Urogenital myiasis - An atypical presentation

The infestation of the human body by maggots has been reported worldwide and occurs most commonly in people of lower socioeconomic status and poor personal hygiene. Urogenital is the rarest site of myiasis presentations. Here we report the case of a 20-year-old, sexually inactive female student who presented with a necrotic growth in the paraurethral region infested with numerous maggots. The lesion involved the urethra and the bladder base. She was treated with debridement and bladder irrigation. The cystoscopy and local examination performed 2 weeks after admission, confirmed the complete healing of the urogenital lesion. Managing this patient's unique challenge was to assess the extent of the involvement and removal of all maggots from the deepest wound portion. The female internal and external urogenital myiasis is a very occasional and under-reported health hazard. Reporting such cases increases the public and physician awareness about the mode of presentation, right diagnosis, and available treatment options.

Characteristics of carcinogenic HPV genotypes in North China Plain and the association with cervical lesions.

Human papillomavirus (HPV) infection is a crucial health problem and caused substantial malignancy diseases among female worldwide. We aim to investigate the distribution of HPV subtype and the status of cervical cancer and precancerous lesions caused by HPV infection in North China Plain population. A total of 61,870 samples of outpatients and inpatients from January 2015 to May 2017 at the Affiliated Hospital of Jining Medical University were collected. All of the samples were tested by rapid flow-through hybridization HPV genotyping. Approximately 17,280 of the cases tested positive for HPV, indicating an infection rate of 27.9%. Approximately 7009 cases were compared to the results of cytological diagnosis. The top five HPV genotypes were HPV-16 (4.5%), HPV-52 (2.9%), HPV-58 (2.8%), HPV-53 (1.9%), and HPV-81 (1.9%). The youngest age group (age < 20 years) showed the highest infection rate (59.9%), and then decreased with age. As the degree of cervical lesions worsened gradually, the rate of high-risk HPV infection increased, such as 24.3% (322/1324) in the Cervicitis, 31.30% (560/1785) in the CINI, 54.1% (568/1050) in the CINII, 80.1% (693/865) in the CIN III, and 99.5% (428/430) in the cervical cancer group. These findings were significantly different from the 9.7% (155/1555) observed in the normal medical examination group (P < .05). This is the first study to demonstrate the characteristics of HPV and the association with cervical lesions in North China Plain population.

Primary non-Hodgkin's lymphoma of the vagina (PNHLV): a gynaecologist's enigma!

Primary lymphoma of the female genital tract is very rare, particularly those presenting primarily in the vagina are even rarer. We report a case of a 60-year-old woman who presented with generalised abdominal pain, vaginal discharge and a thickening of the posterior vaginal wall. Prompt radiological investigations and biopsy led to early diagnosis and appropriate treatment. Complete metabolic remission was obtained with three cycles of chemotherapy and radiotherapy. This case highlights the need for increasing the awareness about lymphomas presenting as vaginal lesion(s) and for clinicians to keep an open mind when working up such patients.

Risk factors associated with reproductive performance in Japanese dairy cows: Vaginal discharge with flecks of pus or calving abnormality extend time to pregnancy.

The present study aimed to determine possible risk factors affecting reproductive performance, especially time taken to establish pregnancy in dairy cows, using Cox's proportional hazard model. The data were collected from 154 Holstein Friesian cows (199 lactations). Cows diagnosed with a vaginal discharge score (VDS) of one or calving abnormality showed significantly delayed pregnancy: hazard ratio (HR)=0.654 (95% confidence interval [CI]: 0.436-0.983; P=0.041) and HR=0.457 (95% CI: 0.270-0.774; P=0.004), respectively. Our study suggested that the occurrence of VDS of one or calving abnormality might be possible risk factors increasing the number of days open and affecting reproductive performance in dairy cows.

Infectious complications in morbidly adherent placenta treated with leaving placenta in situ: a cohort series and suggested approach.

Background: The aim of this study is to assess the clinical and microbiological features of infections in patients with morbidly adherent placenta (MAP) treated by leaving placenta in situ (LPIS). Materials and methods: Retrospective analysis of MAP cases who were treated by LPIS between 2 May 2010 and 15 March 2017. The inclusion criteria were gestational age at or above 24 weeks, prenatal diagnosis, elective operation, and complete data. Results: Nineteen MAP cases were treated by LPIS during the study period. The mean ± SD duration for total placental resorbtion was 145 ± 47 days. Three patients were readmitted to the hospital because of fever (3/19). A total of 65 culture samples were taken from the patients during their follow- up periods. In four cases (4/12) cervical cultures showed positive growth [Escherichia coli (2), Klebsiella pneumoniae (1), mixed culture with Enterococcus spp. and E. coli (1)]. Fifteen (15/26) urine samples were sterile, three were polymicrobial. In eight cases, urine culture revealed E. coli growth (one E. coli and Enterococcus spp.). Three out of 16 (3/16) surgical incision samples revealed growth of E. coli. No bacterial growth was detected in blood cultures. Susceptibility results of Gram-negatives indicate that the resistance rates of beta-lactam antibiotics are high (14/20, 70%). No secondary surgical intervention occurred during the study period due to infection. Conclusions: Majority of postpartum cervical discharge, fever, and increased CRP levels do not represent morbid infections and/or sepsis. With early detection, and implementation of antibiotherapy (combination of an aminoglycoside and clindamycin), they can be easily controlled and secondary surgical interventions can be prevented.

[Diagnosis of vaginal discharge].

Changes in vaginal discharge are often caused by imbalance in the vaginal microflora, and laboratory testing is usually of little use, as most microbes detected are commensals. In-office diagnosis in general practice using wet mount microscopy and Amsel criteria is helpful and often sufficient to ensure correct diagnosis and treatment. Laboratory testing of vaginal discharge should only be performed, if sexually transmitted disease is suspected, if there is treatment failure or inconclusive wet mount prior to gynaecological surgery, and in pregnant women with recurrent miscarriage or preterm birth.

Tuberculosis of the cervix: An uncommon cause of vaginal discharge in a post-menopausal woman.

Discharge per vaginum is a common symptom of a variety of gynaecological diseases. Among post-menopausal women, atrophic vaginitis, cervicitis and cervical carcinoma are common causes of this symptom. We present a 64-year-old woman who had foul-smelling discharge per vaginum for the past 1 year. Per speculum examination revealed an unhealthy-looking cervix and white discharge. On bi-manual examination, the cervix was flush with the vagina. There was no obvious growth felt, the exact uterine size could not be ascertained and the finger was stained with thick discharge. A biopsy of the cervix showed epithelioid cell granulomas and a diagnosis of tuberculosis was made. The patient responded to antitubercular therapy. Tuberculosis of the cervix may be a rare cause of foul- smelling discharge per vaginum in post-menopausal women but there should be a high index of suspicion of this condition, especially in areas where tuberculosis is common. We report this post-menopausal woman owing to the rarity of tuberculosis of the cervix mimicking a gynaecological malignancy.

Transvaginal postpartum manual removal of a prolapsed submucous leiomyoma, initially diagnosed hybrid predominantly intramural.

We present a rare case of a large infarcted submucous fibroid removed manually after a normal vaginal delivery. This patient was known to have a large postero-fundal hybrid predominantly intramural uterine fibroid, measuring 11 x 10 cm in diameter and diagnosed 2 years prior to last conception. Thirty-five days postpartum, she presented with severe lower abdominal pain and foul smell per vaginum. Abdominal examination revealed a very tender bulky uterus at 24 weeks size, and vaginal examination revealed a big fleshy smelly mass with friable surface just bulging from a dilated cervix. Examination under anaesthesia revealed a very foul smelly large pedunculated submucous fibroid that was felt through a dilated cervix. It was deliverable vaginally, so the submucous leiomyoma was removed manually, a procedure similar to manual removal of placenta. Histopathology examination confirmed an infarcted massive fibroid.

Effect of diagnosis and treatment of clinical endometritis based on vaginal discharge score grading system in postpartum Holstein cows.

In this study, the prevalence, effectiveness of diagnosis, and treatment based on vaginal discharge score (VDS) of clinical endometritis in cattle were evaluated. To detect clinical endometritis and classify its severity, vaginoscopy was performed during 21 to 60 days postpartum in 164 Holstein cows consisting of 229 lactations. Groups were defined using the 4-point VDS scale. Study groups included the following: non-endometritis (VDS=0; no/clear mucus; NEM group; n=168); mild endometritis, no treatment (VDS=1; mucus containing flecks of white/off-white pus; NTR group; n=30); and severe endometritis, treated with PGF2α (VDS≥2; discharge containing <50% pus; and VDS=3; discharge containing >50% pus, and fluid or uterine horn asymmetry; TEM group; n=31). Cows treated with PGF2α that did not recover (VDS≥1, n=5) received intrauterine procaine penicillin and streptomycin. Prevalence of clinical endometritis (VDS≥1) was 26.6%. The NTR group required significantly more artificial inseminations per pregnancy than NEM and TEM groups (2.8 ± 1.8 vs 2.0 ± 1.3, 1.9 ± 0.8, P<0.05). In survival analysis, the proportion of non-pregnant cows was higher in the NTR group compared to the NEM (P=0.012) and TEM (P=0.076) groups. In the TEM group, calving to first artificial insemination interval tended to be higher in cows treated 41 to 60 days postpartum than cows treated 29 to 40 days postpartum (97.2 ± 27.1 vs 74.4 ± 19.7, P=0.084). Our study suggests that cows with VDS=1 may require treatment to recover fertility. Diagnosis and treatment of clinical endometritis based on a VDS grading system may improve dairy herd reproductive performance.

High Risk Human Papilloma Virus Genotypes in Kurdistan Region in Patients with Vaginal Discharge.

BACKGROUND: The human papilloma virus (HPV) is considered as the major risk factor for the development of cervical cancer. This virus is of different genotypes and generally can be classified into high and low risk types. OBJECTIVE: To determine the rate of high risk HPV genotypes in women with vaginal discharge and lower abdominal pain in Kurdistan region, Iraq. MATERIALS AND METHODS: Cervical swabs were taken from 104 women. DNA was extracted and the polymerase chain reaction (PCR) technique was used to determine the presence of high risk genotypes. RESULTS: It was found that 13/104 (12.5%) of the samples were positive for high risk HPV genotypes. Amongst those who were positive, 4/13 (30.7%) were typed as genotype 16 and 7/13 (53.8%) showed mixed genotyping. On the other hand, genotypes 53 and 56 were found in only one sample each. CONCLUSIONS: High risk HPV genotypes are not uncommon and further community based study is needed to determine the prevalence of HPV and its genotypes and plan for prevention of infection.

Identification of cytolytic vaginosis versus vulvovaginal candidiasis.

OBJECTIVE: This study aimed to observe the morphological characteristic of vaginal discharge in patients with cytolytic vaginosis (CV) under the microscope and to identify it in patients with CV and in patients with vulvovaginal candidiasis (VVC). METHODS: A total of 108 subjects including 21 healthy women, 33 patients with CV, and 54 patients with VVC were enrolled in the present morphological study. Vaginal discharge was collected and made into smear. The morphological characteristics of these vaginal smears with Gram staining were observed under the microscope. The smears were assessed for the quantity of lactobacilli, epithelial cell morphology, and the absence or presence of Candida species, Trichomonas vaginalis, and clue sells. RESULTS: First, the age, the level of education, and especially the status of pregnancy of patients with CV were significantly different from those of the patients with VVC. Second, the morphological characteristics of patients with CV consisted of overgrowth of lactobacilli, the presence of naked nuclei and fragments of the epithelial cells, a paucity of leukocytes, and the absence of Candida species and other pathogens. However, the morphological characteristic of patients with VVC consisted of the presence or absence of lactobacilli and the presence of normal epithelial cells, candidal spores, blastospores, hyphae, or other pathogens such as T. vaginalis and Gardnerella vaginalis. CONCLUSIONS: Both CV and VVC can be identified based on the quantity of lactobacilli, the morphology of the epithelial cells, and the absence or presence of Candida species and other pathogens, and the misdiagnosis of CV as VVC can be avoided.

Evaluation of vaginal discharge with the Metricheck device and the relationship to reproductive performance in postpartum dairy cows.

Vaginal mucus during estrus was examined with the Metricheck device and the relationship to the reproduction of high-yielding dairy cows was studied. The study was conducted in 99 dairy herds located in Western Germany and 1348 Holstein-Friesian heifers and cows showing spontaneous estrus were examined. Independent of the Metricheck result, the animals were inspected by professional insemination technicians and those suitable for insemination (n = 989) were bred by artificial insemination (AI). Reproductive performance was characterized by non-return rate at 90 days (NRR90). The discharge of the animals predominantly had a clear appearance (70%) and a stringy consistency (80%). Animals with clear vaginal discharge had higher NRR90 (56%; n = 697) than animals with abnormal (turbid, mucopurulent, purulent, sanguineous) vaginal secretion (48%, n = 292; P < 0.05). NRR90 was lower in animals with short calving to AI interval (< 70 days; 39%) than with medium (70-130 days; 54%) or long (> 130 days; 62%) intervals (P < 0.05). NRR90 decreased by 12% from the lowest (< 15 kg) to the highest (> 45 kg) milk yield class. In conclusion, the use of the Metricheck device integrated into the insemination procedure is recommended to identify dairy cows suffering severely from uterine disease.

Effect of oral supplementation of the probiotic capsule UB-01BV in the treatment of patients with bacterial vaginosis.

Bacterial vaginosis (BV) is a common condition affecting millions of women annually and is characterised by a reduction in native lactobacilli. Antimicrobial therapy used to cure the disease is often found to be ineffective. We postulate that the potential probiotic capsule UB-01BV might be efficient in the treatment of BV. In the present study, 30 Indian women diagnosed with BV presenting symptoms such as white discharge, pH greater than 4.7, increased discharge, odour, colour of discharge and pruritus were included. All subjects were assigned to receive two potential probiotic capsules UB-01BV a day for 7 days. At the end of the treatment all subjects showed significant (P<0.001) positive response as revealed by a reduction in vaginosis symptoms. Therefore, the results of the present study provide the first preliminary evidence that the potential probiotic capsule UB-01BV can exert a significant reduction in vaginal infection.

Surgical treatment of persistent vaginal granulation tissue using CO(2) laser vaporization under colposcopic and laparoscopic guidance.

INTRODUCTION: There have been many reports in the literature on vaginal mesh erosion as a complication of pelvic floor reconstructive surgery. Several reports describe successful surgical excision of the exposed mesh as a resolution. However, in rare cases of mesh erosion, poor surgical outcomes and multiple resection failures have been reported. We describe an innovative surgical approach to persistent vaginal mesh erosion using CO(2) laser vaporization under colposcopic and laparoscopic guidance. CASE DESCRIPTION: A 58-y-old postmenopausal woman first presented with a 3-y history of vaginal discharge and spotting after undergoing a Mentor ObTape transobturator sling (Mentor Corp, Santa Barbara, CA), for the treatment of stress urinary incontinence. Despite surgical removal of the mesh and multiple attempts at cauterization of persistent granulation tissue, her symptoms persisted. DISCUSSION: Using a CO(2) laser under colposcopic and laparoscopic guidance, we were able to safely expose and remove the remaining portion of retained mesh. To our knowledge, this is the first report describing CO(2) laser vaporization as a surgical approach for the successful treatment of recurrent mesh erosion.

'Pap smear' for screening of precancerous conditions of cervix.

BACKGROUND: Cervical intra-epithelial neoplasia (CIN) and cervical cancer remain important health problems for women worldwide. It is largely a preventable disease that is characterised by a long lead time. The objective of this study was to determine the frequency of precancerous conditions of cervix (CIN I-III) in women with chronic vaginal discharge by Pap smear screening. METHODS: The study was conducted at the outpatient department of Obstetric and Gynaecology, Nishtar Hospital Multan, and Multan Institute of Nuclear Medicine & Radiotherapy (MINAR) from February 2009 to February 2010. Two hundred and eighty patients with complaint of chronic vaginal discharge were selected. Their detailed history was documented on a Proforma, Pap smear taken at MINAR, and samples sent to pathology department of Nishtar Hospital Multan for cytological examination. All mild dyskaryosis or CIN I cases were advised follow-up with repeat Pap smear in 6-12 months and those with moderate to severe neoplasia (CIN II-III) were further investigated by cervical biopsy and managed accordingly. RESULTS: Of the total, 100 patients were between 25-30 years of age, and 180 between 31-35 years of age. Mean age of patients was 31.6 years, mean age at marriage 21.7 years, and mean parity was 3.6. Most of the patients (67.9%) belonged to low socioeconomic status. The cytological examination of the smears showed no changes (normal) in 100 (35.7%) cases, while 156 (55.7%) cases showed inflammatory changes, 10 (3.6%) showed dysplastic changes, of whom 8 cases had CIN-I (2.8%) and one case was of CIN-II (0.4%). One was having CIN-III/severe dysplasia (0.4%). Inadequate sample was reported in 14 (5%) cases. CONCLUSION: Pap smear should be used as a routine test for all sexually active, young females presented to the gynaecology outpatient department, for early detection of cervical pre cancer (CIN) as it is not uncommon in our set up.

[Detection of vaginal discharge by ultra-high power microscope and conventional microscope].

OBJECT: To study the significance of the ultra-high power microscope in the examination of vaginal discharge. METHODS: By the ACT-2000 ultra-high power microscope system and Olympus CX21 microscope, the vaginal discharge of 1,100 gynaecology out-patients was examined respectively. RESULTS: The positive rate of mould in the patients was 11.55% by CX21 and was 20.27% by ACT-2000, respectively. The positive rate of trichomonas vaginalis was 2.55% by CX21 and 3.0% by ACT-2000, respectively. The clue cell was detected in 11.27% of the patients by ACT-2000, but no such cell reported by CX21. Totally, positive results were obtained in 14.09% of the patients by CX21 and 32.55% by ACT-2000. CONCLUSION: By using the ultra-high power microscope, the positive result can be increased obviously in the examination of vaginal discharge. It is very important in clinical practices.

Adenoid cystic carcinoma of uterine cervix in a young patient.

Adenoid cystic carcinoma of uterine cervix is a rare tumor. Its origin is debatable. It has a high incidence in postmenopausal women but rarely can develop in patients under 40. An association with squamous cell carcinoma has been described. We report a case of adenoid cystic carcinoma of the endocervical canal with foci of squamous cell carcinoma in a 34-year-old suffering from menorrhagia associated with blood-stained vaginal discharge. Per vaginum and per speculum examination revealed a growth. Cervical biopsy showed bits of tissue, suggesting adenoid cystic carcinoma. Patient was operated upon and uterus with cervix sent for histopathological examination. We report this case because of its rarity, particularly in young patients, with description of illustrative pathology and discussion on the histological diagnosis.

Expression of cyclooxygenase-2 in the inflammatory changed porcine uterus.

In the present study, the pattern of cyclooxygenase-2 (COX-2) expression in health and inflamed porcine uteri was analyzed using real-time reverse transcriptase-polymerase chain reaction (RT-PCR), Western blot and immunohistochemistry. On day 3 of the estrous cycle, 50 ml of saline or 50 ml of Escherichia coli (E. coli) suspension containing 10(9) colony-forming units/ml, were injected into each uterine horn of the control (n=6) and experimental gilts (n=7), respectively. This latter procedure lead to a moderately (n=3) or severely intense (n=4) acute endometritis after eight days. Expression of both the COX-2 mRNA and protein was increased in the endometrium (ENDO) of animals suffering from the moderate (P < 0.05, P < 0.01, respectively) and severe (P < 0.01) acute endometritis, as compared to the control tissues. Moreover, COX-2 mRNA level and protein content were higher (P < 0.05) in the ENDO of animals with severe than with a moderately acute endometritis. An elevation in the COX-2 gene (P < 0.05) and protein (P < 0.001) expression was also observed in the myometrium (MYO) of animals suffering from severe endometritis, when compared with the levels observed in MYO of both the health and moderate intensely inflamed uteri. However, both the COX-2 mRNA and protein levels were similar in MYO of the control and moderately inflamed organs. The luminal epithelium, some of uterine glands and circular layer of the MYO were more intensely stained for COX-2 in animals with severe endometritis, than in animals with healthy or moderately inflamed uteri. Nonetheless, stronger COX-2 reaction was found in some of the uterine glands in latter group, when compared to that observed in uteri of the control animals. While positive COX-2-labeling was observed in the muscular layer of all arteries supplying the health and inflamed uteri, such staining was exclusively present in the endothelium of some arteries in inflamed organs. Likewise, some arteries in uteri of the animals with severe endometritis displayed immunoreaction stronger than that found in uteri of the animals with moderate inflammation. The present study revealed an up-regulation of COX-2 mRNA and protein in the inflamed porcine uterus, which was directly related to the intensity of the organ inflammation. An increase in the COX-2 expression in the uterus challenged by E. coli-induced inflammation indicates that this enzyme is crucial for elevated prostaglandins production in the inflamed organ.