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Sarcomas arising from the cervix are rare, and the reported prevalence is 0.20–0.55%. A 15-year-old Para 0+0 secondary school student presented to the emergency department in shock with a 1-year history of painless vaginal protrusion, vaginal bleeding, foul-smelling vaginal discharge, occasional passage of blood clots, fatigue, fainting episodes, and weight loss. She was resuscitated with intravenous fluids and blood transfusions. General examination revealed a young girl with a 16-week sized abdominal mass. Vaginal examination revealed a large mobile fleshy mass 14 cm by 10 cm with an offensive discharge and odour. It was externally friable, bled actively on contact, had areas of tissue necrosis, and was oedematous. It was difficult to determine the adnexa structures because of tenderness. Examination under anaesthesia showed that the mass was continuous with the cervix and was not attached to the vagina or vulva. The histology report of the biopsied specimens showed features consistent with cervical leiomyosarcoma (LMS). Cervical LMS was confirmed by immunohistochemistry and a total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed as definitive treatment. Postoperative hormone replacement therapy was initiated. The patient's postoperative condition was stable and there was no tumour recurrence for >2 years on follow-up. Making a diagnosis and instituting surgical and adjuvant treatments for LMS in a low-resource setting are challenging. This is due to lack of access to universal healthcare coverage. A multidisciplinary approach with early diagnosis and complete surgical resection of the tumour provides the most favourable possibility of an improved survival and quality of life.

Study Objective Evaluation of acute abdominal pain in an adolescent female patient should include consideration of all potential sources of pain, including gynecologic etiologies. The goal of our study was to determine the frequency of evaluation of gynecologic causes of abdominal pain in adolescent girls seen in a pediatric emergency department. Study Design A retrospective review was performed of girls between 12 and 21 years of age presenting to the emergency department or urgent care centers at a single pediatric institution with the chief complaint of abdominal pain during 2016. Frequency analyses of demographic and clinical characteristics are presented. Results A total of 1082 girls presented with a chief complaint of abdominal pain. Menarche was documented in 85% of patients, sexual history in 52% of patients, and assessment of contraception use in 28%. Pregnancy testing was performed in 77%. Sexually transmitted infection (STI) testing was performed in 31%, and in only 73% of patients who reported being sexually active. Imaging was performed in 52%. In the subgroup of patients who reported being sexually active and presented with abdominal pain and vaginal discharge, only 37% had a pelvic examination performed. In multivariable modeling, Black patients were significantly more likely than White patients to have STI testing performed (adjusted risk ratio [aRR] = 1.39; confidence interval [CI] = 1.13-1.70) and to undergo a pelvic examination (aRR = 2.45; CI = 1.34-4.50), and less likely to undergo imaging (aRR = 0.69; CI = 0.59-0.81). Conclusion The assessment of abdominal pain in adolescent girls should include gynecologic etiologies. Our results raise concerns that there are deficiencies in the evaluation of gynecologic sources of abdominal pain in girls treated at pediatric facilities, and evidence of potential racial disparities.

Study Objective To compare clinical characteristics, treatment histories, and microbiology of premenarchal girls who presented to a pediatric gynecology specialty clinic with short-duration and chronic vulvar symptoms. Design Retrospective cohort study. Setting Pediatric and adolescent gynecology clinic at a tertiary care children's hospital. Participants One hundred eighty-two premenarchal patients ages 2-14 years who presented to a pediatric gynecology specialty clinic with vulvar complaints and who were evaluated with a yeast and/or bacterial culture. Interventions None. Main Outcome Measures Chronic and short-duration vulvar symptoms, microbiology, and diagnosis. Results Patients with chronic symptoms were more likely to present with itching (59/102 (57.8%) vs 34/80 (42.5%); P = .04), redness or rash (53/102 (52.0%) vs 22/80 (27.5%); P = .0009), and discomfort (59/102 (57.8%) vs 30/80 (37.5%); P = .006), compared with patients with short-duration symptoms. Overall, 44.5% of patients had a history of antifungal treatment, with a greater proportion of patients with chronic symptoms having received antifungal treatment compared with those with short-duration symptoms (53/102 (52.0%) vs 28/80 (35.0%); P = .02). Despite a history of antifungal treatment in nearly half of the patients, Candida albicans was isolated in only 3/144 (2.1%) yeast cultures. Bacterial vulvar cultures were positive in 75/159 (47.2%), and there was no difference among the symptom duration groups (38/71 (53.5%) vs 37/88 (42.1%); P = .15). Conclusion Vulvovaginitis is a common gynecological diagnosis among premenarchal girls with short-duration and chronic vulvar symptoms. Regardless of symptom duration, yeast cultures are rarely positive. Antifungal treatment should be avoided in toilet-trained prepubertal girls.

Cows in estrus but with signs of clinical endometritis (CE) are often not inseminated or undergo an intrauterine treatment after artificial insemination (AI). Decades ago, the so-called Astrom method was described as intrauterine infusion of iodine-potassium solution 2–4 days after AI. Nowadays, it is common to use antibiotics instead of iodine solution and the treatment is performed only a few hours after AI. Although widespread in practice, there is only little information about the efficacy of this treatment. Thus, this study evaluated the effect of a post-breeding intrauterine treatment with cephapirin on insemination success in cows with signs of mild CE. In total, 281 cows subjected to an Ovsynch program with fixed-time AI and examined for vaginal discharge straight after AI by use of the Metricheck device were included. Cows with cloudy discharge or flecks of pus in the mucus were assigned to a treatment or a control group. The treatment group (MET; n = 87) received 6 ± 1 h after AI an intrauterine treatment with 500 mg of cephapirin (Metricure, Intervet Deutschland GmbH). Control cows (CON; n = 91) remained untreated. Animals with clear discharge were assigned to a healthy comparison group (HE; n = 103). Pregnancy diagnosis was performed 39 days after AI. The proportion of pregnant cows after the AI directly preceding the enrollment did not differ significantly (P > 0.05) between HE (35.0%), CON (27.5%) and MET (32.2%). Cephapirin treatment had also no positive effect on other reproductive performance measures, i.e, the percentage of pregnant cows 200 days after enrollment (HE: 64.1%, CON: 73.6%, and MET: 73.6%) or the mean interval from enrollment to conception (HE: 25.4 days, CON: 30.0 days, and MET: 29.7 days). The binary logistic regression showed that the only risk factors with a detrimental effect on fertility were a history of CE 28–34 days postpartum and season. Although cows in MET and HE were 1.74 and 1.37 times more likely to conceive after AI than CON, this effect was not significant. Uterine sampling of a subset of cows with CE (n = 50) revealed 127 bacterial isolates. The most frequently found genera were Staphylococcus (19.7%), Bacillus (12.6%), Streptococcus (10.2%), Corynebacterium (8.7%), and Lysinibacillus (7.9%). The finding that common uterine pathogenic bacteria were rarely detected additionally questions an intrauterine antibiotic treatment of cows with mild CE at AI.

Objective The danger of VVC for pregnant women are: premature birth, premature rupture of the membranes, low birth weight. In America, 75% of women during reproduction have experienced VVC. Between 40–50% have recurrent infections and 5–8% have chronic candida infections. The purpose of this study is to obtain more comprehensive information regarding the development of models of health education (vaginal hygiene) in the prevention of vaginal candidiasis in pregnant women. Methods The design used is Literature review. Articles were collected through Cochrane, Science Direct, Pubmed, Elseiver, Proquest (Links are from the library of unhas.ac.id) Pubmed, WHO, CDC, Google Scholar. The keywords used were VVC, prevention, audio-visual, modules, pregnant women. After collecting the article then article synthesis was made. Results Based on the articles collected, the result shows the lack of development of the health education model, namely the provision of modules and audio-visuals in the prevention of early VVC in pregnant women. Thus, through the provision of health education in the form of audio-visual and modules needed in the prevention of vaginal discharge of VVC in pregnant women. Conclusion The development of models of health education (vaginal hygiene) can effectively prevent vaginal candidiasis by providing audio-visual and modules to pregnant women.

A 23-year-old woman presented to the clinic with a malodorous vaginal discharge, which she described as similar to a prior episode of bacterial vaginosis. She denied flu-like symptoms and had no rash, lesions, or lymphadenopathy. Her test results confirmed bacterial vaginosis and were negative for gonorrhea, chlamydia, and HIV. Her rapid plasma reagin returned as 1:4. What is the diagnosis for this patient and how should she be managed?

Background Cutaneous congenital candidiasis (CCC) is a rare condition consisting of invasive fungal infection of the epidermis and dermis that mostly affects preterm infants. Maternal vaginal candidiasis is present in half of the cases, although the occurrence of invasive candidiasis during pregnancy or peripartum period is exceptional. Case report We present the case of a full-term infant that was born by vacuum-assisted vaginal delivery to an apparently healthy 33 year-old woman with no history of intravenous drug use or vaginal candidiasis during pregnancy. The newborn showed a diffuse maculopapular rash with respiratory distress and bilateral interstitial lung infiltrates, requiring nasal continuous positive airway pressure support. Blood cultures obtained from the mother due to intrapartum fever yielded Candida albicans. Cultures of vaginal discharge and neonate skin also yielded C. albicans with the same in vitro susceptibly pattern. No alternative source for candidemia was identified. The clinical course after starting a systemic antifungal therapy was favorable in both the mother and the neonate, with clearance of candidemia and resolution of the skin lesions. Conclusions CCC must be considered in full-term newborns with maculopapular rash at birth or during the first days of life. The absence of alternative sources for bloodstream infection in the present case suggests a potential etiopathogenic relationship between CCC and maternal candidemia. It is reasonable to rule out postpartum candidemia when CCC is suspected.

Study Objective This study characterizes the etiology, clinical features and outcomes of prepubescent vaginal bleeding and summarizes our experience. Design The data of patients who were hospitalized with vaginal discharge or bleeding treated from January 2012 to December 2018 were retrospectively reviewed. Setting A provincial Grade III Level A Maternity and Children’s Hospital. Participants Prepubertal patients with vaginal discharge or bleeding. Main outcome measures Patient age, bleeding duration, etiology, treatment and prognosis were recorded. Physical examinations and color Doppler ultrasonography were also performed. Results There were 158 patients aged from 1 month to 10 years (mean age 5.2 years). Bleeding duration ranged from 1 to 98 days, with an average of 13.3 days. Sixty patients were diagnosed with vaginal foreign bodies, 34 with vulvovaginitis, 34 with vulvar trauma, 13 with ovarian granulosa cell tumors, 8 with urethral mucosa prolapse, 5 with vaginal yolk sac tumors and 1 each with pituitary tumor, hypothyroidism, McCune-Albright syndrome, and short-term intake of a large number of strawberries. All the children were treated according to their different disease etiologies. Conclusion Prepubertal vaginal bleeding is caused by a variety of different conditions. In our study, the most common causes were vaginal foreign bodies, vulvovaginitis, trauma, vaginal malignant tumors and urethral mucosa prolapse. Careful medical histories and targeted examinations are needed. Vaginoscopy could be considered. Considering the different causes, different treatments should be administered to achieve a good prognosis.

Prepubertal vaginal discharge is most commonly caused by vulvovaginitis and is rarely caused by lymphatic malformations, resulting in chylous vaginal discharge. The diagnosis of chylous vaginal discharge remains a challenge because of a knowledge gap. We describe a 12-year-old girl with intermittent vaginal discharge for 10 years. Although we found a high signal in the vagina on T2-weighted magnetic resonance imaging (MRI), the final diagnosis, vaginal lymphatic leakage, was established on lymphoscintigraphy. Lymphatic leakage in the vagina on lymphoscintigraphy was the key imaging feature of chylous vaginal discharge in this patient. Moreover, diffuse radioactivity was found in the abdomen and thorax on lymphoscintigraphy, which indicated the multiple cystic lymphatic malformations and intestinal lymphangiectasia combined with T2-weighted MRI. Thus, T2-weighted MRI could be used in combination with lymphoscintigraphy to simply identify chylous vaginal discharge. Keywords: Vaginal discharge, Lymphatic malformation, Lymphoscintigraphy, Magnetic resonance, Intestinal lymphangiectasia

Bacterial vaginosis is the most common cause of abnormal vaginal discharge or malodor, affecting up to one third of US women. Most women with bacterial vaginosis are unaware of the infection, making it difficult to diagnose in the absence of a microscopic examination of vaginal discharge or using point-of-care testing. Untreated bacterial vaginosis elevates the risk of postoperative surgical infections in women undergoing obstetric and gynecological procedures. Treatment with antimicrobial agents that target bacterial vaginosis has been shown to reduce the rate of postoperative infections following hysterectomy and surgical abortions. Furthermore, in a cost-comparison model, screening for and treatment of bacterial vaginosis prior to hysterectomy was shown to be superior to no screening in terms of infection rates and cost. The bacterial vaginosis diagnostic criteria are simple and screening tests are inexpensive; bacterial vaginosis screening is a relatively fast process in patients who present for preoperative appointments. Treatment options approved by the Food and Drug Administration include metronidazole, clindamycin, tinidazole, and secnidazole. Given the prevalence of bacterial vaginosis and the risks associated with operating on a woman with untreated bacterial vaginosis, women undergoing hysterectomy, surgical abortion, and potentially cesarean delivery should be screened for bacterial vaginosis, and those who screen positive should be treated with an appropriate antimicrobial agent.

Polypropylene mesh (PPM) has been used in abdominal sacrocoplopexies since the 1990's however following a patient led campaign controversy surrounds its use incontinence procedures, midurethral slings (MUS) and vaginal mesh prolapse repairs. The complication rates following mesh surgery may be as high as 10%. NHS England paused the vaginal insertion of polypropylene mesh in July 2018 pending a review by Baroness Cumberledge. This review will outline the assessment and basic management of complications of polypropylene mesh. This is a relatively new area of urogynaecological practice which non-specialist obstetric and gynaecology clinicians and GPs need to be aware of. Symptoms which could be due to mesh complications are vaginal discharge or bleeding, recurrent urinary tract infection, haematuria, dyspareunia and pelvic pain. Women presenting with any of the above symptoms should be asked if they have had previous surgery for stress incontinence or prolapse. The women may not recall having mesh inserted and may use different terms “sling” “net” or “tape”. They should be examined to both look and feel for PPM. Mesh complications should be managed by the designated mesh centres which are listed on the BAUS and BSUG websites. All mesh complications should be reported to the Medicines & Healthcare products Regulatory Agency (MHRA) by the yellow card system. All mesh complications requiring further surgical intervention should be recorded on the British Society of Urogynaecology (BSUG) national database.

Background Several states have deemed abortions as non-essential services, effectively calling for a halt to abortion care during the COVID-19 pandemic. In response, women may elect for self-managed abortions by obtaining abortion medications online. Case A 15-year-old female presented with abdominal cramping and vaginal discharge after taking Misoprostol obtained from an online retailer for a self-managed abortion in her second trimester during the COVID-19 pandemic. Exam showed products of conception protruding from the vagina. The patient was emergently evaluated for an incomplete and possible septic abortion and underwent a dilation and evacuation (D&E) procedure. Summary and Conclusion Providers caring for adolescents should recognize the availability of self-managed abortions, become familiar with the expected course, possible complications, and the unique challenges of accessing abortion care faced by adolescents.

Urinary tract infections, including cystitis and pyelonephritis, are the most common bacterial infection primary care clinicians encounter in office practice. Dysuria and frequency in the absence of vaginal discharge and vaginal irritation are highly predictive of cystitis. Urine culture is recommended for the diagnosis and management of pyelonephritis, recurrent urinary tract infection, and complicated urinary tract infections. Antibiotics targeted toward Escherichia coli, Proteus, Klebsiella, and Staphylococcus saprophyticus are the recommended treatment. The duration of treatment varies by specific drug and type of infection, ranging from 3 to 5 days for uncomplicated cystitis to 7 to 14 days for pyelonephritis.

Objectives Few studies in the literature take into account the WHO’s 2014 redefinition of the characteristics of mucinous adenocarcinoma of the uterine cervix. Our objective was to describe the characteristics of a group of these patients. Material and methods This was a retrospective descriptive study of patients diagnosed between 1 January 2005 and 31 May 2016 in three hospitals in Lyon, France. All the cases of cervical adenocarcinoma were reanalysed by an expert in gynaecological pathology to retain the mucinous subtypes as defined in the 2014 WHO classification. We analysed their clinical and pathological characteristics. Results Among the 82 cases of cervical adenocarcinoma, 21 (26%) were diagnosed as mucinous. Ten were gastric type, of which four were in the extremely well differentiated form of minimal deviation adenocarcinomas, six were intestinal type, two were signet-ring cell type, and three were not otherwise specified. The patients’ mean age was 42 years and 18 patients were premenopausal. The revealing symptom was metrorrhagia in eight cases (38%) and mucinous vaginal discharge in four (19%). Fifteen (72%) of the cervical smear were abnormal. Five (31%) of the 16 patients with gastric or intestinal type adenocarcinoma had a specific radiological presentation: multiple cysts of the uterine isthmus, visible on ultrasound and with T2 hyperintensity on MRI. Conclusion Mucinous adenocarcinoma is a rare form of cervical cancer that can be confused with other pathological types. It can be detected using cervical smears and should be suspected in cases of mucinous discharge and characteristic MRI features.

Objective The objective of our study is to report our experience of treatment of a patient with endometrioma who was diagnosed with blood deficiency and blood stasis. Methods A 36-years-old Korean woman diagnosed with endometrioma of the right ovary complained of pelvic pain around the menstrual periods, vaginal discharge, and swelling and itching of the pudenda. The patient was administered the modified Gyejibokryeong-hwan (GBH) and the Bogol-gongjin-dan (BGD) for 6 months. Results After treatment, the size of the endometrioma in the right ovary was reduced to 17 × 11 × 10 mm from 25 × 21 × 17 mm before treatment. The level of CA 125 decreased from 47.2 U/ml at baseline to 34.3 U/ml after treatment. The level of CA 125 after treatment was within normal range. After treatment, the pelvic pain around the menstrual periods (VAS 7→1), vaginal discharge (VAS 4→1), and swelling and itching of the pudenda (VAS 5→2) decreased from the baseline values. Conclusion Herbal medicine is a potential alternative therapy for patients with endometrioma of the ovary. Further studies, including case-control studies and RCTs based on an international standard and higher methodological quality, are needed.

This report evaluates the performance and species specificity of an immuno-latex chromatography card (ICC) for rapid detection of Candida spp. Double-manipulator single-blind Gram staining smear examination (GSSE) and ICC were used to analyze 354 vaginal discharge specimens (VDS) (including 98 tested as positive by GSSE) from women with suspected candidal vaginitis , simulated specimens with a concentration gradient, and vaginitis causing organism suspensions (0.9% NaCl) of 22 species from nine genera. Limit of detection, semi-quantitative detection performance, total detection performance and species specificity were determined for ICC, and the results were compared with those of the GSSE method. The limits of detection of ICC for Candida spp. in organism suspensions with 0.9% NaCl and simulated specimens were 7 × 106 cells/L and 7 × 108 cells/L respectively. For species specificity, the results were positive for six Candida spp. ( C. albicans , C. glabrata, C. parapsilosis, C. tropicalis, C. krusei and C. guilliermondii) and negative for the remaining 16 species (C. lusitaniae, Saccharomyces cerevisiae ; three Gram-positive coccus species, four Gram-negative bacillus species, three Gram-negative coccus species and four common microbes causing vaginal infection) from eight genera. The overall sensitivity, specificity, accuracy, positive predictive value and negative predictive value of ICC for VDS were 93.81%, 99.10%, 97.31, 98.14% and 96.90%, respectively. The above indicators in the 98 VDS evaluated as positive were 84.39%, 92.86%, 86.74%, 96.72% and 70.27%, respectively. In summary, ICC offered better specificity, sensitivity, positive predictive value and negative predictive value for the detection of Candida spp. in VDS.

The objectives of this retrospective study were: 1) to determine the sensitivity (Se) and specificity (Sp) of leukocyte esterase test (LE), endometrial cytology (CYTO) and vaginal discharge score (VDS) for diagnosis of reproductive tract diseases in dairy cows at the moment of sampling; 2) to assess the impact of different thresholds on test accuracy and misclassification costs; and 3) to quantify herd prevalence of reproductive tract diseases in dairy farms from Quebec, Canada. Data from 2092 cows (39 herds) enrolled in two randomized control trials were included. Cows were examined at 35 (± 7) days in milk using LE, CYTO, and VDS to determine their reproductive tract health status. A latent class model assuming conditional dependence of CYTO and LE was fit within a Bayesian framework. Non-informative priors were used for the Se and Sp of LE, CYTO, and VDS, while prior information for disease prevalence was obtained from expert opinions (mode = 20%, 5th percentile = 10%). Posterior inferences (median and 95% Bayesian credible intervals; BCI) were obtained using the WinBUGS statistical freeware. An initial model was built using thresholds of ≥ 1 (small amount of leukocytes), of ≥ 6%, and of ≥ 3 (mucopurulent discharge) for the LE, CYTO, and VDS, respectively. Then, the impact on tests accuracy and misclassification costs of using different thresholds was explored. Optimal thresholds balancing the need for good antimicrobial stewardship and animal health considerations were proposed. The optimal thresholds obtained in the final model were: LE ≥ 2 (moderate amount of leukocytes), CYTO ≥ 6%, and VDS ≥ 2 (mucus with flecks of pus). In the final model, median (95% BCI) Se for LE, CYTO and VDS were 42.6% (38.8–47.0), 45.9% (41.9–50.7), and 64.2% (59.1–70.3), respectively. Median Sp was 90.9% (88.0–93.6) for LE, 92.2% (89.2–94.9) for CYTO and 96.6% (91.3–99.8) for VDS. Median within-herd prevalence of reproductive tract disease was estimated at 47.9% (39.0–56.7). At a threshold ≥ 2 (mucus with flecks of pus), VDS had the highest Se and Sp among the tests evaluated. The LE is an interesting diagnostic alternative for detecting reproductive tract disease in dairy cows. At a threshold ≥ 2 (moderate amount of leukocytes), LE Se and Sp were comparable to those of CYTO. This is the first study reporting the accuracy of LE, CYTO, and VDS for diagnosing reproductive tract diseases in dairy cows at the moment of sampling.

Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy [1-3].Case presentation with showing anatomic structures in detail.Tertiary academic teaching hospital.A 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension 9 years ago presented with fever and was found to have bacteremia. Abdomen and pelvic magnetic resonance imaging showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. Transgluteal drain placed with cultures growing Streptococcus constellatus and Gemella morbillorum. Blood cultures grew same bacteria. She was started on vancomycin, cefepime, and metronidazole and was transitioned to ceftriaxone with a plan for 6-week antibiotic course. Her blood sugar levels were well controlled during hospitalization with baseline insulin and moderate sliding scale. Physical therapy started preoperative and continued postoperative. She was managed with an interdisciplinary team of gynecologists, urogynecologists, orthopedic doctors, neurosurgeons, nutritionists, infectious disease doctors, endocrinologists, hematologists, rehabilitation specialists, and physical therapists. This video showcases laparoscopic resection of sacrospinous fistula tract. Postoperative pathology result showed squamous mucosa, submucosa, and deep soft tissue with a submucosal abscess surrounded by fibrosis, consistent with a fistula tract.Preoperative planning is of paramount importance in cases with multiple comorbidities. Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection. Knowing the precise anatomy of critical structures close to the area of interest is crucial.

Objectives: The objective of this study is to characterize the population of women who are diagnosed with cervical cancer after age 65. Current guidelines allow for discontinuation of cervical cancer screening at age 65 if women have met criteria for adequate screening, which is defined as three consecutive negative cytology results or two consecutive negative co-testing results within ten years before stopping screening, with the most recent test occurring within five years. However, twenty percent of incident cervical cancers occur in women over the age of 65. Download : Download high-res image (289KB) Download : Download full-size image Methods: A retrospective analysis of patients diagnosed with cervical cancer at age 65 or older from 2000-2020 at our institutions. Study subjects were identified by ICD-9 and ICD-10 codes. Demographic information, pathologic data, treatment history, and screening history were abstracted from the electronic medical record. Results: There were 53 patients diagnosed with cervical cancer at age 65 or older from 2000-2020 with sufficient records for review. The median age at diagnosis was 73.8 years, 59% were smokers, and 94% were White. The most common method of detection was the presence of symptoms (81%), and the most common presenting symptom was vaginal bleeding (70%), followed by vaginal discharge (23%), pelvic pain (17%), and bowel or urinary symptoms (13%). At diagnosis, 40% of patients had localized disease, 57% had regional disease, and 4% had distant disease at diagnosis. The histology distribution was 70% squamous cell carcinoma, 19% adenocarcinoma, 6% clear cell carcinoma, 4% small cell carcinoma, and 2% poorly differentiated carcinoma, unspecified. Only 19% of patients had a known history of prior abnormal screening, but prior screening history was not available for 32% of patients. A total of twelve patients (23%) had not met criteria for adequate cervical cancer screening; 3 patients (6%) had met criteria for adequate screening, and 4 patients (8%) were still undergoing screening due to abnormal results. For 34 patients (64%), however, there were insufficient screening records to determine whether they met criteria for adequate screening. Conclusions: Twenty percent of patients with complete records had met criteria to stop cervical cancer screening prior and went on to develop cervical cancer after age 65. This calls into question the current guidelines defining adequate screening prior to discontinuation. The remaining 80% of patients did not meet criteria for adequate screening and, thus, their cancers may have been detected and treated while still at a pre-invasive stage. Notably, there was not sufficient documented history of cervical cancer screening in 64% of these patients who were diagnosed with cervical cancer after age 65.

Study Objective To evaluate a unique learning system for uterine artery embolization (UAE) and examine its feasibility and clinical outcomes for the treatment of symptomatic uterine leiomyomas and adenomyosis when performed by obstetrician-gynecologists in cooperation with interventional radiologists (IVRs). Design Retrospective study (Canadian Task Force classification II-2). Setting University hospital. Patients One hundred seventy-three patients who underwent UAE for symptomatic leiomyomas and adenomyosis. Interventions We examined the medical records of patients who underwent UAE for symptomatic uterine leiomyomas and adenomyosis at our department between 2003 and 2012 using our learning system for UAE for obstetrician-gynecologists in cooperation with IVRs. The charts of all patients were reviewed, and data on etiologic factors, past medical history of leiomyomas and adenomyosis, symptoms, details of UAE, and clinical outcomes after UAE were extracted. Measurements and Main Results A total of 173 patients who underwent 177 UAEs were identified, including 4 patients who underwent embolization twice because of primary treatment failure or symptom recurrence. During the study period, 2 gynecologists successfully acquired endovascular skills. The technical success rate was 97.7% (174 of 177). The duration of fluoroscopy in procedures performed by obstetrician-gynecologists who acquired endovascular skills was not significantly different from that in procedures performed by IVRs at our institution; however, this duration was significantly longer in procedures performed by obstetrician-gynecologists who did not have sufficient experience with our learning protocol for UAE because of inadequate live observation of UAEs performed by skilled IVRs. Complications that necessitated discontinuation of the procedure occurred in 2.3% of cases (4 of 177). The clinical outcomes were similar to those reported in previous studies. Adverse events after UAE included myeloid passages in 7.0% (11 of 158), infections in 2.5% (4 of 158), vaginal discharge in 2.5% of patients with leiomyomas (4 of 158), and vaginal discharge in 7.1% of patients with adenomyosis (1 of 14). All the adverse events were adequately treated by the obstetrician-gynecologists themselves. The timing of hysterectomy due to complications or recurrence of symptoms after UAE varied widely. Conclusion UAE performed by obstetrician-gynecologists in cooperation with radiologists can be achieved safely and successfully with acceptable clinical outcomes. Live observation of the procedure performed by skilled IVRs is essential to improving the skills and reducing the fluoroscopic time of obstetrician-gynecologists.

With the widespread application of artificial intelligence technology in the field of biomedical images, the deep learning-based detection of vaginal discharge, an important but challenging topic in medical image processing, has drawn an increasing amount of research interest. Although the past few decades have witnessed major advances in object detection of natural scenes, such successes have been slow to medical images, not only because of the complex background and diverse cell morphology in the microscope images, but also due to the scarcity of well-annotated datasets of objects in medical images. Until now, in most hospitals in China, the vaginal diseases are often checked by observation of cell morphology using the microscope manually, or observation of the color reaction experiment by inspectors, which are time-consuming, inefficient and easily interfered by subjective factors. To this end, we elaborately construct the first large-scale dataset of microscopic vaginal discharge images, named MVDI25K, which consists of 25,708 images covering 10 cell categories related to vaginal discharge detection. All the images in MVDI25K dataset are carefully annotated by experts with bounding-box and object-level labels. In addition, we conduct a systematical benchmark experiments on MVDI25K dataset with 10 representative state-of-the-art (SOTA) deep models focusing on two key tasks, i.e., object detection and object segmentation. Our research offers the community an opportunity to explore more in this new field.

Determination of the timing of the estrus cycle is essential for fertile mating. There are physiological variations among breeds, between bitches, and between cycles of the same bitch. If serial monitoring and many tools are applied, the exact moment of ovulation could be pin-pointed. However, it leads to time and costly difficulties. Progesterone concentrations during estrus cycles follow a specific pattern, and it is largely used in timing of fertile period. Although it has similar pattern in general, it is likely that breed-specific differences exist. The aim of this study was to investigate the way of timing the fertile period for successful pregnancy in American Bully dogs based on vaginal cytology and progesterone assay with minimized cost. To identify the empirical relations among reproductive characteristics, we performed statistical analyses on data from proestrus-to-estrus 27 American Bully dogs referred for 7 months. We found the significant correlations between the cyclic changes of vaginal cytology and progesterone assay. The relationship of serum progesterone concentrations with the days from vaginal discharge onset was analyzed through linear regression assay. In conclusion, we addressed two standards in the timing of fertile period with a minimal number of progesterone assays in the breeding management of American Bully dogs.

Background According to the Centers for Disease Control and Prevention, rates of infection for Chlamydia trachomatis and Neisseria gonorrhoeae are increasing in the United States. EVO100 is an investigational antimicrobial, pH-modulating, vaginal gel with active ingredients L-lactic acid, citric acid, and potassium bitartrate that is being evaluated for the prevention of sexually transmitted infections. Objective The objective of this phase 2B/3 study was to assess the efficacy and safety of EVO100 for the prevention of chlamydia and gonorrhea. Study Design AMPREVENCE was a double-blinded, placebo-controlled, multicenter study based in the United States conducted over approximately 16 weeks in women at the age of 18 to 45 years who were at risk of urogenital chlamydia and gonorrhea infection. Enrolled women had been diagnosed as having and treated for chlamydia or gonorrhea ≤16 weeks before enrollment. Women received either EVO100 or placebo vaginal gel and were instructed to apply the study drug immediately before or up to 1 hour before each act of vaginal sexual intercourse. The primary and secondary endpoints were the prevention of urogenital chlamydia and gonorrhea, respectively. Exploratory outcomes include women’s overall satisfaction with EVO100. Results In total, 860 women were randomized 1:1 to receive EVO100 (n=426) or placebo (n=434), and 764 women (EVO100, n=376; placebo, n=388) were documented as using the study drug at least once. Baseline characteristics were similar between treatment arms. Overall, women had a mean age of 27.7 years (standard deviation, 6.9) and body mass index of 28.9 kg/m2 (standard deviation, 8.0). Most women were of White (54.3% [467 of 860]) or African American (41.6% [358 of 860]) race and of non-Hispanic/Latina ethnicity (67.1% [577 of 860]). The chlamydia infection rate in EVO100 users was 4.8% (14 of 289) compared with 9.7% (28 of 290) among placebo users (P=.0256), representing a relative risk reduction of 50%. For gonorrhea, the infection rate was 0.7% (2 of 280) in the EVO100 arm compared with 3.2% (9 of 277) in the placebo arm (P=.0316), representing a relative risk reduction of 78%. Increased efficacy was observed with increased adherence, and chlamydia infection rates were significantly reduced with increased adherence in the EVO100 group compared with placebo. Across both arms, there were similar rates of all-cause adverse events (EVO100, 21.3% [80 of 376]; placebo, 20.4% [79 of 388]) and treatment-related adverse events (EVO100, 7.2% [27 of 376]; placebo, 7.5% [29 of 388]). The most common adverse events in the EVO100 arm were vulvovaginal candidiasis (5.1% [19 of 376]), vaginal discharge (3.2% [12 of 376]), and urinary tract infection (3.2% [12 of 376]) and, in the placebo arm, bacterial vaginosis (4.6% [18 of 388]), urinary tract infection (2.6% [10 of 388]), and vaginal discharge (2.6% [10 of 388]). Few women discontinued owing to adverse events in either arm (EVO100, 1.1% [4 of 376]; placebo, 1.5% [6 of 388]). No treatment-related serious adverse events were reported. Most EVO100 users (88%) were satisfied or very satisfied with EVO100 after 16 weeks of use. Conclusion EVO100 significantly reduced the risk of chlamydia and gonorrhea infections in women at high risk of Chlamydia trachomatis and Neisseria gonorrhoeae infection and was well tolerated, with observed adverse events consistent with its known safety profile.

Highlights • SMARCA4 deficient Uterine sarcoma is a rare but highly aggressive sarcoma. • Diagnostic dilemma is the major hurdle. • Germline testing warranted to identify hereditary syndrome (RTPS). • Established chemotherapeutic guidelines for SDUS is sparse. • Gemcitabine-taxol based regimen yielded significant clinic-radiological benefit., Background SMARCA4 deficient uterine sarcoma (SDUS) is a relatively new entity added to the family of uterine sarcoma characterised by SMARCA4/BRG1 deficiency. Case A 62 years old lady presented with abdominal pain and vaginal discharge. On evaluation, found to have a pelvic mass with lymph nodal involvement. She underwent hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy. Preliminary diagnosis made outside was endometrial stromal sarcoma. On further review, had epithelioid and rhabdoid morphology with SMARCA4 loss documented on comprehensive gene profiling. Recurrence within few months of surgery was seen. She was started on gemcitabine and taxol based chemotherapy, showing significant clinical and radiological improvement. Conclusion Diagnostic dilemma of this infrequent, aggressive subtype of uterine sarcoma adds to the hindrance in early recognition. Identifying histology surmounted with gene profiling is helpful in establishing diagnosis resulting in early treatment and improving outcomes.

Study Objective To present a pediatric case with nonspecific vaginal symptoms where exam under anesthesia and vaginoscopy were indicated as a diagnostic and therapeutic measure. To review the strengths of vaginoscopy in this specific population. To describe vaginoscopy instrumentation and techniques given the infrequent use of this modality in gynecologic practice. Design Case Report. Setting Academic Hospital. Patients or Participants A 5-year-old pre-pubertal female presented with persistent vaginal discharge and spotting for four months. Prior workup and treatment included empiric antibiotics given for urinary tract infection and wet prep and vaginal cultures that were unrevealing. Interventions Vaginoscopy was performed in the operating room under general anesthesia using a 6mm 0-degree operative hysteroscope and distension of the vaginal cavity using saline media. Measurements and Main Results Visualization of the vaginal cavity demonstrated multiple foreign bodies including nine 1-cm rubber-bands, one 3-cm LEGO toy, and multiple fragments of toilet paper. The foreign bodies were removed using flexible graspers without complications. Visualization of the vaginal cavity and cervix thereafter ensured complete removal of all foreign objects (photos available). Care was taken to document examination of the external genitalia and hymen preceding vaginoscopy in the event that further investigation for sexual abuse was warranted. Conclusion Vaginoscopy is a minimally invasive tool critical in the diagnosis and management of pediatric vaginal symptoms including evaluation for presence of foreign bodies. A multitude of hystero- or cystoscopes can be used for evaluation of vagina, however an operative channel is required in case there is a need for a biopsy or removal of a foreign body. Zero-degree optics are preferable. Benefits include preservation of hymenal integrity, enhanced visualization of the vaginal cavity, and increased flexibility in obtaining samples and removing foreign bodies.

Study Objective To determine detection rates of cuff dehiscence in asymptomatic women at the 6-week post-hysterectomy examination. Design Retrospective cohort Setting Tertiary care academic institution Patients or Participants 2168 women who underwent hysterectomy over a seven-year period Interventions Routine evaluation of vaginal cuff by pelvic examination Measurements and Main Results 2051 women were included in the final analysis. 117 women were excluded due to no documented post-hysterectomy visit (5.7%). There were 1642 women (80.1%) who were asymptomatic at the 6-week post-hysterectomy examination while others endorsed vaginal bleeding (n=122, 5.9%), vaginal discharge (n=101, 4.9%), pelvic pain (n=97, 4.7%) or a combination of symptoms (n=89, 4.4%). Of the asymptomatic women, 1419 had normal findings (90.1%) on exam, 129 demonstrated granulation tissue (8.2%), 68 had no pelvic exam performed (4.8%), 24 had vaginal discharge (1.5%), 2 had partial cuff dehiscence (0.1%), and 0 had complete cuff dehiscence (0%). Irrespective of time, the total rate of complete cuff dehiscence in this cohort was 0.6% (n=13). Of the patients that developed a cuff dehiscence, at the 6 week exam all were noted to have an intact cuff, 9 patients were asymptomatic and 3 were symptomatic (vaginal bleeding n=1, pelvic pain n=2). One patient presented with dehiscence before her 6 week post-hysterectomy exam. Median time to cuff dehiscence was 106±5.6 weeks (range 5.1–119) for the cohort, 18.8±0.15 weeks (range 5.1–19.1) for benign hysterectomy, and 81.6±26.7 weeks (range 5.4–119) for oncologic hysterectomy. Patients with dehiscence following hysterectomy for benign indications presented with symptoms of pelvic pain and vaginal bleeding at the time of dehiscence, while those who had hysterectomy for oncologic indications were more likely to present with unprovoked dehiscence and without symptoms. Conclusion Performing a pelvic examination at the 6-week post-hysterectomy visit did not negate risk for future complete cuff dehiscence. Routine 6-week post-hysterectomy pelvic examinations in asymptomatic women may not be necessary.

Objectives Vulvovaginal candidiasis (VVC) or vaginal candidiasis is a common fungal infection of the genitals causing inflammation, irritation, itching, and vaginal discharge. Common yeast infections are caused by the yeast species C. albicans. However, there are other species of Candida such as C. dubliniensis which are considered as the causative agents of this infection. Hydrolytic enzymes such as proteinase and coagulase are known as virulence factors. The aim of this study was the molecular confirmation and differentiation of C. dubliniensis among C. albicans strains isolated from women with vulvovaginal candidiasis by PCR-Restriction Fragment Length Polymorphism (PCR-RFLP) and the evaluation of proteinase and coagulase activities. Methods A total of 100 C. albicans strains isolated from women with vulvovaginal candidiasis referred to Shiraz medical clinics were enrolled in the study. All the isolates were primarily identified by conventional methods. PCR-RFLP method was used for the confirmation and identification of C. albicans and C. dubliniensis . Moreover, in vitro proteinase and coagulase activities of these isolates were evaluated using bovine serum albumin media and classical rabbit plasma tube test. Results As a result, PCR-RFLP identified 100% of the isolates as C. albicans , and no C. dubliniensis could be identified in this study. 84% of the isolates showed proteinase activity, whereas coagulase activity was only detected in 5% of the isolates. Conclusions This study reveals that C. dubliniensis plays no role in vaginal candidiasis in Iranian patients. Proteinase production could be an essential virulence factor in C . albicans pathogenicity, but coagulase activity has less potential in this matter.

Introduction: To date, there are no descriptions in the literature on gynecologic and sexual function evaluation in female patients with dermatomyositis (DM) and polymyositis (PM). Objective: To assess sexual function in female patients with DM/PM. Patients and methods: This is a monocentric, cross-sectional study in which 23 patients (16 DM and 7 PM), with ages between 18 and 40 years, were compared to 23 healthy women of the same age group. Characteristics on sexual function were obtained by applying the questionnaires Female Sexual Quotient (FSQ) and Female Sexual Function Index (FSFI) validated for the Brazilian Portuguese language. Results: The mean age of patients was comparable to controls (32.7 ± 5.3 vs. 31.7 ± 6.7 years), as well as the distribution of ethnicity and socioeconomic class. As for gynecological characteristics, patients and healthy controls did not differ with respect to age at menarche and percentages of dysmenorrhea, menorrhagia, premenstrual syndrome, pain at mid-cycle, mucocervical secretion, and vaginal discharge. The FSQ score, as well as all domains of the FSFI questionnaire (desire, arousal, lubrication, orgasm and satisfaction), were significantly decreased in patients vs. controls, with 60.9% of patients showing some degree of sexual dysfunction. Conclusions: This was the first study to identify sexual dysfunction in patients with DM/PM. Therefore, a multidisciplinary approach is essential for patients with idiopathic inflammatory myopathies, in order to provide prevention and care for their sexual life, providing a better quality of life, both for patients and their partners. Resumo Introdução: Até o presente momento, não há descrições na literatura da avaliação ginecológica e da função sexual em pacientes do sexo feminino com dermatomiosite (DM) e polimiosite (PM). Objetivos: Avaliar a função sexual em pacientes do sexo feminino com DM/PM. Casuística e métodos: Estudo transversal unicêntrico em que 23 pacientes (16 DM e sete PM), entre 18 e 40 anos, foram comparadas com 23 mulheres saudáveis, com a mesma faixa etária. As características sobre a função sexual foram obtidas por meio da aplicação dos questionários Female Sexual Quotient (FSQ) e Female Sexual Function Index (FSFI) validados para a língua portuguesa do Brasil. Resultados: A média de idade das pacientes foi comparável à dos controles (32,7 ± 5,3 vs. 31,7 ± 6,7 anos), assim como a distribuição de etnia e da classe socioeconômica. Quanto às características ginecológicas, pacientes e controles saudáveis não apresentaram diferenças em relação à idade na menarca e às porcentagens de dismenorreia, menorragia, síndrome pré-menstrual, dor no meio do ciclo, secreção mucocervical e corrimento vaginal. O escore de pontuação do FSQ, assim como todos os domínios do questionário do FSFI (desejo, excitação, lubrificação, orgasmo e satisfação), estavam significantemente diminuídos nas pacientes comparativamente com os controles, 60,9% das pacientes apresentavam algum grau de disfunção sexual. Conclusões: Este foi o primeiro estudo que identificou disfunção sexual nas pacientes com DM/PM. Assim, uma abordagem multidisciplinar é essencial para pacientes com miopatias inflamatórias idiopáticas para fornecer medidas de prevenção e cuidados para sua vida sexual e propiciar uma melhor qualidade de vida das pacientes e de seus parceiros.

The objectives were to evaluate the effect of different categories of endometritis on follicular growth and ovulation, reproductive performance, dry matter intake (DMI), and milk yield (MY) in dairy cows. Lactating Holstein cows (n = 126) were examined for endometritis on 25 ± 1 day postpartum (DPP) using vaginoscopy, transrectal ultrasonography, and endometrial cytology to determine the presence and type of vaginal discharge, uterine fluid, and proportion of polymorphonuclear (PMN) cells, respectively. Cows that had mucopurulent vaginal discharge and/or presence of uterine fluid, no mucopurulent vaginal discharge or uterine fluid but 8% or more PMN, and mucopurulent vaginal discharge and/or uterine fluid and 8% or more of PMN were defined as having clinical (CLIN; n = 45), cytological (CYTO; n = 15), and clinical and cytological (CLINCYTO; n = 30) endometritis, respectively. Cows that had none of the above pathological conditions were classified as unaffected (UNAF; n = 36). The diameter of the largest follicle at first examination, intervals from calving to first dominant (diameter = 10 mm) follicle, preovulatory size (diameter = 16 mm) follicle, ovulation, presence of follicular cyst, and proportion of ovular cows at 35 and 65 DPP were recorded as the measures of follicular growth and ovulation. None of the ovarian follicular parameters analyzed was affected by categories of endometritis. The first service conception rate tended (P = 0.06) to differ among categories of endometritis; cows that had CLIN and CLINCYTO endometritis were four times less likely to conceive to the first insemination compared to UNAF cows. Cows that had CLIN (hazard ratio: 0.52) and CLINCYTO (hazard ratio: 0.40) endometritis had decreased likelihood of pregnancy at 150 DPP compared to UNAF cows. Similarly, cows diagnosed as having CLINCYTO endometritis had decreased likelihood (hazard ratio: 0.48) of pregnancy at 250 DPP compared to UNAF cows. The DMI and MY up to 5 weeks postpartum were not affected by categories of endometritis. In summary, categories of endometritis as determined at 25 DPP did not affect follicular growth and ovulation, DMI, or MY. However, the combined (CLINCYTO endometritis) category had a negative impact on first service conception rate and subsequent services.

Video Objective This video is a demonstration of radical trachelectomy done laparoscopically with a nerve sparing approach. The uniqueness of the surgery lies in the fact that it is nerve sparing which helps prevent urinary dysfunction, anorectal problems and sexual issues postoperatively which is the ultimate goal for any surgeon doing a radical fertility sparing surgery. The difference between a nerve sparing radical hysterectomy and trachelectomy is that, in the latter we are limited in the space available for dissection due to preservation of supports of uterus. Setting A 24-year-old married lady with a history of abortion underwent examination due to excessive vaginal discharge. Pap Smear examination revealed HSIL & acetowhite area was found at 11 o'clock position on visual inspection with acetic acid and lugol's iodine. On HPV DNA examination, strains 18 & 51 were positive. On cervical biopsy, it was proved to be invasive squamous cell carcinoma, but imaging study revealed no visible growth in the cervix or spread to pelvic viscera. Interventions As we had to preserve her fertility potential, trachelectomy was chosen but our challenge was the nerve sparing radical approach. With the help of laparoscopy, we could achieve a magnified view of the pelvic anatomy and meticulous dissection could be done to preserve the innervation to the vital organs. The video explains the need for understanding the pelvic anatomy of avascular spaces and fascia in order to achieve the optimum result. On follow up, she didn't have any change in bladder and bowel habits. This also prevented vaginal dryness & dyspareunia which would help in her conception in the future! Conclusion Thus, nerve sparing approach to a radical trachelectomy is a breakthrough in minimally invasive surgery & the field of reproductive medicine.

Background Although generally asymptomatic, severe Chlamydia trachomatis (C. trachomatis) infections have been documented. C. trachomatis has been associated with myocarditis as well as sepsis. Case A 19-year-old girl with type 1 diabetes mellitus developed sudden-onset mental status change and shock after resolution of diabetic ketoacidosis. Abdominal and pelvic imaging showed uterine and adnexal inflammation, and pelvic examination confirmed a diagnosis of pelvic inflammatory disease. The patient was intubated, required vasopressor support, and developed severe biventricular myocardial dysfunction. Infectious myocarditis workup was negative. Nucleic acid amplification testing from vaginal discharge was positive for C. trachomatis and Trichomonas vaginalis and negative for Neisseria gonorrhoeae. Summary and Conclusion C. trachomatis should be considered in the workup of septic shock, particularly in populations at high risk for sexually transmitted infections.

Metronidazole is administered in an inactive form then activated to its cytotoxic form within the hydrogenosome of trichomonads. Two hydrogenosomal proteins, pyruvate ferredoxin oxidoreductase (PFOR) and ferredoxin, play a critical role in the reductive activation of metronidazole. The expression of these proteins and other hydrogenosomal proteins are likewise positively regulated by iron. In the present study, the effect of iron on minimal lethal concentration (MLC) of metronidazole on in vitro cultured Trichomonas vaginalis(T. vaginalis) isolates was investigated. Interestingly, Addition of Ferrous ammonium sulphate (FAS) to T. vaginalis culture led to decrease in the MLC of metronidazole. On using aerobic assay, MLC of metronidazole on untreated T. vaginalis of both isolates was 12.5 μg/ml that decreased to 0.38 μg/ml on FAS treated trichomonads. Also anaerobic assay revealed that MLC on untreated parasites was 3.12 μg/ml that decreased to 0.097 μg/ml and 0.19 μg/ml for isolate 1 and isolate 2 respectively after iron addition. It was concluded that, addition of iron to in vitro cultured T. vaginalis decreases metronidazole MLC that was detected by both aerobic and anaerobic assays.

Objective To review the use, care, and fitting of pessaries. Target population Women requiring the use of vaginal pessaries for pelvic organ prolapse and/or stress urinary incontinence. Use may also be indicated for women with certain pregnancy-related clinical scenarios, including incarcerated uterus. Options Pessaries are an option for women presenting with prolapse and/or stress urinary incontinence. In addition, certain types of pessaries can be considered for patients with cervical insufficiency or incarcerated uterus. Outcomes Most women with prolapse or stress urinary incontinence can be successfully fitted with a pessary and experience excellent symptom relief, high satisfaction rates, and minimal complications. Benefits, harms, and costs Women with pelvic organ prolapse and/or stress urinary incontinence may choose to use a pessary to manage their symptoms rather than surgery or while waiting for surgery. Major complications have been seen only when pessaries are neglected. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. Evidence Medline was searched for relevant articles up to December 2018. This is an update of the SOGC technical update published in 2013, which was the first internationally published guidance on pessary use. Subsequently, an Australian guideline on the use of pessaries for the treatment of prolapse was published later in 2013. Validation methods The authors rated the quality of evidence and strength of recommendations using the approach of the Canadian Task Force on Preventive Health Care (Appendix A). Intended audience Gynaecologists, obstetricians, family physicians, physiotherapists, residents, and fellows. SUMMARY STATEMENTS 1Most women can be successfully fitted with a pessary to treat the symptoms of pelvic organ prolapse or stress urinary incontinence (II-2). 2Satisfaction rates for pessary use are very high (I). 3Some vaginal pessaries may prevent recurrence of incarcerated uterus (III). 4The role of pessaries specifically designed to prevent preterm labour is not yet elucidated (I). 5Complications associated with pessary use are usually minor, with vaginal discharge being the most common problem (II-3). 6Vaginal erosions can be treated with removal of the pessary and optional vaginal estrogen supplementation (II-2). RECOMMENDATION 1Pessaries should be considered in all women presenting with bothersome pelvic organ prolapse and/or stress urinary incontinence (I, A).

Pyometra is an uncommon condition in mares associated with various symptoms. Here, we report a case of a 13-year-old Icelandic barren maiden mare with recurrent vaginal discharge. Ultrasonographically, the mare displayed intrauterine spherical masses of inhomogenous texture, which were identified as purulent concrements in hysteroscopy. The purulent concrements were successfully removed via uterine lavage after endoscope-assisted comminution. Microbiologic examination of the concrements revealed growth of Streptococcus equi subspecies zooepidemicus, Actinobacillus species, Pseudomonas aeruginosa, Staphylococcus intermedius, Pseudomonas fulva, Citrobacter freundii, and Chryseobacterium species. Systemic antibiotic treatment with trimethoprim-sulfadiazine and additional uterine lavages were performed for 10 days. A follow-up examination revealed absence of intrauterine masses but reoccurrence of pyometra due to an impatent cervical canal. The pyometra condition was resolved by insertion of a cervical stent for prevention of intrauterine fluid accumulation. In conclusion, uterine masses, which may severely impact fertility, are best diagnosed by hysteroscopy. Intrauterine purulent concrements should be considered as an atypical form of equine pyometra.

Bacterial vaginosis (BV) is the principal cause of vaginal discharge among women, and it can lead to many comorbidities with a negative impact in women’s daily activities. Despite the fact that the pathophysiological process of BV remains unclear, great advances had been achieved in determining consequences of the shift in the vaginal community, and it was defined that Gardnerella spp., plays a key role in the pathogenesis of BV. Interactions of vaginal phage communities and bacterial hosts may be relevant in eubiosis/dysbiosis states, so defense mechanisms in Gardnerella spp., against phage infections could be relevant in BV development. In this study, we analyzed CRISPR-Cas systems among the 13 Gardnerella species recently classified, considering that these systems act as prokaryotic immune systems against phages, plasmids, and other mobile genetic elements. In silico analyses for CRISPR-Cas systems mining over the 81 Gardnerella spp., strains genomes analyzed led to the identification of subtypes I-E and II-C. Spacers analyses showed a hypervariable region across species, providing a high resolution level in order to distinguish clonality in strains, which was supported with phylogenomic analyses based on Virtual Genomic Fingerprinting. Moreover, most of the spacers revealed interactions between Gardnerella spp., strains and prophages over the genus. Furthermore, virulence traits of the 13 species showed insights of potential niche specificity in the vaginal microbiome. Overall, our results suggest that the CRISPR-Cas systems in the genus Gardnerella may play an important role in the mechanisms of the development and maintenance of BV, considering that the Gardnerella species occupies different niches in the vaginal community; in addition, spacer sequences can be used for genotyping studies.

Objective:To assess the predictive value of quantitative fetal fibronectin (fFN) concentration in cervicovaginal fluid for spontaneous preterm birth in women with bulging fetal membranes. Study Design:This was a prospective observational study from five UK tertiary centres of a cohort of women with singleton pregnancy and bulging fetal membranes presenting between 18 and 32 weeks of gestation (n = 62), in the period 2010-2014. fFN concentrations in cervicovaginal fluid were measured both quantitatively and qualitatively at presentation in all women. Predictive statistics and receiver operating characteristic (ROC) curves were calculated for both tests to predict spontaneous preterm birth within 14 days from testing and before 34 weeks of gestation. Results:62 eligible women with bulging fetal membranes were recruited from screening of 2571 women at high risk of preterm birth. The median gestational age was 24+0 (LQ-UQ, 21+2-25+3) at presentation and 34+4 (25+2-39+0) at delivery, with a median time from testing to delivery of 58 days (17-110). Concentration of quantitative fFN at presentation correlated negatively with time to delivery (Spearman's rs = -0.615, p < 0.001). The area under the ROC curve for quantitative fFN testing was 0.81 (95% CI 0.69-0.94) for prediction of spontaneous preterm birth within 14 days, and 0.84 (0.73-0.95) before 34 weeks of gestation. Conclusion:Quantitative fFN has a role in predicting spontaneous preterm birth even in women with bulging fetal membranes, suggesting that fFN leakage could potentially be an active process. This may aid the clinical management of this high-risk group in the future.

Study Objective To determine and compare clinical and microbiological features of vulvovaginitis in prepubertal girls. Vulvovaginitis is the most common gynecological problem of childhood. Design, Setting, Participants, Interventions, and Main Outcome Measures This study involved 45 girls from 2-12 (5.38 ± 2.9) years old; and 26 girls from 3-12 (5.72 ± 3.1) years old as a control group. Anamnesis and physical examination were followed by vaginal smear, urine culture, and stool analyses from both groups, and the personal hygiene status and education level of the mother were determined. Results The most common symptoms among the patients were vaginal discharge (44.4%, vulvar erythema (37.8%), and vaginal itch (24.4%). Microorganisms, isolated from vaginal smears, were detected in 48.9% of the patients. Escherichia coli was shown in the urine culture of 3 patients with vulvovaginitis (6.70%). In microscopic stool analysis parasites were detected (45.9%). We found some relevant personal hygiene factors, such as wiping back to front (42.9%), cleaning by herself after defecation (89.3%), using toilet paper (60.7%) and wet wipes (21.4%), and bathing standing (14.3%) and sitting (46.4%) among patients. The questionnaire also showed that the children wore tight clothing (35.7%). Conclusion Our findings suggest that vulvovaginitis in prepubertal girls is related not only to microorganisms but also poor personal hygiene, the educational status of mothers, and specific irritants.

The objectives of this study were to evaluate the reproductive and productive performance of dairy cows with and without puerperal metritis and to evaluate the effectiveness of using a long-acting ceftiofur preparation. Dairy cows in one dairy farm, calving from July 2009 to January 2010, were examined between 3 and 14 days postpartum and classified on the basis of vaginal discharge into three groups: cows with normal discharge (control; C); cows with a bloody mucus purulent or pathologic nonfetid discharge (PnFD), and cows with bloody mucopurulent or purulent fetid discharge (PFD). Cows in C and PnFD groups were not treated, whereas those in the PFD group were randomly allocated to receive 2.2 mg/kg of ceftiofur subcutaneously behind the ear (PFD-T) or remain untreated (PFD-No T). From the 640 cows examined, 58.2% formed the C group, 13.4% formed the PnFD group, and 28.4% formed the PFD group. Survival curves differed between cows in the C group and PFD-No T group (P = 0.0013) and between PFD-No T versus PFD-T group (P = 0.0006). Survival curves of PnFD were intermediate and did not differ from those in the C group (P = 0.2) and PFD-T group (P = 0.1) but tended to be different from the PFD-No T group (P = 0.056). The postpartum interval to achieve a 25% pregnancy rate was 72 days for cows in the C group, 73 days for the PFD-T group, 83 days for PnFD group, and 95 days for the PFD-No T group. The chance of pregnancy in a cow in the C group was 1.98 times higher (95% confidence interval = 1.33, 3.08) and in cows in the PFD-T group was 2.16 times higher (95% confidence interval = 1.37, 3.50) than that in the PFD-No T group. Finally, the chance of pregnancy in cows in the PnFD group tended to be higher (P = 0.08) than that in the PFD-No T group but did not differ from the other two groups. Cumulative 305-day milk production was higher (P < 0.0001) in C group than those with vaginal discharge, regardless of fetidness and regardless of treatment. It is concluded that puerperal metritis affects the reproductive and productive performance of dairy cows and the treatment with ceftiofur was effective in reducing the adverse effects on reproductive performance but not on milk production.

Background Vulvovaginal candidiasis (VVC) is a vaginal mucosal infection that usually infects women in their reproductive age. When the signs of VVC persist on a daily basis or last for a long time and repeat at least three times per year, the disease is considered chronic and recurrent. Objectives The purpose of this study was to determine the expression rate of 2 genes responsible for adhesion and virulence of candida in RVVC patients using Real-time PCR, and comparing them together and assess the presence or absence of ALS9–2 allele in these patients. Patients/methods The vaginal discharge was collected from 120 women aged (22–55) attending lolagar hospital which were all diagnosed with RVVC and 120 age-matched healthy controls. The expression rate of ALS2 and ALS 9 genes was quantified using real-time PCR. PCR method was used for Identification of ALS9 gene alleles. Results Results showed an increase in ALS2 gene expression and a decrease in ALS9 gene expression, comparing to basic level and standard sample. 42.5% (51 of total 120 samples) contained the small allele. Conclusions The significant difference in expression rates of ALS2 and ALS9 genes indicates their different roles in making morphogenesis changes during the virulence of Candida albicans. Emergence of heterogeneous form and detection of ALS's short allele in invasive form of fungi proves the significant pathogenic role of this allele, specially when attached to mucosal tissue. Invasive and recurrent form of the disease can be accompanied by genetic-morphologic changes in fungi. Considering the form of this disease and the reduction in ALS9 gene expression, it can be concluded that this gene plays a significant role in attachment and initiation of the pathogenic phase.

Vulvovaginitis, referring to inflammation of the vulva and vagina, is a commonly reported concern among adolescents and young women presenting for gynecologic care. Symptoms of vulvovaginitis may include vaginal discharge, odor, itching, pain, dysuria, skin irritation, burning, and dyspareunia. Vulvovaginitis may result from infectious or non-infectious causes. Bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis represent the three most common infectious causes of vulvovaginitis in adolescents and young adults. Additionally, non-infectious causes such as the presence of a foreign body in the vagina, chemical irritants, douching, and poor hygiene may also lead to symptoms of vulvovaginitis. A thorough history in combination with the appropriate physical examination and laboratory evaluation is necessary to identify the cause of a patient's symptoms. Importantly, adolescent patients should be given the opportunity to speak privately with the provider without a parent or guardian present in the room, particularly when gathering the sexual history. Appropriate anticipatory guidance and counseling should be provided once a diagnosis has been made, and prevention of future episodes of vulvovaginitis should be discussed.

Background & Aims Inflammatory bowel diseases (IBD) affect 200–400 people per 100,000 in the United States, about half of whom are women. We aimed to define the prevalence of vulvovaginal symptoms and association with IBD activity in a large cohort of women. Methods Women more than 18 years old with IBD (1250) completed an online survey querying the presence and severity of vulvar or vaginal itch, burn, or irritation, vaginal discharge or dryness, and vulvovaginal pain. The survey collected information on demographic features and IBD activity (categorized using the Manitoba index). Women with and without symptoms were compared using bivariate analyses. Logistic regression evaluated associations between IBD severity and vulvovaginal symptoms, adjusted for diagnosis, menopause, smoking, depression, and use of medications to treat IBD. Results A total of 512 (41%) women reported at least 1 moderate–severe vulvovaginal symptom. All vulvovaginal symptoms except vaginal dryness were more common in women with active IBD. In a multivariate model controlled for menopause, smoking, t-score from the PROMIS depression instrument, and use of IBD medications, women with constant or frequent active IBD, based on Manitoba index scores, had increased odds for moderate–severe vulvovaginal symptoms (odds ratio, 1.68; 95% CI, 1.22–2.32) compared to women in remission. Vulvovaginal discomfort frequently or always decreased interest in sex (n=336; 28%) or ability to have sex (n=207; 16%). Conclusions In an online survey of 1250 women, we found that women with more active IBD have increased prevalence of vulvovaginal discomfort, compared to women in remission. These symptoms affect sexual health.

Summary Introduction Failure of kidney migration during embryonic life results in an ectopic kidney, with an incidence varying from 1 in 500 to 1 in 1200. Pelvic kidney can be a rare cause of recurrent urinary tract infection (UTI), warranting nephrectomy in some cases. Material and methods A 7-year-old girl with a history of recurrent UTIs and vaginal discharge was diagnosed with a dysplastic afunctional ectopic kidney located in the pelvis, with ureter draining into the cervix or vaginal wall. Results A robot-assisted approach was chosen, with side docking of the robot to allow concurrent vaginoscopic/hysteroscopic exploration. A uterus bicornis was found. The ectopic ureter was dissected toward its drainage in the vaginal wall, where it was sutured and resected. The dysplastic kidney and ureter were removed. Compared to pure laparoscopic approach, dissection deep into the pelvis toward the vaginal wall is aided by the robotic dexterity and facilitates complete resection of the structure, which avoids leaving a ureteric stump into the vaginal wall. Conclusions Robot-assisted surgery is a safe and effective option for resection of ectopic kidneys with ectopic ureter in children. Dissection up until the vaginal wall in children is aided by robotic dexterity, making this kind of surgery the ideal indication for robotic-assisted surgery.

Background Adenoma malignum of the cervix (also referred to as minimal deviation adenocarcinoma) is a rare malignancy. Although previous reports have described adenoma malignum presenting with mucinous vaginal discharge, no reports to our knowledge have described a presentation with profound hyponatremia due to fluid losses. Case We present a case of adenoma malignum in a 52-year-old woman who presented with substantial watery vaginal dischargeand profound hyponatremia. Conclusion Despite being a rare cervical tumour, adenoma malignum should be considered in the differential diagnosis of watery vaginal discharge. This tumour can present with severe electrolyte disturbances.

The objectives of the study were to assess responses to treatments (clinical cure and resumption of estrous cycles) of cows with purulent vaginal discharge (PVD) that received intrauterine infusion of a hypertonic solution of 50% dextrose (DEX) or untreated control (CON) cows and the subsequent pregnancy per artificial insemination (PAI) in cows with and without PVD. Cows (n=2,852) from 2 dairy herds were screened for PVD using the gloved hand technique at exam 1 [26±3 d in milk (DIM)]. Cows with vaginal discharge scores of 2 or 3 (0-3 scale) were stratified by parity and randomly allocated into 1 of 2 treatment groups: (1) intrauterine infusion (~200 mL) of 50% DEX solution (n=456), or (2) untreated control animals (CON, n=491). Fourteen days posttherapy (40±3 DIM), cows with PVD were re-examined at exam 2 (40±3 DIM) to assess the response to treatments. All cows were subjected to the same reproductive program, which consisted of estrus detection twice daily (using tail chalking and visual observation) for the first 5 artificial inseminations; then, open lactating cows were turned out with bulls. Cows displaying signs of standing estrus underwent AI and no reproductive hormones were used. Pregnancy diagnosis (PD) was performed via transrectal palpation at 40±3 d post-AI. The risk of culling within 14 d posttherapy was not different among treatment groups. Cows with PVD had greater cervical diameter at exam 1 and decreased PAI compared with cows without PVD. Treatment with DEX increased the proportion of cows with clear vaginal discharge (clinical cure) and cyclicity 14 d posttherapy compared with CON cows. Pregnancy per AI for DEX (29.2±2%) cows was significantly greater than that for CON (22.5±2%) cows. Cows without PVD had a greater proportion of cycling cows (65.6%) and PAI (37%) with reduced pregnancy losses (5.7%) compared with DEX or CON cows. The use of intrauterine DEX alone improved reproductive performance of cows with PVD.

El herpesvirus bovino 4 [Bovine herpesvirus 4 (BoHV-4)] ha sido aislado de bovinos con infecciones respiratorias, vulvovaginitis, mastitis, abortos, endometritis y de animales aparentemente sanos en diferentes partes del mundo. Si bien no se ha reconocido como agente causal de una entidad patológica en particular, se asocia principalmente con infecciones del tracto reproductivo de los bovinos. Este virus puede infectar un amplio rango de especies tanto in vivo como in vitro. Los primeros aislamientos dieron origen a dos grupos de cepas prototipo: el grupo americano tipo DN599 y el grupo europeo tipo Movar. En Argentina, el BoHV-4 fue aislado y caracterizado en el año 2007; este aislamiento se obtuvo de muestras de mucus cérvico-vaginal de vacas que abortaron. Hasta el momento se han registrado más de 40 aislamientos, provenientes principalmente de hembras bovinas que han abortado. Bovine herpesvirus 4 (BoHV-4) has been isolated from cattle with respiratory infections, vulvovaginitis, mastitis, abortions, endometritis and from apparently healthy animals throughout the world. Although it has not yet been established as causal agent of a specific disease entity, it is primarily associated with reproductive disorders of cattle. This virus can infect a wide range of species, either in vivo or in vitro. Two groups of prototype strains were originated from the first isolates: the DN599-type strains (American group) and the Movar-type strains (European group). In Argentina, BoHV-4 was isolated and characterized in 2007 from vaginal discharge samples taken from cows that had aborted. So far, more than 40 isolates, mainly associated with aborting bovine females have been registered in our country. Fil: Morán, Pedro Edgardo. Universidad Nacional del Centro de la Provincia de Buenos Aires. Facultad de Ciencias Veterinarias; Argentina Fil: Perez, Sandra. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Tandil. Centro de Investigación Veterinaria de Tandil. Universidad Nacional del Centro de la Provincia de Buenos Aires. Centro de Investigación Veterinaria de Tandil. Provincia de Buenos Aires. Gobernación. Comision de Investigaciones Científicas. Centro de Investigación Veterinaria de Tandil; Argentina Fil: Odeón, Anselmo Carlos. Instituto Nacional de Tecnología Agropecuaria. Centro Regional Buenos Aires Sur. Estación Experimental Agropecuaria Balcarce; Argentina Fil: Verna, Andrea Elizabeth. Instituto Nacional de Tecnología Agropecuaria. Centro Regional Buenos Aires Sur. Estación Experimental Agropecuaria Balcarce; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Objectives To compare efficacy, satisfaction and tolerability of oral dydrogesterone and micronized vaginal progesterone gel used for luteal supplementation. Study design Randomized controlled trial. A total of 853 infertile women undergoing IVF/ICSI treatment in University Hospital Center "Sisters of Mercy", Zagreb, Croatia. Luteal support was provided as Crinone 8% ® vaginal progesterone gel (90mg) administered daily, or oral dydrogesterone Duphaston ® (2× 10mg) administered two times daily. Progesterone was administered from the day of oocyte retrieval (day 0) till pregnancy test or in a case of pregnancy, until week 10. Results The on-going pregnancy rates were comparable between Crinone 8% ® vaginal progesterone gel and oral dydrogesterone – Duphaston ® (28.1% versus 30.3%; OR 1.11 (0.82–1.49 with 95% CI)). Overall satisfaction and tolerability were significantly higher in the dydrogesterone group than in the Crinone group. Vaginal bleeding, interference with coitus and local adverse side effects such as vaginal irritation and discharge occurred significantly more in Crinone group than in dydrogesterone group. Conclusions Oral dydrogesterone is effective drug, well tolerated and accepted among patients and can be considered for routine luteal support. Clinical trial registration number: NCT01178931; www.clinicaltrials.gov.

For the interpretation of clinical findings of endometritis and the development of disease prevention and intervention strategies a better understanding of the dynamics and interactions within intrauterine bacterial communities in healthy and diseased cows is required. To gain deeper insights into fluctuations within the uterine microbiota, intrauterine samples were collected from 122 cows at the day of calving, days 3, 9, 15, 21 and 28 postpartum. A total of 2052 bacterial isolates were identified by Fourier-transform-infrared spectroscopy. This culturomics-based approach showed that the aerobic uterine microflora comprised a huge diversity of bacteria belonging to 202 different species, representing 76 genera, with members of the genus Staphylococcus (24.2%) being predominant. On species level the uterine microflora was dominated by Trueperella pyogenes (13.2%), Escherichia coli (11.2%), Staphylococcus xylosus (5.4%), Bacillus pumilus (5.2%) and Streptococcus uberis (4.9%). Comparative analysis of uterine bacteria from cows with different vaginal discharge scores (VDS) revealed health status specific temporal microbial diversifications. Although the intrauterine flora of all VDS groups was dominated by T. pyogenes, E. coli and Staphylococcus spp., the relative number of bacteria differed between VDS groups. The presence of T. pyogenes on days 15 and 21 significantly increased the risk of VDS 2 and 3 at day 21, whereas Staphylococci at day 9 reduced the likelihood of VDS 3 (P

The diversity and dynamics of the uterine microbiota of dairy cows are poorly understood although it is becoming increasingly evident that they play a crucial role in the development of metritis and endometritis. Fourier-transform infrared (FTIR) spectroscopy was used to monitor the bovine microbiota of 40 cows on the day of calving and days 3, 9, 15, and 21 after parturition, and to investigate the associations of selected species with clinical endometritis (CE). Trueperella pyogenes (43.5%), Escherichia coli (21.5%), Bacillus spp. (21.0%) and Streptococcus uberis ( 18.5%) were the most frequently isolated microbes. Analyses of different sampling time points revealed that the presence of S. uberis on day 3 increased the risk of subsequent T. pyogenes infection on day 9 (odds ratio [OR] = 5.1, 95% confidence interval [CI] = 1.2–22.6). T. pyogenes infection (OR = 36.0, 95% CI = 3.8–343.2) and retained fetal membranes (RFM) (OR = 12.4, 95%CI = 1.4–112.7) were significant risk factors for CE. Cows with S. uberis on day 3 tended to have greater odds of CE than S. uberis -negative cows (OR = 7.1, 95% CI = 0.9–55.6). Chemometric analysis revealed significant differences in the metabolic profile of S. uberis strains isolated from cows with different vaginal discharge scores. This is the first study showing the association of specific S. uberis subtypes with the uterine health status of post-partum dairy cows. The study demonstrates that uterine clearance is a highly dynamic process, during which time bacteria show distinct patterns of progression, and provides information about interactions between bacterial species involved in the occurrence of CE.

Gardnerella vaginalis is associated with bacterial vaginosis (BV), the most common cause of vaginal discharge. Metronidazole is a front-line therapy for BV, and treatment failure and recurrent disease are common problems. Whole-genome sequencing studies have revealed that G. vaginalis has a population structure that consists of 4 clades: clades 1 and 3 are associated with BV, whereas clades 2 and 4 are not. To determine if metronidazole susceptibility is associated with population structure, we analyzed 87 clinical isolates and found that metronidazole resistance (MIC ≥32 μg/mL) was highly associated with clade (P0.0001), as 14/14 clade 3 isolates (100%) and 22/22 clade 4 isolates (100%) exhibited resistance, compared to only 16/37 clade 1 isolates (35%) and 1/14 clade 2 isolates (7.1%). The identification of intrinsically metronidazole-resistant G. vaginalis clades will facilitate future studies on the relationship between metronidazole resistance and BV treatment failure.