Reviews in Gynaecological Practice最新文献

The vulval pain syndromes are enigmatic causes of vulval pain. Although not new conditions, only since the mid-1980s have the clinical descriptions of these women have been standardised. In 1991 the term vulvodynia and its subsets were introduced by the International Society for the Study of Vulval Diseases (ISSVD) to describe women with chronic vulval discomfort characterised by burning, stinging, rawness or irritation. The terminology is potentially confusing as vulvodynia was originally described as having subsets including both infective and dermatological diagnoses. These included vulval dermatoses (e.g. lichen sclerosus), vulval vestibulitis, vestibular papillomatosis, dysaesthetic (formerly essential vulvodynia) and cyclical vulvitis. This review article focuses on vulval vestibulitis and dysaesthetic vulvodynia as these relate to vulval pain when infection and organic causes have been excluded and together form the vulval pain syndromes. Recent interest in these pain syndromes probably relates to an increasing number of patients attending vulval clinics, patients’ demands and general increased awareness amongst women and health professionals.

Chronic pelvic pain (CPP) forms a significant number of referrals both in primary care and to gynaecology clinics. Much has been written and reported on the subject, however, it remains a poorly understood and managed condition. CPP is defined as recurrent or constant pain in the lower abdominal region that has lasted at least 6 months. A specialist in the field encompassed within a multidisciplinary setting should ideally manage CPP. The causes of CPP can be not only of a gynaecological nature, but also span other branches of medicine including urology, gastroenterology, rheumatology, genitourinary medicine and psychiatry. Investigations are often unrewarding in eliciting a cause for particular symptomatology, which highlights the difficulty in treating these patients. Most studies have been directed towards the major gynaecological causes of CPP including pelvic venous congestion, endometriosis, and pelvic inflammatory disease (PID). However, these have been limited and evaluated treatments are confined to small sample sizes. This review aims to provide evidence-based medical management of the main causes of CPP.

There are many uncertainties about the symptom complex which comprises urinary frequency, urgency and pain, and in the absence of any other cause is defined as interstitial cystitis (IC). The name itself is controversial. Should it be known as painful bladder, irritable bladder, chronic pelvic pain of the bladder or part of chronic pelvic pain syndrome? It is difficult to obtain a consensus view where to date there is no specific clinical sign, serum or urine marker, or tissue diagnosis. At the same time, the options available for the treatment of interstitial cystitis are continuing to increase. General and supportive measures are of great importance as is education and information through the support group network. Oral therapies such as amitriptyline, elmiron, hydroxyzine and analgesics including nonsteroidal anti-inflammatories can be useful. Intravesical dimethyl sulfoxide (DMSO) and/or heparin have proven efficacy. Sacral neuromodulation is an exciting development for those not responsive to conservative therapy; the surgical techniques continue to evolve and long-term evaluation is awaited. Major urologic surgery is occasionally required for a small percentage of IC patients. The evaluation of efficacy of treatments for IC is difficult because of factors such as the natural history of the condition with its flares and remissions, and the known placebo effect of 30%. Nonetheless, this is an important exercise which is currently underway and the results of the randomized controlled trials are eagerly awaited.

Anorectal malformations in females are characterized by an abnormal position of the anal orifice, anterior to the normal site. In such children, there is a close association between the anorectum and the genitourinary systems, with possible gynaecologic and obstetric implications. The malformations include a spectrum of defects, ranging from the least severe, where the anus opens on the perineum, to the most severe—the common cloaca. Here the urinary, genital and alimentary systems open into a common orifice. There is a high incidence of genital and urinary anomalies associated with the cloaca. At times, the vagina may have to be reconstructed. The surgery of anorectal anomalies is usually done through the posterior sagittal approach. This approach allows for good visualization and access to the anorectal and genital region. Frequently, it is possible to observe, but not correct the associated genital anomalies, which are usually asymptomatic in childhood. However, on attaining menarche, such anomalies may be manifest. Also, these anomalies may be of significance at the time of conception and childbirth.

The management of women with minor cytological abnormalities is a contentious issue. The UK cervical screening guidelines recommend a policy of cytological surveillance after one smear showing mild dyskaryosis and a referral for colposcopy only if the smear abnormality persists. But, there have been calls from various groups to change this in favour of immediate coloposcopy. In this article, we address this increasing problem and discuss the pros and cons of each management policy.