Functional and sexual outcomes following surgical vaginal introital reduction

OBJECTIVE

Surgical introital reduction procedures are commonly performed for the treatment of vaginal laxity (VL), yet poorly studied. The aim of this study was to assess clinical outcomes following surgical vaginal introital reduction for VL.

METHODS

This was an ambidirectional cohort study conducted in a single urogynecology center. All sexually active women who had vaginal introital surgical reduction for VL between March 2015 and September 2020 were included in this study. VL was defined as a genital hiatus distance ≥4cm according to the POP-Q classification, associated with symptoms of laxity. The primary endpoint was sexual health assessed by the Pelvi-Perineal Surgery Sexuality Questionnaire (PPSSQ), while the secondary endpoints included postoperative pain, perioperative complications, rate of dyspareunia, patient satisfaction and success rate based on the Patient Global Improvement Index (PGI-I) and Vaginal Laxity Questionnaire (VLQ).

RESULTS

Of the 27 patients sent the questionnaires, 23 sexually active patients returned the completed ones and were included in the study. Participants had a mean age and BMI of 41 years (range 24-74) and 21.3 (range 17.6-31.9) respectively. The most prevalent preoperative symptom was feeling of VL in 82.6% followed by bulging sensation in 47.8%. Preoperative dyspareunia was reported in 8/23 (34.8%). Surgical interventions involved perineorrhaphy with (n=14) or without (n=9) levator ani plication. The PPSSQ mean sexual health score was 86.7/100 (SD 5.8; range 16.7-93.3) and the mean discomfort and pain score was 27.5/100 (SD 26.0; range 0-80). Postoperative sexuality was reported to better, identical or worse in 16 (69.6%), 2 (8.7%) and 5 (21.7%) patients respectively. On PGI-I, patients reported feeling much better, better, slightly better and no change in 10 (43.5%), 5 (21.7%), 5 (21.7%) and 3 (13.0%) respectively. None of the women reported feeling worse. The overall post-operative complication rate was 3/23 (13.0%), including a perineal hematoma, and two cases of reoperation for narrow introitus. De novo dyspareunia was reported by 11/18 (61.1%) patients, occurring often or more in 4/18 (22.2%) patients, due to narrow introitus (n=2), enlarge introitus (n=1) and vaginal dryness (n=1).

CONCLUSION

Vaginal introital reduction surgery is a viable treatment option for symptoms of vaginal laxity after failure of conservative measures. However, patients should be made aware of the risk of de novo dyspareunia.

LEVEL OF EVIDENCE: 4

Obstetrics and Gynaecology as a Future Career for Medical Graduates in Oman: Factors that attract and discourage graduates

Objectives

Obstetrics and gynaecology (OBGYN) is a major speciality in the medical field that is often demanding yet rewarding; however, OBGYN receives the least number of applicants in Oman. This study aimed to determine the factors that influence graduates in choosing OBGYN as their speciality.

Methods

This cross-sectional questionnaire-based study was conducted from February to March 2017 at Sultan Qaboos University Hospital, Royal Hospital, Khoula Hospital and Al Nahdha Hospital, Muscat, Oman. The questionnaire was distributed to 150 Omani medical graduates (interns and post-intern doctors).

Results

A total of 145 Omani graduates took part in the study (response rate: 96.7%) and the participants' average age was 26 years. Family medicine ranked as the first choice followed by paediatrics and emergency medicine. OBGYN was the first choice for eight female graduates. The top factors attracting male graduates to the OBGYN speciality were its surgical opportunities (80.6%), intellectual content (77.4%), faculty interactions and the opportunity to care for a healthy population (54.8% each); however, the top factors attracting females were the intellectual content (88.6%), patients' desire for female physicians (85.1%), the opportunity to care for a healthy population (76.3%) and cultural expectations (69.5%). The most discouraging factors for male graduates were cultural expectations (100%), the patients' desire for a female physician (93.5%) and the level of stress (71%), while the discouraging factors for female graduates were the level of stress (82.5%), time demands (78.1%), night duties and the length of the residency (71.9% each).

Conclusion

Most of the factors that discourage female graduates from choosing OBGYN are to some extent modifiable. These changes should be considered to encourage the selection of OBGYN as a career by medical students.

[Retrospective study on the isolated strains of Salmonella in an Iranian hospital in Kermanshah]

A survey of occurrence of Salmonella in blood and bone marrow cultures was conducted in 1989-1990 and 1999-2000 (Sina hospital, Kermanshah). A total of 496 (12.3%) and 60 (2.4%) Salmonella strains were isolated (from 4020 and 2447 cultures). In 1989-1990, the isolated strains were: S. typhi 448 (98.5%), S. paratyphi A 40 (8%), S. paratyphi B 5 (1%) and S. paratyphi C 3 (0.5%). In 1999-2000, the isolated strains were S. typhi 59 (98%) and S. paratyphi B 1 (1.5%). There was a 60.9% reduction in the number of specimens over the 2 periods. The rate of Salmonella isolation fell from 12.3% (1989-1990) to 2.4% (1999-2000). There was a 10.2, 8.3 and 6.6 times increase in resistance of S. typhi strains to ampicillin, chloramphenicol and trimethoprim-sulfamethoxazole respectively.

Islet lysosomal enzyme activities and glucose-induced insulin secretion: effects of mannoheptulose, 2-deoxyglucose and clonidine

In previous investigations we have shown a striking relationship between the activity of glycogenolytic glucose producing acid hydrolases in pancreatic islet tissue and certain insulin-releasing processes. In the present investigation we have studied the relation between islet lysosomal enzyme activities and glucose-induced insulin secretion in vitro in the presence of various insulin secretory inhibitors. It was observed that the nonmetabolizable glucose analogue, mannoheptulose (5 mmol/l) did induce a 2-fold increase in insulin release at low (1 mmol/l) glucose, and a total suppression of insulin release at high (16.7 mmol/l) glucose. These changes in the insulin-secretory pattern were accompanied by similar changes in the activity of islet acid alpha-glucosidase. The activities of neutral alpha-glucosidase (endoplasmic reticulum) or acid phosphatase and N-acetyl-beta-D-glucosaminidase (lysosomes) were not affected by mannoheptulose. 2-Deoxyglucose (5 mmol/l), another glucose analogue, did not increase insulin secretion or acid alpha-glucosidase activity at low glucose. At high glucose, however, a partial inhibition of both insulin release (approximately 50%) and acid alpha-glucosidase activity was seen. 2-Deoxyglucose slightly suppressed acid phosphatase activity but did not influence the activities of neutral alpha-glucosidase or N-acetyl-beta-D- glucosaminidase. Direct addition of glucose to islet homogenates showed a suppressive effect on alpha-glucosidase activity at pH 4.0 and 5.0. The glucose analogues displayed only marginal (-10%) inhibition of alpha-glucosidase activity at pH 5.0. No effect of the analogues was seen at pH 4.0.(ABSTRACT TRUNCATED AT 250 WORDS)

Homologous islet amyloid polypeptide: effects on plasma levels of glucagon, insulin and glucose in the mouse

We examined the effects of a single intravenous injection of homologous islet amyloid polypeptide (IAPP) on the plasma levels of glucagon, insulin and glucose in the freely fed mouse. It was observed that IAPP suppressed basal glucagon levels concomitant with a decrease of the blood glucose concentrations. Basal plasma insulin levels were not affected. IAPP did not appreciably modulate the plasma concentration of glucose, insulin or glucagon after an intravenous glucose load. Further, IAPP inhibited the insulin secretory response to beta 2-adrenoceptor stimulation. IAPP also lowered the plasma glucagon levels following beta 2-adrenoceptor stimulation, whereas no apparent effect on plasma levels of glucose was observed. The data suggest that IAPP suppresses glucagon secretion and lowers blood glucose levels in the freely fed mouse. It might also exhibit a negative feedback inhibition on beta 2-adrenoceptor-induced insulin secretion, but has little influence on glucose-induced insulin release. Since IAPP is co-secreted with insulin, it is not inconceivable, that in the freely fed mouse, IAPP may act to amplify the blood glucose lowering effect of insulin through a direct suppression of glucagon secretion via the islet microcirculation.

Effect of the lysosomotropic drug suramin on islet lysosomal enzyme activities and the insulin-secretory response induced by various secretagogues

The trypanocidal drug suramin is known to concentrate in lysosomes and to depress the activity of different lysosomal enzymes. We have previously shown that suramin can inhibit the activity of the islet lysosomal enzyme acid amyloglucosidase, a glycogenolytic glucose-producing hydrolase, which seems to be involved in certain insulin-secretory processes. In the present investigation we studied the pH dependency and dose-response effects of suramin on islet lysosomal enzyme activities as well as the effect of suramin treatment on the insulin-secretory response to various secretagogues in mice. It was found that two injections of suramin (0.18 mmol/kg) to normal NMRI mice at -24 and -2 h induced a moderate depression of the activities of islet acid amyloglucosidase (-22%) and acid phosphatase (-13%), whereas no effect was recorded for the activities of acid alpha-glucosidase, N-acetyl-beta-D-glucosaminidase and the non-lysosomal enzyme neutral alpha-glucosidase. Direct addition of different concentrations of suramin to islet homogenates showed that the drug was a potent inhibitor of acid amyloglucosidase and acid alpha-glucosidase at pH 4.0. At pH 5.0, suramin induced a large increase in acid alpha-glucosidase activity, whereas acid amyloglucosidase and acid phosphatase were inhibited. Suramin-injected mice showed a reduced insulin-secretory response to the sulphonylurea drug glibenclamide (-45%), whereas the insulin response to the cholinergic agonist carbachol or the phosphodiesterase inhibitor IBMX (1-isobutyl-3-methylxanthine) was unaffected. It is concluded that suramin inhibits islet acid amyloglucosidase activity in vivo and in vitro, whereas its effect on acid alpha-glucosidase is complex and pH dependent.(ABSTRACT TRUNCATED AT 250 WORDS)