A 24-year-old patient with paraplegia and acquired urethral diverticulum: a case report

Urethral diverticulum is a rare pathology in male patients. It is most often encountered in patients with paraplegia due to iterative catheterizations. The diagnosis of a large diverticulum is easy to make when faced with clinical symptoms, such as: repeated urinary tract infections, perineal pain and especially when there is penile swelling. We report the case of a 24-year-old patient with paraplegia and urethral diverticulum. In this case, the issue lies in the therapeutic possibilities.

[Which is the method of choice for evaluating uterine cavity in infertility workup?]

Uterine factors represent only 2 to 3 % of infertility, but intra-uterine lesions are much more common in infertile women (40-50 %). These lesions can interfere with spontaneous fertility and can compromise pregnancy rates in assisted reproduction. Exploration of the uterine cavity is actually one of the basic explorations in infertility workup. Classically, hysterosalpingography and transvaginal sonography are most communally used for this purpose. Hysteroscopy, with the development and miniaturization of equipment, is currently simple, outpatient cost-effective exploration and it is considered the gold standard for diagnosis of intrauterine lesions. However, the benefit of the systematic use of hysteroscopy in the initial assessment of infertility remains unclear and the exploration of the uterine cavity in the initial assessment of infertility should be based on hysterosalpingography or hysterosonography. Systematic hysteroscopy before IVF is widely accepted practice that is supposed to improve pregnancy rates but still lacks scientific evidence. After repeated implantation failure in IVF cycles, uterine cavity should be reevaluated by hysteroscopy and this practice has been demonstrated to improve pregnancy rates.

Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause

BACKGROUND

Normal menstrual periods last 3-6 days and involve blood loss of up to 80ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years.

INVESTIGATION

A blood count for red cells+platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure.

TREATMENT

In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes.

[An unusual paraneoplastic manifestation in lung cancer: eosinophilic erythroderma]

An 81-year-old man was admitted for generalized weakness, erythrodermia and eosinophilia. His chest CT showed nodules related to lung adenocarcinoma. Chemotherapy induced a tumour response with the disappearance of the erythrodermia and eosinophilia. A tumour relapse indicating the recurrence of the erythrodermia and eosinophilia was confirmed 2 months after completion of the chemotherapy. The outcome was rapidly fatal. The evolution of the symptoms suggests that eosinophilic erythrodermia is a paraneoplastic syndrome. Cutaneous paraneoplastic syndromes are rare but may be associated with lung cancer.

Les hémorragies utérines fonctionnelles

Dysfunctionnal uterine bleeding (DUB) is a significant health problem in premenopausal women. First line therapy is traditionally medical therapy but often ineffective. Hysterectomy is obviously effective in stopping bleeding but is associated with morbidity and is most costly. Endometrial ablation technique is becoming the first conservative line in the management of DUB. In 2007, the Cochrane Data Base, and the NICE published the new guidelines for DUB treatment. Pharmaceutical treatments should be considered in the following order: levonorgestrel-releasing intra uterine system and if hormonal treatment is not acceptable, tranexamic acid can be used. This is the exclusive line of treatment for women who desire to be pregnant, and the first step for the others one. The rapid development of second generation technique of endometrial destruction suggests that these techniques are becoming "the gold standart" for the patients without desire of future pregnancy. These techniques are easier that endometrial resection/ablation by hysteroscopy without major complications. In France, the National Health Insurance must find a codification CCAM for giving an exact price to the procedure. This new tarification could include the device cost and could avoid either inefficient procedure like datation and curetage or morbide procedure like hysterectomy.

[Vaginal mesh extrusion after transvaginal repair of cystocele using a prosthetic mesh: Treatment and functional outcomes]

OBJECTIVE

To describe management of vaginal mesh erosion following transvaginal repair of acystocele by placement of a polypropylene mesh.

MATERIALS AND METHOD

Retrospective analysis of 34 consecutive cases of vaginal mesh erosion following transvaginal repair of cystocele using synthetic mesh (Gynemesh or Gynemesh-Soft). We have analyzed the results of both medical and surgical management of this complication. Furthermore, we also assessed sexual and urinary morbidity in women with mesh erosion (n = 34) and in women who had undergone the same procedure but without mesh erosion (n = 111).

RESULTS

Among the 34 patients with vaginal mesh erosion, 23 (68%) have undergone local therapy using Colposeptine (Chlorquinaldol + Promestriène). In 12 (52%) cases no modification of the surface of the erosion was observed. In 6 (26%) cases, a decrease of the surface of the mesh erosion was observed. In 5 (22%) cases the mesh erosion had completely disappeared, with a follow-up of 2 to 9 months. Nineteen symptomatic patients (19/32, 59%) required partial (n = 18) or complete (n = 1) excision of the mesh, associated with vaginal mucosal closure, under general anaesthesia. Duration of operation ranged from 15 to 40 minutes for partial excision of the mesh. This procedure was successful in 14 cases (77%). Four women required repeated resection of the mesh because of recurrence. The incidence of de novo dyspareunia was 12% in patients with vaginal mesh erosion, and 11% in patients without mesh erosion (p = 0.81). The incidence of urge urinary symptoms and voiding dysfunction symptoms was respectively 8% versus 9% (p = 0.95), and 8% versus 10% (p = 0.81) in the 2 groups.

CONCLUSION

Management of vaginal mesh erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal erosion of the mesh can occur.

Essure®sterilization associated with endometrial ablation

OBJECTIVE

To evaluate the feasibility and the outcome of Essure sterilization associated with different techniques of endometrial ablation.

METHOD

Retrospective study conducted among 23 women with confirmed menometrorrhagia and with the desire for or the medical need for permanent tubal sterilization. Patients underwent combined hysteroscopic placement of Essure and hysteroscopic endometrial resection procedures: ThermaChoice (n=14), NovaSure (n=4), Hydrothermablator (n=2) and endometrial resection using monopolar energy (n=1), or bipolar energy (n=2).

RESULTS

Fallopian tubes were successfully cannulated bilaterally in 87% of the cases (20/23). No adverse event was reported. Adequate bilateral occlusion was confirmed for all patients (20/20) by 3D ultrasound and pelvic X-ray at a 3-month follow-up. Furthermore, 85% of these patients were satisfied with the results of the procedure, all experiencing a significant reduction in menstrual blood loss (Higham blood loss score).

CONCLUSION

Combining EA and hysteroscopic sterilization seems to be feasible and efficient in patients with menometrorrhagia.