Comparing the effectiveness of functional electrical stimulation via sexual cognitive/behavioral therapy of pelvic floor muscles versus local injection of botulinum toxin on the sexual functioning of patients with primary vaginismus: a randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: Most patients suffering from vaginismus feel sinful, anxious, and incompetent, with reduced self-confidence. This study was aimed at comparing the effectiveness of the physiotherapy of pelvic floor muscles as a standard treatment and local injection of botulinum toxin on the sexual functioning of patients with primary vaginismus. METHODS: In this randomized clinical trial (RCT), the study population included women with primary vaginismus referred to the Sexual Health and Gynecologic Clinics of Imam Khomeini Hospital during 2013-2014. They were diagnosed according to DSM-5 criteria and underwent treatments with botulinum injection (intervention group) and physiotherapy as the current treatment (control group). The participants' primary and secondary outcomes were measured based on successful intercourse and sexual functioning of each group. RESULTS: The results indicated that the overall standard physiotherapy, along with other measurements, such as functional electrical stimulation and desensitization, could effectively improve the patients' Female Sexual Function Index compared with botulinum treatment. At the end of the study, it was found that 20 and 26 patients out of the 30 and 28 patients in the intervention and control groups managed to have successful intercourse respectively (P = 0.014). Also, sexual dysfunction frequencies were seen to be decreased by 26.6% and 50% in the mentioned groups respectively (p = 0.008 and p < 0.001). CONCLUSIONS: Considering the higher efficacy of physiotherapy procedures compared with those of the desensitization and electrical stimulation techniques, this therapeutic method should be considered the first-line treatment of vaginismus (IRCT2016061828486N1).

A randomized clinical trial to compare levonorgestrel-releasing intrauterine system (Mirena) vs trans-cervical endometrial resection for treatment of menorrhagia.

OBJECTIVE: To compare the acceptability, efficacy, adverse effects, and user satisfaction of the levonorgestrel intrauterine system (LNG-IUS) and trans-cervical resection of the endometrium (TCRE) for the treatment of menorrhagia. METHOD: 104 women with menorrhagia were divided into 2 groups: 52 women had the LNG-IUS inserted and 52 underwent TCRE. Menstrual pattern, pictorial blood loss assessment chart score, adverse effects, and rates of acceptability and satisfaction, were recorded at 6 and 12 months after the procedure. RESULTS: After a year there were reductions of 93.9% and 88.4% in menstrual blood loss in the TCRE and LNG-IUS groups, respectively. Amenorrhea was more common in the TCRE group and spotting and systemic effects in the LNG-IUS group. Satisfaction rates of the TCRE group were higher than the LNG-IUS group (80.8% vs 69.2%), but the difference was not statistically significant. CONCLUSION: Although both treatments were found to be equally effective, LNG-IUS was less invasive and can be advised for younger women with a desire to preserve fertility.

Human papilloma virus infection in female kidney transplant recipients.

The objective of this study was to evaluate the incidence of genital human papilloma virus (HPV) infection and cervical intra-epithelial lesions in transplanted patients. Cervical Papanicolaou (Pap) smear/HPV test and colposcopic examinations were performed in 58 patients who were candidates for renal transplant surgery; these tests were repeated one year later. Their age range was 26-53 years (mean, 37.2 years). Hypertension was the most common cause of renal insufficiency (34.4%), while in 41.4% of the patients, the causative pathology was unknown. In 24.1% of the patients, there was no history of dialysis, i.e. they had pre-emptive transplantation. The mean duration of marriage (years since first intercourse) was 16.2 years (range, 1-35). Coitus interruptus was the most common contraceptive method used (37.9%), followed by tubal ligation and condom (10.3% and 6.9%, respectively). All patients had negative Pap tests and normal gynecologic exam before undergoing transplantation. The Pap test remained normal after transplant surgery, although the HPV test became positive in four patients (6.9%). There were five cases of white epithelium on colposcopy, but biopsy showed normal metaplasia. Two cases of extensive anogenital warts were treated by CO 2 laser, and one patient had recurrent warts, which responded well to second laser surgery. None of the study patients had squamous intra-epithelial lesions (SIL) or vulvar intra-epithelial neoplasia. Our study suggests that screening with HPV and Pap test should be performed before transplant surgery and should be repeated at regular intervals in order to avoid irreversible situations such as high-grade SILs, which are difficult to treat. Avoiding high-risk sexual relations in this group of patients is highly recommended.

Stress urinary incontinence: pre-pregnancy history and effects of mode of delivery on its postpartum persistency.

INTRODUCTION AND HYPOTHESIS: We aimed to determine the prevalence of mild stress urinary incontinence (SUI) 1 year postpartum in relation to mode of delivery and pre-pregnancy SUI. METHODS: This cohort study was performed on 618 primiparous women who delivered by elective cesarean section and NVD. Development of SUI during pregnancy till 12 months after delivery was studied. Frequency of mild SUI among patients with and without pre-pregnancy SUI was compared at the ante-partum (RR, 5.75), 40 days postpartum (RR, 9.3), 3 months postpartum (RR, 10.1), 6 months postpartum (RR, 10.1), and 12 months postpartum (RR, 16.8). RESULTS: Regarding the mode of delivery, incidence of SUI showed significant difference at 40 days, 3 and 6 months postpartum in both patients with and without pre-pregnancy history of SUI (P<0.05, all groups). CONCLUSION: The mode of delivery had significant effect on the persistency of SUI up to 6 months postpartum, while pre-pregnancy SUI revealed such effect till 1 year.

Sexual and reproductive function in end-stage renal disease and effect of kidney transplantation.

Advanced chronic kidney disease is associated with impaired spermatogenesis and testicular damage. Semen analysis typically shows a decreased volume of ejaculate, oligo- or complete azoospermia, and a low percentage of motile sperm. Erectile dysfunction (ED) is also common in patients with chronic renal failure (CRF) and is observed in excess of 50% of these patients. There have been ongoing improvements in survival and quality of life after renal transplantation. One of the most impressive aspects of successful renal transplantation in the young people is the ability of the male patient to father a child. In this article we first review pathophysiology of reproductive failure in end-stage renal disease (ESRD), then ED in ESRD and its management are discussed, finally sexual function in renal transplant patients and management of ED in these patients are reviewed.

Infertility among kidney transplant recipients.

We studied 122 women with a transplanted kidney to evaluate their reproductive performance. 15 of the patients were either post-menopausal or underwent hysterectomy and 33 were unmarried. Of the 76 married reproductive age women, 10 (13.1%) were infertile. Three had male factor infertility, three had ovulatory problems and in four cases, the cause was uncertain. Six of these patients were actively treated by ovulation induction with or without IUI and two of these patients became pregnant. The remaining four patients refused treatment for infertility. We conclude that the incidence of infertility among kidney transplant recipients is similar to the general population, but they are less motivated to be treated for infertility.

Reproduction in women with end-stage renal disease and effect of kidney transplantation.

Menstrual problem is common among women with chronic kidney disease, and patients with end-stage renal disease usually have amenorrhea. The rate of pregnancy in women on dialysis is low. Fetal survival in this population has improved, with half of such pregnancies resulting in delivery of a live infant. However, prematurity remains common and accounts for the low-birth weight of these infants. Intensifying hemodialysis by increasing the frequency of treatments is associated with longer gestation and increased likelihood of a successful pregnancy. Intense hemodialysis also improves the control of maternal intravascular volume and reduces the risk of hypotension due to excessive ultrafiltration. Women with chronic kidney disease tend to experience decreased libido and reduced ability to reach orgasm. Sexual difficulties in uremic patients are often worsened by hemodialysis, with a lowered frequency of intercourse, reduced sexual desire, and an increased incidence of sexual failure. There have been ongoing improvements in survival and quality of life after kidney transplantation. In most patients, sexual desire increases significantly after successful transplantation; however, improvement in the frequency of sexual activity and the overall sexual satisfaction is not as high as that in sexual desire. These have been accompanied by an improvement in reproductive function. Pregnancy success rate exceeds 90% after the first trimester in women with kidney transplant. Contraceptive counseling should be provided before transplantation, because ovulatory cycles may begin within 1 to 2 months after transplantation in women with functioning grafts. Breastfeeding is discouraged for patients taking any immunosuppressive drugs.

Botulinum toxin in the treatment of refractory vaginismus.

OBJECTIVE: To investigate the efficacy of botulinum toxin injection to treat women with moderate and severe vaginismus. METHODS: Twenty-four women referred to our clinic from February 2002 to February 2004 (mean age 25 years; range 19-34 years) with third- to fourth-degree vaginismus were recruited for this study. These women had previous unsuccessful treatments. Botulinum toxin (150-400 mIU) was injected into the puborectalis muscles in 3 sites on each side of the vagina. RESULTS: Twenty-three patients (95.8%) had vaginal examinations 1 week postoperatively that showed little or no vaginismus, 18 (75%) achieved satisfactory intercourse after the first injection, 4 (16.7%) had mild pain, 1 was cured after a second injection, 1 patient refused vaginal examination and did not attempt to have coitus, and another had no coitus as a result of her husband's secondary impotence. The women were followed up for a mean of 12.3 months (range 2-24 months), and there were no cases of recurrence. CONCLUSION: In refractory cases of vaginismus when conventional therapies have failed, local injection of botulinum toxin can be considered. LEVEL OF EVIDENCE: III.

Relationship between increased blood lead and pregnancy hypertension in women without occupational lead exposure in Tehran, Iran.

This study was conducted to assess the relationship between blood lead levels and pregnancy-induced hypertension. Participants were 110 pregnant women, of whom 55 were hypertensive, 27 +/- 5.6 yr of age (mean +/- standard deviation) (range = 17-40 yr); the other 55 women were age- and gravidity-matched normotensive controls. Participants were selected on the basis of their medical history and the results of a questionnaire-based interview. Subjects were at gestational ages 37 +/- 2.5 wk (range = 30-41 wk) and were not occupationally exposed to lead. Blood samples were collected within 24 hr after delivery, and blood lead levels were measured. For the hypertensive cases, blood lead levels were 5.7 +/- 2 microg/dl (range = 2.2-12.6 microg/dl [0.27 +/- 0.10 micromol/l; range = 0.11-0.60 micromol/l]), which were significantly higher than those of the control group (i.e., 4.8 +/- 1.9 microg/dl; range = 1.9-10.6 microg/dl [0.23 +/- 0.09 micromol/l; range = 0.09-0.51 micromol/l]). There were no significant differences in blood lead concentrations among hypertensive subjects with proteinuria (n = 30) and those without proteinuria (n = 25). Results of this study indicated that low-level lead exposure may be a risk factor for pregnancy hypertension.