Reviews in Gynaecological Practice最新文献

Fistula related to childbirth, once prevalent in North America and Europe, remains a significant women’s health problem in developing countries today most notably in sub-Saharan Africa. A recent United Nations Report estimates that two million women are living with the condition. Described by the World Health Organisation as the “forgotten disease,” the identification of patients, assessment, surgical treatment and rehabilitation remain challenges to gynaecologists and governments responsible for providing adequate resources for treatment and rehabilitation.

This article describes the epidemiological, psychological, physical, reproductive and socio-cultural factors associated with obstetric fistulae and its clinical management. Following a discussion of the prevalence, aetiology and diagnosis of the condition, the classifications and sub-classifications of the different types of fistulae, specifically vesico-vaginal and recto-vaginal fistulae, are explained.

The section on surgical repair of both types of fistulae covers the pre-operative assessment, timing of the repair and the basic operative principles. Details of the basic technique for repair and the different graft techniques are described.

Finally, the authors make a case for the development of special units dedicated to the comprehensive treatment and rehabilitation of women who have obstetric fistulae. As well, these units must provide training units for doctors and, nurses and other health professionals from countries where obstetric fistula as a consequence of birth is prevalent.

A mass in the pelvis is a frequent gynaecological problem. Clinical presentation is usually late or fortuitous. More widespread use of imaging is identifying many masses in the pelvis at an earlier stage than previously. Imaging techniques can be used to identify masses, to evaluate their nature and to help in the planning of treatment. Because of logistic problems and the widespread availability of ultrasound, magnetic resonance plays little part in the identification of pelvic masses. It is, however, of considerable value in the evaluation of disease in the uterus and ovaries. Experience in interpreting MR appearances of the various types of ovarian and uterine tumours is growing, frequently allowing preoperative differentiation between benign and malignant pathologies. Spread of tumour is evaluable, particularly cervical tumours into the parametrium and upper vagina and endometrial cancer into the myometrium and cervix. MR currently has an important role in planning management of gynaecological tumours, but in the future it is likely that this will be overtaken by positron emission tomography (PET) in the form of PET/CT or PET/MRI.

Paediatric vulvovaginitis, with or without vaginal discharge is a very distressing condition and at times very difficult to treat. The current article reviews the aetiopathology and the systematic approach towards the management of the condition.

The possibility of achieving a pregnancy with just one spermatozoon has led to the evolution of a number of methods aiming to obtain sperm from testicular tissue. This achievement now offers men with azoospermia a reasonable chance of fathering their own children. The choice of the best testicular sperm retrieval technique has always been a challenge. There has been a trend to use percutaneous needle aspiration but controlled studies have demonstrated that open testicular biopsy is necessary to obtain the best results, particularly in non-obstructive azoospermia. Since azoospermic men are at risk of specific genetic defects, careful genetic testing and counselling prior to treatment should be considered to allow the couple to make an informed decision as to whether or not to use the husband sperm. The recovery of sperm may not always be successful particularly in non-obstructive azoospermic men, an event that encompasses important emotional and financial implications. Unfortunately, no clinical or laboratory test can clearly predict success with sperm retrieval procedures.

Endometrial polyps are common, increasing in incidence with age. They are also commoner in women with obesity and hypertension, and those treated with tamoxifen. They can be asymptomatic or can be associated with abnormal uterine bleeding. Diagnosis can be made with ultrasound or hysterosonography, but diagnostic hysteroscopy remains the gold standard is as it allows assessment of the rest of the uterine cavity. Although the risk of malignant transformation is low, the general consensus is that polyps should be removed. The most widely recommended method of removal is hysteroscopic resection. Long term follow up studies have shown that after polypectomy, symptomatic relief is greater in the older age group, so a causative role of polyps in abnormal uterine bleeding in younger women is questionable.

The conventional surgical treatment for women with symptomatic uterine fibroids is a hysterectomy. Hysterectomy guarantees the removal of all uterine fibroids without a risk of recurrence. It also guarantees the cure of symptoms such as menorrhagia and pressure effects and has been shown to be associated with a high degree of patient satisfaction and improved quality of life scores. However, in addition to women who desire fertility, there are a growing number of women who have completed their family who do not wish to undergo a hysterectomy. Uterine conserving surgical methods include myomectomy or fibroid shrinkage either by embolisation/laparoscopic clipping of both uterine arteries or myolysis.

This article reviews the surgical alternatives to hysterectomy and analyses the data that is currently available with each method. Laparoscopic interstitial laser photocoagulation of uterine fibroids is a relatively new modality of treatment and is carried out in our centre. Results of this method are presented and discussed in this article.

Myomectomy is associated with significant morbidity and difficulty in long term management because of high recurrence rates. Surgical alternatives to myomectomy are still limited to large series in a few centres with a special interest in the procedure developed. Well designed long term studies are required to properly evaluate the efficacy and feasibility of each procedure in normal practice and its effect on infertility.

Tamoxifen, a nonsteroidal synthetic anti-oestrogen is the most widely used selective estrogen receptor modulator (SERM). Designed as a contraceptive it is most frequently used in prevention and treatment of breast cancer. Its role in gynaecology is limited to ovulation induction. Although it has a favourable effect on lipid profiles and increases bone density in postmenopausal women its use for these indications is not warranted. The practising gynaecologist will most likely be faced with the risks associated with long-term tamoxifen use: endometrial polyps, endometrial hyperplasia and endometrial cancer; venous thromboembolism, ovarian cysts and endometrioid ovarian cancers. Further insight into the oestrogen receptor (ER) tamoxifen induced changes could potentially identify new therapeutic opportunities.