%) belonged to 15-19 years group. The median number of life time partners was 2.0. Only 43 (33.1%) were on monogamous relationship. The 15-34 age groups had maximum number of sexual partners. Married person living singly had more frequent extramarital contact. Only 10 (7.7%) used condom consistently. Conclusions: Younger people should be educated about monogamous relationship along with correct and consistent use of condom for the prevention of STIs.

Time to resolution of genital symptoms for uncomplicated gonorrhoea: a prospective cohort study

ObjectivesTo determine the time to resolution of symptoms (TTR) following treatment of uncomplicated gonorrhoea and to identify factors associated with TTR in a cohort of sexual health clinic attendees.MethodsParticipants were...

Changes of pelvic organ prolapse and pelvic floor dysfunction throughout pregnancy in singleton primigravidas: A prospective cohort study

ObjectiveTo document the deterioration in pelvic organ support occurring throughout all trimesters during the first pregnancy of women with no known risk factors. Secondarily to make a comprehensive review in order to verify the current findings and methodologies of similar studies in the literature. Study DesignIn this prospective study, forty-one primigravid women with a singleton pregnancy were recruited during their first trimester. During follow-up pelvic organ support changes were documented by using Pelvic Organ Prolapse Quantification (POP-Q) system. Additionally, pelvic floor muscle strength examination, by modified Oxford scoring (MOS), and symptom assessment by Pelvic Floor Distress Inventory-Short Form (PFDI-20) were performed at three time points: first (T1), second (T2), and third trimester (T3) (n = 33). The Wilcoxon test was performed to test the significance of pairwise differences. Spearman correlation coefficient was estimated to determine the linear association of the findings. ResultsBoth distal and proximal anterior and posterior vaginal walls (Points Aa, Ba, Ap and Bp) with cervix (C) descended towards the hymen, throughout first pregnancy with a significant caudal shift on progressing from T2 to T3 (p ≤ 0.017). Posterior fornix (Point D) made a non-significant cranial shift (p = 0.527). The genital hiatus, perineal body and total vaginal length increased significantly (p ≤ 0.001). No significant difference in MOS was observed throughout pregnancy. The scores of PFDI-20 with all its domains worsened significantly during pregnancy, especially in T3 (p ≤ 0.011). Moderate correlations were observed between posterior vaginal descent and anorectal symptoms (rho 0.427, p < 0.05), and between the changes in genital hiatus and prolapse symptoms (rho 0.406, p < 0.05). ConclusionA significant descent both in all compartments of vaginal wall and perineum with an increase in total vaginal length, was observed together with an associated pelvic floor dysfunction throughout the first pregnancy of women.

Prevalence of syphilis among men who have sex with men: a global systematic review and meta-analysis from 2000–20

SummaryBackgroundThe WHO Global Health Sector Strategy aims to reduce worldwide syphilis incidence by 90% between 2018 and 2030. If this goal is to be achieved, interventions that target high-burden groups, including men who have sex with men (MSM), will be required. However, there are no global prevalence estimates of syphilis among MSM to serve as a baseline for monitoring or modelling disease burden. We aimed to assess the global prevalence of syphilis among MSM using the available literature.MethodsIn this global systematic review and meta-analysis, we searched MEDLINE, Embase, LILACS, and AIM databases, and Integrated Bio-Behavioral Surveillance (IBBS) reports between April 23, 2019, and Feb 1, 2020, to identify studies done between Jan 1, 2000, and Feb 1, 2020, with syphilis point prevalence data measured by biological assay among MSM (defined as people who were assigned as male at birth and had oral or anal sex with at least one other man in their lifetime). Studies were excluded if participants were exclusively HIV-infected MSM, injection-drug users, only seeking care for sexually transmitted infections (STIs) or genital symptoms, or routine STI clinic attendees. Data were extracted onto standardised forms and cross-checked for accuracy and validity. We used random-effects models to generate pooled prevalence estimates across the eight regions of the Sustainable Development Goals. We calculated risk of study bias based on the Appraisal tool for Cross-Sectional Studies, and stratified results based on low versus high risk of bias. This systematic review and meta-analysis was registered with PROSPERO, CRD42019144594.FindingsWe reviewed 4339 records, 228 IBBS reports, and ten articles from other sources. Of these, 1301 duplicate records were excluded, 2467 records were excluded after title and abstract screening, and 534 articles were excluded after full-text analysis. We identified 345 prevalence data points from 275 studies across 77 countries, with a total of 606 232 participants. Global pooled prevalence from 2000–20 was 7·5% (95% CI 7·0–8·0%), ranging from 1·9% (1·0–3·1%) in Australia and New Zealand to 10·6% (8·5–12·9%) in Latin America and the Caribbean.InterpretationUnacceptably high syphilis prevalence among MSM warrants urgent action.FundingWellcome Trust.

The clinical indications for testing women for Mycoplasma genitalium

BackgroundWhile the contribution of Mycoplasma genitalium (MG) to symptoms in men is well described, less is known about its association with common genital symptoms in women. We aimed to determine...

P206 Paediatric Genital Crohn’s Disease: Presentation and Treatment, a combined case series

Abstract Background Metastatic Crohn’s Disease (MCD) affecting the genitalia is a rare condition, characterised by granulomatous inflammation of the genital tract. Only few paediatric cases have been described in the literature with a female preponderance. Paucity of literature is noted with regards to treatment and outcome. Methods: Aim To describe the clinical presentation, associated features, and response to treatment in a cohort of paediatric patients diagnosed as genital metastatic Crohn’s disease (MCD). Methods All cases of paediatric genital MCD were retrospectively collected from two centres at Great Ormond Street Hospital for Children and Leeds Children’s Hospital for the past 20 years (January 2001 to January 2021). Medical history, symptoms at presentation, histological characteristics, results of investigations and response to treatment were reviewed. Results A total of 12 patients (7 male and 5 female) were diagnosed with genital MCD. The mean age at presentation of genital MCD symptoms was 8.9 years of age (1.5–14 years). Generalised swelling of the genital region was the most common presentation. 5/12 (42%) children had luminal Crohn’s disease (CD) before development of Genital MCD whereas 4/12 (33%) children developed luminal CD after Genital MCD presentation. 3/12 (25%) children after evaluation were found to have only Genital MCD with no luminal pathology of CD. Genital MCD was the first presentation of Crohn’s disease in 7/12 children (58.3%) in our cohort. 6/12(50%) children were seen to have perianal disease. All children were extensively investigated endoscopically and radiologically. Genital biopsy was done in 6/12(50%) patients showing non caseating granulomatous inflammation. 11/12 patients received dual therapy at some point in their treatment with azathioprine and infliximab. Switch of infliximab to adalimumab was seen in 7/12 (58.3%) patients mostly in view of escalating treatment to control luminal CD. Initiation of treatment since first symptoms of genital MCD appeared to be prolonged, perhaps due to delay in diagnosis via referral pathways from local paediatrician via urologist to paediatric gastroenterologist. Improvement of genital MCD was seen in most children with dual therapy of azathioprine and infliximab. Conclusion Genital MCD can be the first presentation of Crohn’s disease and may not be associated with GI symptoms or luminal CD. All children with MCD do benefit from histological as well as radiological and endoscopic evaluation. Formal MDT discussions with the urologist, radiologist and gastroenterologist may help in early diagnosis and treatment. A retrospective multi-centre case reviews will help to identify the prevalence of genital MCD in children and also help develop a national pathway.

Mapping Schistosoma haematobium for Novel Interventions against Female Genital Schistosomiasis and Associated HIV Risk in KwaZulu-Natal, South Africa.

.Women with female genital schistosomiasis (FGS) have been found to have genital symptoms and a three-fold higher risk of HIV infection. Despite WHO recommendations, regular antischistosomal mass drug administration (MDA) has not yet been implemented in South Africa possibly because of the lack of updated epidemiological data. To provide data for future prevention efforts against FGS and HIV, this study explored Schistosoma haematobium prevalence in girls and young women and the effects of antischistosomal MDA, respectively. Urinary schistosomiasis and genital symptoms were investigated in 70 randomly selected secondary schools in three districts within KwaZulu-Natal and 18 primary schools. All study participants were treated for schistosomiasis, and schools with the highest urinary prevalence were followed up after 1 and 4 years of MDA. At baseline, urine analysis data showed that most schools were within the moderate-risk prevalence category where biennial antischistosomal MDA is recommended, as per WHO guidelines. Young women had high prevalence of genital symptoms (36%) after correcting for sexually transmitted infections. These symptoms may be caused by infection with schistosomes. However, FGS cannot be diagnosed by urine analysis alone. In KwaZulu-Natal rural schools, this study suggests that antischistosomal MDA with praziquantel could prevent genital symptoms in more than 200,000 young women. Furthermore, it is feasible that more than 5,000 HIV infections could be prevented in adolescent girls and young women by treatment and prevention of FGS.

Factors Affecting the incidence of VIA positive at Halmahera Health Care Center in 2018-2019

Abstract Background : VIA is a simple test with moderate sensitivity and specificity for early cervical lesions screening. The purpose of this study was to determine the relationship between risk factors and the incidence of positive IVA at Halmahera Health Center in 2018-2019.Methods : This type of research is an observational analytic with a case control design. Using purposive sampling technique, the minimum sample size is 68, consisting of 34 cases and 34 controls. Using a questionnaire instrument with interview data collection techniques. Data were analyzed using univariate and bivariate tests using the Chi-Square test with SPSS software.Results : The factors associated with the incidence of positive IVA at Halmahera Health Center were personal hygiene in genital areas (p=0.001, OR = 5.5), history of parity (p= 0.001, OR= 5.9 ) symptoms of vaginal diseases (p=0.003, OR=5.9), and duration of use of hormonal contraceptives (p=0.001, OR=5.25).Conclusion: factors associated with the incidence of positive IVA at Halmahera Public Health Center are personal hygiene of genital area, history of parity, history of genital disease symptoms, and duration of hormonal contraception use.Keywords: Factors, Visual Examination of Acetic Acid, Incidence.

Unwarranted hysterectomy in a case of oro-vaginal-vulvar lichen planus in a young woman: a case report

BackgroundLichen planus is a rare autoimmune disease primarily affecting the skin and mucous membranes of the oral mucosa, vulva, and vagina. Diagnosis is difficult and often delayed as the clinicians do not associate the oral symptoms with the genital symptoms. This has a negative impact on the out-of-pocket expenditure and quality of life of the patients. We report this case, as only anecdotal cases have been reported so far from a developing country such as India. We highlight the unindicated hysterectomy that the patient had undergone because of lack of awareness regarding this condition. Our case report also highlights the importance of the multidisciplinary team approach to optimize outcomes and avoid unnecessary morbidity to such patients.Case presentationWe report a North-Indian patient with oro-vaginal-vulvar lichen planus who presented to us with complaints of recurrent vulvovaginal symptoms for the last 5 years. She had been previously treated with multiple courses of antibiotics, antifungals, and topical steroids over the course of 3 years and finally offered laparoscopic-assisted vaginal hysterectomy (LAVH) by a private practitioner but got no relief. She also had complained of oral symptoms in the form of a burning sensation after eating spicy food, but did not seek any treatment for this. After multidisciplinary team discussion, a final diagnosis of oro-vaginal-vulvar lichen planus was made at our institute based on the clinical and histopathological findings. The patient was immediately started on oral prednisolone to which she responded with improvement in her symptoms.ConclusionLichen planus is a chronic painful condition with significant impact on the quality of life. Women often suffer for several years before an accurate diagnosis is made. Treatment is challenging and needs to be individualized with a multidisciplinary approach to prevent progressive anatomical distortion and associated morbidity.

Are Mycoplasma hominis, Ureaplasma urealyticum and Ureaplasma parvum Associated With Specific Genital Symptoms and Clinical Signs in Nonpregnant Women?

There is limited evidence supporting an association between Mycoplasma hominis, Ureaplasma urealyticum, and Ureaplasma parvum with symptoms or disease in nonpregnant women. However, testing and reporting of these organisms frequently occurs, in part due to their inclusion in multiplex-PCR assays for sexually transmitted infection (STI) detection. We investigated if M. hominis, U. urealyticum, and U. parvum were associated with symptoms and/or signs in nonpregnant women attending a sexual health service. Eligible women attending the Melbourne Sexual Health Centre completed a questionnaire regarding sexual practices and symptoms. Symptomatic women underwent examination. Women were assessed for bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC), and tested for M. hominis, U. urealyticum, and U. parvum, and 4 nonviral STIs using a commercial multiplex-PCR. 1272 women were analyzed. After adjusting for STIs and VVC, M. hominis was associated with abnormal vaginal discharge (aOR = 2.70, 95%CI:1.92-3.79), vaginal malodor (aOR = 4.27, 95%CI:3.08-5.91), vaginal pH > 4.5 (aOR = 4.27, 95%CI:3.22-5.66), and presence of clue cells (aOR = 8.08, 95%CI:5.68-11.48). Ureaplasma spp. were not associated with symptoms/signs. Bacterial vaginosis was strongly associated with M. hominis (aOR = 8.01, 95%CI:5.99-10.71), but was not associated with either Ureaplasma spp. In stratified analyses, M. hominis was associated with self-reported vaginal malodor and clinician-recorded vaginal discharge in women with BV, but not with symptoms/signs in women without BV. Only M. hominis was associated with symptoms/signs, and these were manifestations of BV. Importantly, M. hominis was not associated with symptoms/signs in women without BV. These findings do not support routine testing for M. hominis, U. urealyticum, and U. parvum in nonpregnant women.

Testicular Atrophy Following Inguinal Hernia Repairs

Testicular atrophy is a rare complication of hernia repairs which often results in litigations. While early detection and treatment of ischemic orchitis obviate this grave complication, good communication and adequate counseling are known to minimize the associated litigations. Herein, we report two cases of testicular atrophy following herniorrhaphy. Both patients noticed scrotal pain and swelling within three days after the surgery and were given antibiotics and analgesia by the attending surgeons. They subsequently developed a gradual reduction in testicular volume after two months with severe atrophy of the affected testis. The objectives of this case series are to emphasize the need for immediate evaluation of genital symptoms such as scrotal pain, swelling, and redness after inguinal hernia repairs and the need to counsel patients for possible orchitis, atrophy, and testicular loss before any groin surgery.

1530. A Cluster of Disseminated Gonococcal Infections in a Non-Immunocompromised Veteran Population

BackgroundDisseminated gonococcal infection (DGI) is an uncommon manifestation of N. gonorrhoeae that is estimated to occur in 0.5-3% of cases, with a decreasing incidence that has been attributed to changes in circulating serotypes. At a Veterans Affairs Medical Center (VAMC), 3 cases were identified within 4 months in 2019.MethodsA case series of patients with DGI between March and July 2019 was conducted at a 399-bed tertiary care VAMC that serves central Virginia. Clinical case data was abstracted from the medical record, and data regarding prior gonorrhea cases at the facility was obtained from the laboratory information system.ResultsIn 2019, the rate of DGI was 4.9%, with 3 cases out of 61 reported. All occurred in immunocompetent, African-American males with a mean age of 59 years, and all had female sexual partners (Table 1). All presented with joint symptoms, 2 had skin manifestations, and none had genital symptoms. Two patients had positive synovial fluid cultures and the third had a positive blood culture. All isolates were beta-lactamase negative. Orogenital testing by nucleic acid amplification was only positive in 1 patient. No other sexually transmitted infections were identified. One patient underwent surgical washout of the involved shoulder joint, but the others were managed non-operatively. All received a single dose of azithromycin and a 14-day course of ceftriaxone with full symptom resolution. These were the first positive N. gonorrhoeae isolates from invasive specimens at this VAMC since at least 2016.Table 1. Clinical History and Laboratory Results at Presentation for Patients with Disseminated Gonococcal Infection ConclusionThis cluster of DGI cases was unusual given the recent rarity at this VAMC, the age of the patients, and lack of overt risk factors. In Virginia, DGI is reported to the health department no differently than uncomplicated infections, so the actual rate of DGI regionally is unknown. One isolate was preserved and sent to the Centers for Disease Control and Prevention for deidentified whole genome sequencing. More refined reporting is necessary to improve understanding of local gonorrhea epidemiology, as well as coupling with additional methodologies such as serotyping or whole genome sequencing. Clinicians should be aware of the possibility of DGI, even in older patients without classic risk factors.Disclosures All Authors: No reported disclosures

Characterization Of Vaginitis Among Women Complaining Of Genital Tract Symptoms

Vaginitis is the inflammation of the vagina as a result of a change in the balance of normal flora affecting women of reproductive age. It is one of the most frequent reasons that women visit clinics. The objective of this study was to determine the importance of&#x0D; laboratory diagnosis methods in the treatment of the disease and to study the symptoms and risk factors associated with vaginitis among women with genital tract symptoms. Vaginal swabs were collected from 50 women attending Maternity hospital and Chwarchra dormitory camps in Sulaimani city. Samples were examined microbiologically and causative agents were isolated. All relevant clinical information such as patient demographic profiles, socioeconomic variables, risk factors and symptoms have been collected by questionnaire based study. Different species of microorganisms were isolated from vaginal samples including yeast and bacteria. Culture analysis and gram stain had shown that bacterial vaginosis was 22%, while the rate of yeast infection was 16%. The higher percentage was 62% for the normal flora (Lactobacillus). Microscopic examination of patient’s vaginal swabs revealed that 63.6% of infectious group had high level of epithelial cells (&gt;10), while the most patients with non-infectious vaginitis had (10) or less epithelial cell in the microscopic field. The presence of epithelial cell was significantly associated with infectious vaginitis (p-value 0.04). Most patients were aged between 25-35 years. The result showed a significant association between infectious vaginosis with education level (p-value 0.02). The most common symptom present among patients with infectious vaginitis group was itching (38.5%) and smelly discharge (40%). The majority of women had history of previous infections in both infectious and non-infectious vaginitis groups. Furthermore, there was different types of vaginitis including infectious vaginitis (bacterial and yeast infection) and non-infectious vaginitis. Therefore, it is essential to perform laboratory examination for the patients to detect the causative agents of vaginitis, and ensure the most appropriate treatment can be administered. In addition, the treatment of vaginitis can be done by topical application of Lidocaine 5% ointment (as a local anesthetic) nightly for seven weeks has been shown to decrease the pain of vaginitis in women.

First Use of Thermal Stabilized Hyaluronic Acid Injection in One-Year Follow-Up Patients with Genitourinary Syndrome.

ObjectiveEvaluation of the impact of hyaluronan hybrid cooperative complex (HCC) injections in premenopausal and postmenopausal Italian women affected by vulvar-vaginal atrophy (VVA), one of the symptoms of genitourinary syndrome (GS), on self-reported quality-of-life, vaginal symptoms, and sexual activity, as well as treatment side-effects.MethodsWe surveyed a sample of 26 women affected by VVA with follow-up at 6 and 12 months. Deep intradermal injections of HCC were delivered at 1-month intervals. Evaluation of the treatment impacting the VVA patients was assessed by three international validated questionnaires (Visual Analogic Scale, VAS; health-related quality-of-life test, SF12; Female Sexual Function Index, FSFI). The statistically significant differences between pre- and after-treatment responses have been assessed by Wilcoxon signed-rank test and repeated measures ANOVA test.ResultsAt 6–12-month follow-up, general quality-of-life (SF12) did not show any significant improvement. On the contrary, VVA patients showed significant improvements of genital symptoms (VAS) and sexual function (FSFI). Global FSFI score increased by 58% and evidenced important satisfaction (P≤0.05).ConclusionVestibular HCC injection is an office, safe, fast, not expensive, and reproducible procedure effective in vulvar-vaginal atrophy. This study can be used as a pilot for future trials.

A Randomized Controlled Ixekizumab Vs Secukinumab Trial to Study the Impact on Sexual Activity in Adult Patients with Genital Psoriasis

ABSTRACT Introduction: There is limited data on the effects of biologic therapies on genital psoriasis and sexual activity. Recently, Ixekizumab was reported to be effective. Aim: To compare the efficacy of ixekizumab and secukinumab for the treatment of genital psoriasis and sexual inadequacy in adult patients with moderate‐to‐severe psoriasis. Patients and methods: We assessed adult patients with moderate-to-severe psoriasis having genital involvement. They were randomly assigned in a 1:1 ratio to receive either ixekizumab (80 mg/2 weeks after 160-mg initial dose) or secukinumab (300 mg subcutaneous injection at Weeks 0, 1, 2, 3, and 4 then every 4 weeks). The severity was assessed using Genital Psoriasis Symptoms Scale (GPSS), and impact on sexual health by evaluating the Massachusetts General Hospital-Sexual Functioning Questionnaire (MGH-SFQ). Results: Twenty eight patients on ixekizumab, and 26 on secukinumab showed improvement in genital psoriasis symptoms, beginning week 2 (GPSS total and individual items), and from week 4 onwards, improvement in sexual activity was seen with both drugs. Conclusion: Both genital psoriasis symptoms and impact on sexual activity improved rapidly and significantly with both the IL-17 inhibitors. Limitations included small number of patients and lack of follow-up period.

The role of the genital hiatus and prolapse symptom bother.

Pelvic organ prolapse (POP) severity is poorly correlated with prolapse symptoms. The objective of this study was to investigate the association between genital hiatus (GH) size and presence and severity of bulge symptoms. This analysis utilized data from a longitudinal study of parous women. Women underwent annual assessment of POP, GH size, and bulge symptoms. "Bother" was scored by participants reporting bulge symptoms. Three analyses evaluated the association between GH size and bulge symptoms, each using linear mixed models. First, we compared case visits (bulge symptoms reported) to control visits (bulge symptoms never reported), matching for stage. Second, among women who reported bulge sensation at least once during the study, we compared GH size at visits with and without bulge symptoms. Third, among women who reported bulge sensation, we investigated whether GH size was associated with "bother" score, controlling for stage. Of 1528 women (7440 visits), 148 women (803 visits) reported bulge symptoms at ≥ 1 visit and 1380 women never reported bulge symptoms (6637 visits). Comparing 315 case visits (bulge symptoms reported) to 1260 control visits (bulge symptoms never reported), GH size was significantly greater among case visits (3.05cm versus 2.85cm, p ≤ 0.0001). In the case-crossover analysis, GH size was similar for visits with and without bulge symptoms (p = 0.63). When evaluating GH size and degree of bulge symptom bother, bother severity was significantly associated with GH size (p = 0.003). Independent of stage, GH size was significantly associated with prolapse bulge symptoms and bother severity.

Hereditary Angioedema Due to C1-Inhibitor Deficiency in Romania: First National Study, Diagnostic and Treatment Challenges.

Hereditary angioedema (HAE) is a rare genetic potentially life-threatening disease characterized by episodic non-pruritic subcutaneous and submucosal edema attacks in different parts of the body. To assess the status of Romanian HAE patients after the recent introduction of a new therapy through a nationwide program. This cross-sectional observational study included patients from the Romanian HAE Registry. The study included 84 patients with HAE type I (91.7%) and type II (8.3%). The mean delay in diagnosis was 2.4 years in children and 16.7 years in adults (p=0.019). Stress and tiredness were the most frequent trigger factors. The majority of the HAE episodes involved subcutaneous (89.3%), abdominal (77.4%), genital (51.2%), facial (41.7%), and laryngeal (39.3%) symptoms during the preceding 12 months. One or several misdiagnoses were reported in 83.33% patients and 44.1 % of the patients were subjected to or proposed unnecessary surgery during abdominal episodes. Plasma-derived C1-INH (pdC1-INH) and recombinant C1-INH (rhC1-INH) were respectively used in 10 (11.9%) and 13 (15.5%) of the HAE patients for life-threatening attacks over the past 12 months. Forty-three (51.19%) patients practiced home treatment with subcutaneous injection of the bradykinin B2-receptor antagonist for acute HAE attacks. The significantly lower delay observed in children suggests an improvement in the awareness of C1-INH-HAE among physicians in recent years. The management of HAE in Romania has been somewhat enhanced as the majority of HAE patients have recently gained access to pdC1-INH, rhC1-INH, and bradykinin B2-receptor antagonist.

Metastatic Breast Lobular Carcinoma to Unusual Sites: A Report of Three Cases and Review of Literature

Invasive lobular carcinoma of the breast is the second most common type of invasive breast carcinoma. Invasive lobular carcinoma has an unusual pattern of metastases, which poses a diagnostic challenge for both clinicians and pathologists. We herein present three cases of breast invasive lobular carcinoma presented with metastasis to unusual sites, namely, uterus, colon and stomach. We recommend a higher index of suspicion in any case with breast cancer developing gastrointestinal tract or genital tract symptoms. J Med Cases. 2020;11(9):292-295 doi: https://doi.org/10.14740/jmc3538