Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Post-Coital Seepage - A Rarely-Discussed, Yet Common Inconvenience for Most Women: A Main Systematic Review

Summary

Women have a significant number of sexual dysfunctions that are not often discussed in a clinical setting. This study identified post-coital seepage of semen as a prevalent issue among sexually-active women. A survey was constructed to include questions on female sexual hygiene to quantify the discomfort women may experience after intercourse. Approximately half (52%) of women involved in the study experienced semen seepage or dripping of fluids after intercourse, with 41% of women admitting to being moderately or severely bothered. Multiple women also admitted further to various complaints including sensation of feeling unclean, vaginal odor, and/or vaginal yeast infections after vaginal intercourse. We conclude that the prevalence of post-coital semen seepage in sexually-active women is high. Our study found that these women had significant bother not only from the immediate seepage, but also from the prolonged after-effects of odor and discomfort even hours after sex.

Keywords: Post-coital; Semen; Discomfort; Intercourse; Sexually active women

Introduction

Despite the significant number of sexual dysfunctions in women, physicians often avoid discussing these concerns in the office setting [1]. With recent research on the role of the pelvic floor, and recently approved medical therapies for hypoactive sexual desire disorder, physicians have begun to adapt to questioning patients about libido and pain-related sexual dysfunctions. However, pain-related sexual questionnaires often focus on insertional and penetrational dyspareunia, without asking about discomfort minutes, hours, or even the day following sexual intercourse [1]. One common compliant in our ambulatory sexual medicine clinic is the bothersome dripping, odor, and discomfort women experience after sexual activity when no condom is used, and when intravaginal ejaculation occurs. Novel products have been introduced in the past year to address this concern some women have (DripStick, Costa Mesa CA). However, there is no data on the actual prevalence of this complaint in women.

Previous studies have shown the effects of semen on alterations in the vaginal flora [1]. These changes contribute to a multitude of clinical complaints and diagnoses, including malodor, continuous discharge after intercourse, and bacterial vaginosis (BV). The exposure of semen changes the vaginal flora by increasing the pH levels, in turn altering the bacterial growth pattern [2]. This implies the persistent presence of semen in the vagina may be one of the causes of malodor and development of BV. Chvapil utilized gas chromatography and demonstrated that the longer period of time semen was present in the vagina, the more likely it resulted in a strong and unattractive vaginal odor [3]. Gallo showed that an incidental diagnosis of BV was correlated with detection of sperm on gram stain, and frequent coitus with or without condom use [2].

Our goal in this study was to identify the prevalence of the complaint of continuous seepage of semen and vaginal odor after intercourse and determine the bother in these women.

Materials and Methods

The research instrument was co-designed by the authors in partnership with a professional research and online survey research company, Centiment (Denver, CO). Respondents were sampled from a diverse geographic representation across the United States. The respondent pool was a statistically representative sample of the target population. Inclusion criteria were age 18 or older, female, heterosexual, sexually-active with regular penile-vaginal intercourse within the previous year. Women were excluded if their primary birth control was male condoms. The survey was administered using a customized interface built on Typeform survey platform and on average took 3 min from start to completion. Respondents were compensated with a small honorarium for completion.

To ensure respondents were attending to the questions an attention check question was inserted into the survey. Those who answered incorrectly were disqualified from the research sample. The full list of survey questions and answer choices is shown in Tables 1-4 and Charts 1-2.

Results and Discussion

A total of 1,940 women completed the survey. 940 were excluded due to the aforementioned criteria. Demographics of the entire survey population is shown in Table 1 and Table 2. The majority of respondents were over 18 years of age, married or with a partner, and were white. Most were premenopausal and used tampons.

Approximately half (52%) of women experienced semen seepage or drippling of fluids after intercourse. One in 4 women (27%) stated they felt “unclean” after sex. As expected, other common complaints were urinary tract infection (21%), vaginal odor (20%), and yeast infections (13%).

The subset of women who were bothered by seepage or drippling was analyzed. Most of these women experienced the dripping either immediately following ejaculation (71%) and/ or within the hour (42%) after completed sexual intercourse. A significant number of women (21%) stated that the dripping/ seepage occurred several hours after intercourse (14%) to the following day (7%) (Table 3).

When specifically asked about their displeasure with vaginal discharge and seepage of sexual fluids after intercourse, 29% of women involved in the study admitted being moderately bothered, and 12% admitted being extremely bothered (Chart 1). 28% of women reported to be interested in using a method to reduce amount of discharge or dripping of sexual fluids after intercourse (Chart 2). The most common methods women use to reduce the seepage are by either showering, washing, urinating, or using a towel and wiping (Table 4).

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Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Management of Placenta Accrete in a Tertiary Care Hospital: Step by Step Approach

Summary

The study aimed to evaluate the value of management of placenta accrete using step by step approach using case series clinical study. This study was conducted on 74 pregnant females, who were selected to suffer from placenta accrete either diagnosed antenatal by MRI or Doppler U/S or both. Or diagnosed intraoperative .and the patients were excluded if the patient had previous four or more cesarean scars. Or If the patient is 40 years old or more.

The patients were submitted to steps by step approach for management of placenta accrete from step one to step five in order, but they will not proceed from any step to the next step except if this step fails to control the condition. The data from this approach regarding the duration of the step ,amount of bleeding ,units of blood used intraoperative ,any surgical complication, postpartum sepsis ,need of postpartum ICU were recorded.

This study enrolled 74 patients. six cases were found intraoperative to suffer from placenta percreta ,and 29 cases were found to suffer from placenta increte ,the range of preoperative and postoperative HB in non-complicated cases was 1-2.6gm (mean 1.628) and the range of no of needed units for intraoperative blood transfusion in non-complicated cases was 0-3 units (mean 1.04), the total operative time was range from 18-108 minutes (mean 46.08 minutes), 12 cases (16%) were complicated by bladder injury, 6 cases (8%) were complicated by uterine atony, 21 cases (28%) were complicated by sepsis, 9 cases (12%) needed ICU admission.

So, step by step approach should be used in management of placenta accrete as it has shorter operating time ,less intraoperative blood loss and shorter hospital stay ,it also has less intraoperative and postoperative complications despite being insignificant.

Keywords: Placentas accrete; Hysterectomy; Step by step; Bleeding

Introduction

Placenta accrete refers to an aberrant placental implantation as the anchoring villi invade to the myometrium, rather than being contained by decidual cells. There are many types of abnormally adherent placenta according to the degree of invasion of villi to the myometrium or to the serosal layer or extend beyond the uterus, but term placenta accretes collectively describe all of these [1].

The most important risk factors are placenta previa and prior uterine surgery, mainly cesarean section. So, the incidence of placenta accrete is increasing with the rising rate of cesarean section. It reaches about 25% to 50% incidence of placenta accrete in patients with placenta previa and prior cesarean delivery [2]. It is well noticed that the rate of placenta accrete in Egypt is high and increasing, yet there is no reported statistical data or documented study to evaluate the incidence of placenta accrete in Egypt . the most important actor for increasing rate of placenta accrete in Egypt is high rate of cesarean section in Egypt ,which also increasing [3].

Conservative management of the uterus turns into a surgical challenge in case of placenta accrete. Many surgeons tried many techniques including non-removal of the placenta and cut the cord short with postoperative methotrexate [4], resection of placental adhesion site also had been tried in selected cases [5], systematic devascularization of the uterus [6-8], transverse B lynch [9].

Stepwise technique had been developed in conservative management of placenta accrete ,and it passes through one step technique [10], two step technique [11] and reach to the simplest three step technique [12].

But placenta accrete is a potential emergency which couldn’t be managed by single technique or single approach. The authors think the condition mostly like postpartum hemorrhage which couldn’t be managed by single approach or single technique.

Also, conservative management of all cases is not possible and also non predictable, as every case has its own characteristics and its own randomly arranged placental vessels and the severity of adhesion cannot be diagnosed accurately except intraoperive.

So surgical management of placenta accrete couldn’t be managed by single surgical technique. And we suggest management begins with simple technique and if the condition is not controlled we proceed to another more complicated technique and so on to end with hysterectomy if not controlled.

Methods

Study design

Case series clinical study

Setting

This was conducted at tertiary care hospital (Department of Obstetrics and Gynecology of Tanta University- Egypt), in the period from October 1, 2017 to September 31, 2020.

Eligibility

This study was conducted on pregnant females, who were selected to suffer from placenta accrete either diagnosed antenatal by MRI or Doppler U/S or both. Or diagnosed intraoperative .and the patients were excluded if the patients:

• Had severe attack of bleeding before operation affecting patient’s general condition.

• Had previous four or more cesarean scars.

• was 40 years old or more

As in the last two conditions there is no need to expose the female to surgical hazard of conservation, and the safe surgical option for those patients is to perform hysterectomy without attempting to remove the placenta.

All patients selected for the study were counseled thoroughly about the procedure, its value and its hazards, written consent was taken from every patient.

If U/S and MRI suspected the presence of placenta accrete preoperative, then intraoperative the placenta was found to have normal adhesion to the uterine wall, this case was excluded.

Interventions

All patients in were submitted to the following surgical steps (each step doesn’t interfere with any other steps) in the following order, but they wouldn’t proceed from one step to the next step except if the previous step fails to control the condition.

Step 1:

1. Dissection of the bladder from anterior wall of lower uterine segment as much as possible

2. Transverse incision of the uterus at a higher level at upper border of placenta

3. Before fetal extraction ecbolic are administrated as oxytocin (syntocinon, Novartis) 20 IU i.e. infusion as a direct dose, methergin 0.1mg as maximum dose and rectal misoprostol up to 100 micrograms.

4. Extraction of the baby

5. Bilateral uterine artery ligation below the level of uterine incision

6. Removal of placenta, if there is line of cleavage total placenta removed or either piece meal according to the degree of placental invasion

7. Haemostatic quadruple sutures at lower uterine segment as many as the uterine wall could stand.

Step 2:

If step 1 failed known by difficult in removal of placental tissue or by still uncontrolled bleeding:

1. If the lower uterine segment is long enough, excision of wide part of lower uterine segment which may hold greater part of invaded placenta (segmental uterine wall resection)

Step 3:

If step 2 fails known by lower uterine segment is too short for application of step 2, or still uncontrolled bleeding:

1. Second bilateral uterine artery ligation below level of uterine incision and below level of first uterine artery ligature

2. Third Bilateral uterine artery ligation above the level of uterine incision.

3. Over sewing of placenta bed with sutures from outside the uterine cavity ,and other sutures may be taken intracavitary at the placental bed to control bleeding.

Step 4:

If step 3 failed known by still uncontrolled bleeding:

1. Insertion of intrauterine pack inside uterus with its lower end passing through opened cervix, the pack must be impacted in lower part of the uterus to ensure compression of placental bed

2. Closure of uterine incision only

3. observe the amount of vaginal bleeding, fundal level and vital measures of patient

Step 5:

If step 4 failed known by excessive vaginal bleeding, rising Fundal level or unsure vital measures for patient:

1. Total abdominal hysterectomy without oophorectomy after vaginal removal of the pack

Methods

All patients’ demographic data were taken, operation time (the duration of step 1 measured from the beginning of dissection of the bladder till the end of the step ether failed or succeeded ,then the duration of next steps measured later on), preoperative HB level, immediate postoperative HB level ,HB difference ,units of blood used intraoperative ,any surgical complication, any postoperative complications and postoperative hospital stay.

Outcomes of Study

primary outcomes include: (a) operation time (b) amount of bleeding known by HB difference

The secondary outcomes include: (a) amount of units of blood needed intraoperative for transfusion (b) intraoperative complications like (bladder injury, uterine atony) hysterectomy wasn’t considered as a complication as it was a part of the surgical steps, step 5) (c) postoperative complications like sepsis, need of ICU. (d) Duration of postoperative hospital stay.

Ethical Approval and Clinical Trial Registration

This study was approved by local ethical committee of Tanta University before the start of this study and registered on Pan African Clinical Trials Registry (pactr) under the code of PACTR201712002774233 All patients were informed about study design, interventions, and risks. All patients signed written consent. Privacy and security were maintained all over the duration of study.

There were no unexpected risks during the course of research.

Results

This study enrolled 74 patients who were assessed for eligibility. After selection according to inclusion and exclusion criteria for eligibility.

The mean age of selected patients was 29.44 and mean gestational age at time of cesarean section was 36.5 weeks gestation ,the whole demographic data of enrolled patients were demonstrated in Table 1.

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Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

COVID-19 Pandemic; Impact on the Colposcopy Service

Summary

Objectives: The COVID-19 pandemic caused by SARS-CoV-2 has radically changed global healthcare and colposcopy services are no exception. The aim of this study was to review the effect of COVID-19 pandemic on colposcopy services in a tertiary center.

Study design: A retrospective observational study was conducted in a tertiary center between March to August 2020. We included all women referred to our colposcopy services. The practice has been reviewed according to guidance from BSCCP.

Results: For high grade dyskaryosis referral, 64% of patients were offered an appointment within the target 2 week-wait time frame. For low grade dyskaryosis referral, 47% of patients were seen within the target 12-week timeframe.

Conclusions: The COVID-19 pandemic has resulted in longer waiting times for both high- and low-grade colposcopy referrals. This highlights the need for better preparation for potential future disruption of services and improvement of the existing service provided in order to support a faster and more efficient recovery from the pandemic.

Keywords: Colposcopy service; Covid 19 pandemic; Service provision

Introduction

In March 2020, the World Health Organization (WHO) declared the novel coronavirus disease 2019 (COVID-19) as a pandemic [1]. In the space of a few months after the start of the pandemic crisis, profound organizational changes have been adopted worldwide to optimize the healthcare facilities resources utilization.

Cervical cancer is the only one of the five gynaecological cancers to have an effective screening programme, however, during the COVID-19 pandemic, some of the 2 weeks wait cancer referrals were delayed or avoided when hospital’s capacity was particularly constrained, which affected cervical cancer prevention and management, including Human Papilloma Virus (HPV) vaccination, screening programme, colposcopy, and outpatient surgery.

A guidance by British Society for Colposcopy and Cervical Pathology [2] was put in place to triage patients who needed prompt evaluation in a colposcopy clinic including patients who had a high-grade smear, borderline nuclear change in endocervical cells, glandular neoplasia or suspicion of invasive disease [2]. Virtual consultations were advised for low grade referrals and for these patients to only be seen if resources permitted and to be deferred if colposcopy clinic capacity were reduced [2].

The aim of this study is to review the effect of the COVID-19 pandemic on colposcopy services in a tertiary center. We evaluated the process of patient selection in this tertiary unit’s colposcopy services during the pandemic benchmarked with Trust’s policy during the first wave of the pandemic and BSCCP guidelines. Our study will help understand the effect of such pandemic on our cervical cancer referral pathways to help plan our services in the future, especially should this pandemic result in a third wave of cases [3].

Materials and Methods

The colposcopy cases were undertaken at a United Kingdom (UK) teaching hospital trust, University Hospitals Birmingham NHS Foundation Trust, where colposcopy service runs at three hospital sites (Heartlands, Good Hope and Solihull Hospitals) from March 2020 to August 2020, during the first wave of the pandemic. That period, it was decided by Trust to offer appointments only to women with high grade cytology after smear test and with urgent referral from General Practitioner (GP). Results are presented for 151 patients referred with high grade dyskaryosis (group A) and 538 women with low grade cytology results (group B), from March 2020 to August 2020. Mean patient age at referral was 35.5±8.46 years, ranged (25-71) for group A and 35.4±9.31 years, ranged 24 to 66 years for group B.

Retrospective observational study on data from a populationbased cervical cancer screening database. This is the national database which is used to each colposcopy department in the UK and is provided by NHS England. For each patient information gathered regarding age, reason of referral/ smear result, histology result and treatment, when necessary, based on the information from colposcopy database. Steps in the screening process being disrupted (primary screening, surveillance, colposcopy, excisional treatment) were documented.

Baseline histology testing and delay in diagnosis were reported in patients referred for colposcopy. Categorical variables were presented as frequencies and percentages. It has to be mentioned that before the pandemic, our service was able to follow the national guidelines and keep the targets recommended by NHS England without any delays.

Precautions undertaken during COVID-19

Precautions undertaken for diagnostic and operative colposcopy were reviewed in line with Trust’s guidance and BSCCP guidelines including appropriate personal protective equipment (gloves, apron and appropriate mask) and minimum staff presence during procedures (BSCCP, 2020). BSCCP advised the avoidance of laser ablation and excision as well as use of coagulation procedures with diathermy due to vaporization [2]. For any large loop excision of transformation zone (LLETZ) procedure, the use of a serviced smoke extractor was advised [2]. For patients with symptoms suggestive of COVID-19 infection, colposcopy assessment was delayed until symptoms resolved, or patient tested negative. In accordance with our Trust’s policy, the number of women seen in colposcopy clinic had to be reduced by 5 for each clinic, to avoid unnecessary contact in waiting area. In addition, waiting area had to be reformed, to keep the rules for distance of two meters.

Results

High grade dyskaryosis colposcopy referrals

In total we had 151 patients referred with high grade dyskaryosis during this time period, out of which 149/151 (99%) attended. The commonest index cytology for referral was severe dyskaryosis 82/149 patients (55%) followed by moderate dyskaryosis 59/149 patients (40%). Three patients were referred directly due to suspected malignancy from cytology. Eight more patients were referred urgently with glandular cytology or post coital bleeding with known previous borderline cytology (Table 1).

Of the total high-grade patients that were referred to colposcopy services, 95/149 patients (64%) were offered an appointment within the two weeks wait timeframe, and 54/149 patients (36%) were offered an appointment outside the two weeks’ timeframe. The average time from referral to 1st appointment being offered was 12.79±7.24 days (Table 2). This wait-time interval ranged from 1 to 35 days. All first-time appointments offered were face-to-face appointments.

Furthermore, we had 128/149 (86%) patients attending their first appointment compared to 21/149 (14%) of patients failing to attend. All patients that failed to attend their initial appointment were re-offered a second appointment date. Out of the 21 patients who did not attend their initial appointment date, 9/21 patients (43%) attended the second appointment date offered. 8/21 patients (38%) attended on their third appointment date offer. 4/21 patients (19%) were discharged back to their GP after failing to attend their second appointment date that was offered. On colposcopy database the reason of patient’s nonattendance was not documented.

Overall, 4/149 patients (3%) did not attend at all and were discharged back to their GP. All 149 patients who attended their appointments had a biopsy taken. The commonest histological finding was CIN 3 which was 67/149 patients (45%) followed by CIN 2, 29/149 patients (20%). Furthermore, we had 12/149 (8%) reported as CIN 1, and 41/149 (28%) were reported as cervicitis due to HPV changes or normal.

Out of the 149 patients with high grade cytology referrals, 9/149 patients (6%) were diagnosed with cancer. Five of these were offered an initial appointment within 2 weeks of referral and 4 patients had their first appointment date after 2 weeks of referral. Two patients failed to attend the first initial appointment that was offered. The average time from referral to patient being seen for these 9 patients was 35.8 days (Table 3).

Low grade dyskaryosis colposcopy referrals

There were 539 referrals with low grade dyskaryosis during this time. One patient was excluded as the patient opted to be seen privately before appointment.

Out of the total patients who were referred due to low grade dyskaryosis, 252/538 of patients (47%) were offered an appointment within 12 weeks, as per BSCCP recommendation for management of low grade dyskaryosis during COVID-19 pandemic first wave (2), whilst 286/538 patients (53%) were offered an appointment after 12 weeks of referral in view of the prioritization of referrals during the COVID-19 pandemic depending on the smear result. The average wait-time interval for low grade patients was 84.62±23.86 days and ranged from 3 to 224 days (Table 2). In our study, 447/538 patients (83%) attended their initial appointments, whilst 83/538 patients (15%) did not attend this appointment. Information on appointment date could not be found for 8 patients due to incomplete data input.

Out of the 447 patients seen, 145/447 (32%) had a biopsy for further analysis, whilst 302/447 (68%) were discharged. The most common histological finding was CIN 1 in 40/145 patients (28%), followed by viral changes due to HPV effect in 36/145 patients (25%). Furthermore, 69/447 (15%) had normal biopsy result. No patients in this referral group had cancer and all firsttime appointments offered were face-to-face appointments for colposcopy.

From the retrospective analysis of this sample, we were in the position to identify that all the necessary precautions were taken according to the BSCCP recommendations at the time that the guidance was published. The time for each appointment increased from 20 to 40 minutes, to provide extra time for the relevant PPE and at the same time to prevent women being in contact in the waiting area.

Discussion

This study shows a delay in offering an appointment in time for low- and high-grade cytology referrals. Nine patients had a diagnosis of cancer and 5 of these patients had a delay in diagnosis (i.e., referral-to-diagnosis interval of > 2 weeks). This delay in diagnosis would inevitably lead to a delay in treatment and subsequently impact on morbidity and mortality, but it is necessary to mention that data is not enough to support this assumption. Studies from Australia reported disruptions to routine screening in 2020 resulting in a 1.1-3.6% increase in cervical cancer diagnoses, in addition to increase in cervical cancer mortality, and morbidity or both over the long term (~6–20 deaths) [3]. In this study, we are not in the position to declare something similar, since there were only nine patients diagnosed with cervical cancer and they all had treatment between 2-4 weeks later, after the diagnosis. It is important to note that with regards to our unit’s colposcopy service, there was a gap of two weeks, where all clinics had been cancelled with some doctors and nursing staff being redeployed to other medical areas. This would have unsurprisingly impacted on the wait-time-referral which has been reflected in the results of our study. Even after clinics started running, according to Trust’s guidelines, the number of face-to-face clinics had to be reduced, such as the slots available for each clinic, to reduce the exposure of staff and patients. This has caused problems with capacity and was addressed by increasing the number of clinics.

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