Clitoral Phimosis

I saw a patient recently who complained of reduced sexual pleasure due to 'clitoral phimosis'. The term phimosis when used  among medical practitioners refers to the male aspect of phimosis where the foreskin of the penis is tight and causes problems. It was not surprising that all the doctors that she had seen before didn't understand what clitoral phimosis was and therefore were unable to treat her. This young patient was however very knowledgeable about her body and knew exactly what needed attending to so that she was able to attain the sexual pleasure that she so desired.

Although not often complained about but a very common condition which affects a woman's ability to reach a climax, clitoral phimosis is similar to her male counterpart's condition in which the skin or 'hood' over the clitoris is either excessively tight and adherent to the clitoris. Sometimes however, the reduced sensation can be due to an excessively long 'hood' which covers the clitoris. There are more nerve ending on the sides of the clitoris and during sexual stimulation, the 'hood' retracts and more of the clitoris is exposed to be stimulated.

The patient had an excessively long 'hood and it was not adherent to the clitoris. She was advised to have a 'hoodectomy', a minor procedure in which the excess skin is removed similar to a circumcision in the male counterpart.

Endometriosis and kidney involvement

Endometriosis is a very common condition which may start early in life. It is thought to be an autoimmune disease but nobody really knows what the cause is. I had a 30 year old patient who started having painful and irregular periods from her teenage years. She had seen many gynaecologists over the years all of whom told her that she will grow out of the pains treating her with hormonal therapy. Unfortunately she did not 'grow out of her pains' but instead the painful periods worsened. She also started getting pain in her back where her right kidney was. When I saw this young lady she was also concerned that although she had been trying for a pregnancy for the last two years, nothing was happening and her in-laws were getting anxious. Mdm FKL had an ultrasound scan which then showed that she had ovarian cysts on both ovaries and they appeared to be stuck to back of the womb. As I suspected that she had endometriosis. I proceeded to do the full endometriosis work-up for her including an MRI of her pelvis and a hormonal profile. The MRI confirmed the endometriotic cysts and the adhesions. In addition there was a suggestion that the right kidney and urinary tract may be involved. MRI is now an important tool in the assessment of endometriosis as it will give the gynaecologist an indication of the extensiveness of the endometriosis. In this way he is not taken by surprise during surgery, and instead will have a well thought out plan to deal with the endometriosis prior to operation. Mdm FKL was referred to a urologist to assess the extent of the urinary tract involvement. The urologist was also there to insert stents into the ureters so as to aid in the operation. I then performed a laparoscopic key hole removal of the cysts and extensive freeing of all the adhesions so that the tissues were returned as best as possible to their original state. I am happy to say that Mdm FKL is now free of her pain and is now 6 weeks pregnant!
Extensive work-up prior to surgery is vitally important so as to get the best results. Planned well executed surgery is better than a haphazard approach and perhaps incomplete surgery which may result in the patient having to have further surgeries in the future.

  

Recommendations for individuals who are BRCA1/2 +ve

It is a well known fact that breast cancer may be due to a genetic mutation of the BRCA1 and 2 gene. Women who have a family history of persons having breast cancer at a relatively young age should have the gene mutation tested to see if they are at risk of breast cancer. It is also known that the risk of ovarian cancer is high with a positive BRCA1/2 mutations. The link between ovarian and breast cancer is well established.

Women with BRCA1 or 2 mutations should have clinical breast examinations every 6 to 12 months and annual breast MRI screening from the age of 25 or earlier depending on family history. At 30, mammograms should be added and alternated with MRIs every 6 months until 75 years. Prophylactic bilateral mastectomy should be discussed as it decreases the incidence by more than 90%.

Twice yearly screening for ovarian cancer by ultrasound and CA125 should begin at 30 years or earlier, and if completed family, removal of both tubes and ovaries is indicated at 35 years of age to prevent ovarian cancer.

Irregular vaginal bleeding due to endometrial hyperplasia

Irregular vaginal bleeding or intermenstrual spotting is a very common problem. It is very often the result of a hormonal imbalance where there is excessive amounts of oestrogen, and will need to be investigated. In postmenopausal women there is the possibility that this is due to a cancer of the lining of the womb and should be investigated urgently. My latest patient was a peri-menopausal lady with heavy irregular bleeding for several months. An ultrasound scan showed that the lining of the womb was thickened to more than 15 mm. In addition there was an ovarian cyst measuring 4 cms in diameter. In view of the unusual thickening of the lining, I advised a minor procedure. Using a hysteroscope (fine telescope), I examined the lining and took a sample for examination. The histology turned out to be simple endometrial hyperplasia.
Endometrial hyperplasia can be simple, complex, with or without atypia. The risk of cancer developing is highest in complex endometrial hyperplasia with atypia and lowest in simple endometrial hyperplasia without atypia.
My patient had the best prognosis. However I advised her to have treatment in the form of low dose progesterone and regular follow-up. The risk of progression to a cancer is less than 5% for her. The risk of progression in simple or complex with atypia is around 30%.
The take home message is that all abnormal bleeding needs to be investigated without delay particularly when it is around the time of menopause.

Bladder Prolapse

These two weeks were unusual in that I operated on two similar cases in which both ladies were postmenopausal and suddenly presented with a lump appearing in their vagina, one after carrying extra heavy objects and the other after a bout of a persistent cough. Examination of both showed similar pathology in that their bladder had prolapsed into their vagina through a weakness in the tissues supporting the bladder wall.
 This problem is quite common and very often ignored by older women who pass it off as part of ageing and think nothing of it until it either causes pain, becomes uncomfortable or the protrusion is out of the vagina and starts to rub against her underwear.
Closer examination showed that these were defects not only in the bladder wall but also of the rectum. Tears in the tissue of the bladder wall and tissues surrounding the rectum during vaginal childbirth very often contribute to this condition, and it starts to show up when the hormone levels fall as a result of menopause causing the tissues to weaken even more. The exception is the young woman in their 20's or 30's with this problem which is then caused by an inherent defect in the collagen tissues of the supporting structures of the pelvic organs.
After much discussion of the alternatives, it was decided to do a formal repair of the defects under anaesthesia. Mesh implantation was discussed with the patients but due to the incidence of long term complications with mesh it was decided to do a traditional repair of the bladder wall and a tight closure of the musculature of the pelvic floor to prevent a recurrence.
Both women have recovered well and are they will no doubt be able to continue their active lifestyles after this such as going to the gym, resuming golf and tennis and household chores.

Incontinence...Stress or Urge

A problem not many women want to complain about and keep to themselves. It often comes out only on routine questioning of a patient or if there is an associated problem such as prolapse. Unfortunately it is a very common problem especially in older women who have had many or difficult vaginal deliveries. With age the collagen tissues that support the bladder neck become weak and cannot hold the urine when she coughs, sneezes or does physical activity such as jogging. This is pure stress incontinence. I recently had a patient who had stress incontinence but was too embarrassed to bring up this problem even though it had affected her lifestyle so that she had to give up her favourite excercise of jogging. Each time she went out she had to wear pads and was always aware that there was a smell of urine about her.
Urge incontinence presents differently. The patient will feel the urge to constantly go to toilet but very often will not be able to get there in time and will leak urine. After voiding she may feel the urge to go again. This is not due to a weakened bladder neck but an overly sensitive bladder.
Both urge and stress incontinence may co-exist to complicate matters as in my recent patient.
It was my job to firstly determine which of the two was the predominant symptom that was causing her more distress and then to deal with the problem.
In my patients case it was the stress incontinence that needed attention. She was counselled about the various methods of treating stress incontinence and eventually opted for a sling operation. To date she has been free of her stress incontinence and has happily resumed her favourite excercise of jogging!

Chronic fungal infections

This is the most common condition that a gynaecologist like myself sees almost on a daily basis. The most common and unfortunately one of the most difficult to eradicate. Chronic recurrent fungal infection can however be controlled. It depends on how motivated a patient is. There are many naturopathic treatments that have been advocated but most results with 'candida and parasite cleansing diets are anecdotal and not proven. Why is it so difficult to control ..because it is a condition that is related to the bodies immune system of which a great is not known about. We do know that the parasite lives as a commensal in parts of the body just as other harmless bacteria. In some patients there is a greater abundance of these yeast spores and when during times of stress as in chronic illness, pregnancy or when taking antibiotics, the yeast spores multiply and cause infections which present as vaginal itch and discharge.
Certain measures taken can help to reduce the chances of recurrence such as reducing sugar intake, carbohydrates, taking antibiotics, maintaining a healthy lifestyle of sufficient rest, sleep and excercise.
Taking probiotics may very well help if the correct probiotic is taken. There have been some advocates of probiotic vaccines as opposed to oral probiotics, however their value has not been proven.
The take home message is to treat the fungal infection vigorously in the early stages. If not with each subsequent infection it becomes more difficult to treat with medication and takes longer to resolve with a higher chance of recurrence. There are many medical treatment regimes for controlling and preventing recurrent chronic fungal infections. It is important to see a gynaecologist for a proper workup and appropriate treament. Self medication is very common for fungal infections but sometimes the diagnosis of the vaginal discharge or itch may be wrong and therefore treatment inappropriate.