Recalcitrant vulvodynia. A clinicopathological study.

This study is an analysis of 26 women with burning vulva syndrome. They seldom had frankly abnormal physical findings, and application of acetic acid and colposcopically directed biopsy are therefore mandatory. Histopathological study showed characteristic features of human papillomavirus (HPV) in 20 patients (77%). HPV has been shown to be a cause of vulvar vestibulitis syndrome and was an associated problem in 3 of the 5 patients who had essential or dysaesthetic vulvodynia. The latter is similar to causalgia, with a poor prognosis for resolution. Single patients had the following specific conditions: lichen planus, lichen sclerosus, mature neuroma and chronic candidiasis. The study shows that vulvodynia is a multifactorial problem for which management strategies have evolved over the course of time. Although interferon-alpha-2b offers much promise for the treatment of vulvodynia caused by subclinical HPV infection, the complete cure rate was only 58%. Overall 38% of patients still experience their problem, which indicates that they should be discouraged from going from physician to physician in the hopes of finding a 'cure'.

Ovarian cancer with metastatic deposits in the cervix, vagina, or vulva preceding primary cytoreductive surgery.

Ovarian cancer rarely metastasizes to the uterine cervix, vagina, or vulva. Equally important is the rarity of the disease in these sites at initial presentation. In a review of 148 patients with FIGO Stage III or IV ovarian cancer, 7 patients had cervical metastatic deposits. Four were due to direct extension of the primary; the 3 patients who had truly metastatic deposits all presented with cervical cytology showing the presence of adenocarcinoma cells. All the patients with cervical metastases had associated malignant ascites, retroperitoneal lymph node involvement, and significant peritoneal carcinomatosis. Their median survival was 4.4 months. There was no significant difference in survival between the patients who had truly metastatic deposits compared with those in whom the cervical disease was due to direct extension of the ovarian cancer. One patient presented with a vaginal secondary deposit 11 months prior to definitive diagnosis, and 1 had a vulval metastasis at initial examination. The patient with the vaginal deposit is still alive with no clinically detectable disease 27 months after initial presentation, while the patient with the vulval deposit had significant distant metastases at the time of presentation and died preoperatively.

Neuroma of the vulva. A case report.

Even in the definitive textbook on vulvar conditions edited by Ridley no description of neuroma of the vulva exists, although neural tumors and neurofibroma are considered. The medical literature covering the past 25 years records only one case of terminal fiber neuroma in an episiotomy scar and one neuroma of the clitoris. The latter occurred in a patient with neurofibromatosis. This report documents a symptomatic neuroma of the labia minora considered to be the result of a vulval injury. It is postulated that dyspareunia related to episiotomy may be associated with disorganized proliferation of proximal nerve stumps. Because of the rarity and lack of expertise on management of vulval neuroma, we suggest that the International Society for the Study of Vulvar Disease (ISSVD) further investigate this condition.

Three cycles of chemotherapy followed by primary cytoreductive surgery for unresectable ovarian cancer.

Definitive primary cytoreductive surgery was achieved at second laparotomy after three cycles of combination chemotherapy (cisplatin and cyclophosphamide) in three patients who presented with unresectable disease at our Ovarian Tumor Unit. The ovarian cancer was inoperable at the first laparotomy and no surgical procedure was performed other than biopsy of malignant tumor to confirm the diagnosis. Following interventional surgical cytoreduction the patients were given a further six courses of combination chemotherapy and then maintained for a further six cycles on oral chlorambucil. Two patients are disease free at 17 and 21 months, respectively, while the other patient has cytological evidence of malignancy but no other clinically detectable tumor deposits at 27 months.

A clinical comparison of sonographic hydrotubation and hysterosalpingography.

OBJECTIVE: To assess the value of vaginal sonographic hydrotubation as a preliminary test of uterine configuration and tubal patency in infertility investigation, and to compare this new test with hysterosalpingography. DESIGN: A prospective blind comparison of the two tests in an unselected group of infertile women. SETTING: Hillbrow Hospital, Johannesburg, South Africa. SUBJECTS: Sixty women undergoing routine infertility investigations agreed to participate in the study. There were no refusals. INTERVENTIONS: Within 4 weeks before or after hysterosalpingography sonographic hydrotubation was performed as follows: The uterus and tubes were identified using a 5 MHz vaginal ultrasound probe and between 10 and 20 ml of normal saline were injected into the uterine cavity through an endocervical catheter. MAIN OUTCOME MEASURES: The shape of the uterus and its cavity, the flow of saline through the tubes, the presence of hydrosalpinges before and after injection of saline and the presence of free fluid in the pouch of Douglas. RESULTS: The sonographic and hysterosalpingographic findings were similar in 82% of the women with respect to uterine assessment and in 72% with respect of tubal findings. In seven women (12%) found to have bipolar tubal disease on sonography and cornual block on hysterosalpingography, the sonographic diagnosis was confirmed at laparoscopy. Septate uterus in three women was diagnosed with greater certainty with sonographic hydrotubation. CONCLUSIONS: Sonographic hydrotubation is a simple office procedure which should be used in the preliminary assessment of the uterine cavity and fallopian tubes. Its use will reduce the need for hysterosalpingography and in some cases laparoscopy.

Evaluation of preoperative investigations in patients admitted for ovarian primary cytoreductive surgery.

Consistent with universally established practice, it has been customary in our unit to subject patients with clinically suspected or biopsy proven ovarian cancer to a large number of preoperative investigations. This is in order to determine metastases, surgical strategy, and exclusion of pelvic kidney. This study presents a comparison of the preoperative ultrasonography, computerized tomography, intravenous pyelography, chest X-ray, liver and bone scintigraphy, and barium enema results performed in 100 cases with the operative findings. These investigations were found to have marginal value in determining extent of disease, upper gastrointestinal metastatic deposits, and the need for or extent of bowel resection. It is concluded that such a standard workup, which is time-consuming and distressing for an already anxious patient, is not cost effective for a surgical procedure which is ultimately determined at laparotomy.

Comparison between renal ultrasonography and excretory urography in cervical cancer.

Renal ultrasonography was compared with intravenous pyelography in order to establish the suitability and accuracy of the former investigation as a screening method for ureteric obstruction in patients with carcinoma of the uterine cervix. With a sensitivity of 96.30%, specificity of 96.75%, a positive predictive value of 87.64% and a negative predictive value of 99.09% calculated on a large sample of 420 kidneys, it is recommended that renal ultrasonography is the method of choice in screening for ureteric obstruction in patients with cervical cancer. At the very least it is a suitable and equivalent alternative to intravenous pyelography in such patients.

Natural childbirth--the Johannesburg Hospital experience, 1983-1989.

The Johannesburg Hospital Active Birth Unit (ABU), the only one of its kind in southern Africa to date, has provided an alternative to conventional labour practices since 1983. In a retrospective study of the results achieved in this unit the intrapartum records of 492 patients admitted to the ABU between 1 March 1983 and 30 June 1989 were analysed. During the 6.3-year study period 364 patients (74%) successfully laboured and delivered within the unit. These figures included 50 underwater deliveries. One hundred and twenty-eight patients required intrapartum transfer to the conventional labour ward and of these 44 achieved spontaneous vaginal delivery. Thirty-four patients (7%) 'self-selecting' for natural childbirth ultimately required caesarean section delivery. Primiparous patients were more likely than their multiparous counterparts to require intrapartum transfer to the labour ward (38% v. 13%). Birth outcome results achieved in the Johannesburg Hospital ABU compare favourably with those for 6 other ABUs reported in the literature.

New design rigid and soft vacuum extractor cups: a preliminary comparison of traction forces.

Women due for vacuum extraction were randomly allocated to delivery using one of two soft cups (Silc or Silastic) or two new design rigid cups (New Bird or O'Neil). Traction forces were recorded continuously and higher values were reached with the rigid than the soft cups (median 15.8, range 7.5-19.7 vs 11.1, 7.2-15.1 kg, P less than 0.01). Selection of the most appropriate vacuum cup for each clinical situation should take into account that the flexible cups are associated with less cosmetic disfigurement but have a lower capacity for traction.

In vitro study of fracture forces associated with the Copper 7, Nova T and MLCu 250/375 intrauterine devices.

In the literature there is a paucity of reports of cases of intrauterine breakage of IUDs. In this study the forces required to break the Copper 7, Nova T and Multiload (MLCu) devices were measured. New and used devices were examined in vitro. The devices were broken in a water bath at body temperature. The mean rupture force of new and used Copper 7 devices was 30.4 newtons. The mean rupture forces for new Nova T and MLCu 250/375 IUDs was 6.8 and 15.7 newtons, respectively, and for used Nova T and MLCu 250/375 devices was 16.8 and 8.7 newtons, respectively. The decreased fracture forces associated with used as opposed to new MLCu devices may explain the reports of intrauterine breakage with this type of device.

Effects of conjugated equine oestrogens with and without the addition of cyclical medrogestone on hot flushes, liver function, blood pressure and endocrinological indices.

Despite widespread clinical use of conjugated oestrogens, there is a paucity of reported studies concerning the effect of such therapy in sequential combination with the progestin, medrogestone (Colpro; Akromed). In a double-blind study, 22 oestrogen-deficient women who had undergone hysterectomy (mean age 52,8 years) were treated initially for 6 cycles with either conjugated equine oestrogens 0.625 mg (CEE) for 21 days plus a placebo during the last 10 days of each cycle or the same oestrogen regimen with 10 days of medrogestone 5 mg/d. Thereafter the treatments were crossed over for a further 6 cycles. CEE monotherapy resulted in significantly decreased levels of follicle-stimulating hormone (FSH), luteinising hormone (LH), prolactin (PRL) (P less than 0,001) and gamma-glutamyl transferase (P less than 0,01) with an increase in 17 beta-oestradiol (P less than 0,001). Medrogestone had a synergistic effect on the lowering of FSH, LH and PRL. No treatment modality caused any significant changes in blood pressure, fasting glucose value or vaginal cellular percentages. The decrease in hot flush scores, already manifest at the end of the first cycle, were sustained throughout (P less than 0,001).

Splenectomy during primary maximal cytoreductive surgery for epithelial ovarian cancer.

Six patients with epithelial ovarian cancer underwent splenectomy as part of their extensive primary cytoreductive surgical management at the Johannesburg University Hospital. These patients represented 7.6% (6 of 79) of advanced-disease patients (stages III and IV) followed during the study period. Five splenectomies were performed because of metastatic disease confirmed on microscopy. One of these showed parenchymal involvement and represented only the third case in the world literature. The remaining patient required splenectomy for capsular avulsion injury and resultant bleeding. Late thrombotic complications occurred in 4 of 6 (67%) patients, resulting in death of one patient from massive pulmonary embolism 20 days after surgery. Three patients (50%) currently have no evidence of disease 14, 25, and 32 months after surgery. The remaining 2 patients died of recurrent disease 19 and 58 months following primary operation. This, the largest reported series in the English literature, indicates that splenectomy, albeit potentially hazardous, is justified when it permits optimal cytoreductive surgery.

Involvement of the appendix in ovarian epithelial cancer--an update.

Appendicectomy was performed at the time of primary definitive surgery in 60 of 102 patients with epithelial ovarian cancer at Johannesburg Hospital over a 9-year period (January 1979-December 1987). Metastases were present in 37 of the 46 (80.4%) appendices removed from patients with advanced disease (stage III or IV) and in only 1 of the 14 patients (7.1%) with early disease. Metastases were not limited to serosal implants and included vascular and lymphatic space involvement, chronic obliterative appendicitis and almost complete replacement of the appendix by adenocarcinoma. The role of appendicectomy in the surgical management of epithelial ovarian cancer is discussed.

Serum lipoprotein effects of conjugated estrogen and a sequential conjugated estrogen-medrogestone regimen in hysterectomized postmenopausal women.

The progestogen chosen for addition to estrogen replacement is important because some progestins adversely influence the effects of oral estrogens on lipid metabolism. In this double-blind study, 22 estrogen-deficient hysterectomized women were treated initially for six cycles with either 0.625 mg conjugated equine estrogens for 21 days plus a placebo during the last 10 days of each cycle or the same estrogen regimen with 10 days of 5 mg medrogestone per day. Thereafter, the treatments were crossed over for a further six cycles. Levels of lipids, lipoproteins, and apolipoproteins were determined at baseline and the last day of sixth and twelfth treatment cycles. Conjugated equine estrogen monotherapy resulted is significantly increased levels of high-density lipoprotein cholesterol (p less than 0.01); percent high-density lipoprotein cholesterol (p less than 0.001), and high-density lipoprotein2-cholesterol (p less than 0.001), with significantly decreased total cholesterol (p less than 0.01), low density lipoprotein cholesterol, and atherogenic index (p less than 0.001). Medrogestone caused no attenuation of any of these clinically important lipoprotein changes. Therefore from the lipoprotein aspect medrogesterone is a desirable progestogen.

Hypothesis: a central role for platelet activating factor in the pathogenesis of pre-eclampsia.

The pathophysiology of pre-eclampsia is uncertain, though many mechanisms have been postulated. These include an immune response to fetal or placental antigens, a thromboxane-prostacyclin system imbalance and an increase in levels of or responsiveness to angiotensin. We propose the hypothesis that platelet activating factor (PAF), a mediator of inflammatory and allergic responses, may be an important link between these pathophysiological events.

Rectosigmoid resection without colostomy during primary cytoreductive surgery for ovarian carcinoma.

A nine year experience with rectosigmoid colectomy during primary cytoreductive surgery for epithelial ovarian cancer is reported. During the period 1979-1987, 20 patients underwent such resections with primary sutured end-to-end anastomosis without a protecting colostomy. Only one of these patients required a secondary colostomy. In a further five patients, anterior resection and reanastomosis was performed concomitant with additional bowel resections, again without diversion colostomy. Subsequent secondary colostomy for a recto-vaginal fistula was required in one. There were two post-operative deaths, both in the group who required bowel resections in addition to recto-sigmoid resection. Of the entire group of 25 patients, 12 (48%) are currently alive free of disease, with a median survival of 32 months. Excluding the two post-operative deaths (at 20 and 39 days), the median survival of the remaining 11 who subsequently died of recurrent disease, was 14 months. The Authors recommend that anterior resection with primary reanastomosis without a protecting colostomy, is performed during primary cytoreductive surgery for ovarian cancer in patients in whom such a procedure facilitates resection of all or nearly all their disease.

Is routine second-look laparotomy for ovarian cancer justified?

Thirty-nine patients with epithelial ovarian malignancy underwent second-look laparotomy (2LL), as part of their plan of management at the Johannesburg University Hospital. Twenty-eight patients (71.8%) were found to have no gross or microscopic evidence of disease. Only 1/12 (8.3%) of patients with initial Stage I disease had evidence of persistent disease and after a median follow-up of 53 months (range 29-77) after 2LL, the remaining 11 remain free of relapse. Second-look laparotomy is regarded as unjustified in this subgroup of patients. Twenty-nine percent of the patients with advanced disease (Stage III and IV) who were disease-free at 2LL subsequently developed recurrent disease and died. In this group 2 additional patients died of nonmalignant disease. All 3 of the patients with original Stage II disease were disease-free at 2LL, but subsequent recurrence developed in 1 patient. On the basis of the findings in this study and evidence in the literature, the practice of submitting patients who are in complete clinical remission to 2LL as part of their management plan is questioned and challenged.

Cancer of the ovary. The Johannesburg Hospital experience.

Experience with 100 patients with epithelial ovarian cancer, who underwent primary definitive surgery at Johannesburg Hospital between 1 January 1979 and 31 July 1987, is presented and the absolute 4-year survival figures are compared with those from 1977. For patients with advanced disease (stages III and IV) the 4-year survival rate has improved from 4.4% to 42% (P = 0.001). Reasons for this substantial progress are outlined. Fifty per cent of the patients had nonspecific gastro-intestinal symptoms at the time of diagnosis and 20% had previously undergone hysterectomy. A case is made for prophylactic oophorectomy at the time of hysterectomy.