Vaginal Side Research Articles

Cancer therapy-related vaginal toxicity: its prevalence and assessment methods-a systematic review.

In 2020, almost 9 million women were diagnosed with cancer worldwide. Despite advancements in cancer treatment strategies, patients still suffer from acute and long-term side effects. This systematic review aims to evaluate the most frequently reported adverse effects in the genitourinary system and compare them across cancer types, treatment modalities, and evaluation methods. Pubmed Central, SCOPUS, and Cochrane Library were searched following the PRISMA guidelines to identify all prospective and retrospective observational cohort studies and randomized controlled trials assessing vaginal side effects of adult female cancer patients. The study quality was evaluated using The Newcastle-Ottawa Scale or the Risk of Bias 2 tool, as appropriate. The most prevalent population was breast cancer patients, followed by gynaecological cancer patients. Overall, the focus was on vaginal dryness, while vaginal stenosis was the primary outcome in gynaecological cancer patients. Significant discrepancies were found in the frequency and severity of the reported adverse events. Most studies in this review evaluated side effects using patient-reported outcome measures (PROMs). Genitourinary syndrome of menopause following cancer treatment is most frequently documented in breast and gynaecological cancer patients, often focussing on vaginal dryness and vaginal stenosis based on PROMs. This review provides a complete overview of the literature, but more high-quality clinical trials are necessary to draw firm conclusions on acute and chronic vaginal toxicity following cancer treatment. This review could help improve the current preventive and curative management options for genitourinary complications, thereby increasing the patient's QoL and sexual functioning.

83 Dehydrated human amniotic membrane and amniotic fluid for the treatment of rectovaginal fistulas

The presence of a rectovaginal fistula (RVF) can be devastating to patients thus greatly affecting their quality of life. The most common etiologies of RVF are those resulting from obstetric complications, pelvic radiation, malignancy, infection, and postoperative complications. The treatment of RVF is mainly surgical; however, current techniques still have a high rate of recurrence. Our objective is to present a novel surgical technique with the use of a dehydrated amniotic membrane (VendajeTM) and an amniotic suspension allograft (RheoTM) in repair of rectovaginal fistula. Two cases of chronic rectovaginal fistula were seen in the urogynecology office. Informed consent was obtained to proceed with surgical repair using the dehydrated amniotic membrane and amniotic suspension allograft. Under general anesthesia, the RVF fistula repair was done by first using a #5 silk suture that was threaded back and forth in the fistula tract to de-epithelialize the tract and uncover healthy tissue (Figure 1). The rectal side of the fistula tract was closed with 3-0 vicryl interrupted sutures. The amniotic membrane was soaked in 1 mL of the amniotic suspension before being placed into the fistula tract from the vaginal side. The vaginal side of the tract was reapproximated with 3-0 vicryl interrupted sutures (Figure 2). Finally, the remainder of the amniotic suspension was injected into the tract. The patients were also advised to use estrace vaginal cream to promote wound healing and increase blood supply to the surgical site. One case of complete resolution (5 mm to closure) of rectovaginal fistula and one case of 90% improvement (1cm to 1mm) of fistula is presented utilizing a novel therapeutic approach with the amniotic membrane pre-soaked in an amniotic suspension allograft followed by injection of remaining allograft into the fistula tract. This novel application of dehydrated human amniotic membrane allograft and amniotic suspension allograft is an effective therapy for chronic rectovaginal fistula. This procedure also highlights the importance of the complexity of the fistula and health of the supporting tissue prior to fistula repair seen in the case with 70% improvement.

Interventions Preventing Vaginitis, Vaginal Atrophy after Brachytherapy or Radiotherapy Due to Malignant Tumors of the Female Reproductive Organs-A Systematic Review.

Background: Radiotherapy, as a method of treatment of cervical and uterine cancers, may induce severe late-onset vaginal side effects. Unfortunately, little evidence on the management of adverse effects has been presented. This study aimed to evaluate the available interventions which reduce symptoms of vaginitis and vaginal atrophy by improving dyspareunia, mucosal inflammation, vaginal pH and vaginal dryness in women who have undergone brachytherapy or radiotherapy due to uterine or cervical malignancies. Materials and methods: A comprehensive literature search was performed following PRISMA guidelines. The systematic search was conducted using electronic databases, namely Scopus, Web of Science and PubMed, between October and November 2020 to identify randomized controlled trials (RCT) and, prospective randomized studies (PRS). Results: The analyzed population consists of 376 patients with uterine or cervical cancer, treated with hyaluronic acid, vitamin A, vitamin E, alpha-tocopherol acetate and dienestrol. Intervention with HA along with vitamin A and vitamin E revealed advantage in endpoints such as reduced dyspareunia, vaginal mucosal inflammation, vaginal dryness, bleeding, fibrosis and cellular atypia. Administration of alpha-tocopherol acetate reduced vaginal mucosal inflammation and improved vaginal acanthosis, whereas dienestrol resulted in reduced dyspareunia, vaginal caliber and bleeding. Conclusions: Vaginal suppositories were found to be clinically effective at the management of late-onset vulvovaginal side effects after radiotherapy.

Is location of urethral kinking a confounder of association between urethral closure pressure and stress urinary incontinence?

Intact urethral support and normal sphincter function are deemed important for urinary continence. We aimed to test whether the location of urethral kinking (as the probable anatomical correlate of maximal pressure transmission) is associated with stress urinary incontinence and/or urodynamic stress incontinence. This was a retrospective study of women seen at a tertiary urogynecological center in 2017. Patients had undergone an interview, multichannel urodynamic testing and four-dimensional translabial ultrasound examination. Those with a history of anti-incontinence surgery, absence of urethral kinking on ultrasound and/or missing or inadequate ultrasound volume data were excluded. Volume data were used to assess urethral mobility using a semi-automated Excel® urethral motion profile program. Mobility vectors were calculated using the formula √((x valsalva - x rest )2 + (y valsalva - y rest )2 ), where x and y are the coordinates of six equidistant points along the length of the urethra from the bladder neck to the external urethral meatus. The location of urethral kinking was identified as a concave contour of the urethra on the vaginal side in the midsagittal plane on maximum Valsalva maneuver. The distance between the center of the kink and the bladder neck was measured and expressed as a centile in relation to the total length of the urethra, using the formula: (distance from bladder neck/total length of urethra) × 100. Univariate and multivariate analyses were performed to test the associations of stress urinary incontinence and urodynamic stress incontinence with age, maximum urethral pressure, urethral mobility vectors and location of urethral kinking. Of 450 women seen during the study period, 61 were excluded owing to previous incontinence surgery and 82 owing to absence of urethral kinking, inadequate volume data or missing data, leaving 307 women included, of whom 227 (74%) complained of stress urinary incontinence and 211 (69%) complained of urgency urinary incontinence. 190 (62%) of the women were diagnosed with urodynamic stress incontinence. On multivariate analysis, maximum urethral pressure (36 vs 50 cmH2 O; P < 0.001), mid-urethral mobility (2.27 vs 2.03 cm; P = 0.003) and location of urethral kinking (63.1st vs 59.7th centile; P = 0.002) were associated significantly with urodynamic stress incontinence. The location of urethral kinking was associated with stress urinary incontinence on univariate analysis (P = 0.026) but not on multivariate analysis (P = 0.21). The location of urethral kinking is associated with urodynamic stress incontinence. The further urethral kinking is from the mid urethra, the more likely is urodynamic stress incontinence. This provides circumstantial evidence for the pressure-transmission theory of stress urinary continence. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Vaginal cuff brachytherapy practice in endometrial cancer patients: a report from the Turkish Oncology Group.

PurposeThe American Brachytherapy Association is attempting to develop standards for delivering brachytherapy, although differences in practice have been reported in the literature. This study evaluated vaginal cuff brachytherapy (VBT) practice and quality of life-related recommendations among Turkish radiation oncologists.Material and methodsA nationwide web-based 17-item survey was distributed to the members of the Turkish Society for Radiation Oncology. These members received e-mail notifications, and a link was posted on the Turkish Society for Radiation Oncology internet site to solicit voluntary responses The survey addressed the simulation processes, target volume, prescribed dose, delivery schedules, and recommendations related to vaginal side effects.ResultsFifty-seven radiation oncologists responded to the survey. The most used dose fraction schemes for adjuvant VBT were 7 Gy × 3 fractions (30%), 5.5 Gy × 5 fractions (26%), and 6 Gy × 5 fractions (28%). The preferred VBT scheme was 5 Gy × 3 fractions (50%) when the external beam radiotherapy (EBRT) dose was 45 Gy external radiotherapy, while the preferred schemes were 6 Gy × 3 fractions (30%) or 5 Gy × 3 fractions (32%) when the external radiotherapy dose was increased to 50.4 Gy. One-half of the respondents delivered VBT twice a week, and the dose was prescribed to 0.5 cm from vaginal mucosa by 86% of the respondents. There was no common definition for the dose prescription length, which was defined as 3 cm from the vaginal cuff in 33% of responses and as 4 cm in 35% of responses. For serous and clear cell histological types, 38% of the respondents targeted “full cylinder length”. To prevent vaginal side effects, 78% of the respondents recommended using a vaginal dilator and/or sexual intercourse after VBT.ConclusionsThis survey revealed variations in the clinical practice of VBT among Turkish radiation oncologists, which suggests that standardization is necessary.

Results of a Phase I-II Study on Laser Therapy for Vaginal Side Effects after Radiotherapy for Cancer of Uterine Cervix or Endometrium.

Women who have previously received radiotherapy (RT) for gynecologic cancer often suffer from vaginal fibrosis and stenosis. The success of “non-ablative” laser therapy for postmenopausal vaginal atrophy has led to the idea of testing the laser in patients submitted to RT. In this prospective observational study, we selected patients who underwent pelvic RT followed by vaginal laser treatment. We scheduled three treatment sessions (at T0–T1–T2) and three controls (at T1–T2–T3) one month apart. The follow-up (at T4) was carried out six months after the last treatment. Vaginal Health Index (VHI) and vaginal length were evaluated. Sexual function was assessed through Female Sexual Function Index (FSFI). Overall, 43 patients with severe vaginal shortening, atrophy and stenosis was enrolled and treated with intravaginal non-ablative CO2 laser. We observed a progressive increase in vaginal length of 9% (p = 0.03) at T2 and 28% (p < 0.0001) at T3; effects were maintained at T4 (p < 0.0001). After the first application VHI showed a significant improvement of 57% at T3 (p < 0.0001). The results were maintained at T4 (p < 0.0001). No changes were found in FSFI. All procedures were well tolerated. In conclusion, laser therapy improved vaginal length and VHI in women undergoing pelvic RT; prospective studies are needed.

Abstract P2-12-07: Vaginal and sexual health of hormone-receptor positive breast cancer survivors on oral endocrine therapy: A cross-sectional study

Abstract Background: Tamoxifen and Aromatase Inhibitors (AI) are highly effective forms of oral endocrine therapy (ET) used to prevent recurrences in women with hormone-receptor positive (HR+) breast cancer, often with a treatment duration of five or more years. However, the host of side effects women may experience, some related to vaginal health and sexual functioning, greatly impact quality of life (QoL). Those who experience side effects from oral ET are more likely to become non-adherent to their treatment protocol, adversely affecting survival outcomes. Despite this, general communication between cancer patients and their oncologists about sexual health is limited. Few studies have focused specifically on vaginal and sexual health when investigating ET side effects and patient-provider communication in women with HR+ breast cancer. This study aimed to determine the prevalence of vaginal and sexual-related side-effects in women with HR+ breast cancer on oral ET. Secondary objectives were to examine patient-provider communication around sexual health, female sexual dysfunction (FSD), and QoL in this patient population. Methods: We conducted a cross-sectional study between July 2017 and June 2018 in the outpatient oncology clinic at St. Michael’s Hospital (SMH), a tertiary-care center in Toronto, Canada. English-speaking women with HR+ breast cancer who had a treatment history with Tamoxifen or an AI (Anastrozole, Letrozole or Exemestane) for ≥ 6 consecutive months were eligible to participate. We developed a questionnaire to obtain self-reported information about vaginal and sexual-related side effects, sexual history, and patient-provider communication around sexual health. Two validated questionnaires were also used. Total scores for the Female Sexual Function Index (FSFI) could range from 1.2 to 36.0, with ≤ 26.55 indicating possible female sexual dysfunction (FSD). Domain scores within the 1-week recall version of the Menopause-Specific Quality of Life Questionnaire (MENQOL) range from one to eight, with higher scores indicating worse QoL. Additional demographic and clinical variables were collected from electronic medical records. Results: The mean age of the 151 respondents was 56.2 (±10.3), 51.0% of which were receiving Tamoxifen and 49.0% an AI. Ninety-six (63.6%) reported having a current sexual partner, and 71 (47.0%) reported being sexually active. Hot flashes/insomnia (41.7%), decreased libido (32.5%), and vaginal dryness (27.8%) were the three most commonly reported side effects that women experienced “all the time” in the past year. Only 44 (29.1%) women reported ever having been asked about their vaginal and/or sexual health by their oncologist, but 123 (81.5%) reported that they would be comfortable discussing this topic with them. Almost half of participants (68/151, 45.0%) indicated that their current vaginal or sexual-related side effects are not severe enough to want treatment. Thirty-four (22.5%) indicated wanting to know what their options are to best address side effects, 28 (18.5%) would be open to potential treatment for side effects, and 21 (13.9%) would be interested in seeing a physician specialist. Of the 87 women who fully completed the FSFI, 67 (77%) were classified as likely experiencing FSD. The mean score in the MENQOL’s sexual QoL domain was 3.89 ± 2.38 (n = 119), which indicated greater rates of vaginal dryness, avoidance of intimacy, and decreased sexual desire in this group. Conclusion: Our results support the notion that side effect management and patient-provider communication should be prioritized to optimize the vaginal and sexual health of women with HR+ breast cancer receiving oral ET. Women may be unaware of potential treatment options that can help manage side effects accompanying this therapy, and possibly accept these as a new standard of life. Citation Format: Amy Skitch, Alexandra Moskalewicz, Samantha Scime, Rosane Nisenbaum, Ronita Lee, Rashida Haq, Christine Dzerko, Christine Brezden-Masley. Vaginal and sexual health of hormone-receptor positive breast cancer survivors on oral endocrine therapy: A cross-sectional study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-12-07.

Robotic Vesicovaginal Fistula Repair

To illustrate a technique of robotic vesicovaginal fistula repair in a patient with a previous history of pelvic radiation therapy and multiple abdominal surgeries. Stepwise demonstration of the technique with narrated video footage. This 59-year-old woman presented with vesicovaginal fistula. She had a history of rectosigmoidectomy followed by pelvic radiotherapy for stage III colon cancer 23 years earlier and subsequent robotic hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with bilateral pelvic and para-aortic lymphadenectomy for stage II mixed cell endometrial carcinoma, which required surgical reintervention because of a pelvic hematoma and complete vaginal cuff dehiscence. We performed a robotic approach to vesicovaginal fistula with several key steps to repair the fistula and maintain the integrity of the abdominopelvic structures: (1) careful bowel adhesiolysis involving multiple segments of the intestine to the abdominal and pelvic peritoneum; (2) cystotomy with vaginal probe guidance; (3) fistulectomy by monopolar scissors after ureteral orifice visualization; (4) dissection of the retropubic space of Retzius, relieving bladder tension; (5) transverse sutures to coapt the raw surfaces on the vaginal side and the bladder in 2 layers with minimal tension; and (6) transurethral instillation of methylene blue into the bladder. Traditionally, patients with vesicovaginal fistula after pelvic radiation therapy and multiple abdominal surgeries are managed by laparotomy. This video demonstrates a feasible robotic approach to vesicovaginal fistula repair, with superior imaging affording 3-dimensional visualization and stabilization of instruments, allowing wrist-like movements.

Stable Pentadecapeptide BPC 157 and Vesicovaginal Fistulas in Rats

AimFrequently, large vesicovaginal fistulas need operation treatment. Stable gastric pentadecapeptide BPC 157, tested in clinical trials for ulcerative colitis therapy and now multiple sclerosis (Curr Pharm Des. 2017;23(27):4012–4028; Curr Pharm Des. 2014;20(7):1126–35; Curr Pharm Des. 2010;16(10):1224–34), already resolved the healing of various fistulas (Eur J Pharmacol. 2016 Jun 5;780:1–7; Life Sci. 2016 Mar 1;148:63–70; J Physiol Pharmacol. 2015 Aug;66(4):581–90; Eur J Pharmacol. 2013 Feb 15;701(1–3):203–12; J Pharmacol Sci. 2008 Sep;108(1):7–17; Dig Dis Sci. 2009 Jan;54(1):46–56). Thus, BPC 157 may be a successful therapy of vesicovaginal fistulas in rats.MethodsVesicovaginal fistulas were created in Wistar rats. The vesicovaginal fistula was surgically created (4mm length between posterior wall of the urinary bladder and anterior vaginal wall ). Medication. Pentadecapaptide BPC 157 (10 μg/kg/day, 10ng/kg/day) was given intraperitoneally (5 ml/kg) or in drinking water (0.16 μg/ml, 0.16 ng/ml, 12 ml/rat/day) while controls received equivolume of saline or drinking water only. Assessment (the pressure required for leakage of fluid through fistula (mLH2O), diameter of the fistula defects (mm) (bladder, vaginal side), macro/microscopical evaluation, urinary stone presentation) was 1, 2, 3, 4, and 6 weeks. Prophylactic regimen. Medication was started immediately after fistulas creation. Therapy regimen. Medication was initiated with already advanced fistula formation, after 2 weeks.ResultsUnlike poor healing in controls, BPC 157 reduced fistulas diameters (7th day) leading to the complete closure at 46th day and considerable volume needed to leakage of fluid through fistula (V: 5.3+/−0.3 mL). Finally, the fistula was successfully healed and microscopically confirmed in BPC 157 rats (day 46, 0+/−0 mm (diameter, bladder/vagina), unlike open defects in controls: 3.1+/−0.6 (mm, bladder), 3.3+/−0.8 (mm, vagina)) diameter and small volume sustained before leakage (V: 1.2+/−0.4 mL, day 14). In posttreatment BPC 157 group we noticed reducing of fistula diameter since a first posttreatment week ( con 3.8 +/−0.2 mm, BPC 157 3.1 +/−0.1 mm) leading to fistula closing during the 4th posttreatment week. In all control animals, we noticed urinary bladder stone creation which was absent in BPC 157 animals. In posttreatment animals, BPC 157 (therapy regimen) stopped further urinary stone creation.ConclusionPentadecapeptide BPC 157 improved vesicovaginal fistula healing, and it could be the pharmacological solution for the complex clinical problem of vesicovaginal fistulas healing. Vesicovaginal fistula could be used as a urinary stone animal model. BPC157 reduces urinary stone creation.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Novel Approach in Therapy of Internal Fistulas: The Stable Gastric Pentadecapeptide BPC 157 in Therapy of Vesicovaginal Fistulas in Rats

AimAs a novel approach in therapy of various fistulas, we hypothesize the stable gastric pentadecapeptide BPC 157 in therapy of internal fistulas, in particular vesicovaginal fistulas in rats. BPC 157 was originally an anti‐ulcer peptide used in trials for ulcerative colitis and now is in trials for the treatment of multiple sclerosis that largely interacts with NO‐system (Curr Pharm Des 2014;20(7):1126–35) and thought to be novel mediator of Robert's cytoprotection in rat studies, known to exert an immediate endothelium protection alongside with mucosal protection in stomach, known to counteract variously induced gastrointestinal lesions in various species, and in particular, various fistulas healing, external fistulas (esophagocutaneous (Eur J Pharmacol 2013;701(1–3):203–12), gastrocutaneous (Dig Dis Sci 2009;54(1):46–56), duodenocutaneous (J Physiol Pharmacol. 2015;66(4):581–90), colocutaneous (J Pharmacol Sci 2008;108(1):7–17)), and internal fistulas (colovesical (Eur J Pharmacol 2016;780:1–7) and rectovaginal (Life Sci 2016;148:63–70)). Thereby, providing simultaneous healing of different tissues, and likely correlation with human fistulas disturbances, it seems to be suited for the necessary generalization of the fistulas concept healing. Thus, BPC 157 was used in further therapy of internal fistulas, in particular vesicovaginal fistulas in rats.Materials and methodsIn female Wistar Albino rats, 200g vesicovaginal fistulas were created by longitudinal incision on the posterior wall of the urinary bladder and anterior vaginal wall (4mm) were performed. Fistula was created using single‐layer suture technique. Medication includes pentadecapeptide BPC 157 (10μg/kg/day, 10ng/kg/day) dissolved in saline, applied (a) intraperitoneally (first application 30min after surgery, last 24h before sacrifice, 5ml/kg) or (b) in drinking water (0.16μg/ml, 0.16ng/ml, 12ml/rat/day) or an equivolume of saline i.p. or drinking water only (controls) for 7, 14, 21, 28 and 42 days. As described before in our fistulas studies, assessed were the pressure required for leakage of fluid through fistula (mLH2O), diameter of the fistula defects (mm) (bladder, vaginal side).ResultsIn general, unlike poor healing in controls, BPC 157 reduced fistulas diameters (7th day) leading to the complete closure. Finally, the fistula was successfully healed in all rats underwent BPC 157 therapy (i.e., day 46, 0+/−0mm (diameter, bladder/vagina), considerable volume needed to leakage of fluid through fistula (V: 5.3+/−0.3 mL), in rats treated intraperitoneally), unlike open defects in controls: 3.1+/−0.6 (mm, bladder), 3.3+/−0.8 (mm, vagina)) diameter and small volumen sustained before leakage (V: 1.2+/−0.4 mL).ConclusionEffectiveness of BPC 157 in therapy of fistulas in rats, internal fistulas in particular, and especially in vesicovaginal fistulas, may be a particular indication for further clinical studies.Support or Funding InformationUniversity of Zagreb, Croatia (Grant number BM099)

Tandem vaginoscopy with colonoscopy: a diagnostic technique for the assessment of colovaginal fistula.

Colovaginal fistula (CVF) has a negative impact on quality of life. Identifying the fistula track is a critical step in its management. In a subset of patients, localizing the fistula preoperatively can be difficult. The purpose of this report is to describe the technique and results of tandem vaginoscopy with colonoscopy (TVC). A retrospective analysis was conducted of all patients referred to a tertiary centre with symptoms suggestive of CVF but no prior successful localization of a fistula. TVC was performed by one colorectal surgeon in the endoscopy suite under intravenous sedation. Between 2003 and 2013, 18 patients (median age 58years) underwent TVC. CVF was ruled out in three patients. In the remaining 15 patients, TVC documented the fistula in 13. In eight cases a wire was passed through the fistulous track from the vagina to the colon, in three the track was large enough to be traversed with the endoscope and in two a fistulous opening was noted on the vaginal side but passage of a wire to localize the opening on the colonic side was not possible due to extensive scarring. No TVC-related complications were recorded. The sensitivity, specificity, positive predictive value and negative predictive value for TVC in detecting CVF were 86.7%, 100%, 100% and 60%, respectively. TVC is a useful technique that can localize the fistulous track in most patients with CVF.

Multi-Channel Vaginal Cylinder Brachytherapy: Impact of Tumor Size and Location on Dose to Organs at Risk

Multichannel vaginal brachytherapy (MCVB) allows dose to be preferentially delivered to particular portions of the vaginal side wall while sparing other regions. For superficial lesions MCVB has been used as an alternative to interstitial brachytherapy and can be thought of as an extension of intracavitary brachytherapy. Due to the exponential dose fall off associated with brachytherapy, treating lesions of increasing depth requires exponentially higher doses to more proximal tissue. The aim of this study was to investigate the dosimetric consequences of treating lesions of varying size and location with a multi-channel vaginal cylinder. We identified patients previously treated with MCVB and randomly selected one patient for each of six categories based on location (lateral, anterior, or vaginal cuff/apex) and size of cylinder (2.5 cm or 3.0 cm). Based on MRI, each patient’s target lesion was extended circumferentially into theoretical high risk clinical target volumes (HRCTV) measuring 5 mm, 7 mm, and 10 mm in depth. Rectum and bladder were contoured for each patient. Using Nucletron Oncentra version 4.0 (Nucletron, Veneendal Netherlands), image-based brachytherapy treatment plans for each of the six patients’ three target volumes were generated. Each plan was required to have a D90 of 100%. Total dose EQD2 dose was calculated using an EBRT dose of 45 Gy in 25 fractions in conjunction with a high dose rate (HDR) brachytherapy dose of 25 Gy in five fractions. Vaginal surface was contoured by creating a 1 mm expansion from the cylinder surface and subtracting out the cylinder. Maximum EQD2 vaginal surface doses in gray for 5 mm/7 mm/10 mm targets were as follows (location-cylinder size): lateral-3.0 cm:122/153/210, lateral-2.5 cm:145/195/301, anterior-3.0 cm:115/135/197, anterior-2.5 cm:132/173/283, apex-3.0 cm:173/241/367, apex-2.5 cm: 349/461/706. This represents an average increase of 121 Gy to the vaginal surface when moving from a 5 mm thick lesion to a 10 mm thick lesion and treating with a 3 cm cylinder and 221 Gy for a 2.5 cm cylinder. Across all 18 plans, total EQD2 dose to 2 cc of the rectum ranged from 53.9-67.2 Gy. There was an average 3.44 Gy (range=0.83-6.01 Gy) absolute increase in rectal 2 cc EQD2 total dose when target depth increased from 5 mm to 10 mm. Total EQD2 bladder 2 cc dose ranged from 51.5-71.2 Gy. There was an average 5.24 Gy (range=0.66-9.99 Gy) absolute increase in total EQD2 bladder 2 cc dose when target depth increased from 5 mm to 10 mm. The vaginal surface dose appears to be the dose-limiting structure for anterior, lateral, and apical vaginal lesions. Caution should be taken when treating apical lesions and lesions greater than 5mm in depth especially with cylinders smaller than 3.0 cm in diameter. In such cases, interstitial brachytherapy should be given strong consideration.

Perspectives on HIV prevention among urban black women: a potential role for HIV pre-exposure prophylaxis.

Limited data exist regarding attitudes and acceptability of topical and oral HIV pre-exposure prophylaxis (PrEP) among US black women. This investigation explored interest in HIV chemoprophylaxis and modes of use. Five focus groups enrolled 26 black women recruited from an inner-city community health center and affiliated HIV testing sites. Thematic analysis utilized Atlas.ti. Most women expressed interest in PrEP, as many reported condom failure concerns. Most women preferred a pill formulation to intravaginal gel because of greater perceived privacy and concerns about vaginal side effects and gel leakage. Women who had taken pills previously advocated daily dosing and indicated adherence concerns about episodic or post-coital PrEP. Many women desired prophylactic strategies that included partner testing. Urban black women are interested in utilizing PrEP; however, misgivings exist about gel inconvenience and potential side effects for themselves and their partners. Most women preferred oral PrEP, dosed daily.

Female Longitudinal Anal Muscles or Conjoint Longitudinal Coats Extend into the Subcutaneous Tissue along the Vaginal Vestibule: A Histological Study Using Human Fetuses

PurposeIt is still unclear whether the longitudinal anal muscles or conjoint longitudinal coats (CLCs) are attached to the vagina, although such an attachment, if present, would appear to make an important contribution to the integrated supportive system of the female pelvic floor.Materials and MethodsUsing immunohistochemistry for smooth muscle actin, we examined semiserial frontal sections of 1) eleven female late-stage fetuses at 28-37 weeks of gestation, 2) two female middle-stage fetus (2 specimens at 13 weeks), and, 3) six male fetuses at 12 and 37 weeks as a comparison of the morphology.ResultsIn late-stage female fetuses, the CLCs consistently (11/11) extended into the subcutaneous tissue along the vaginal vestibule on the anterior side of the external anal sphincter. Lateral to the CLCs, the external anal sphincter also extended anteriorly toward the vaginal side walls. The anterior part of the CLCs originated from the perimysium of the levator ani muscle without any contribution of the rectal longitudinal muscle layer. However, in 2 female middle-stage fetuses, smooth muscles along the vestibulum extended superiorly toward the levetor ani sling. In male fetuses, the CLCs were separated from another subcutaneous smooth muscle along the scrotal raphe (posterior parts of the dartos layer) by fatty tissue.ConclusionIn terms of topographical anatomy, the female anterior CLCs are likely to correspond to the lateral extension of the perineal body (a bulky subcutaneous smooth muscle mass present in adult women), supporting the vaginal vestibule by transmission of force from the levator ani.

機能性子宮を有する子宮頸管閉鎖・上部腟欠損の治療に腹腔鏡・子宮鏡下手術の併用が有用であった一例

A 14-year-old girl experienced lower abdominal pain of one week's duration that recurred monthly for the past year. Her family physician suspected menstrual molimina and referred her to our facility. On pelvic examination, the vagina was 7 cm long and ended blindly; a cervix was not visible. Transrectal ultrasound and magnetic resonance imaging revealed fluid accumulation at sites thought to be the endometrial cavity and cervix. Menstrual molimina due to a transverse vaginal septum or cervical atresia and partial vaginal aplasia was suspected. Laparoscopic evaluation revealed a symmetrical uterine corpus with a normal appearance. A vaginal incision was made with a scalpel, however, a stoma could not be created. During laparoscopy, the fundus was incised by electrocautery, a uterine probe was inserted, and an incision was made from the vaginal side of the probe tip in an attempt to create a stoma. Due to limited tissue distensibility, suturing the vaginal wall and cervix was difficult. Therefore, we created a stoma under hysteroscopy. Menstrual flow promptly occurred after creation of the stoma. At her 6-month follow-up exam she reported that her menses were regular and not accompanied by severe dysmenorrhea. The stoma has remained functional. For cases of cervicovaginal atresia, a combined laparoscopic and hysteroscopic procedure can resolve the condition.

Martius flap for ano-vaginal fistula: a photographic step by step guide

A 24-year-old developed an ano-vaginal fistula following a normal vaginal delivery. Direct repair of the fistula with separation of the vaginal and rectal wall failed. A Martius flap was raised and tunnelled through to the vaginal side and sutured over the rectal defect. The vaginal defect was excised, and the vaginal mucosa closed without tension. The labial skin incision was closed with a small bore closed suction drain. Only one dose of perioperative antibiotic prophylaxis was administered. The patient made an uneventful recovery (Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9).

Surgical repair of traumatic cloaca

A 30-year-old female presented to our colorectal clinic with incontinence to solid and liquid stool. During her first vaginal delivery, she sustained a fourth-degree perineal tear. Primary repair of this injury failed secondary to infection. Two years later, after her second vaginal delivery, she sustained another fourth-degree perineal tear, the repair of which also failed. Upon physical examination a traumatic cloaca was noted (Fig. 1). Time from second injury to presentation at our clinic was 3 years. Her past medical history was significant for multiple sclerosis, which was in remission. Surgical repair was recommended. Perineal reconstruction utilizing X-flaps, as described by Corman and Kaiser [3, 6], was the procedure of choice. The patient underwent standard bowel preparation. Broad spectrum antibiotic prophylaxis was administered. In the operating room, after administration of general anesthesia, the patient was placed in the prone-jacknife position, with the buttocks taped apart. A urinary catheter was placed. Sterile preparation and drapes were placed. The planned incisions were marked on the skin (Fig. 2). The convergence of the incisions in the center created the ‘‘X’’. Dissection of the flaps was developed to the ischiorectal fat laterally and to the puborectalis muscle cephalad. Sutures were then placed in the rectovaginal septum, both on the rectal and the vaginal side (Fig. 3). Using these sutures for traction, the septum was divided, thus mobilizing both the rectal and vaginal ‘‘tubes’’ caudally. Division of the septum was carried out up to the level of the levator muscles (Fig. 4). The next step was to identify and dissect the edges of the divided sphincter. These were mobilized to perform an overlapping sphincteroplasty. The puborectalis and levator muscles were approximated in the midline, thus reinforcing the new perineal body (Fig. 5). Overlapping of the X-flaps was then undertaken (Fig. 6). The posterior wall of the vagina and anterior wall of the anus were sutured to the newly reconstructed perineal body. Layered closure with absorbable sutures was performed. No drains were used (Fig. 7). Postoperative care consisted of bed rest for 48 h, with pressure dressings for the same time. Ambulation was permitted after this period, but sitting was discouraged to avoid shearing forces on the wound. A regular diet was started on the second postoperative day. Bowel confinement was empirically implemented with loperamide thrice daily for 4 days. Afterwards, a regimen of fibre and lactulose was initiated. Antibiotics were continued for 7 days. The patient was carefully followed once weekly for the first month after surgery. There was a minor wound disruption in one corner of the closure, which healed on its own within a month. There were no wound infections. At 3-month post-repair, there was excellent healing of all wounds. There was significant improvement in continence to flatus, solid and liquid stool. Sexual abstinence was advised for 3 months.

Dose volume parameter D 2cc does not correlate with vaginal side effects in individual patients with cervical cancer treated within a defined treatment protocol with very high brachytherapy doses

The study aimed to determine whether post-radiation vaginal side effects in cervical cancer patients can be correlated with DVH parameter D 2cc. The result was negative in that no correlation could be demonstrated between D 2cc and the presence and grade of side effects in this patients’ subset treated with high brachytherapy doses.

Female urology: What method will you select?

When I was a resident, my leader taught me that the gold standard forpatients with stress incontinence is the Marshall–Marchetti–Krantz(MMK) procedure. But a few years later, urologists who could performadvanced techniques showed me needle suspension as the best methodat a urological meeting. Fortunately my boss gave me a chance for ahand-to-hand lesson of the stamay procedure by the specialist. Sincethen, I have been selecting this procedure for a few years. Withoutdoubt, this needle suspension was the gold standard at that time.But now most urologists do not select this technique because of badresults. After I had mastered the technique of tension-free vaginal tape(TVT), I could see the smiling faces of patients after the operation. Atthat time I believed that TVT would be the gold standard for thiscondition. But the present status is what you know.Recently most specialists, including myself, believe that using‘mesh’ is the best operation for patients with pelvic organ prolapse. Isthis tendency good for the patients in the long run? No one can predictthe results of this procedure more than ten years from now.God knows what procedure will be the gold standard in the future.Assistant Professor Yasuyuki Suzuki

Anatomy of the perineal membrane as seen in magnetic resonance images of nulliparous women

Recent cadaver research demonstrates the perineal membrane's ventral and dorsal portions and close relationship to the levator ani muscle. This study seeks to show these relationships in women by magnetic resonance (MR) images. The subjects were 20 asymptomatic nulliparous women with normal pelvic examinations. MR images were acquired in multiple planes. Anatomical relationships from cadaver studies were examined in these planes. In the coronal plane the ventral perineal membrane forms an interconnected complex with the compressor urethrae, vestibular bulb, and levator ani. The dorsal part connects the levator ani and vaginal side wall via a distinct band to the ischiopubic ramus. In the sagittal plane the parallel position of perineal membrane and levator ani are seen. The perineal membrane's anatomical features can be seen in women with MR. The close relationship between the perineal membrane and levator ani is evident.