Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item A case of labial adhesions following primary genital herpes infection(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Casather, D.M.; Herath, R.P.; Ranathunga, R.D.J.; Pannala, W.S.INTRODUCTION: Genital Herpes is one of the common sexually transmitted diseases in Sri Lanka. Although, the labial adhesions usually associated with hypo-oestrogenism, it may occur as a rare complication of Genital Herpes infection. Here we present a case of almost complete thick band labial adhesions following Genital Herpes infection. Case Report: A 23 year old nulliparous woman presented with vulval pain, dysuria and fever for two days. On vulval examination she had extensive, multiple, painful genital ulcers with some blistering lesions over both labia majora and minora. She had been in a monogamous relationship with the partner, with last sexual exposure about 10 days prior to the development of ulcers. Presumptive diagnosis of primary genital herpes was made on clinical manifestations. She was treated with 7 days course of oral Acyclovir. Ten days later she presented with a complaint of narrowing of the vaginal introitus and dysuria. On examination vulval lesions were in the partial remission and there was thick band of adhesion on the upper two third of labia minora with multiple scars of healing ulcers on either side. Manual separation of adhesions was not attempted due to tense nature of the adhesions. Surgical separation of labial adhesions was done under general anesthesia. After two weeks she made complete remission of Genital herpes ulcers and there were no further labial adhesions. A further follow up appointment was arranged in three months. DISCUSSION: Labial adhesions are not common among women in reproductive age who are having well oestrogenised vulva, in comparison to prepubertal and postmenopausal women with less oestrogenised vulva. Labial adhesions are rare, but severe form of local complication of genital herpes infection. The formation of labial adhesions can be prevented by early treatment with adequate dose of oral acyclovir. Gentle application of local anaesthetic over the labia minora alleviates pain and prevents labial adhesions formation in patients with genital herpes. The usual solution for adult labial adhesion following genital herpes infection is surgical adhesiolysis. Manual separation of the labia under application of local anaesthesia can be considered in patients who have less dense adhesions. This is the first published material in Sri Lanka on this matter. The importance of this report is to maintain the vigilance among health care providers about this rare complication as Genital Herpes infection is a very common sexually transmitted infection in Sri Lanka.Item A case of pulmonary endometriosis treated by bronchial angiographic embolization(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Casather, D.M.; Herath, R.P.; Sanjeewa, J.M.P.; Sandaruwan, N.K.T.S.; Ganewatte, E.INTRODUCTION: Although usually confined to the pelvis, endometriosis can be found in extra-pelvic organs and tissues as well. One of the rare forms of extra-pelvic endometriosis is thoracic endometriosis (TE). It is characterized by presence of functional endometrial tissues within the pleura, in the lung parenchyma or the airway. We present a case of TE managed with bronchial angiographic embolization (BAE). CASE REPORT: A 32-year-old woman with two children presented with repetitive catamenial haemoptysis for 8 months’ duration Haemoptysis usually started on the first day or the second day of each menstruation and it continued for 5 to 6 days and it was identical with the menstrual interval. She had one vaginal delivery and one caesarean section 10 years ago and 6 years ago respectively. Two years ago, she had diagnostic laparoscopy for chronic pelvic pain and which revealed pelvic endometriosis. Her medical history was otherwise unremarkable. Physical examination of the respiratory system was normal. Chest X-ray had symmetrical thorax and plain lung markings without abnormal findings. A chest computed tomography taken during the menstruation revealed a focal consolidation with adjacent ground glass opacification in the basal segment of the right lower lobe. Since, haemoptysis spontaneously resolved with the menstruation we assumed this catamenial haemoptysis due to pulmonary endometriosis and planed for BAE. During the procedure ultrasound guided diagnostic descending aortogram was performed using a catheter placing in the proximal descending thoracic aorta. Angiogram revealed a hyperaemic area in the lower lobe of the right lung, supplied by the hypertrophied lower lobe branch of right intercosto-bronchial artery. Super selective cauterization and embolization of the feeding right bronchial artery was done with PVA particles. Post embolization angiogram revealed satisfactory occlusion of the arterial supply to the hyperaemic area. Post procedure course was uneventful and there were no recurrences of catamenial haemoptysis following the procedure. CONCLUSION: There is no guidance for the treatment of TE. Hormonal therapy can be considered to suppress the endometrial tissues. Considering the surgical options to treat TE, video assisted thoracic surgery was reported and which was found to be safer and less invasive than lobectomy. In general BAE is an alternative to surgery in the management haemoptysis caused by Tuberculosis and chest trauma. Even though, BAE has not been frequently used to treat TE we reported case of TE successfully treated with BAE. This suggests that BAE is an alternative treatment option for symptomatic TE.Item Cost-effectiveness of three routes of hysterectomy: a multi-centre randomized controlled trial(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Ekanayake, C.D.; Pathmeswaran, A.; Kularatna, S.; Herath, R.P.; Wijesinghe, P.S.BACKGROUND: Hysterectomy is the commonest major gynaecological surgical procedure. The aim of this study was to evaluate the cost-effectiveness of non-descent vaginal hysterectomy (NDVH) and total laparoscopic hysterectomy (TLH) compared to total abdominal hysterectomy (TAH). METHODS: A randomized controlled trial was conducted at the gynaecology unit, District General Hospital, Mannar and professorial gynaecology unit, North Colombo Teaching Hospital, Ragama. Study population (n=49 per arm) were women needing hysterectomy for non-malignant uterine causes. Exclusion criteria were uterus 14 weeks, previous pelvic surgery, those requiring incontinence/pelvic floor surgery, comorbidities which preclude laparoscopic surgery and women who were illiterate. Primary outcome was the time to recover following hysterectomy which was considered as the earliest time to resume activities done prior to surgery. A Kaplan-Meier survival analysis was done with pairwise comparison through log-rank test for the primary outcome. A micro-costing approach calculated utilization of hospital resources from the time of presentation up to six months after surgery. Incremental costeffectiveness ratios (ICER) were obtained by calculating the incremental costs divided by the incremental effects (time to recover) for the intervention groups (NDVH and TLH) over the standard care (TAH) group. RESULTS: The overall combined results from both centres did not show a significant difference in time to recover (median, 95% confidence interval) between TLH [30 days (29.0-31.0)], NDVH [32 days, (28.3-35.7)] and TAH [35 days (32.0-38.0)] (Kruskal-Wallis test, p=0.373). There was a significant difference in direct cost (median, inter quartile range) between TAH [Rs.41943, (38256-44476)] versus TLH [50608 (46670-54859)], Mann-Whitney U test, p<0.001, NDVH [Rs.40373 (3693244212) versus TLH, Mann-Whitney U test, p<0.001. There was no significant difference between TAH and NDVH, Mann-Whitney U test, p=0.076. ICERTLH-TAH was Rs. 1733/ day compared to TAH. ICERNDVH-TAH was not calculated as both the cost and effect were more favourable than TAH. ICERTLH-NDVH was Rs.3412/day compared to NDVH. CONCLUSIONS: There was no significant difference in time to recover between TLH, NDVH and TAH. The optimum approach to hysterectomy appears to be NDVH in terms of costeffectiveness due to its lower cost, a fact that was suggested from the interim analysis presented at SLCOG sessions in 2017.Item A Possible progression of an atypical leiomyoma to a leiomyosarcoma(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Ekanayake, C.D.; Liyanage, A K.; Herath, R.P.; Fernando, W.S.; Mahendra, B.A.G.G.BACKGROUND: The spectrum of uterine smooth muscle cell tumours can range from leiomyoma to leiomyosarcoma. Atypical leiomyomasare a group of tumours with cellular atypia and a mitotic indexof up to 5/HPF that are classified between the innocuous leiomyoma and leiomyosarcomas. The absence of coagulative necrosis helps to differentiate it from leiomyosarcomas.Traditionally atypical leiomyomas are thought to have a low recurrence rate. CASE DETAILS: A 41-year-old woman underwent a myomectomy for ananteriorcervical fibroid.Histology revealed a smooth muscle tumour (SMT) withdiffusely scattered hyperchromatic large cells. The maximum mitotic count was 5/10 HPF.There was no coagulative necrosis or atypical mitotic figures. It was classified as an atypical leiomyomas and had close follow up. However, 30 months later she developed heavy menstrual bleeding. The ultrasound scan revealed an anterior fibroid. She underwent a total abdominal hysterectomy with ovarian conservation. The specimen showed a well-defined myometrial nodule of 7cm with haemorrhagic areas,compressing the cervix. It was a SMT with high a mitotic activity (11-12/HPF), atypical cells with bizarre nuclei and focal coagulative necrosis confirming a leiomyosarcoma (FIGO 1B). CONCLUSION: As atypical leiomyomashave a low risk profile and are mostly found in younger women,it invariably leads to treatment that offers fertility preservation. This case challenges the generalisability of this currently held viewpoint and recommends more extensive surgery or further heightened surveillanceItem Validation of the Sinhala translation of the International Consultation on Incontinence modular Questionnaire on Vaginal Symptoms (ICIQ-VS)(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Ekanayake, C.D.; Patabendige, M.; Wijesinghe, P.S.; Pathmeswaran, A.; Herath, R.P.; Weerasinghe, N.OBJECTIVE: To translate and validate the International Consultation on Incontinence Modular Questionnaire on vaginal symptoms (ICIQ VS) from English to Sinhala.METHODS: ICIQ-VS questionnaire was translated to Sinhala and a validation study was carried out among women attending the gynaecology clinic at North Colombo teaching hospital, Ragama. RESULTS: Basic demographic characteristics of women with prolapse (n=64) versus women without prolapse (n=135) were as follows; Age 55.8 (SD 13.1) years, median parity 2.5 (IQ1IQ3=2-4), BMI 23.8 kg/m2 (SD 3.2) versus age 42.6 (SD 13.1), median parity 2 (IQ1-IQ3=1-3), BMI 23.2 kg/m2 (SD 2.9) respectively. Content validity was assessed by the level of missing data which was less than 1% for each item. Internal consistency was assessed using Cronbach’s coefficient alpha scores which ranged from 0.75 to 0.78. Test–retest reliability as assessed by kappa values ranged from 0.54 to 0.80, except for item, ‘vagina too tight’ which demonstrated moderate reliability (kappa 0.41). Construct validity was assessed by the ability of the questionnaire to differentiate between patients and controls. The questionnaire differentiated between patients and controls on vaginal symptoms score (VSS) (p<0.001), sexual symptoms score (SSS) (p<0.05) and quality of life (p<0.001). There was a positive correlation between pelvic organ prolapse quantification system (POP-Q) scores and VSS (rs= 0.61, p<0.001), SSS (rs = 0.22, p<0.01) and quality of life (rs = 0.52, p<0.001). CONCLUSIONS: The preliminary results for ICIQ VS (Sinhala) validation are satisfactory and once completed it will be invaluable to objectively assess vaginal and sexual symptoms in Sinhala speaking population in Sri LankaItem A possible progression of an atypical leiomyoma to a leiomyosarcoma(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Ekanayake, C.D.; Liyanage, A.K.; Herath, R.P.; Fernando, W.S.; Mahendra, B.A.G.G.BACKGROUND: The spectrum of uterine smooth muscle cell tumours can range from leiomyoma to leiomyosarcoma. Atypical leiomyomasare a group of tumours with cellular atypia and a mitotic indexof up to 5/HPF that are classified between the innocuous leiomyoma and leiomyosarcomas. The absence of coagulative necrosis helps to differentiate it from leiomyosarcomas.Traditionally atypical leiomyomas are thought to have a low recurrence rate. CASE DETAILS: A 41-year-old woman underwent a myomectomy for ananteriorcervical fibroid.Histology revealed a smooth muscle tumour (SMT) withdiffusely scattered hyperchromatic large cells. The maximum mitotic count was 5/10 HPF.There was no coagulative necrosis or atypical mitotic figures. It was classified as an atypical leiomyomas and had close follow up. However, 30 months later she developed heavy menstrual bleeding. The ultrasound scan revealed an anterior fibroid. She underwent a total abdominal hysterectomy with ovarian conservation. The specimen showed a well-defined myometrial nodule of 7cm with haemorrhagic areas,compressing the cervix. It was a SMT with high a mitotic activity (11-12/HPF), atypical cells with bizarre nuclei and focal coagulative necrosis confirming a leiomyosarcoma (FIGO 1B). CONCLUSION: As atypical leiomyomashave a low risk profile and are mostly found in younger women,it invariably leads to treatment that offers fertility preservation. This case challenges the generalisability of this currently held viewpoint and recommends more extensive surgery or further heightened surveillance.Item Validation of the Sinhala translation of the International Consultation on Incontinence modular Questionnaire on Vaginal Symptoms (ICIQ-VS)(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Ekanayake, C.D.; Patabendige, M.; Wijesinghe, P.S.; Pathmeswaran, A.; Herath, R.P.; Weerasinghe, N.OBJECTIVE: To translate and validate the International Consultation on Incontinence Modular Questionnaire on vaginal symptoms (ICIQ VS) from English to Sinhala. METHOD: ICIQ-VS questionnaire was translated to Sinhala and a validation study was carried out among women attending the gynaecology clinic at North Colombo teaching hospital, Ragama. RESULTS: Basic demographic characteristics of women with prolapse (n=64) versus women without prolapse (n=135) were as follows; Age 55.8 (SD 13.1) years, median parity 2.5 (IQ1- IQ3=2-4), BMI 23.8 kg/m2 (SD 3.2) versus age 42.6 (SD 13.1), median parity 2 (IQ1-IQ3=1-3), BMI 23.2 kg/m2 (SD 2.9) respectively. Content validity was assessed by the level of missing data which was less than 1% for each item. Internal consistency was assessed using Cronbach’s coefficient alpha scores which ranged from 0.75 to 0.78. Test–retest reliability as assessed by kappa values ranged from 0.54 to 0.80, except for item, ‘vagina too tight’ which demonstrated moderate reliability (kappa 0.41). Construct validity was assessed by the ability of the questionnaire to differentiate between patients and controls. The questionnaire differentiated between patients and controls on vaginal symptoms score (VSS) (p<0.001), sexual symptoms score (SSS) (p<0.05) and quality of life (p<0.001). There was a positive correlation between pelvic organ prolapse quantification system (POP-Q) scores and VSS (rs= 0.61, p<0.001), SSS (rs = 0.22, p<0.01) and quality of life (rs = 0.52, p<0.001). CONCLUSION: The preliminary results for ICI Q VS (Sinhala) validation are satisfactory and once completed it will be invaluable to objectively assess vaginal and sexual symptoms in Sinhala speaking population in Sri Lanka.Item Validation of the international consultation on incontinence questionnaire-vaginal symptoms (ICIQ-VS) in two South- Asian languages(Springer, 2017) Ekanayake, C.D.; Pathmeswaran, A.; Herath, R.P.; Perera, H.S.; Patabendige, M.; Wijesinghe, P.S.INTRODUCTION: The multifaceted nature of pelvic floor disorders means that a systematic evaluation is required for optimal treatment outcome. It is also generally acknowledged that a valid tool is necessary to objectively assess symptoms reported by affected women. METHODS: The International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) questionnaire was translated to Sinhala and Tamil and a validation study carried out among women attending gynecology clinics at North Colombo Teaching Hospital, Ragama, and the district general hospitals Mannar and Vavuniya. RESULTS: Content validity was assessed by the level of missing answers, which was < 4% and 2% for each item in Sinhala and Tamil, respectively. Construct validity was assessed by the ability of the questionnaire to differentiate between patients and controls. Both differentiated patients from controls on vaginal symptoms score (VSS) (p < 0.001), sexual symptoms score (SSS) (p < 0.01), and quality of life (QoL) (p < 0.001). There was a strong positive correlation between Pelvic Organ Prolapse Quantification (POP-Q) scores and VSS (Sinhala r s = 0.64, p < 0.001, Tamil r s = 0.65, p < 0.001), and QoL (Sinhala r s = 0.49, p < 0.001, Tamil r s = 0.60, p < 0.001). Internal consistency as assessed using Cronbach's coefficient alpha: 0.78 (0.76-0.78) and 0.83 (0.80-0.84) in Sinhala and Tamil, respectively. Test-retest reliability was assessed by weighted kappa scores (Sinhala 0.58-0.88 and Tamil 0.76-0.90). Both questionnaires were sensitive to change and showed that VSS and QoL improved following surgery (Wilcoxon matched-pairs signed-rank test p < 0.001). CONCLUSION: The validated Sinhala and Tamil translations of ICIQ-VS will be useful for assessing vaginal and sexual symptoms among women speaking Sinhala and Tamil.Item Toxoplasmosis awareness, sere-prevalence and risk behavior among pregnant women in the Gampaha district, Sri Lanka(Sri Lanka College of Microbiologists, 2015) Chandrasena, T.G.A.N.; Herath, R.P.; Rupasinghe, J.I.N.; Samarasinghe, S.A.D.B.P.; Samaranayake, W.W.S.R.M.H.; de Silva, N.R.OBJECTIVES: To determine the prevalence and awareness of toxoplasmosis and to identify risk factors and possible routes of infection among pregnant women in the Sampaha district, Sri Lanka. DESIGN, SETTING AND METHODS: Pregnant women attending obstetric clinics at the Colombo North Teaching Hospital (CNTH) in February -June 2014 were systematically selected and tested for Igondiispecific IgG and IgM antibodies using the OnSite Toxo IgG/ IgM Rapid Test-Dip Strip®. Socio-demographic details and information regarding disease awareness and risk behavior patterns of the partici pants were collected. RESULTS: The mean age of the 293 women tested was 27 years (3D, +/-5.92). Thirty eight percent were primigravidae with a mean gestational age of 16.2 weeks (SD 7). The prevalence of anti-T gondii IgG antibodies was 12.3% (n=36). All participants were sero-negative for anti-T gondii IgM antibodies. Prevalence of anti-T.gont/// IgG antibodies was significantly higher among those eating commercially prepared meals, thrice a week or more (17.3%) compared to once a month or not at all (9.3%) (p< 0.05). No significant relationships were observed with other risk factors (cat-ownership, handling cats, consumption of meat, consumption of unwashed raw vegetables and fruits, handling soil and not washing hands after handling soil). Awareness of toxoplasmosis was 4.4% (n=13); health personnel (46.2, n=6) and media (53.8%, n=7) being sources of information. CONCLUSIONS: The presence of a large population of non-immune women of child bearing age (88%) with Low disease awareness, indicates the necessity of an educational program targeted at this high risk group to avoid exposure to toxoplasmosis during pregnancy. The importance of consuming hygienically prepared meals during pregnancy needs to be emphasized.Item Diagnostic and therapeutic dilemmas of cervical ectopic pregnancy(Williams and Wilkins, 2014) Hosni, M.M.; Herath, R.P.; Mumtaz, R.IMPORTANCE: Cervical pregnancy is a rare variety of ectopic pregnancy. The etiology is obscure. Its diagnosis may be difficult, and its management has enormously changed during the last 10 years. Unfortunately, the most effective, fertility-sparing treatment is still unclear until now. OBJECTIVES: The aim of this study was to explore the safety and efficacy of different treatment modalities of cervical pregnancy. Evidence Acquisition: A comprehensive systematic review of the literature was performed using the electronic databases MEDLINE and PubMed, using key words cervical, ectopic, and pregnancy, between January 2005 and June 2013. We included all case reports and case series reporting on cervical ectopic pregnancy. RESULTS: A total of 252 cases of cervical ectopic pregnancy were analyzed. Eighty-eight cases (34.9%) had medical treatment, 69 cases (27.5%) had surgical treatment, and 95 cases (37.6%) had combined medical and surgical treatment. Various conservative treatment regimens have been introduced to preserve fertility in young women, with methotrexate being one of the most widely used and effective drugs. CONCLUSIONS and Relevance: A high index of suspicion, combined with meticulous review of clinical and radiological findings, is essential to make an accurate diagnosis of cervical pregnancy. The success of conservative treatment depends mainly on early diagnosis. Such cases would be best managed at specialist tertiary referral centers and preferably, where available, Early Pregnancy Assessment Units, whether medical, surgical, or combined treatment modalities were attempted. Target Audience: Obstetricians, gynecologists, family physicians Learning Objectives: After participating in this activity, physicians should be better able to identify the most likely predisposing factors for cervical ectopic pregnancy, appraise different modalities of treatment, and apply the selection criteria for conservative management of cervical ectopic pregnancy. © 2014 by Lippincott Williams & Wilkins.