Response to treatment with tadalafil in men with erectile dysfunction who reported no successful intercourse attempts at baseline.

The purpose of this post hoc analysis was to evaluate response to tadalafil in patients with erectile dysfunction (ED) who reported failures in all sexual intercourse attempts before treatment. In a multicenter, open-label study, 1911 men received tadalafil 20 mg dosed as needed (up to once daily), for 12 weeks following a 4-week treatment-free run-in period. Efficacy measures included the sexual encounter profile (SEP) and the erectile function (EF) domain of the International Index of Erectile Function (IIEF-EF). Approximately, one-half (n=952, 49.9%) of the patients reported no successful intercourse attempts during the 4-week run-in period. Of these, 771 patients (81.0%) had at least one successful intercourse attempt during the treatment period. Furthermore, among responders, mean IIEF-EF scores at study end were similar regardless of success or no success at baseline. Patients who are unable to have successful intercourse should be encouraged to try oral phosphodiesterase type 5 inhibitor treatment for ED.

Non-classic 21-hydroxylase deficiency in an 18-year-old female athlete. A case report

Background: In non-classic 21-hydroxylase deficiency, age at presentation and genital findings are variable. Late diagnosis with dramatic signs of virilization precludes early treatment and thus prevention of anatomic and psychosocial consequences. The following case illustrates the complexity of late diagnosis.Case: An 18-year-old West Indian female was seen for evaluation of clitoromegaly and hirsutism discovered in the emergency department when she presented after sexual assault. She had allegedly been drugged and raped in her dorm room. She was a college student with an athletic scholarship and had a striking masculinized, broad-shouldered appearance. She denied any use of anabolic steroids or other drugs. Menarche was at age 16 with infrequent menses. She was sexually active with 4 life-time partners, all male. On physical exam, her height was 152 cm, weight 50 kg, blood pressure 110/70 mm Hg. Breasts were hypoplastic with hyperpigmented nipples. She was hirsute with a Ferriman-Gallwey score of 14. Genitalia were abnormal with clitoris measuring 5.5 x 1.5 cm and posterior labial fusion. Initial non-fasting serum 17-hydroxyprogesterone level was 2890 ng/dL, testosterone was 274 ng/dL, and cortisol was 9 &mgr;g/dL. Chromosome analysis was 46, XX and ACTH stimulation test confirmed the diagnosis of 21-hydroxylase deficiency. The patient was initially reluctant to begin glucocorticoid treatment because of concern that it would decrease her muscle mass and negatively impact on her athletic performance and scholarship support. One year after diagnosis and 10 months after beginning treatment, she elected surgical correction of her clitoromegaly because of extreme embarrassment over having erections during sex. She underwent excision of most of the corpus cavernosum with repositioning of the glans. The neurovascular elements were preserved. The patient is pleased with the cosmetic result and reports no change in achieving orgasm. She has not notices any change in muscle mass or athletic performance since beginning glucocorticoid therapy.Conclusion: This case illustrates the somatic and genital abnormalities as well as the psychosocial impact of a delayed diagnosis of 21-hydroxylase deficiency in this young female athlete.

Common problems in pediatric gynecology: new developments.

Physicians, particularly gynecologists, pediatricians and family practitioners, are often called upon to perform a gynecological evaluation of a child. The following article is a review of current developments in the area of pediatric and adolescent gynecology. It outlines the recent clinical information and offers a review of common gynecological disorders among children and adolescent girls.

Diagnostic accuracy of colposcopic photographs in child sexual abuse evaluations.

STUDY OBJECTIVE: To evaluate the utility of colposcopic photographs in child sexual abuse evaluations and to assess whether such photographs can be reliably used for peer review, second opinion, and court testimony. METHODS: A prospective review of colposcopic photographs at the Pediatric and Adolescent Gynecology Clinic in Louisville, Kentucky. Participants were 189 girls who were referred for evaluation for possible sexual abuse. Interventions used included gynecologic evaluation, colposcopic photographs, and review of photographs. The main outcome measure was the degree of agreement between the examining physician and the reviewers. RESULTS: The reviewers' accuracy for the entire set of 189 cases is uniformly high (93%-95%). Accuracy rates are significantly lower for pubertal girls (83%-90%) and for girls with signs of abuse (58%-88%). CONCLUSIONS: The diagnostic accuracy of the colposcopic photographs is sufficiently high to warrant continued use of medical photography for documentation and peer review. One should anticipate some disagreements between the examining physician and the reviewers, and contradictory opinions are more likely to occur with girls exhibiting physical signs of abuse and with pubertal girls.

Treatment of prepubertal girls with labial adhesions.

BACKGROUND: The purpose of this study was to evaluate the efficacy of topical estrogen therapy for the treatment of prepubertal girls with labial adhesions. METHODS: This was a retrospective chart review at a pediatric and adolescent gynecology clinic in Memphis, Tennessee. Participants included 289 prepubertal girls who were referred for evaluation and treatment of labial adhesions. Interventions were gynecologic evaluation, topical estrogen, and manual and surgical labial separation. Main outcome measures were separation of labial adhesions and relief of symptoms. RESULTS: The use of topical estrogen resulted in a separation of the fused labia in approximately half of patients. Separation with the patient under topical or general anesthesia was required in the remaining patients. CONCLUSIONS: Further intervention may be required in many patients with labial adhesions after topical therapy with estrogens. Patients with dense, fibrous adhesions and girls who have undergone previous surgical separation of the labia are less likely to respond to topical estrogen therapy.

Limitations of the medical evaluation for child sexual abuse.

The purpose of this review is to highlight the inherent difficulties that a clinician faces during the evaluation of child sexual abuse cases. Each component of the medical evaluation has its own unique problems. Some of them are caused by the nature of the abusive relationship, while others are the result of the children's limited verbal skills. Readers should be aware of these limitations as they formulate an opinion at the conclusion of the examination.

Single serum progesterone as a screen for ectopic pregnancy: exchanging specificity and sensitivity to obtain optimal test performance.

OBJECTIVE: To investigate the diagnostic accuracy of screening serum P in diagnosis of ectopic pregnancy (EP) and to identify a cutoff value that provides the best compromise between test sensitivity and specificity. DESIGN: Retrospective analysis. SETTING: University hospital. INTERVENTIONS: Observation only. PATIENTS: First trimester pregnant women at risk for EP. MAIN OUTCOME MEASURE: Single P measurements were obtained from 3,674 pregnancies with outcomes defined as EP, viable intrauterine pregnancy (IUP), and spontaneous abortion (SAB). Diagnostic accuracy of the test was analyzed by generating receiver operating characteristic (ROC) curves, which quantify the ability of the test to distinguish EP and SAB from IUP. RESULTS: Diagnostic accuracy for EP versus IUP was 88.7% +/- 0.1% (mean +/- SEM); for SAB versus IUP, 93.8% +/- 0.4%; and for SAB + EP versus IUP, 92.8% +/- 0.4%. Diagnostic accuracy for SAB versus EP was only 39.4% +/- 0.2%. In the interval of 15.0 to 19.9 ng/mL (47.7 to 63.3 nmol/L), P missed 5.3% of the EPs and incorrectly included 84.3% of the viable IUPs; in the interval of 20.0 to 24.9 ng/mL (63.6 to 79.2 nmol/L), sensitivity improved in that only 3.5% of the EPs were missed but 88.8% of viable IUPs were included incorrectly. A cutoff value of > or = 17.5 ng/mL (55.7 nmol/L), the median point of the 15.0 to 19.9 ng/mL (47.7 to 63.3 nmol/L) interval, missed only 35 of 423 (8.3%) total EPs in the study. CONCLUSION: Analysis of ROC curves demonstrates that single serum P has high diagnostic accuracy for differentiating accidents of pregnancy (SAB and EP) from viable IUP, both individually (SAB versus IUP and EP versus IUP) and collectively (SAB + EP versus IUP); it cannot efficiently discriminate SAB versus EP. We conclude that for P > or = 17.5 ng/mL (55.7 nmol/L), patients thought to be at risk for EP may be followed reasonably without ultrasound or further invasive diagnostic studies.

Methotrexate therapy for ectopic pregnancy in adolescents.

STUDY OBJECTIVE: To determine the suitability and efficacy of methotrexate (MTX) therapy for adolescent patients with ectopic pregnancy. MATERIALS: Patients with ectopic pregnancy were treated with methotrexate, 50 mg/m2 intramuscularly. Follow-up determinations of quantitative beta hCG levels were done on days 1, 4, and 7. They were then seen weekly until beta hCG levels were less than 15 mIU/ml. PARTICIPANTS: Adolescents with ectopic pregnancy (55 patients) received MTX therapy and comprised the study group. They were compared with 186 adults similarly treated. The groups were compared for treatment outcome and for compliance with the rigid protocol requirements. MAIN OUTCOME MEASURES: Treatment success was defined as a patient who required no surgical intervention and whose beta hCG levels declined to < 15 mIU/ml. RESULTS: 85% of patients required no surgical intervention following MTX injection. Surgical intervention rates were slightly higher and success rates slightly lower for adolescent patients, but these differences were not statistically significant (p = .71). Although adult patients were more likely to have a perfect compliance rating, comparison of all compliance categories showed no significant differences (p = .17). CONCLUSIONS: MTX therapy is satisfactory for adolescent patients. It is effective, and adolescent patients are able to comply with the requirements of a rigid protocol.

Child sexual abuse examination: is there a need for routine screening for N. gonorrhoeae?

PURPOSE: To determine the yield of routine vaginal cultures for Neisseria gonorrhoeae from asymptomatic girls following sexual abuse. METHODS: Cultures were obtained from 865 prepubertal girls seen within 72 hours following an assault. Adult females (2743), age 18 or older, who were treated according to the same protocol constitute the control group. Data were analyzed using chi square analysis and comparison of proportions. RESULTS: It was found that 165 (4.6%) cultures were positive for N. gonorrhoeae. Of the 2743 adults, 153 were positive (5.6%) compared with 12 of the 865 prepubertal girls (1.4%). The differences are statistically significant. All 12 prepubertal children who had positive vaginal cultures for N. gonorrhoeae revealed that they had signs of acute vulvovaginitis. CONCLUSION: Routine vaginal cultures in asymptomatic prepubertal girls may not be indicated as part of the initial evaluation.

Teaching pediatric and adolescent gynecology: a pilot study at one institution.

PURPOSE: To assess resident physicians' clinical recognition skills in Pediatric and Adolescent Gynecology. MATERIALS: 1) A questionnaire to identify demographic data and self-assessment as to the ability to perform a gynecologic evaluation of children. 2) Twenty color photographs of normal genitalia and common gynecologic problems in children. PARTICIPANTS: Sixty-one University of Tennessee resident physicians; 51 from the Memphis campus--20 obstetrics-gynecology (Ob-Gyn) residents, 20 pediatrics residents, and 11 family practice residents--and 10 Ob-Gyn residents from the Chattanooga campus. MAIN OUTCOME MEASURES: Ability to identify normal features of the prepubertal genitalia and to diagnose common gynecologic disorders. RESULTS: Ob-Gyn residents from the University of Tennessee, Memphis scored significantly better (58.1% correct) than did the other three groups; 38.8, 36.9, and 39.1%, respectively (p = .009). Mean performance score increased with higher pediatric gynecology PGY levels. PGY-4s performed best, whereas PGY-1s scored the lowest, with mean scores of 57.5% and 35.3%, respectively (p = .021). Residents who reported having a well-defined program in pediatric gynecology scored significantly better than those who did not have such a program, 55.3% and 39.5%, respectively (p < .001). CONCLUSIONS: A well-defined program in pediatric gynecology enhances resident education and provides them with better tools to perform gynecologic evaluations of children and adolescents.

Adolescent victims of sexual assault.

PURPOSE: The purpose of this study was to evaluate a group of female adolescent victims (n = 176) of sexual assault and assess the similarities and differences between them and older female victims. METHODS: All the adolescents in this study were physically mature. The demographic data and the findings of the medical evaluation are compared with those of women, 25-44 years of age, who were assaulted during the same time period (n = 197). RESULTS: The mean age of the adolescent patients was 15.2 (+/- 1.6), while the control group had a mean age of 31.9 (+/- 5.1). Racial distribution was similar in both groups. One hundred thirty-nine (79%) adolescents reported prior consensual sexual activity and 32 (18%) had been pregnant at least once. Thirty-one adolescents (19%) reported a previous sexual assault. Many adolescent victims (64%) knew their assailant. Weapons or physical force was used less frequently to subdue an adolescent victim, and firearms were used very infrequently in adolescent assault. Use of alcohol or drugs just prior to the assault was prevalent among adolescent victims (47%). Finally, adolescent victims were less likely to sustain physical injuries during the assault. CONCLUSION: The preexisting relationship between the victim and the assailant may explain other elements that distinguish an adolescent rape victim from her adult counterpart. Compared to adolescent victims, the assault on adult women is more often perpetrated by a stranger, the victim is more likely to be abducted, and weapons, especially firearms, are more likely to be used to carry out the victim's capture.

Use of a menstrual calendar in patients with Rokitansky syndrome. A report of two cases.

In two cases the menstrual calendar was used to determine the cyclic nature of abdominal pain in women with the Rokitansky syndrome who could not otherwise find a regular pattern in their symptoms. Surgical intervention to remove the rudimentary bicornuate uterus was needed in both, and complete resolution of pain was attained. The menstrual calendar is a valuable diagnostic tool in confirming the cyclic nature of pain and can be used in guiding treatment decisions.

Gestational diabetes: postpartum glucose tolerance testing.

OBJECTIVE: Our purpose was to determine the incidence of and evaluate risk factors for postpartum glucose intolerance among predominantly black gestational diabetic women. STUDY DESIGN: One hundred forty-five gestational diabetics underwent a standard 2-hour glucose tolerance test in the early puerperium according to the criteria of the National Diabetes Data Group. RESULTS: Fourteen patients (10%) were diabetic and eight (5%) showed impaired glucose tolerance. Maternal age, race, or obesity did not predict abnormal postpartum glucose tolerance testing. The requirement of insulin for glucose control during gestation and gestational age at diagnosis were significantly associated with abnormal postpartum glucose tolerance (p < 0.0001 and p = 0.012, respectively). Multivariate analysis showed that only a requirement for insulin for glucose control was significant (p < 0.001). CONCLUSION: Pregnancies complicated by gestational diabetes are at increased risk of glucose intolerance during the early postpartum period. Abnormal glucose tolerance occurs predominantly among those patients requiring insulin therapy during gestation or those diagnosed before 24 weeks' gestation.