Chronic vulvar pain in gynecological outpatients.

OBJECTIVES: Chronic vulvar pain (CVP) is pain in the vulvar area exceeding three months of duration. Previous studies have reported a prevalence of 7-8% in the general population and observed an association between CVP and other chronic pain, affective disorders and early life stressors. The aim of this study was to estimate the prevalence of CVP among gynecological outpatients and to explore its association with child sexual abuse, comorbid fibromyalgia and mental health. METHODS: We conducted a questionnaire-based cross-sectional study among consecutive women attending an unselected general gynecological outpatient clinic at St Olav's University Hospital, Trondheim, Norway, during the period August 1st, 2017, to June 30th, 2018. CVP was defined as having experienced either vulvar burning, sharp pain or allodynia for three months or more within the previous year. Fibromyalgia was defined as widespread pain in the past six months in conjunction with a symptom severity score ≥5 on the fibromyalgia symptom severity score inventory, an ordinal scale from zero to 12. We collected information on sexual coercion experience and assessed mental health with the mental health inventory (MHI-5) of the SF-36 health survey, which yields a zero to five scale. RESULTS: Of 1,125 questionnaires distributed, 810 (72%) were returned, and 762 (68%) included in final analyses. Among these, 130 (17.1%) reported CVP within the previous year and 92 (16.7%) were classified as suffering from fibromyalgia. Fibromyalgia was associated with CVP (adjusted OR of 1.8, 95% CI 1.1-3.1). Child sexual abuse was reported by 96 (13.1%) and was associated with CVP (adjusted OR 2.0, 95% CI 1.2-3.3). CVP and fibromyalgia were both associated with lower mental health scores; 0.51 and 0.58 points on the MHI-5 scale, respectively. CONCLUSIONS: Chronic vulvar pain is common among women in a gynecological outpatient clinic and associated with child sexual abuse, comorbid fibromyalgia and worse mental health. Ethical committee number: REK Midt No. 2016/2150.

The Vaginal Microbiome: III. The Vaginal Microbiome in Various Urogenital Disorders.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "Candida," "vaginitis," "urinary microbiome," "recurrent urinary tract infections," "sexually transmitted infections," "human immunodeficiency virus," "human papillomavirus," "nonspecific vaginitis," "vulvodynia," and "vulvovaginal symptoms." Full article texts were reviewed. Reference lists were screened for additional articles. The third article in this series describes VMB in various urogenital disorders. RESULTS: Variable patterns of the VMB are found in patients with vulvovaginal candidiasis, challenging the idea of a protective role of lactobacilli. Highly similar strains of health-associated commensal bacteria are shared in both the bladder and vagina of the same individual and may provide protection against urinary tract infections. Dysbiotic VMB increases the risk of urinary tract infection. Loss of vaginal lactic acid-producing bacteria combined with elevated pH, increase the risk for sexually transmitted infections, although the exact protective mechanisms of the VMB against sexually transmitted infections are still unknown. CONCLUSIONS: The VMB may constitute a biological barrier to pathogenic microorganisms. When the predominance of lactobacilli community is disrupted, there is an increased risk for the acquisition of various vaginal pathogents. Longitudinal studies are needed to describe the association between the host, bacterial, and fungal components of the VMB.

The Vaginal Microbiome: IV. The Role of Vaginal Microbiome in Reproduction and in Gynecologic Cancers.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "reproduction," "infertility," "fertility," "miscarriages," "pregnancy" "cervical cancer," "endometrial cancer," and "ovarian cancer." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: The fourth article of this series focuses on 2 distinct areas: the role of VMB in various aspects of human reproduction and, in sharp contrast, the association between the VMB and gynecologic malignancies. Several of the negative pregnancy outcomes have been associated with an altered VMB. Dysbiosis is remarkably linked with poor pregnancy outcomes from preconception to delivery. The associations between the microbiome and gynecologic cancers are described. CONCLUSIONS: The development of the microbiome research, enabled by molecular-based techniques, has dramatically increased the detection of microorganisms and the understanding of bacterial communities that are relevant to maternal-fetal medicine in health and disease, as well as in gynecological malignancies. Proving causation in cancer is difficult because of the complex interactive nature of potential causative factors. Certain elements of the microbiota have been shown to provoke inflammatory reactions, whereas others produce anti-inflammatory reactions; this balance might be impaired with a change in microbial variety.

Diagnosing Sexual Dysfunction in Men and Women: Sexual History Taking and the Role of Symptom Scales and Questionnaires.

INTRODUCTION: A detailed sexual history is the cornerstone for all sexual problem assessments and sexual dysfunction diagnoses. Diagnostic evaluation is based on an in-depth sexual history, including sexual and gender identity and orientation, sexual activity and function, current level of sexual function, overall health and comorbidities, partner relationship and interpersonal factors, and the role of cultural and personal expectations and attitudes. AIM: To propose key steps in the diagnostic evaluation of sexual dysfunctions, with special focus on the use of symptom scales and questionnaires. METHODS: Critical assessment of the current literature by the International Consultation on Sexual Medicine committee. MAIN OUTCOME MEASURES: A revised algorithm for the management of sexual dysfunctions, level of evidence, and recommendation for scales and questionnaires. RESULTS: The International Consultation on Sexual Medicine proposes an updated algorithm for diagnostic evaluation of sexual dysfunction in men and women, with specific recommendations for sexual history taking and diagnostic evaluation. Standardized scales, checklists, and validated questionnaires are additional adjuncts that should be used routinely in sexual problem evaluation. Scales developed for specific patient groups are included. Results of this evaluation are presented with recommendations for clinical and research uses. CONCLUSION: Defined principles, an algorithm and a range of scales may provide coherent and evidence based management for sexual dysfunctions.

Self-reported pelvic organ prolapse surgery, prevalence, and nonobstetric risk factors: findings from the Nord Trøndelag Health Study.

INTRODUCTION: The aim of this study was to assess prevalence and risk factors of self-reported pelvic organ prolapse (POP) surgery in a Nordic county. METHODS: We assessed cross-sectional data collection from participants in the Nord-Trøndelag Health Study in 2006-2008. All women in the county ≥30 years were eligible, of whom 20,285 (50.3 %) responded by completing questionnaires and attending screening stations. Outcome measures were self-reported POP surgery, age at survey, sociodemographic factors, and information on selected risk factors for POP: self-reported smoking, chronic obstructive pulmonary disease (COPD), asthma, constipation a decade prior, and measured body mass index (BMI). Descriptive statistics, Kaplan-Meier estimates, and multivariate logistic regression were used. Statistical significance was defined as p ≤ 0.01. RESULTS: POP surgery was reported by 1,123 (5.3 %) of all women: 0.7 % < age 40, 3.1 % between age 40 and 59, and 10.8 % age >60. Cumulative incidence by age 85 was 14.6 %; mean age at surgery was 51.6 [standard deviation 14.7]. After adjustment for sociodemographic and lifestyle factors, odds ratios (OR) with 99 % confidence intervals (CI) for reporting the need for POP surgery were marked constipation 1.83 (1.30-2.56), BMI categories above normal 1.58-1.64 (1.10-2.25), COPD 1.51 (1.06-2.16), occupation involving lifting compared with sitting 1.40 (0.98-2.01), and asthma 1.25 (0.98-1.59). Cigarette smoking was not significantly associated. CONCLUSION: Prevalence of self-reported POP surgery was high and increased with age. Constipation reported a decade prior, above-normal BMI, and COPD were significant nonobstetric risk factors.

Male sexual function and pelvic floor surgery of their female partner: A one-year follow-up study.

OBJECTIVE: The aim of this study was to examine if sexual function of male partners changed after surgery for pelvic floor disorders and to explore associated factors. STUDY DESIGN: This was an observational follow-up study at the Gynecological Department at the St Olavs University Hospital, Trondheim. The sample consisted of 35 male partners of women scheduled for pelvic organ prolapse or stress urinary incontinence surgery. Self-administered questionnaires, containing validated instruments as well as exploratory questions, were sent to women and their partners before and one year after pelvic floor surgery. Vaginal dimensions were measured in all women according to the Pelvic Organ Prolapse Quantification System, both before and after the surgery. MAIN OUTCOME MEASURES: The Brief Sexual Function Instrument and the presence of erectile dysfunction. RESULTS: One year after pelvic floor surgery, scores for sexual drive, erection and overall satisfaction from the Brief Sexual Function Instrument were unchanged; the ejaculation score (range 0-4) had mildly improved from a range of 4 (median 4) to a range of 3.5 (median 4), (p = 0.014). The proportion of men with erectile dysfunction was unchanged, while the proportion of men reporting vaginal wind had significantly decreased (p = 0.016). None of the baseline factors, subjective experiences or vaginal dimensions at baseline or follow-up were associated with the improved ejaculation score; only a reduction in the proportion of men reporting their partners with dyspareunia (ns) was significantly correlated (Spearman's rho 0.42, p = 0.019). CONCLUSION: Sexual function of male partners was unchanged or mildly improved after pelvic floor surgery.

Effects of Hysterectomy on Sexual Function.

Hysterectomy remains the most common major gynecological surgery. Postoperative sexual function is a concern for many women and their partners. In this respect, a beneficial effect of hysterectomy for benign disease independent of surgical techniques or removal of the cervix has been demonstrated in the past decade by the majority of studies. For about 20 % of women, deteriorated sexual function has been reported and current research is attempting to identify mechanisms and predictive factors explaining these postoperative changes. Alternative treatments of benign uterine disorders or uterus preserving surgery for genital prolapse appeared to have similar outcomes in terms of sexual function. Concomitant oophorectomy had negative effects on sexual function and long-term health, particularly in premenopausal women. This may not be reversed by estrogen replacement. Hysterectomy performed for malignancy had a detrimental effect on sexual function. Individualized risk assessment and information should be aimed at during preoperative decision making.

What predicts improvement of sexual function after pelvic floor surgery? A follow-up study.

OBJECTIVE: To analyze factors predictive for changes in sexual function after pelvic floor surgery and explore differences between stress urinary incontinence (SUI) and pelvic organ prolapse (POP) surgery. DESIGN: Prospective observational study. SETTING: St Olav Hospital, Trondheim University Hospital, Norway. SAMPLE: Of 346 mailed questionnaires for women scheduled for SUI and POP surgery, 65 questionnaires were available for analysis together with examination findings before and 1 year after surgery. METHODS: Postal questionnaires including Prolapse and Incontinence Sexual Function Questionnaire (PISQ 12), Hopkins Symptom Checklist 5 for psychological distress, questions from the validated Body Image Questionnaire, a general health question, questions addressing goals for improvement after surgery, clinical findings based on the Pelvic Organ Prolapse Quantification System and Brief Sexual Function Index for partners. Uni- and multivariate linear regressions adjusting for age were performed. MAIN OUTCOME MEASURES: Change in PISQ 12 score at follow-up. RESULTS: Sexual function significantly improved in the total group (p = 0.000). After stratification into SUI and POP surgery, improvement only remained significant after SUI surgery (p = 0.001). Improvement for the total group was predicted by good health or coital incontinence, whereas psychological distress or the goal of improved defecation predicted deterioration. For women undergoing SUI surgery, increasing age, parity or the goal of improving sexuality or body image predicted improvement, while for women undergoing POP surgery, menopausal status or anterior colporrhaphy predicted improvement. CONCLUSION: Significantly improved sexuality was observed after pelvic floor surgery. Predictive factors for change differed for women undergoing SUI surgery and and those undergoing POP surgery.

Sexual experience of partners after hysterectomy, comparing subtotal with total abdominal hysterectomy.

BACKGROUND: There is a lack of knowledge about partners' sexual experience after hysterectomy. The aim of this study was to explore potential differences in the experience of sexual intercourse by the partner, related to the operation method (subtotal versus total abdominal hysterectomy). METHOD: Of all patients having undergone abdominal hysterectomy for benign indications at St Olav Hospital, Trondheim between February 2001 and March 2003, Norway, 120 patients (60 total, 60 subtotal abdominal hysterectomy) were identified. Each patient and partner received a postal questionnaire addressing sexuality in connection with the operation. RESULTS: Of the 240 questionnaires, 111 were returned, a response rate of 46%. Among partners of women having undergone total hysterectomy, proportionally more noticed during sexual intercourse that the uterus had been removed (12%) compared to partners of women having undergone subtotal hysterectomy (4%); this was not significant and all of these partners experienced this as positive. Sexual satisfaction was improved or unchanged in most women and their partners, regardless of operation type. Partners who reported poor satisfaction before the operation were significantly more likely to report poor satisfaction after the operation. A high proportion of partners in both hysterectomy groups had not discussed sexuality in relation to the surgery either before or after the operation (subtotal: 44%; total: 24%; not significant). CONCLUSION: The majority of women and their partners reported no negative impact on sexual satisfaction after abdominal hysterectomy, regardless if subtotal or total. The only predictor of negative sexual experience of partners after hysterectomy was negative sexual experience before hysterectomy.

[Female circumcision--complications and treatment]. / Omskjaering av kvinner--komplikasjoner og behandling.

The majority of women with extensive forms of genital cutting develop one or more chronic complications such as dysmenorrhea, dyspareunia, pain and cysts in the perineum, vaginal obstruction with haematocolpos, relative urine retention and recurrent urinary tract infections. Extensive forms of circumcision also influence childbirths. The severity of the cutting is associated with the probability of developing later complications. The women's clinics at the regional hospital in Norway have established outpatient clinics to receive women with complications after genital cutting. The aim was to develop an adequate health service to the affected. In order to improve the access to care and to ensure anonymity the women may refer themselves. During 2004, a total of 60 women were treated. The majority suffered from poor urinary flow, pain at micturition, dysmenorrhea and dyspareunia. Reconstruction of the vaginal orifice was performed to relieve some of the discomforts. The numbers of women who visit the clinics are increasing. The surgical procedure itself is not technically difficult, but the consultation before and after the surgery require cultural sensitivity. As health care personnel we can influence the affected to realise that genital cutting is an assault against a small girl. Norwegian health care workers need to learn more about how to communicate well about the medical as well as the cultural and mental aspects of genital cutting.