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PubMed1992

Accuracy in diagnosis of ectopic pregnancy by transvaginal ultrasonography.

Forty patients suspected to have ectopic pregnancy by transvaginal ultrasonography had surgery. 77.5% were confirmed to have ectopic pregnancy and 10% had other abnormal pelvic findings. The transvaginal approach appears to enable us to diagnose ectopic pregnancy at an earlier date, with the earliest diagnosis made at 4 weeks 0 days of amenorrhoea. In cases of confirmed ectopic pregnancy, the presence of a complex adnexal mass was the most common feature seen on transvaginal ultrasound and its predictability of ectopic pregnancy is enhanced by a concomitant finding of an empty uterus (95%) or free fluid in the Pouch of Douglas (94%) in the presence of a positive hCG test. The significance of transvaginal ultrasound features, and the advantages of transvaginal over transabdominal ultrasound, are discussed.

Female↗
PubMed1999

Thermal balloon endometrial ablator: a preclinical safety and effectiveness study.

OBJECTIVE: To evaluate the preclinical safety and efficacy of the thermal balloon endometrial ablator (TBEA). METHODS: Informed consent was taken from all patients for TBEA and hysterectomy at same sitting. TBEA was performed in vivo just before hysterectomy on 6 patients' uteri to determine uterine rupture, perforation and thermal damage to surrounding viscera and peritoneum. Temperatures in the pouch of Douglas, uterovesical peritoneum and serosa of uterus were taken by a sterile laboratory thermometer to note for any rise in temperature before, during and after the procedure. The extirpated uteri were then examined grossly for the nature and extent of thermal damage which was visible as a zone of erythema in the endomyometrium. Five extirpated uteri, 3 from the above group and 2 on whom TBEA was performed 3 months ago were histopathologically examined to study the nature and extent of damage to endomyometrial cells. A 5 mm longitudinal strip of uterus along with both the cornual ends were sectioned in such a way that it was representative of the entire uterus. RESULTS: There was no evidence of uterine perforation, rupture or any damage to the surrounding viscera and peritoneum. There was no rise in temperature in most sites while TBEA was performed. The only area that felt warm was the surface of the uterus and there too the measured rise was only 1 degree C. On gross examination the zone of erythema measured 5.4 mm (mean) (range 3-9 mm). In those uteri subjected to histopathology immediately after TBEA early evidence of thermal damage was visible as hemorrhage, congestion, edema, eosinophilic infiltration and necrosis in 2 out of 3 cases. Late changes of thermal damage after TBEA were seen as basal endometrium and areas of hyalinization. The changes in general were patchy and not uniform. CONCLUSIONS: TBEA is a safe device with no thermal damage to uterus and surrounding viscera. The mean zone of thermal damage in the endomyometrium is 5.4 mm. On histopathology, the early changes of thermal damage are hemorrhage, congestion, edema, eosinophilic infiltration and necrosis and the late changes are visible as areas of hyalinization and presence of basal endometrium.

Adult↗
PubMed1991

A clinical comparison of sonographic hydrotubation and hysterosalpingography.

OBJECTIVE: To assess the value of vaginal sonographic hydrotubation as a preliminary test of uterine configuration and tubal patency in infertility investigation, and to compare this new test with hysterosalpingography. DESIGN: A prospective blind comparison of the two tests in an unselected group of infertile women. SETTING: Hillbrow Hospital, Johannesburg, South Africa. SUBJECTS: Sixty women undergoing routine infertility investigations agreed to participate in the study. There were no refusals. INTERVENTIONS: Within 4 weeks before or after hysterosalpingography sonographic hydrotubation was performed as follows: The uterus and tubes were identified using a 5 MHz vaginal ultrasound probe and between 10 and 20 ml of normal saline were injected into the uterine cavity through an endocervical catheter. MAIN OUTCOME MEASURES: The shape of the uterus and its cavity, the flow of saline through the tubes, the presence of hydrosalpinges before and after injection of saline and the presence of free fluid in the pouch of Douglas. RESULTS: The sonographic and hysterosalpingographic findings were similar in 82% of the women with respect to uterine assessment and in 72% with respect of tubal findings. In seven women (12%) found to have bipolar tubal disease on sonography and cornual block on hysterosalpingography, the sonographic diagnosis was confirmed at laparoscopy. Septate uterus in three women was diagnosed with greater certainty with sonographic hydrotubation. CONCLUSIONS: Sonographic hydrotubation is a simple office procedure which should be used in the preliminary assessment of the uterine cavity and fallopian tubes. Its use will reduce the need for hysterosalpingography and in some cases laparoscopy.

Diagnosis, Differential↗
PubMed1992

Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser.

OBJECTIVE: To present the technique and results of videolaparoscopy and the CO2 laser as a treatment for deep, infiltrative endometriosis of the rectovaginal septum, uterosacral ligaments, pouch of Douglas and anterior wall of the rectosigmoid colon. DESIGN: Observational study with 1-5 year follow up. SETTING: Sub-specialty practice: Endometriosis clinic and centre for special pelvic surgery. SUBJECTS: 185 women, aged 25-41 years. All had pelvic endometriosis and were referred because of the failure of previous medical and/or surgical treatment. INTERVENTIONS: Vaporization and excision of endometriotic implants and nodules, ureterolysis, ureteric stents, laparoscopic anterior rectal wall resection and reanastomosis, presacral neurectomy, laparoscopic hysterectomy, salpingo-oophorectomy and appendicectomy using the CO2 laser. MAIN OUTCOME MEASURES: 174 patients were followed for 1-5 years after surgery by office visit questionnaire or telephone interview. Eleven were lost to follow-up. RESULTS: 175 patients were discharged within 24 h. Nine with bowel perforations and one with a partial bowel resection were discharged 2-4 days postoperatively. Two patients required ureteric stents, which were removed 6 weeks postoperatively without sequelae. 162 women reported moderate to complete pain relief (145 after one procedure, 13 after two and four after three). 12 reported persistent or worse pain following the surgery. Seven eventually underwent total hysterectomy, four had bowel resections and one had a salpingo-oophorectomy. Of 61 with infertility, 25 achieved pregnancy. Postoperative complications included shoulder pain, anterior abdominal wall ecchymosis, urine retention and dyschezia for one to two weeks. CONCLUSIONS: Our experience suggests that rectosigmoid colon and infiltrative rectovaginal septum endometriosis can be effectively treated via videolaparoscopy in the hands of experienced endoscopic gynaecologists.

Adult↗
PubMed1996

Multiple polypoid endometriosis--a rare complication following withdrawal of gonadotrophin releasing hormone (GnRH) agonist for severe endometriosis: a case report.

A 30-year old female who initially had typical endometriosis treated according to a standard regimen later developed numerous highly vascular endometrial polyps on the vagina, cervix, ureter, serosal surfaces of the uterus, pouch of Douglas (POD) and other areas of pelvic peritoneum as well as the endometrium 8 months after withdrawal of treatment with Zoladex gonadotrophin releasing hormone (GnRH) agonist used for treatment of this disease. We postulate that these polyps developed as a rebound phenomenon upon withdrawal of Zoladex. We believe this is the first report of this complication following use of GnRH analogue.

Adult↗
PubMed2006

Lethal outcome in xanthogranulomatous endometritis.

Xanthogranulomatous inflammation is rare, mainly involving the kidneys, while primary xanthogranulomatous endometritis (XE) is a very unusual finding, histologically characterized by partial or complete replacement of the mucosa by granulation tissue with an abundance of foamy histiocytes, siderophages and multinucleated giant cells. We present the case of a 69-year-old woman with a short history of abdominal pain and a palpable mass in the pouch of Douglas. Dilatation of the cervix drained a pyometra. Histological examination of the curettage rendered the diagnosis of XE. Microbiological studies revealed enterococcus spp. and Peptostreptococcus magnus. Despite antibiotic treatment the patient died of heart failure due to systemic inflammation. Autopsy confirmed the diagnosis of XE with transmural extension into the peritoneal cavity. Such a lethal course of XE is extraordinary. Proposed causes of XE include obstruction, infection and hemorrhage. Demonstration of enterococcus spp. and P. magnus supports the probable significance of bacteria in the development of XE. Because this condition may mimic malignant disease macroscopically and histologically, knowledge of XE is of major importance for both pathologists and gynecologists.

Aged↗
PubMed1994

Deeply infiltrating endometriosis is a disease whereas mild endometriosis could be considered a non-disease.

Deeply infiltrating endometriosis can be defined as endometriosis infiltrating deeper than 5 mm under the peritoneal surface. Type I is a conical lesion suggested to be caused by infiltration; type II is mainly caused by retraction of the bowel over the lesion; type III is the most severe lesion suggested to be caused by adenomyosis externa. Severe cases are clinically apparent by nodularities in the pouch of Douglas, whereas mild and subtle forms of deep endometriosis are easily missed. Clinical examination during menstruation and scrutiny at laparoscopy for indurations, followed, preferably, by CO2-laser-excision are the key features for diagnosis and treatment. It is important to realize that depth of infiltration and lateral spread cannot be evaluated by laparoscopic inspection but only during excision, that CA125 concentration but not ultrasound or nuclear magnetic resonance can be helpful in the diagnosis, and that in the most severe cases medical pretreatment is advocated. Results of excision, as evaluated by disappearance of pain in some 80% of women, by a cumulative pregnancy of some 70% and a low recurrence rate, are excellent. The peritoneal fluid is thought to play a key role in the physiopathology of deep endometriosis which is considered to be endometriosis which has escaped from the influence of the peritoneal fluid. This concept is clinically important for the medical treatment of endometriosis, which is suggested to shrink deep lesions and to bring them back under peritoneal fluid control. A model of endometriosis is proposed and discussed. Subtle lesions are considered a natural condition occurring intermittently in all women, whereas we question whether mild endometriosis is a disease. In some women endometriosis has an aggressive behavior and develops into cystic ovarian endometriosis or into deeply infiltrating endometriosis. In this model subtle and mild forms would be called "endometriosis," whereas deep and cystic ovarian forms could be called "endometriotic disease." It is stressed that deep and cystic ovarian endometriosis are two distinct entities, which is important for our understanding of endometriosis, for classification and for treatment of endometriosis.

Endometriosis↗
PubMed2001

Management of deep endometriosis.

Deep endometriosis is defined as an endometriotic lesion that penetrates the retroperitoneal space for a distance of > or =5 mm. Deep endometriosis is extremely active, occurs in phase with eutopic endometrium, evolves progressively with age, and is most often located in the pouch of Douglas, the rectovaginal septum, the uterosacral ligaments, and occasionally in the uterovesical fold. These lesions are associated with pelvic pain, the intensity of which is proportional to the depth of penetration. It is clear that choice of treatment depends on the location of the endometriotic lesion. In this paper we describe our methods for the initial diagnosis and subsequent treatment of deep endometriosis. These include consultation and clinical examination protocols, use of rectal endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), and transvaginal ultrasonography techniques in diagnosis and surgical treatment approaches.

Endometriosis↗
PubMed1985

Penetration of sulbactam-ampicillin and clavulanic acid-amoxicillin into the pelvic peritoneum.

Sixteen patients were given single intravenous injections of ampicillin (0.5 g) with sulbactam (0.5 g), and 15 patients were given amoxicillin (1 g) with clavulanic acid (0.2 g) before elective laparoscopy. At 2 h after dosing, the concentrations of the four compounds in serum and in the peritoneal fluid from the Pouch of Douglas and the ratio of each combination reached levels shown to be effective for antimicrobial activity in vitro.

Adult↗
PubMed2002

Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature.

An athletic 23 year old man presented with suprapubic tenderness, fever, and raised inflammatory blood variables. A diagnostic laparoscopy was performed, with a presumed diagnosis of retrocaecal appendicitis, but no abnormalities were found, apart from free fluid in the pouch of Douglas. Imaging of the pubic area suggested bony infection and inflammation. Biopsy and culture confirmed the presence of Staphylococcus aureus, a very common pathogen. The final diagnosis was osteomyelitis pubis, an infectious disease, and osteitis pubis, an inflammatory disease.

Adult↗
PubMed2000

Extracts from the "clinical evidence". Endometriosis.

DEFINITION: Endometriosis is characterised by ectopic endometrial tissue, which can cause dysmenorrhoea, dyspareunia, non-cyclical pelvic pain, and subfertility. Diagnosis is made by laparoscopy. Most endometrial deposits are found in the pelvis (ovaries, peritoneum, uterosacral ligaments, pouch of Douglas, and rectovaginal septum). Extrapelvic deposits, including those in the umbilicus and diaphragm, are rare. Endometriomas are cysts of endometriosis within the ovary. INCIDENCE/PREVALENCE: In asymptomatic women, the prevalence ranges from 2% to 22%, depending on the diagnostic criteria used and the populations studied. In women with dysmenorrhoea, the incidence of endometriosis ranges from 40% to 60%, and in women with subfertility it ranges from 20% to 30%. The severity of symptoms and the probability of diagnosis increase with age. Incidence peaks at about age 40. Symptoms and laparoscopic appearance do not always correlate. AETIOLOGY: The cause is unknown. Risk factors include early menarche and late menopause. Embryonic cells may give rise to deposits in the umbilicus, while retrograde menstruation may deposit endometrial cells in the diaphragm. Oral contraceptives reduce the risk of endometriosis, and this protective effect persists for up to a year after their discontinuation. PROGNOSIS: We found one small randomised controlled trial (RCT) in which repeat laparoscopy was performed in the women treated with placebo. Over 12 months, endometrial deposits resolved spontaneously in a quarter, deteriorated in nearly half, and were unchanged in the remainder. AIMS: To relieve pain (dysmenorrhoea, dyspareunia, and other pelvic pain) and to improve fertility, with minimal adverse effects. OUTCOMES: American Fertility Society scores for size and number of deposits; recurrence rates; time between stopping treatment and recurrence; rate of adverse effects of treatment. In women with pain: relief of pain, assessed by visual analogue scale and subjective improvement. In women with subfertility: cumulative pregnancy rate, live birth rate. In women undergoing surgery: ease of surgical intervention (rated as easy, average, difficult, or very difficult).

Endometriosis↗