Laparoscopic transfundal approach to cervical dilation: a novel treatment for cervical stenosis and cervical factor infertility.

OBJECTIVE: To demonstrate a novel technique used to restore cervical patency in a patient with severe iatrogenic cervical stenosis. DESIGN: Surgical video case report. SETTING: A single academic institution. PATIENT(S): We highlight the case of a 35-year-old nulliparous woman with a history of primary infertility. Her past medical history was significant for focal, invasive, well-differentiated squamous cell carcinoma of the cervix, for which she underwent a loop electrosurgical excision procedure. During her infertility assessment, she was found to have an extremely stenotic cervix that was refractory to conventional treatment options. INTERVENTIONS: This video highlights our innovative laparoscopic transfundal technique used to restore her cervical patency. MAIN OUTCOME MEASURES: None, as this is a descriptive case report. RESULTS: Postoperatively, the patient had continued cervical patency for >1 year with successful fertility treatment resulting in pregnancy. CONCLUSIONS: To our knowledge, this is the first case report describing a laparoscopic transfundal approach used to reestablish cervical patency. This approach may be considered for patients with cervical stenosis who have not responded to standard conservative therapies.

Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity.

BACKGROUND: To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal. PURPOSE: In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition. METHODS: The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included. RESULTS: Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments. CONCLUSIONS: Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

Interpretation pitfalls and malignant mimics in cervical cytology.

Cervical cytology has remained a diagnostically challenging area despite its long and widespread use. At least part of this challenge has stemmed from the cytomorphologic overlap between benign and neoplastic processes. The present review has highlighted select benign processes that present diagnostic pitfalls. For each of these, we have discussed the pertinent cytologic features and emphasized the morphologic clues that will aid in distinguishing the benign entities from the neoplastic processes they mimic.

Molecular detection of Mycoplasma genitalium in endocervical swabs and associated rates of macrolide and fluoroquinolone resistance in Hong Kong.

INTRODUCTION: There is a global trend of increasing macrolide and fluoroquinolone resistance in Mycoplasma genitalium (MG), such that international guidelines recommend molecular detection of resistance if a patient has MG-positive test results. Tests for MG are not routinely performed in Hong Kong. This study examined the detection of MG in endocervical swabs and the associated macrolide and fluoroquinolone resistance rates. METHODS: Endocervical swabs received from two sexual health clinics in Hong Kong for routine assessments of Chlamydia trachomatis and Neisseria gonorrhoeae were also subjected to detection of MG. All MG-positive samples were tested for resistance-mediating mutations in 23S rRNA, parC, and gyrA genes. Laboratory records and past results for each patient were analysed. RESULTS: In total, endocervical swabs from 285 patients were included in this study. Mycoplasma genitalium was detected in swabs from 21 patients (7.4%) by real-time polymerase chain reaction with a commercial kit. Among MG-positive samples which were successfully analysed further, macrolide resistance-mediating mutations in 23S rRNA were found in 42.1% (8/19); fluoroquinolone resistance-related mutations in parC and gyrA were found in 65% (13/20) and 0% (0/20), respectively. All macrolide-resistant MG strains were also fluoroquinolone-resistant (42.1%, 8/19). No assessed factors were associated with the detection of MG or resistance-related mutations. CONCLUSION: In Hong Kong, MG was detected in endocervical swabs from 7.4% of patients in sexual health clinics, with high rates of macrolide and fluoroquinolone resistance. These findings warrant careful review of testing, clinical correlation, and treatment strategies for MG in the context of increasing antibiotic resistance.

Hyperelastic Ex Vivo Cervical Tissue Mechanical Characterization.

This paper presents the results of the comparison between a proposed Fourth Order Elastic Constants (FOECs) nonlinear model defined in the sense of Landau's theory, and the two most contrasted hyperelastic models in the literature, Mooney-Rivlin, and Ogden models. A mechanical testing protocol is developed to investigate the large-strain response of ex vivo cervical tissue samples in uniaxial tension in its two principal anatomical locations, the epithelial and connective layers. The final aim of this work is to compare the reconstructed shear modulus of the epithelial and connective layers of cervical tissue. According to the obtained results, the nonlinear parameter A from the proposed FOEC model could be an important biomarker in cervical tissue diagnosis. In addition, the calculated shear modulus depended on the anatomical location of the cervical tissue (µepithelial = 1.29 ± 0.15 MPa, and µconnective = 3.60 ± 0.63 MPa).

Uterine Artery Pseudoaneurysm in a Pregnant Patient with Retrocervical Endometriosis.

A pseudoaneurysm of the uterine artery or its branches is usually a result of vascular trauma during invasive procedures such as a cesarean section, vaginal delivery, myomectomy, hysterotomy, or dilatation and curettage. A uterine artery pseudoaneurysm rupture is a rare, yet life-threatening event. Deep infiltrating endometriosis usually involves a decrease in symptoms and imaging findings throughout pregnancy, with the notable exception of the phenomenon of decidualization. We present the case of a pregnant woman with a recent diagnosis of endometriosis, who conceived spontaneously and presented with disabling pain at 13 weeks' gestation. She was diagnosed with a left, huge (and rapidly growing) retrocervical endometriosis nodule encompassing a uterine artery pseudoaneurysm. Selective transarterial embolization was performed at 22 weeks' gestation owing to enlargement of the pseudoaneurysm sac, and the pseudoaneurysm was obliterated successfully. The patient was followed intensively throughout the pregnancy and the baby was delivered at term by cesarean section. After delivery, the nodule returned to the pregestational size.

Female genital tuberculosis in light of newer laboratory tests: A narrative review.

Female genital tract tuberculosis (FGTB) is a chronic disease with varied presentation. The diagnosis of FGTB for early institution of treatment remains a clinical challenge. Its laboratory diagnosis is difficult because of paucibacillary nature of the condition and limitation of available diagnostic tests. In view of the intricate problems in diagnosis of FGTB, physicians tend to over treat with empirical anti-tuberculosis drugs. Apart from concerns of drug toxicity, this may be a contributing factor in the increasing incidence of multidrug-resistant TB reported in India. The main goal for advances in TB diagnostics is to reduce delay in diagnosis and treatment. In addition, there should be reduced complexity, improving robustness, and improving accuracy of the laboratory test for diagnosis of Female genital tuberculosis. OBJECTIVE: This narrative review is written with the following objectives. 1) To get a comprehensive overview as well as recent advances in diagnostic test used in the detection of FGTB. 2) To understand the limitations as well as advantages of these laboratory diagnostic test. 3) To provide clinical guidance regarding the detection in susceptible women. METHOD: The literature search was performed using electronic database of Pubmed, Medline, Embase and Google Scholar. Grey literature search was also done. Studies published in English were included. Following keywords were used for search - Tuberculosis, extra pulmonary tuberculosis, female genital tuberculosis, diagnosis of female genital tract tuberculosis. The personal knowledge and experience of authors in the field, helped in archiving the relevant articles. RESULT: Studies suggest that though culture is an invaluable contributor in the diagnosis of FGTB, molecular tests like PCR, LAMP, Xpert MTB/RIF and line probe assays have shown potential and are now being explored to strengthen the diagnostic algorithm of FGTB. CONCLUSION: The use of algorithm approach with combination of both rapid culture and newer molecular techniques will facilitate the accurate and timely diagnosis of FGTB.

Primary localized amyloidosis of the uterine cervix during pregnancy.

Amyloidosis of the uterine cervix is rare. A 35-year-old pregnant woman underwent a cervical biopsy and was found to have amyloid deposits. The results of liquid chromatography-tandem mass spectrometry revealed that these deposits mainly consisted of immunoglobulin light chain (kappa chain). After undergoing several examinations, the patient was diagnosed with localized amyloidosis, without systemic or secondary amyloidosis. She underwent a normal delivery without disease exacerbation. The possible presence of systemic and secondary amyloidosis must be evaluated carefully during the diagnosis of localized cervical amyloidosis.

Doença inflamatória do colo do útero: indicador indireto da saúde reprodutiva da mulher / Inflammatory disease of cervix uteri: indirect indicator of women's reproductive health / Cervicitis: indicador indirecto de la salud reproductiva de las mujeres

Objetivo: analisar as internações por doença inflamatória do colo do útero e os fatores que influenciam a sua ocorrência. Método: estudo seccional, prospectivo, baseado em um inquérito de morbidade hospitalar realizado em 2013, com amostra de 429 mulheres internadas em hospitais no município de Guarapuava. Os dados foram analisados por meio de análise bivariada e regressão logística. O projeto foi aprovado por Comitê de Ética em Pesquisa. Resultados: do total de mulheres internadas, 45 (10,4%) foram por doença inflamatória do colo do útero. Pertencer ao público alvo, ter realizado o exame no mínimo uma vez, procurar o serviço regularmente para o controle de saúde e apresentar o resultado dentro dos limites de normalidade em 1 ano atuaram como fatores de proteção contra a ocorrência dessas internações. Conclusão: o conhecimento dos fatores que se relacionam ao desfecho fornece subsídios para a readequação dos serviços que prestam assistência às mulheres, a fim de prevenir as internações.

Objective: to examine hospital admissions for inflammatory disease of the cervix uteri and the related factors. Method: this prospective, cross-sectional study based on a hospital morbidity survey was conducted in 2013 with a sample of 429 women admitted to hospitals in the city of Guarapuava. Data were analyzed by bivariate analysis and logistic regression. The project was approved by the institution's research ethics committee. Results: 45 (10.4%) of the women were hospitalized for inflammatory disease of the cervix uteri. Protective factors against the occurrence of such hospitalizations included belonging to the target public, having performed the examination at least once, attending the service regularly for a health check and returning a result within normal limits in the prior year. Conclusion: knowledge of the factors relating to the outcome provides input for adjusting women's care services in order to prevent hospitalizations.

Objetivo: analizar las internaciones por cervicitis y los factores que influencian su ocurrencia. Método: estudio seccional, prospectivo basado en una encuesta de morbilidad hospitalaria realizada en 2013, con muestra de 429 mujeres internadas en hospitales en el municipio de Guarapuava. Los datos se analizaron por medio de análisis bivariado y regresión logística. El estudio fue aprobado por Comité de Ética en Investigación. Resultados: del total de mujeres internadas, 45 (10,4%) lo fueron por cervicitis. Pertenecer al público objetivo, haber realizado el examen al menos una vez, buscar el servicio regularmente para el control de salud y presentar el resultado dentro de los límites de la normalidad en 01 año actuaron como factores de protección respecto a la ocurrencia de estas hospitalizaciones. Conclusión: el conocimiento de los factores que se relacionan al desenlace propo

Isolated Non-16/18 High-Risk Human Papillomavirus Cervical Infection: Re-Evaluation After One Year.

INTRODUCTION: High-risk human papillomavirus cervical infection is currently a well-established cause of cervical cancer. However, only a few women with persistent infections will develop cervical precancerous and malignant lesions. Approximately 20% of all cervical cancers are attributable to non-16/18 serotypes. This study aims to evaluate the results of our clinical approach to women with this infection. MATERIAL AND METHODS: We conducted an observational and prospective study from September 2012 to September 2017, which included women with isolated non-16/18 high-risk human papillomavirus infection (with normal cytology). After re-evaluation, two groups were compared: women with spontaneous regression of the infection and women with persistent infection. Clinical and demographic data were analysed as well as the rate of progression to precancerous and malignant lesions. RESULTS: We included 165 women, of which 121 were re-evaluated with co-test at least one year later. After re-evaluation, 13.2% of women revealed precancerous lesions but only two (1.7%) of them presented high-grade squamous intraepithelial lesions. Sixty-seven women (55.4%) showed spontaneous regression of the infection and 54 women (44.6%) maintained it. Women with persistent infection developed more precancerous lesions (27.8%; p < 0.001) and high-grade squamous intraepithelial lesions (3.7%; p < 0.001). There was also an association between persistent infection and postmenopausal status. DISCUSSION: Human papillomavirus 16/18 cervical infection is associated with higher risk of cervical cancer when compared with other serotypes. CONCLUSION: Re-evaluation with co-test one year after the diagnosis of isolated non-16/18 human papillomavirus infection seems to be a reasonable approach.

Introdução: O cancro cervical é causado pelo papiloma vírus humano de alto risco. No entanto, apenas algumas mulheres com infeções persistentes desenvolvem lesões pré-malignas e malignas. Aproximadamente 20% destas neoplasias são causadas por serotipos que não os 16 e 18. Este estudo surge com o objetivo de avaliar a nossa prática clínica neste âmbito. Material e Métodos: Realizámos um estudo observacional e prospetivo entre setembro de 2012 e setembro de 2017, com inclusão de mulheres com infeção cervical isolada com papiloma vírus humano de alto risco, excluindo os serotipos 16 e 18 (com citologia negativa). Após reavaliação, comparámos dois grupos: mulheres que apresentaram resolução espontânea da infeção e mulheres com infeção persistente. Foram analisados dados clínicos e demográficos bem como a taxa de progressão para lesões precursoras e malignas. Resultados: Incluímos 165 mulheres e reavaliámos com co-teste 121 delas com pelo menos um ano de intervalo. Após reavaliação, 13,2% desenvolveram lesões precursoras, mas apenas duas (1,7%) foram consideradas de alto grau. Sessenta e sete mulheres (55,4%) apresentaram resolução espontânea da infeção e 54 (44,6%) mantiveram-na. As mulheres com infeção persistente desenvolveram mais lesões precursoras (27,8%; p < 0,001) e de alto grau (3,7%; p < 0,001). Constatou-se uma associação entre a persistência da infeção e pós-menopausa. Discussão: A infecção cervical com serotipos 16/18 associa-se a uma maior risco de desenvolvimento de cancro cervical quando comparada com outros serotipos. Conclusão: A reavaliação com co-teste um ano após o diagnóstico de infecção cervical isolada com papiloma vírus humano de alto risco, excluindo os serotipos 16 e 18, parece ser uma abordagem adequada.

Uterine cervical ulceration caused by group C streptococcal infection during pregnancy: A case report.

Causes of cervical ulceration include infection, collagen disease, malignant tumors and external stimuli. Cervical ulceration during pregnancy is rare. We present a case of cervical ulceration caused by group C streptococcal infection during pregnancy. A 36-year-old woman (gravida 1, para 0) complained of metrorrhagia, and a circular cervical ulcer of about 1.5 cm in diameter was detected on her cervix at 37 weeks' gestation. A biopsy and a cultivation test of the ulcer were performed, and pathological diagnosis was made as suppurative inflammation, and group C streptococcal infection was detected by the cultivation test. The ulcer had expanded to about 3 cm in diameter at the onset of labor at 40 weeks' gestation. An emergency cesarean section was performed because of failed induction of labor, and she was delivered of a male baby. The ulcer became gradually smaller after delivery, and completely disappeared on the 35th day after delivery.

Postcoital bleeding is a predictor for cervical dysplasia.

BACKGROUND: Postcoital bleeding (PCB) is a common gynecological symptom that may cause concern among both patients and physicians. Current literature is inconclusive regarding management recommendations. OBJECTIVE: To identify risk-factors for dysplasia/cancer among patients presenting post-coital bleeding (PCB). METHODS: Using large health maintenance organization (HMO) database, all women reporting PCB in 2012-2015 were identified. PCB patient records in a single colposcopy center were reviewed. Age, marital status, ethnicity, gravidity, parity, BMI, smoking, PAP smear result (within 1 year of PCB presentation), colposcopy and biopsy results were recorded. Cases were matched by age and socio-economic enumeration area to controls accessing primary care clinics for routine care. RESULTS: Yearly incidence of PCB ranged from 400 to 900 per 100,000 women; highest among patients aged 26-30 years. Among the sample of 411 PCB cases with colposcopy, 201 (48.9%) had directed biopsy. Biopsy results included 68 cervicitis (33.8%), 61 koilocytosis/CIN 1/condyloma (30.3%), 44 normal tissue (21.9%), 25 cervical polyp (12.4%), 2 CIN 2/3 (1%) and 1 carcinoma (0.5%). Positive predictive value for koilocytosis/CIN 1 or higher pathology was 15.6% (64/411) and 0.7% for CIN 2 or higher grade pathology (3/411). In conditional logistic regression, multiparty was a protective factor: OR 0.39 (95% CI 0.22-0.88, P = 0.02), while pathological PAP smear was a related risk-factor: OR 3.3 (95% CI 1.31-8.35, P = 0.01). When compared to controls, PCB patients were significantly (P = 0.04) more likely to present CIN 1 or higher grade pathology (OR 1.82, 95% CI 1.02-3.33). CONCLUSIONS: Study results indicate that PCB may require colposcopy, especially for nulliparous women with an abnormal PAP smear.

Vaginoscopy Against Standard Treatment: a randomised controlled trial.

OBJECTIVE: To evaluate whether vaginoscopy or standard hysteroscopy was more successful in the outpatient setting. DESIGN: Randomised controlled multicentre trial. SETTING: Outpatient hysteroscopy clinics at two UK hospitals. POPULATION: 1597 women aged 16 or older undergoing an outpatient hysteroscopy. METHODS: Women were allocated to vaginoscopy or standard hysteroscopy using third party randomisation stratified by menopausal status with no blinding of participants or clinicians. MAIN OUTCOME MEASURES: The primary outcome was 'success', a composite endpoint defined as: a complete procedure, no complications, a level of pain acceptable to the patient, and no sign of genitourinary tract infection 2 weeks after the procedure. RESULTS: Vaginoscopy was significantly more successful than standard hysteroscopy [647/726 (89%) versus 621/734 (85%), respectively; relative risk (RR) 1.05, 95% CI 1.01-1.10; P = 0.01]. The median time taken to complete vaginoscopy was 2 minutes compared with 3 minutes for standard hysteroscopy (P < 0.001). The mean pain score was 42.7 for vaginoscopy, which was significantly less than standard hysteroscopy 46.4 (P = 0.02). Operative complications occurred in five women receiving vaginoscopy and 19 women receiving standard hysteroscopy (RR 0.26, 95% CI 0.10-0.69). CONCLUSIONS: Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy and therefore should be considered the technique of choice for outpatient hysteroscopy. TWEETABLE ABSTRACT: Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy.

Meta-analysis of the accuracy of p16 or p16/Ki-67 immunocytochemistry versus HPV testing for the detection of CIN2+/CIN3+ in triage of women with minor abnormal cytology.

BACKGROUND: Women with atypical squamous cells of undetermined significance (ASC-US) can be triaged accurately with a high-risk human papillomavirus (hrHPV) test to identify those who need a referral. However, the triage of low-grade squamous intraepithelial lesion (LSIL) with hrHPV testing has very low specificity. Overexpression of p16, with or without Ki-67, indicates neoplastic transformation of human papillomavirus-infected cervical cells and may more accurately predict underlying cervical intraepithelial neoplasia of grade 3 or worse (CIN3+). METHODS: A literature search was conducted in 3 bibliographic databases. Studies were selected if they included women with ASC-US or LSIL who were triaged with dual staining (p16/Ki-67) and/or p16 staining and, if available, with a comparator hrHPV test to detect cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) or CIN3+. RESULTS: Thirty-eight studies were eligible. The sensitivity of p16 staining for CIN3+ was significantly lower than that of hrHPV DNA testing (ratio for ASC-US, 0.87; 95% confidence interval [CI], 0.78-0.97; ratio for LSIL, 0.86; 95% CI, 0.80-0.93). In contrast, the specificity of p16 staining was substantially higher with relative specificities of 1.60 (95% CI, 1.35-1.88) and 2.29 (95% CI, 2.05-2.56) for ASC-US and LSIL respectively. Dual staining was as sensitive as hrHPV DNA testing but was more specific (ratio for ASC-US, 1.65; 95% CI, 1.42-1.92; ratio for LSIL, 2.45; 95% CI, 2.17-2.77). CONCLUSIONS: This meta-analysis confirms that p16 staining and p16/Ki-67 staining are more specific for CIN2+/CIN3+ than hrHPV DNA testing. Although p16 staining is less sensitive for CIN3+ than hrHPV DNA testing, dual staining has similar sensitivity.

Emergent genital infection by Leptotrichia trevisanii.

We report the first case of an association between Leptotrichia trevisanii and an episode of pelvic inflammatory disease (PID) and the second case of the isolation of this infection in the cervical canal. A 45-yr-old woman was admitted to our emergency department with clinical and radiological signs and symptoms compatible with an episode of PID. She was hospitalized for intravenous antibiotic control and treatment and the subsequent surgical drainage of abscesses. Cultures were taken throughout the process, but only cultures from cervical canal exudate were positive, with the growth of L. trevisanii species. It appears important to carry out a complete microbiological screening, not limited to conventional agents, on adequate clinical samples to detect possible infectious agents that may be missed in these cases.