The cutaneous-vulvar clinic revisited: a 5-year experience of the Columbia Presbyterian Medical Center Cutaneous-Vulvar Service.

OBJECTIVE: To review the recent experience of a busy referral cutaneous-vulvar service. STUDY DESIGN: 500 randomly chosen charts from the last 5 years of patients seen at the Columbia Presbyterian Medical Center Cutaneous-Vulvar Service were reviewed. Information was entered into a computer data base and analyzed. RESULTS: The most common presenting condition was vulvar vestibulitis (36.2%), followed by lichen sclerosus (19.2%) and vaginitis/vaginosis (14.8%). Most patients had undergone a variety of therapies prior to referral. Many were treated for moniliasis in the absence of clinical evidence prior to our evaluation. Most patients responded well to appropriate therapy. CONCLUSIONS: A variety of primary care providers see women with cutaneous-vulvar symptomatology. Awareness of prevalent conditions will lead to correct diagnosis and treatment. We emphasize the importance of interdisciplinary consultation in difficult cases.

Genital fistulas caused by diverticular disease of the sigmoid colon.

OBJECTIVE: Our purpose was to bring to the attention of gynecologists a subject not mentioned in a single textbook of gynecology, namely, genital fistulas resulting from diverticular disease of the sigmoid colon. STUDY DESIGN: We report our experience with 13 genital fistulas caused by sigmoid diverticulitis. RESULTS: Ten fistulas involved the vagina, one the vagina and bladder, one the tube, and one the uterus. Average age of the patients was 68.6 years (range 54 to 89 years). Presenting symptom in 12 patients was a malodorous vaginal discharge. All with vaginal lesions had previously undergone total hysterectomy. A barium enema failed to demonstrate a fistula in 8 of 11 patients. Colonoscopy failed in 8 of 8 patients. All fistulas were demonstrated by retrograde dye studies. Ten patients operated on were cured. Three patients refused surgery; of these, 1 had intestinal obstruction, 1 may have had spontaneous closure of the fistula, and 1 is being observed. Surgery involved staged procedures in 2 patients, fistulectomy in 4, and bowel resection and anastomosis in 4. CONCLUSIONS: Sigmoidovaginal fistulas are the most prevalent variety of cologenital fistula caused by sigmoid diverticulitis. The diagnosis should be considered in a patient > 50 years old who complains of a foul vaginal discharge and has a history of total hysterectomy. Its presence is best demonstrated by vaginogram. Surgical therapy is advised, the extent of which will rest on the surgeon's judgment of the severity of the inflammatory process found at exploration.

Genital fistulas secondary to diverticular disease of the colon: a review.

Genital fistulas that complicate diverticular disease of the sigmoid colon may no longer be considered esoteric, or even rare phenomena. The vast majority of such lesions present with a foul, often fecal, sometimes purulent and occasionally blood-tinged, vaginal discharge for which patients customarily first seek relief from their gynecologists. Despite this fact, the topic is not mentioned in a single American textbook of gynecology. It is the purpose of this report to review the pertinent literature and to include the authors' experience with 13 additional cases in order to bring this topic to the attention of our gynecologic colleagues.

Abnormal cervical cytology in adolescents. A 15-year experience.

The onset of sexual activity at a young age (< 17 years) has been identified in several studies as the most important epidemiologic risk factor in the development of cervical intraepithelial neoplasia (CIN). In characterizing the natural history of CIN, investigators have indicated that a percentage of such lesions progress to invasive carcinoma if left untreated. CIN in adolescents was first reported in 1961. The subsequently reported CIN prevalence rates in sexually active, medically indigent teenage populations have increased over time, temporally paralleling increasing early sexual activity among teenagers. In our 15-year experience with abnormal cervical cytology in adolescents, all grades of CIN were observed. Fully 13% of patients had histologically proven CIN 3, a preinvasive lesion. Given reports of an increase in cervical cancer in young women (< 35 years old), the findings of this and similar studies mandate routine cervical cytologic screening in all sexually active teenage girls.

A report of thirty-four instances of urethrovaginal and bladder neck fistulas.

The current study was done to outline problems noted by an individual surgeon in his experience with the management of urethrovaginal and bladder neck fistulas. Twenty-six women with intact urethras distal to the fistulas had transvaginal layered closures. Five women with completely destroyed posterior urethral walls had transvaginal reconstructions. Three women with special findings had individualized surgical repairs. Successful function, as well as anatomic results, were obtained in 23 of 26 women in the first group, two of five women in the second group and all three women in the third group. An uncomplicated urethrovaginal or bladder neck fistula may be repaired successfully by a transvaginal layered closure. The repair of a complicated fistula, one which is radiation-induced or one in which the entire posterior urethra has been destroyed, may result in functional failure despite an apparently successful anatomic result. The method by which bladder drainage after fistula operation is performed does not effect the result.

Abnormal cervical cytology in pregnancy: a 17-year experience.

OBJECTIVE: To evaluate the safety and accuracy of colposcopy and colposcopically directed biopsy in pregnant women with abnormal cervical cytology. METHODS: A retrospective analysis of 612 gravidas with abnormal cervical cytology was conducted. Colposcopy and directed biopsy were performed using standard techniques. Two patients underwent diagnostic conization during the second trimester. One hundred twelve patients had procedures that provided a final specimen. Endocervical curettage was omitted. The transformation zone was fully visualized in all patients by the 20th week of gestation. Directed cervical biopsy was performed on the following patients: 1) with colposcopic evidence of invasion or cervical intraepithelial neoplasia (CIN) III, 2) with discordancy between colposcopy and cytology, 3) electing termination of pregnancy, and 4) whose anticipated reliability was even remotely questioned. RESULTS: A colposcopically directed biopsy was performed in 449 patients (73%). Ninety-one patients (15%) did not have biopsies because of normal colposcopic findings, and the remaining 72 patients (12%) had either CIN I or II. Thirty-nine of these patients (6%) were lost to follow-up. Colposcopically directed biopsy and colposcopic impression had a 95% concordancy within one degree of severity; however, 14% of CIN I colposcopic impressions and 54% of normal colposcopic findings turned out to be CIN III and CIN I or II, respectively. Ninety-five percent of the biopsy diagnoses correlated with the final pathology to within one degree of severity. CONCLUSION: The data confirm previous findings that colposcopically directed biopsy is a safe and reliable method of evaluating pregnant patients with abnormal cervical cytology.

Observations on prevention and management of vesicovaginal fistula after total hysterectomy.

A retrospective study of genital fistulas of the lower urinary tract revealed 91 percent to be postsurgical. Of these, 91 percent occurred after gynecologic procedures. Total hysterectomy was the most common antecedent procedure (n = 110), and the resulting lesion was the vault fistula. Abdominal total hysterectomy was the most frequent operation to precede a vault fistula (n = 92) and almost 70 percent occurred in the absence of factors identified as placing the patient at risk for injury to the bladder. Such risk factors included prior uterine operation, especially cesarean section, endometriosis, recent cold-knife cervical conization and prior radiation therapy. Twenty-four fistulas occurred despite recognition at the time of hysterectomy of injury to the bladder and its prompt repair. Thirty patients had undergone prior failed attempts at repair elsewhere. Three fistulas closed spontaneously. One hundred and seven were repaired by the Latzko technique. There were nine failures, each of which was successfully repaired by a repeat Latzko operation when vaginal reepithelization was complete. Suggestions to avoid injury to the bladder during abdominal total hysterectomy include use of a two-way indwelling catheter when risk factors are present, use of sharp dissection to isolate the bladder, use of extraperitoneal cystotomy when dissection is difficult, filling the bladder when injury is suspected and repair of an overt bladder injury only after mobilization of the injured area. A Latzko repair of a vault fistula is advised because complications are minimal, the postoperative patient is comfortable and the period of hospitalization is five days or less.

Squamous cell carcinoma of the endometrium. A case report.

Invasive squamous cell carcinoma of the endometrium occurred secondary to squamous cell carcinoma in situ of the cervix. There have been 27 previous reports of secondary endometrial squamous cell carcinoma and 31 of primary.

Oncogenic potential of tamoxifen on endometria of postmenopausal women with breast cancer--preliminary report.

Tamoxifen (TAM), a nonsteroidal antiestrogen, is used for pre- and postmenopausal patients with breast cancer. Recent reports suggest that TAM may cause endometrial neoplasia. This study is designed to evaluate the oncogenic potential of low-dose TAM on the endometrium. Initially, endometrial screening of patients with breast cancer who had received TAM therapy for at least 12 months was conducted. Seventy patients were interviewed and office endometrial biopsies were obtained from thirty-eight patients. Seven (18%) had hyperplastic changes, ranging from simple hyperplasia through complex hyperplasia with atypia. The following prospective study was conducted: after breast surgery and prior to initiation of TAM therapy, an office endometrial sampling was obtained as a control. After initiation of TAM therapy, biopsies were repeated every 4 to 6 months as long as the patients remained asymptomatic. Nineteen patients were interviewed. Twelve patients were biopsied and followed from 3 to 15 months. One patient refused additional biopsies. Eleven patients had repeat biopsies after initiation of TAM. New hyperplastic changes were found in 3/11 (27%) patients. The preliminary results of this study (although with a small number of patients) indicate that TAM may have some neoplastic effect on the endometrium of postmenopausal patients with breast cancer. This study is still in progress. Additional prospective studies are warranted before a significant correlation between TAM and endometrial neoplasia is confirmed.

Lymphvascular space involvement--a prognostic indicator in endometrial adenocarcinoma.

The present study evaluates the effects of various prognostic indicators on survival of patients with clinical Stage I endometrial carcinoma. Ninety-three patients who were treated for clinical Stage I endometrial adenocarcinoma at Maimonides Medical Center from October 1979 to October 1987 had sufficient surgical-pathological information for retrospective surgical staging according to the new FIGO classification. Histology was reviewed. A new grade and surgical stage was assigned to each patient in accordance with the recent FIGO guidelines for surgical staging of corpus cancer. Poor prognostic indicators, namely, tumor grade, depth of myometrial invasion, peritoneal cytology, lymph node metastases, and lymphvascular space (LVS) involvement, were correlated with 5-year survival rates. Survival rates were calculated by the life table method. Depth of myometrial invasion, lymph node involvement, and peritoneal cytology had significant statistical correlation with poor survival. Positive finding of each of the prognostic indicators, including LVS involvement, was significantly associated with poor survival (all P less than 0.001). The value of these prognostic indicators in early endometrial carcinoma is discussed.

Intrapartum, intranasal cocaine use and acute fetal distress. A case report.

Intrapartum, intranasal cocaine was used for relief of labor pains by a healthy woman with an uncomplicated pregnancy. Fetal hypoxemia and distress followed the event. A causal relationship between the intrapartum use of cocaine and the fetal distress was postulated. Cocaine abusers could benefit from hospitalization early in labor for close surveillance and monitoring, thus avoiding exposure to cocaine and its unpredictable systemic effects.

A vesicovaginal fistula and intravesical foreign body. A rare case of the neglected pessary.

A case of neglected pessary is presented. After erosion through the anterior vaginal and bladder walls the device came to rest entirely within the bladder. Surgical management of removal of the pessary and repair of the resulting vesicovaginal fistula are described. Appropriate use of supportive pessaries as well as complications of misuse and neglect are discussed.

Rectovaginal fistula or perineal and anal sphincter disruption, or both, after vaginal delivery.

The management of 52 patients with rectovaginal fistula or perineal and anal sphincter disruption, or both, after vaginal delivery is presented. Adequate physical intestinal preparation and postoperative diet and intestinal care are stressed. Preservation of perineal integrity is suggested whenever possible. Closure in anatomic layers is the technique of choice and sphincterotomy is advised in all instances of anal sphincter anastomosis. The technique for repair of an extensive cloacalike lesion is described in detail, as are three unusual complications of operation. Satisfactory anatomic and functional results were obtained in 100 per cent.

Usefulness of continuous fetal heart rate monitoring during cesarean section.

Cesarean section performed because of fetal distress routinely leaves the fetus unmonitored for a variable period of time (perioperatively and intraoperatively). We present in this report two cases in which continuous fetal heart rate monitoring during cesarean section modified the obstetric management for the benefit of the mother and of the fetus.

Electronic fetal heart rate monitoring during cesarean section in cases of fetal distress.

Twelve fetuses in whom the diagnosis of fetal distress was made during first stage of labor were included in the study. All 12 patients underwent urgent cesarean section during which fetal heart rate (FHR) was recorded continuously. In 50% of the cases, marked improvement of FHR was registered early in the course of the operation. Improvement in fetal status is attributed to adequate oxygenation and cessation of uterine activity.

Carcinoma of the ovary presenting as obstructive jaundice.

Obstructive jaundice due to metastatic lymphadenopathy in the region of the common bile duct has been reported in many malignancies, but never previously as the presenting symptom in ovarian cancer. A case in point is presented.

Antenatal diagnosis of giant cystic cavernous hemangioma by Doppler velocimetry.

A fetal extracranial mass seen on ultrasound was found by Doppler velocimetry to have low resistance to blood flow through its channels. The antenatal diagnosis of giant cavernous hemangioma was confirmed after birth.

Electronic fetal heart rate monitoring during cesarean section.

Fetal heart rate (FHR) response to cesarean section was studied in 65 patients. Induction of anesthesia, skin, fascial, peritoneal and bladder flap incisions were not associated with a change in FHR. Abdominal preparation was associated with FHR decelerations in 15% of cases. Myometrial incision was followed by FHR deceleration in 11% of cases. No correlation between the incision/delivery (I-D) interval and FHR changes was seen.

Uterine and umbilical blood flow during cesarean section under epidural anesthesia.

Umbilical and uterine blood flow velocity waveforms were studied in 22 women undergoing elective cesarean section under epidural anesthesia. The measurements were taken prior to initiation of anesthesia (baseline levels), after the appropriate level of anesthesia had been achieved (prior to the onset of surgery), and intraoperatively immediately prior to the uterine incision and after the delivery (uterine blood flow). Achievement of the therapeutic level of epidural anesthesia was not associated with altered umbilical and uterine blood flow. Intraoperatively, however, 2/3 of the women manifested increased resistance in the utero-fetal circuit, judging by the rise in S/D ratios. Under normal circumstances (absence of fetal distress and maternal complications prior to the cesarean section, adequate maternal hydration and oxygenation, etc.) these changes did not cause any neonatal compromise as evidenced by normal Apgar scores and freedom from complications during the neonatal period.

Simultaneous colpo-recto-sacropexy.

The literature concerning coexisting massive genital and intussuscepting rectal prolapse is reviewed, two cases in point are presented, and the rationale for concurrent surgical management is offered. The technique of combined colporecto-sacropexy is described in detail.