Possible role of perineal ultrasound in the diagnosis of cystocele.

OBJECTIVE: Perineal ultrasound has not yet been adequately evaluated in relation to the diagnosis of anatomical descensus of pelvic organs. Therefore, the aim of the present study was to assess whether it is possible to carry out a topographical comparison between bladders in normal seat and prolapsed ones and to quantify the extent of descensus. MATERIALS AND METHODS: The authors selected 140 women, divided into three groups (two control groups and one case group). All patients underwent urogynaecological examination, according to the Pelvic Organ Prolapse Quantification (POP-Q), and perineal ultrasound to evaluate pubo-bladder distance. RESULTS: Considering the data recorded in the two control groups, the authors established the physiological pubo-bladder distance between 27-33 mm at rest and 25-30 mm under stress. In the group with cystocele, the pubo-bladder distance was significantly lower: 20 mm at rest and three mm under stress (mean value). The authors also performed a classification of ultrasound cystocele in four stages, in accordance with clinical staging. CONCLUSIONS: In conclusion, the present data show the excellent potential role of perineal ultrasound in the diagnosis of cystocele, but it is necessary to perform randomized studies to standardize the method.

Environmental pollution due to cadmium: measure of semen quality as a marker of exposure and correlation with reproductive potential.

PURPOSE: Contradictory reports exist in the literature regarding an association of cadmium with parameters of semen quality. The aim of the study was to assess cadmium levels in both blood and seminal plasma and to analyze the relationships between cadmium concentrations and lifestyle and semen parameters. MATERIAL AND METHODS: Fifty healthy male volunteers were recruited to provide semen and blood samples. Each patient completed an extensive questionnaire regarding his occupation, residence, social status, diet, water source, smoking habits, and medical and surgical history. Semen analysis was carried out according to WHO guidelines. Detection of cadmium in both semen and blood samples was carried out by means of atomic absorption spectrophotometer. RESULTS: Mean concentrations of cadmium were 8.18 ± 1.6 ng/ml in blood samples and 2.56 ± 0.9 ng/ml in semen samples. Cadmium blood levels were significantly higher in men from industrialized areas and in current smokers, but were not correlated with semen levels. A significant positive correlation was found between cadmium blood levels, number of immotile spermatozoa, and teratozoospermia index (TZI). Significant inverse relationships between cadmium blood concentration and type-a and type a + b motility were found. CONCLUSIONS: The present data show a significant correlation between blood cadmium concentrations, cigarette smoking, occupational exposure, and parameters of semen quality. Such a reduction in spermiogenetic function could be an early marker of a toxic effect by cadmium pollution.

Pregnancy management in Behçet's disease treated with uninterrupted infliximab. Report of a case with fetal growth restriction and mini-review of the literature.

BACKGROUND: The mutual impact of Behçet's disease (BD) and pregnancy is variable and still unclear. Among the safe drugs administered, the newer infliximab (IFX) was rarely experienced in pregnancy, particularly in the third trimester. CASE: The authors report a pregnancy with fetal growth restriction at 36 weeks in a 31-year-old primigravida with symptomatic BD, treated with uninterrupted monthly IFX and daily enoxaparin. The patient was induced at 38 weeks and had an uneventful vaginal delivery of a healthy baby. The postpartum period and following six months were uneventful for mother in terms of BD exacerbation, and newborn in terms of potential risks of neonatal BD and/or infections due to late immunosuppressive IFX administration. CONCLUSION: Because of the inconstant mutual impact, BD pregnancies should be precautionary considered at "potential high-risk" and need a careful and close monitoring by a multidisciplinary team with specific expertise.

Asymptomatic large bladder diverticulum.

The authors report a case of a 61-year-old woman diagnosed with large bladder diverticulum. Diagnosis was performed only after a series of investigations carried out for the occasional finding of hypercreatininaemia. Although the significant volumes of post void residual (PVR) and the relevant urine stagnation in the diverticulum, subjective symptomatology was absent and urinalysis and urine culture were negative. The scheduled therapeutic plan consisted of fosfomycin three grams every ten days for sixmonths, self-catheterization twice a day, voiding on a time schedule, and adequate fluid intake. The monthly scheduled follow-up at one year showed good general health, good compliance with the therapy, no urinary tract infections, a decrease in creatininemia to 1.2 mg/dl, and regression of nephrohydrosis to a mild stage. In conclusion, the absence of symptoms and negative urinalysis or urine culture allows expectant management despite the considerable size of the bladder diverticulum.

Risk of pelvic floor dysfunctions in young athletes.

PURPOSE OF INVESTIGATION: Numerous epidemiological studies have shown a correlation between sport and the development of pelvic floor dysfunction. Therefore, the aim of the present study was to evaluate the prevalence of urinary incontinence in female young athletes. MATERIALS AND METHODS: The epidemiological study was conducted on 105 female volleyball players, who were given a questionnaire, self-compiled, consisting of four main domains (personal data and medical history, urinary incontinence, urinary disorders, and judgment on the questionnaire). RESULTS: In a total of 105 athletes, the present authors observed that 65.7% had reported at least one symptom of stress urinary incontinence (SUI) and/or urgency, during sport or in daily life situations. In particular, the 49.52% reported urge urinary incontinence, 20% urine loss for urgency, and 29.52% SUI. In addition, the present authors observed that nocturia was reported in 70.48% of cases, incomplete bladder emptying in 55.24%, urinary hesitancy in the 36.19%, and pelvic pain in 52.38%. In all cases, the symptoms were occasional and low. In relation to the coexistence of symptoms, the present authors observed that 22.85% of athletes had only symptoms of urge urinary incontinence, 6.66% mixed incontinence, and 6.66% symptoms of urge urinary incontinence associated to urine loss for SUI. CONCLUSION: The present authors observed a relationship between the sport and the pelvic floor dysfunction, in particular urinary incontinence.

The possible role of zinc in the etiopathogenesis of endometriosis.

PURPOSE OF INVESTIGATION: Aim of the study was to evaluate the possible involvement of zinc in the complex pathogenic process behind the onset and perpetuation of endometriotic lesions. To study the level of zinc serum between a group of patients affected by endometriosis and a group of healthy patients. MATERIALS AND METHODS: The study included 86 women: 42 patients whose histodiagnosis had revealed pelvic endometriosis and 44 healthy patients. The authors measured the serum zinc concentration for all patients. RESULTS: The group of patients with endometriosis presented serum zinc concentration of 1010 +/- 59.24 microg/l. The observation group presented a serum zinc concentration of 1294 +/- 62.22 microg/l. CONCLUSION: The results showed that serum zinc levels in women with endometriosis are decreased and this seems to actually confirm that this microelement can possibly affect the multifactorial pathogenesis of the disease. As a matter of fact, zinc interferes with many biological processes, among which inflammation and immunity, which seem to be the base of the development of the lesions. Therefore, the authors believe that this hypothesis requires more attention and further investigation to determine its reasonableness. If the results are confirmed, this study opens up future prospects as for the treatment of endometriosis, taking into account also the role of zinc in the onset of male sterility and the development of testicles. Zinc could in fact be used as marker to detect women at high risk of endometriosis and for the elaboration of a new treatment for sterility, from which these women often suffer.

Nonhormonal management of postmenopausal women: effects of a red clover based isoflavones supplementation on climacteric syndrome and cardiovascular risk serum profile.

PURPOSE OF INVESTIGATION: The aim of this prospective randomized study was to evaluate a red clover based isoflavones supplementation in the treatment of climacteric syndrome and its effects on cardiovascular risk serum profile. MATERIALS AND METHODS: The study included 150 healthy postmenopausal women that were randomly assigned to receive phytoestrogens tablets, amounting in a total daily intake of 60.8 mg red clover isoflavones plus 19.2 mg soy isoflavones (n = 75), or placebo (n = 75). The authors evaluated teh following: daily number of hot flushes and Kupperman Index at baseline and after one and three months; serum total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, triglycerides, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and antithrombin III (ATIII) at baseline and after three and six months. RESULTS: One hundred twenty-eight patients completed the study: 67 in the active group and 61 in the placebo group. The treatment led to a progressive significant reduction (p < 0.05) of the number of hot flushes in the active group compared to placebo already after one month, while Kupperman Index was statistically reduced after three months. No significant variation in total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, PT, PTT, fibrinogen, and ATIII were found. CONCLUSION: The present findings suggest that a red clover based isoflavones supplementation in healthy postmenopausal women is promptly effective on climacteric syndrome, improves neurovegetative symptoms, safe on cardiovascular risk serum profile, and does not modify lipids and coagulation.

Low-dose estrogen and drospirenone combination: effects on metabolism and endothelial function in postmenopausal women with metabolic syndrome.

PURPOSE: Metabolic syndrome and endothelial dysfunction play a relevant role in the cardiovascular risk in post-menopause. The aim of the study was to assess the effects of a low-dose hemihydrate estradiol and drospirenone combination on cardiovascular risk parameters in postmenopausal women with metabolic syndrome. MATERIALS AND METHODS: Twenty-eight healthy women (group A) and 28 women with metabolic syndrome (group B) were treated with hemihydrate estradiol one mg + drospirenone two mg. At recruitment and after six months, clinical and laboratory parameters of metabolic syndrome were evaluated. Endothelial function was assessed measuring the flow-mediated dilatation of the brachial artery and the intima-media thickness of the common carotid artery. RESULTS: After six months an overall improvement of metabolism was observed in both groups reaching statistical significance for triglycerides, total cholesterolemia, and systolic pressure in group B. A trend to lower baseline flow-mediated dilatation was also found in group B. CONCLUSIONS: Drospirenone improves cardiovascular risk factors and does not impair endothelial function in menopausal women with metabolic syndrome.

Arterial hypertension and female sexual dysfunction in postmenopausal women.

PURPOSE: To evaluate female sexual dysfunction in hypertensive postmenopausal women and the effects of antihypertensive therapy. MATERIALS AND METHODS: Female sexual dysfunction was assessed by the Female Sexual Function Index (FSFI) in three groups of postmenopausal patients: normotensive women (group A: 240 women), hypertensive women without therapy (group B: 220 women), hypertensive women on therapy (group C: 80 women). RESULTS: The incidence of female sexual dysfunction was increased in group B compared to groups A and C. Healthy patients showed higher FSFI scores compared to hypertensive patients (groups B and C). Hypertensive-treated patients accounted for higher scores in all items compared to hypertensive patients without therapy. CONCLUSIONS: Essential hypertension significantly affects female sexual function. Physicians should recognize and properly manage FSD in hypertensive women.

Oral supplementation with antioxidant agents containing alpha lipoic acid: effects on postmenopausal bone mass.

PURPOSE OF INVESTIGATION: Oxidative stress impacts many age-related degenerative processes, such as in postmenopausal bone loss and in antioxidant defenses that are significantly decreased in elderly osteoporotic women. The authors evaluated the effect of oral supplementation with antioxidant agents containing alpha lipoic acid (ALA) on bone mineral density (BMD) of osteopenic postmenopausal women. MATERIALS AND METHODS: Fifty postmenopausal women with osteopenia (-2.5 < T-score < -1) were prospectively enrolled and randomly assigned to orally receive ALA and other antioxidant agents (vitamin C, vitamin E, and selenium) plus calcium and vitamin D3 (n = 25), or only calcium and vitamin D3 (n = 25). The BMD was estimated at baseline and after 12 months of treatment by heel quantitative ultrasonometry (QUS). RESULTS: Forty-four patients completed the one-year study: 23 in the ALA group, 21 in the control group. The treatment of ALA group led to a better estimated BMD compared to the control group (0.401 +/- 0.026 vs 0.388 +/- 0.025 g/cm2), although this difference barely achieved a statistical significance (p = 0.048). CONCLUSION: These findings, although in a small population, could suggest that oral supplementation with antioxidant agents containing ALA may mitigate bone loss in osteopenic postmenopausal women.

A new approach in the first-line treatment of bacterial and mycotic vulvovaginitis with topical lipohydroperoxides and glycyrrhetic acid: a comparative study.

UNLABELLED: PURPOSE OF INVESTIGATIONS: The aim of this randomized controlled trial was to evaluate efficacy and tolerability of a new association of lipohydroperoxides and glycyrrhetic acid on topical treatment of bacterial and mycotic vulvovaginitis. METHODS: One hundred consecutive patients with bacterial or mycotic vulvovaginitis were randomly assigned to a study group treated with vaginal lipohydroperoxides and a derivative of glycyrrhetic acid for three days (n = 50), and a control group using vaginal antibacterial metronidazole (500 mg) or antimycotic econazole (150 mg) for six days (n = 50). RESULTS: A clinical and microbiological response was achieved in 80.4% and 88.9% in investigational and control group, respectively (p > 0.05). Compared to traditional antimicrobial drugs, the effect appears to be faster and safer, even if not significantly. The 6-month recurrence rate was 7.7% and 5.6% in the investigational and control group, respectively. CONCLUSION: Topical medication based on lipohydroperoxides and glycyrrhetic acid showed a clinical and microbiological efficacy in the first-line treatment of bacterial and mycotic vulvovaginitis, comparable to conventional drugs.

Serum osteoprotegerin correlates with age and bone mass in postmenopausal, but not in fertile age women.

PURPOSE OF INVESTIGATION: Osteoprotegerin (OPG) and receptor activator of nuclear factor kappaB ligand (RANKL) are bone turnover modulators expressed by osteoblasts. The aim of this study was to assess the relationship between the circulating OPG/RANKL system, age and bone mass, in fertile age and postmenopausal women. METHODS: In this cross-sectional observational study on 48 patients (fertile age, n = 22; postmenopause, n = 26), we investigated the correlation between serum OPG and RANKL, age and bone mineral density (BMD). Serum concentrations of OPG and RANKL were determined by enzyme-linked immunosorbent assay (ELISA); estimate BMD evaluation was performed with heel quantitative ultrasonometry (QUS). RESULTS: Serum OPG significantly increased (p = 0.003) and serum RANKL significantly decreased (p = 0.002), in the postmenopausal group compared to fertile age women. A significant correlation of serum OPG with age (r(s) = 0.39, p = 0.047) and BMD (r(s) = 0.45, p = 0.023) in postmenopausal women, and between RANKL and BMD (r(s) = 0.48, p = 0.024) in fertile age was found. CONCLUSION: These data demonstrate in vivo that the OPG/RANKL system is significantly associated with menopausal status and could play a role in postmenopausal osteoporosis.

A new approach to vulvar squamous cell carcinoma: two-year follow-up of a case report.

BACKGROUND: Vulvar carcinoma is relatively rare gynaecologic malignancy. The most prevalent vulvar cancer is squamous cell carcinoma. It is not uncommon for patients to delay seeking medical attention or for physicians to delay diagnosing the condition. This delay results in many cases being diagnosed in advanced stage. The sentinel lymph node "concept" is attractive in vulvar cancer because it has the potential to avoid a radical vulvectomy associated with uni- or bilateral inguinofemoral lymphadenectomy and, thus, to avoid the morbidity associated with formal groin dissection. CASE REPORT: A case of an 88-year-old woman with advanced local vulvar cancer is presented. A study of the inguinal-femoral lymph nodes was also conducted with intraoperative vital blue dye peritumoral injection and as the sentinel node was found to be negative for malignant metastasis, a radical vulvectomy without bilateral inguinofemoral lymphadenectomy and without additional treatment (chemotherapy and/or radiotherapy) was performed. Follow-up was performed at one, three, six, nine, 12, 18 and 24 months. No local recurrence or distant metastasis was found. CONCLUSION: The sentinel lymph node procedure allows a less aggressive treatment to be carried out in patients with invasive vulvar cancer thus reducing the complications and morbidity of treatment. Moreover, reducing the operative stress can change the overall survival and reduce the mortality linked to complications and postoperative stress.

A therapeutic algorithm for early-stage endometrial cancer: indications, patient selection, and feasibility.

Endometrial cancer is the most widely spread gynaecologic neoplasm in industrial countries. Mode of spread includes direct extension, lymphatic and haematic diffusion. Lymphatic involvement, particularly, is a topic of wide debate due to the strong therapeutic implications associated with it. In this regard, anatomic-surgical staging is better in that it corresponds to real conditions whereas clinical-instrumental staging is still today incomplete.

Third stage ovarian carcinoma--case report: the necessity of a multidisciplinary approach to treatment.

Ovarian carcinoma, part of a heterogeneous group of tumours, is the main cause of death by gynaecological neoplasms. The diagnosis, in general, is delayed. Multiorgan diffusion, the necessity of a surgical operation and strong chemotherapy, and the eventual pathology due to patient age are all factors that require a multidisciplinary approach. In fact the case, here reported, refers to a patient who came under our observation for a bilateral ovarian mass discovered casually during an abdominal ultrasound exam carried out for renal colic. Excellent cytoreduction with peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy (Figure 2), bilateral pelvic lymphadenectomy, total omentectomy, removal of nodules from the mesentery, the colon and three nodules in the abdominal wall thickness was executed. The histological report was G3, angioinvasive bilateral ovarian endometrioid adenocarcinoma. Metastasis was found only in one left obturator lymph node out of 17 lymph nodes removed. All of the removed abdominal, mesenteric and intestinal nodules were neoplastic. It is concluded that the complexity of similar cases always requires a multidisciplinary approach as in our case, involving an oncologist, hematologist, surgeon, gynaecologist, radiologist, anaesthesiologist, and nursing staff in the management of third stage ovarian cancer patients to obtain the best treatment thus guaranteeing a higher survival rate and better quality of life.

Local estrogen replacement therapy in postmenopausal atrophic vaginitis: efficacy and safety of low dose 17beta-estradiol vaginal tablets.

PURPOSE OF INVESTIGATION: To verify the effectiveness and safety of low-dose 17beta-estradiol vaginal tablets in the treatment of the postmenopausal atrophic vaginitis. PATIENTS AND METHODS: 325 postmenopausal women with atrophic vaginitis in estrogenic replacement therapy with 0.025 mg 17beta-estradiol vaginal tablets, one application each day for two weeks, and a single application two times a week for the following 22 weeks (total treatment period: 24 weeks). RESULTS: Most of the women reported an improvement of symptoms just after two weeks and minimal incidence of adverse reactions. No patients showed abnormal endometrial thickness and no one had to interrupt the treatment for abnormal uterine bleeding because of systemic absorption. CONCLUSION: Low-dose 17beta-estradiol vaginal tablets in the treatment of the postmenopausal atrophic vaginitis constitutes an extremely valid approach in terms of effectiveness and safety.

Pelvic lipomatosis complicating ovarian cyst removal: a case report.

Pelvic lipomatosis consists of an abdominal capsulated mass containing lipidic tissue, generally with remarkable dimensions, responsible for urinary tract disturbances. Here we describe the first case to our knowledge of accidental intraoperative diagnosis associated to an ovarian cyst in absence of objective symptoms and signs.

Premature ovarian failure. Clinical evaluation of 32 cases.

AIM: Premature menopause, also termed premature ovarian failure (POF), is characterized by cessation of menstruation before the age of 40 years. Pathogenetic mechanisms are not so clear, particularly genetic implications of cellular apoptosis. Diagnostic approach is multifactorial and therapy depends on the pregnancy wish. METHODS: Eight hundred and thirty patients approached the Menopausal Center of the University Department of Gynaecological, Obstetrical and Reproductive Sciences of the Second University of Naples between October 1998 and October 2002. All patients were clinically investigated and selected on the basis of menopausal age, pregnancy wish and menopausal syndrome. RESULTS: Menopausal mean age was 48.31+/-4.62 years and 32 patients (4%) were affected by premature ovarian failure because of menopausal appearance before the age of 40. Three of these patients were treated to have a pregnancy; the remaining 29 required medical treatment to reduce menopausal symptoms. The osteoporosis risk for premature menopause patients was similar to the other women. The cardiovascular risk was increased because of an increase in risk factors in premature ovarian failure patients. No breast or endometrial pathology was revealed and therapy compliance was satisfactory without any drop-out. CONCLUSION: Premature ovarian failure has a varied etiology, pathogenetic aspects, clinical evolution and therapeutical approach. Adequate treatment of premature menopause women presents good compliance, resolution of infertility when required and a successful resolution of menopausal symptoms.

[Indications for hormone replacement therapy]. / Indicazioni alla terapia ormonale sostitutiva.

BACKGROUND: The purpose of the present study is to evaluate indications and contraindications, advisability and compliance of hormone replacement therapy (HRT) in women in the climacteric who, owing to the cessation of ovarian activity, face loss of the state of present and future wellbeing. METHODS: A series of 602 women who have attended the Menopause Centre of the II Division of the Department of Gynaecology and Obstetrics of the Second University of Naples in the period from 1/12/1998 to 10/4/2001. The diagnostic methodology adopted is outlined and the reasons for the prescription of HRT indicated. Patients who do not present contraindications were assessed in relation to the gravity of the climacteric syndrome and the likelihood of a future pathology bound up with the lack of estrogens. The intensity of the symptomatology was assessed on the basis of Kuppermann's nomogram. RESULTS: The cessation of ovarian activity occurred between the ages of 40 and 45 in 16.9% of cases while the percentage was 5.9% prior to the age of 40. Cases in which a climacteric syndrome was present numbered 147, or 24.2%. Women who present a cardiovascular risk represent a noteworthy percentage (27.1%). A high number of women are at osteoporotic risk: 223, or 37.0%. Although it has a great number of indications, HRT is only prescribed in about half the patients. Stress is laid on the caution exercised by physicians in prescribing HRT and the diffidence of women in accepting it. Of the well-known contraindications to HRT the most common are those relative to the mammary risk. CONCLUSIONS: HRT was only prescribed for about half the women who came to our attention both as a result of the caution of the physicians who consider even relative contraindications peremptory, and because of the diffidence of a percentage of women with regard to such therapy. Alternative therapies to HRT are in fact a second valid choice, especially in the prevention of osteoporosis.

Current etiopathogenetic views in vulvar cancer.

We considered 59 patients, from 19 to 79 years, treated for vulvar neoplastic pathology (32 of 59 had multiple squamous neoplasias of the anogenital region). It appeared that vulvar cancer is a disease of aged women and in particular between sixty and seventy years, while it isn't common under the age of thirty years. It is a hormone-independent pathology. 85% of vulvar malignant tumors is constituted by squamous cell carcinomas. The principal risk factors are: 1) chronic vulvitis (in particular Lichen sclerosus); 2) leucoplachia, 3) immunosuppression, 4) coitus in a young woman with different partners, multiple abortions, 5) HPV infection (mostly HPV type 6 and 16), 6) other genital carcinomas, 7) capacity to activate or not protoncogenes and to produce interferon, 8) tobacco smoking, 9) VIN.