Endometriosis presenting as relapsing haemorrhagic ascites in a South Asian woman: A case report.

Endometriosis presenting as ascites is a rare entity, and is more so in women of Asian ethnicity. Less than a hundred cases have been reported worldwide. Majority of patients present with abdominal dist ension and pa in, drai ning massive blood stained serosanguineous fluid. This hinders future fertility prospects of these women. O va rian suppression has been employed as a successful treatment, followed by definitive surgical treatment, such as bilateral salpingo -ooph orectomy, to end the possibility of recurrences, which are otherwise always possible. We present the case of a woman of reproductive age, seeking fertility treatment, who had a more subtle presentation of moderate, but relapsing ascites of un known origin in the past two years. Diagnostic laparoscopy and histopathology of the pe ritoneal deposits suggested endometriosis. Her ovarian func tion was s uppressed, and sh e is curre nt ly underway of a ssisted re produ ction for achieving a pregnancy.

National cervical cancer burden estimation through systematic review and analysis of publicly available data in Pakistan.

BACKGROUND: Cervical cancer is a major cause of cancer-related deaths among women worldwide. Paucity of data on cervical cancer burden in countries like Pakistan hamper requisite resource allocation. OBJECTIVE: To estimate the burden of cervical cancer in Pakistan using available data sources. METHODS: We performed a systematic review to identify relevant data on Pakistan between 1995 to 2022. Study data identified through the systematic review that provided enough information to allow age specific incidence rates and age standardized incidence rates (ASIR) calculations for cervical cancer were merged. Population at risk estimates were derived and adjusted for important variables in the care-seeking pathway. The calculated ASIRs were applied to 2020 population estimates to estimate the number of cervical cancer cases in Pakistan. RESULTS: A total of 13 studies reported ASIRs for cervical cancer for Pakistan. Among the studies selected, the Karachi Cancer Registry reported the highest disease burden estimates for all reported time periods: 1995-1997 ASIR = 6.81, 1998-2002 ASIR = 7.47, and 2017-2019 ASIR = 6.02 per 100,000 women. Using data from Karachi, Punjab and Pakistan Atomic Energy Cancer Registries from 2015-2019, we derived an unadjusted ASIR for cervical cancer of 4.16 per 100,000 women (95% UI 3.28, 5.28). Varying model assumptions produced adjusted ASIRs ranging from 5.2 to 8.4 per 100,000 women. We derived an adjusted ASIR of 7.60, (95% UI 5.98, 10.01) and estimated 6166 (95% UI 4833, 8305) new cases of cervical cancer per year. CONCLUSION: The estimated cervical cancer burden in Pakistan is higher than the WHO target. Estimates are sensitive to health seeking behavior, and appropriate physician diagnostic intervention, factors that are relevant to the case of cervical cancer, a stigmatized disease in a low-lower middle income country setting. These estimates make the case for approaching cervical cancer elimination through a multi-pronged strategy.

Long-term safety and efficacy of non-absorbable abdominal mesh for apical prolapse surgery: A 10-year experience at Tertiary Care Hospital.

Objectives: To evaluate the complications of apical prolapse correction with abdominally placed mesh and to assess the long-term efficacy of Sacrohysteropexy and Sacrocolpopexy. Method: A retrospective cohort study was conducted at the Department of Gynecology and Obstetrics, Aga Khan University Hospital. All women who underwent apical prolapse surgery using abdominal mesh from January 2010 to December 2019 at AKUH were included. Patients with missing routine follow up visits and incomplete data up to one year post op were excluded. Patient notes were reviewed, and subjective and objective success and complications were analyzed. Safety was measured by incidence of intra, early and late postoperative complications and mesh-related complications of both procedures at two weeks, six months, twelve months, postoperatively. Results: A total of 69 cases were retrieved from the database with a mean age of 46.97 ± 13.86 years. It was found that 14 (20.3%) patients had wound infection while six (8.7%) patients developed urinary tract infections. In a median follow-up of 12 months, three patients developed mesh erosion as a complication, with an incidence of 4.3%. Two required surgical excision of the mesh and the third was successfully managed conservatively with topical estrogen and oral antibiotics. Extremely significant improvements were observed in POPDI-six scores six months postoperatively (p=0.0001). Conclusion: The present study signifies the use of abdominally placed mesh in patients with pelvic organ prolapse indicating significant improvement in Pelvic Organ Prolapse-associated symptoms postoperatively.

Urdu translation and validation of the Urogenital Distress Inventory (UDI-6) in women with urinary incontinence.

Objective: To provide an Urdu translation of the six-item version of the Urogenital Distress Inventory (UDI-6) and its validation in patients with urinary incontinence (UI), as the UDI-6 is a recognised, useful disease-specific questionnaire for the evaluation of UI in women. Patients and methods: We used a multi-step linguistic translation of the UDI-6, which comprised backward and forward translations coordinated by clinical investigators, followed by a pre-test in 10 patients. The final version was completed by a larger sample of women (n = 200), of which 100 had UI for the last 3 months and 100 had no UI. To appraise test-retest reliability the patients with UI were re-tested after 2 weeks. To test the questionnaire's capacity to discriminate between women with or without UI, both cases (patients) and controls were included and assessed. The reliability of the UDI-6 was evaluated by internal consistency and was calculated using the Wilcoxon signed-rank test with P values, and test-retest reliability assessed by Spearman's coefficient with P values. Results: The reliability of the UDI-6 was assessed for internal consistency and test-retest reliability was evaluated by Spearman's coefficient, which showed significant P values. Conclusion: The present Urdu version of the UDI-6 is a linguistically valid instrument that can be reliably used in clinical practice and research. Abbreviations: IIQ-7: seven-item version of the Incontinence Impact Questionnaire; IQR: interquartile ranges; QoL: quality of life; UDI-6: six-item version of the urogenital distress inventory; UI: urinary incontinence.

Effects of Bladder Training and Pelvic Floor Muscle Training in Female Patients with Overactive Bladder Syndrome: A Randomized Controlled Trial.

OBJECTIVE: The purpose of our study was to see the efficacy of 3 different modes of treatment for overactive bladder (OAB) in symptoms reduction and quality of life improvement. METHODS: We conducted a 12-week single-blinded randomized controlled trial of women aged 22-65 years with clinical diagnosis of OAB. Arm A (n = 47) received bladder training, arm B (n = 50) received pelvic floor muscle training (PFMT), and arm C (n = 50) received PFMT with biofeedback. Bladder diary was used to assess the difference in urinary frequency, urgency, and leak accidents before and after treatment. Initial and final assessment was made using -validated urogenital distress inventory short form 6 (UDI-SF6) and incontinence impact questionnaire short form 7 (IIQ-SF7). RESULTS: UDI-SF6 scores showed significant improvement in all arms. There was a reduction in UDI-6 scores from 8.38 ± 4.3 to 4.77 ± 5.5 with a mean difference of 3.61 ± 7.4 in patients in arm A (p = 0.002), arm B (p = 0.01), and arm C (p = 0.016). All patients in arms A, B, and C reported significant improvement in quality of life as assessed by IIQ-SF7 scores with significant p values of 0.009, 0.051, and 0.001, respectively. Bladder diary results using paired t test showed the significant difference in day time urinary frequency in arm A after treatment, as well as the reduction in both leak accidents and urgency score in all 3 arms. CONCLUSIONS: All 3 arms of study showed significant results and can be used as the first line of management.

A Rare Case: Rupture of Internal Pudendal and Uterine Artery in a Vaginal Delivery.

The management of puerperal hematomas after normal delivery has always been challenging for obstetricians. Vulvar, vulvovaginal, or paravaginal hematomas are common. On the other hand, retroperitoneal hematomas are uncommon and can be life-threatening. The diagnosis of vascular injury is rarely made preoperatively as atonic or traumatic postpartum hemorrhage (PPH), uterine rupture and amniotic fluid embolism are more common differential diagnoses. Injury to internal pudendal and uterine vessels is extremely rare in cases of vaginal delivery and, therefore, the literature on this topic is very scarce. We present a rare case of both internal pudendal and uterine artery rupture in a normal vaginal delivery, which led to massive postpartum hemorrhage. The diagnosis was made on Magnetic Resonance imaging (MRI) and arterial embolization was performed. This case stresses on the need for careful post-delivery monitoring for revealed postpartum hemorrhage. Vascular injury is a rare life-threatening cause of obstetric shock, and active; and timely operative intervention can prevent morbidity and mortality.

Graft and mesh use in vaginal surgery.

Pelvic organ prolapse and urinary incontinence are among the most common chronic disorders in women. These are common problems whose pathogenesis remains unclear. As life expectancy increases, significantly greater number of women now present with pelvic organ prolapse and urinary incontinence requiring surgical intervention. Currently, the lifetime risk of undergoing prolapse or continence surgery is one in 11, and up to 30% of patients will require repeat reconstructive surgery and repeat surgery for incontinence in 10%. In an attempt to improve surgical outcomes and to preserve vaginal capacity and coital function, a number of synthetic and biological prostheses have been developed. This review aims to look at the role of graft and mesh in vaginal surgery. We conducted a search for English-language articles published during 1997 to 2016, using MEDLINE, PubMed and United States' National Library of Medicine databases. We reviewed around 50 papers but referenced only 30 for this article. The literature review provided us a new insight regarding safety of mesh. Polypropylene mesh is safe for vaginal surgery if used by experienced surgeons. The safety of mesh becomes compromised in the hands of commercial surgical kit providers. All the new mesh tailored kits should undergo evidence-based trials and then can be safely used worldwide.

Reliability of urodynamic interpretation in women presenting with urinary incontinence at a tertiary hospital.

BACKGROUND: Urodynamic testing is often regarded as essential to the proper diagnosis of bladder storage and emptying disorders but urodynamic testing is an invasive and expensive procedure. Pakistan is a developing country with limited provision of urogynecological services, and therefore few urodynamic studies. STUDY DESIGN: This cross-sectional study was conducted from January 2009 to January 2010 at the Aga Khan University Hospital to assess the frequency of agreement between clinical findings and urodynamic studies in accurately diagnosing urinary incontinence. METHODS: We included 157 women and their symptoms of urge urinary incontinence (UUI), stress urinary incontinence (SUI) or mixed urinary incontinence were matched with urodynamic study findings. RESULTS: Out of 157 women 47 (29.9%) presented with SUI and 33 (21%) with UUI but urodynamic stress incontinence (USI) was found in 59 (37.6%) and detrusor overactivity in 38 (24.2%). This shows a reliability level of ĸ = 0.41 for SUI and ĸ = 0.7 for UUI. There was a weak agreement (ĸ = 0.33) between clinical findings of urinary incontinence and urodynamic studies; in 78 cases (49.7%) the urodynamic findings matched the clinical findings. CONCLUSIONS: The poor level of agreement between clinical findings and urodynamic study interpretations re-emphasizes the fact that the bladder is not a reliable source of identifying urinary symptoms in women.