Colleen M. Kennedy

Constipation in pregnancy: prevalence, symptoms, and risk factors

OBJECTIVE: To prospectively estimate constipation prevalence and risk factors in pregnancy. METHODS: We enrolled healthy pregnant women in this longitudinal study during the first trimester. At each trimester and 3 months postpartum, participants completed a self-administered bowel symptom questionnaire, physical activity and dietary fiber intake measures, and a prospective 7-day stool diary. Constipation was defined using the Rome II criteria (presence of at least two of the following symptoms for at least one quarter of defecations: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual maneuvers to facilitate defecation, and fewer than three defecations per week). Generalized linear logistic models explored factors associated with constipation during pregnancy. RESULTS: One hundred three women were enrolled with mean (±standard deviation) age of 28 (±5) years; 54% were nulliparous and 92% white. Constipation prevalence rates were 24% (95% confidence interval [CI] 16–33%), 26% (95% CI 17–38%), 16% (95% CI 8–26%), and 24% (95% CI 13–36%) in the first, second, and third trimesters and 3 months postpartum, respectively. Additionally, irritable bowel syndrome (by Rome II criteria) prevalence rates were 19% (95% CI 12–28%), 13% (95% CI 6–23%), 13% (95% CI 6–23%) and 5% (95% CI 1–13%) in the first, second, and third trimesters and 3 months postpartum, respectively. In multivariable longitudinal analysis, iron supplements (OR 3.5, 95% CI 1.04–12.10) and past constipation treatment (OR 3.58, 95% CI 1.50–8.57) were associated with constipation during pregnancy. CONCLUSION: Constipation measured using the Rome II criteria affects up to one fourth of women throughout pregnancy and at 3 months postpartum. LEVEL OF EVIDENCE: II

Risk factors for painful bladder syndrome in women seeking gynecologic care

The aim of this cross-sectional study was to report risk factors for painful bladder syndrome in women. We surveyed 645 women presenting for care to general gynecology clinics and a vulvar specialty clinic using a standardized questionnaire and validated outcome measures. We used two definitions for painful bladder syndrome, based on the O‘Leary–Sant interstitial cystitis symptom and problem indices. Of those women surveyed, 29.5% met broader criteria and 8.5% met more restrictive criteria for painful bladder syndrome. After adjusting for confounders, bladder pain was significantly associated with current smoking, irritable bowel syndrome, and a generalized pain disorder. Tobacco use, the only modifiable association noted on multivariate analysis, has not been previously identified to our knowledge.

Prevalence of vulvar and vaginal symptoms during pregnancy and the puerperium

To identify the prevalence of vulvar and vaginal symptoms during pregnancy and at 3 months post partum.

New approaches to external genital warts and vulvar intraepithelial neoplasia.

Human papillomavirus is the most common sexually transmitted disease in the United States. For the majority of affected individuals, the virus remains subclinical. However, human papillomavirus infection may result in a broad spectrum of vulvar disease including genital warts, dysplasia, and invasive carcinoma. We review the evaluation and currently available therapies to assist in patient management.

Vulvar granuloma fissuratum: A description of fissuring of the posterior fourchette and the repair

OBJECTIVE: To describe the characteristics of women who experience chronic fissuring of the posterior fourchette and the outcome of treatment administered. METHODS: We conducted a retrospective review of 42 women with granuloma fissuratum presenting for care between January 1, 1995, and December 31, 2003. Women underwent medical management first, and if improvement was minimal, perineoplasty was recommended. Dyspareunia and vulvar symptom scores, including itching, burning, and pain, before and after treatment were compared. RESULTS: Twenty women were managed nonoperatively, while 22 women underwent perineoplasty. The median age at diagnosis of granuloma fissuratum was 42.5 years (range 26–78). The fissure resolved in 13 of 20 women (65%) who were managed nonoperatively and in 21 of 22 women (95%) who underwent perineoplasty. Of the 11 women sexually active after perineoplasty, all had preoperative dyspareunia; it resolved in 7 (64%) women. Among the 13 women managed nonsurgically who had resolution of the fissure, 7 women were sexually active after treatment and dyspareunia resolved in 2 (29%) women. Other vulvar symptoms, such as burning, itching, pain, and discharge, showed no significant improvement after either surgical or nonsurgical treatment. CONCLUSION: Although fissuring is common with some vulvar dermatoses, such as lichen sclerosus and contact vulvitis, and often resolves with the appropriate medical management, fissuring may also occur as a primary finding and may benefit from perineoplasty. LEVEL OF EVIDENCE: II-3

Management of atypical squamous cells, low-grade squamous intraepithelial lesions, and cervical intraepithelial neoplasia 1.

In the American Society for Colposcopy and Cervical Pathology 2006 Consensus Guidelines, several changes in the management of mildly abnormal cervical cytology and histology were made. The most notable changes involve the management of adolescents, pregnant women, and postmenopausal women. For adolescents, management of atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions is conservative, eliminating the need for immediate colposcopy. For pregnant women, options have been made to allow for deferral of colposcopy until pregnancy completion, whereas for postmenopausal women, the new guidelines call for the option to rely on human papillomavirus DNA testing or repeat cytology to manage mild cytologic abnormalities. The guidelines for cervical intraepithelial neoplasia 1 now focus on conservative management. The goal of this article is to review the 2006 Guidelines, elaborating on the changes and providing the rationale for management decisions.

Labial Adhesion: A Review of Etiology and Management

Labial adhesion is a rare condition, defined as the partial or complete fusion of the labia minora. The diagnosis is made upon visual inspection of the vulva. Labial adhesion is also called labial fusion, vulvar fusion, occlusion of the vestibule, and agglutination of the labia minora. Its occurrence is typically limited to young girls, usually less than 6 years of age. Labial adhesion also occurs in postmenopausal women and, very rarely, during the reproductive years. In this case, it is related to vulvar trauma, including vaginal delivery. Atrophy, resulting from hypoestrogenism, generally is regarded to be the underlying factor in adhesion formation. The atrophic epithelium is more susceptible to irritation and rawness than estrogenized skin and has the potential to form fibrous adhesions following trauma. However, labial adhesion also has been reported among estrogenized women in association with inflammatory diseases, such as herpes, which involve open sores or rawness of the vestibule or labia minora.1 If separation of the adhered labia is medically indicated, several treatment options are available including both surgical and nonsurgical methods. Typically, the first line of treatment is attention to vulvar hygiene and topical estrogen cream, such as Premarin (Wyeth Pharmaceuticals, Inc.) or Estrace (Bristol-Myers Squibb). Application is recommended once or twice per day for up to 2 months, with separation occurring in most prepubertal cases.2 Use of estrogen or a bland emollient, such as petroleum jelly or A&D ointment (Schering Plough), is recommended for maintenance of labial separation. This provides a mechanical barrier and reduces skin irritation. If medical management is unsuccessful, separation can be achieved surgically via sharp separation under local or general anesthesia. Moreover, surgical separation is often the preferred management option in older patients and in women with recurrent labial adhesion, as the adhesions Labial Adhesion: A Review of Etiology and Management

Histopathology of recurrent mechanical fissure of the fourchette

Recurrent mechanical fissure of the posterior fourchette, previously termed vulvar granuloma fissuratum by Kennedy et al. [1], is characterized by recurrent superficial splitting of the mucosa with severe pain on vaginal penetration particularly with intercourse and vaginal examination [1]. While recurrent fissure of the posterior fourchette is not uncommon, references are scarce concerning this condition [2,3]. Anecdotal evidence suggests that most gynecologists have encountered patients with this disorder. Furthermore, description has been primarily clinical or associated with pathologically confirmed specific diagnoses such as lichen sclerosus and atrophic dermatitis [3].