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The role of genital pathogens in morbidity following diathermy loop excision of the transformation zone of the uterine cervix
International Journal of Gynecology and Obstetrics 117 (2012) 27–29
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
The role of genital pathogens in morbidity following diathermy loop excision of the transformation zone of the uterine cervix Darja Arko, Andraž Dovnik, Nina Fokter ⁎, Iztok Takač University Clinical Department of Gynecology and Perinatology, University Clinical Center Maribor, Maribor, Slovenia
a r t i c l e
i n f o
Article history: Received 12 August 2011 Received in revised form 3 November 2011 Accepted 21 December 2011 Keywords: Genital pathogens Loop excision of the transformation zone Morbidity Uterine cervix
a b s t r a c t Objective: To evaluate the role of genital pathogens in postoperative morbidity following diathermy loop excision of the transformation zone (LETZ) of the uterine cervix. Methods: Patients with cervical intraepithelial neoplasia (CIN) who underwent diathermy LETZ were included in a prospective study. Cervical swabs for genital pathogens were collected before the diathermy procedure. After surgery, women were followed-up regarding the occurrence and severity of postoperative pain, bleeding, and discharge. Results: Genital pathogens were present in 463 of 788 (58.8%) cases. The most frequently isolated groups of microorganisms were group B β-hemolytic Streptococcus, α-hemolytic Streptococcus, Enterococcus species, and coliforms. In patients with genital pathogens, postoperative pain was present in 298 (37.8%), discharge in 262 (33.2%), and bleeding in 236 (29.9%) cases. In patients without genital pathogens, 199 (25.3%) experienced pain, 181 (23.0%) discharge, and 143 (18.1%) bleeding. The differences between the 2 groups were not statistically significant (χ2 for pain= 0.675; χ2 for discharge = 0.031; χ2 for bleeding = 3.444; P > 0.05). Conclusion: Genital pathogens are very common among patients with CIN and do not affect the occurrence or severity of pain, discharge, or postoperative bleeding after diathermy LETZ. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction When offering a patient a given modality of therapy, healthcare providers are obligated to inform the patient of the adverse effects following that therapy [1]. Unfortunately, the type and probability of occurrence of such adverse effects are often unclear. Diathermy loop excision of the transformation zone (LETZ) has become the standard method of treatment for cervical intraepithelial neoplasia (CIN) [2,3] and, although it seems to be the surgical method with the least morbidity among the several techniques used in women with CIN [4], some postoperative adverse effects (e.g. bleeding, discharge, and pain) may appear following the procedure [5,6]. While opposing findings exist about the correlation between bacterial vaginosis and CIN [7–9], it has been shown that bacterial infection of the lower genital tract is strongly associated with the development of postoperative morbidity after abdominal hysterectomy [10,11]. There is also some evidence of the potential role of genital pathogens in morbidity after LETZ [12]. In addition, some studies have investigated the influence of prophylactic antibiotics on the incidence of complications after LETZ [13–15]; they found no indications for the routine use of such therapy.
⁎ Corresponding author at: University Department of Gynecology and Perinatology, University Clinical Center Maribor, Ljubljanska 5, 2000 Maribor, Slovenia. Tel.: + 386 2 321 2178; fax: + 386 2 321 2085. E-mail address: [email protected] (N. Fokter).
The aim of the present study was to investigate the occurrence and severity of postoperative adverse effects—including pain, discharge, and bleeding—among women undergoing LETZ, with and without the presence of genital pathogens of the uterine cervix. 2. Materials and methods The study included women who underwent LETZ at the University Clinical Department of Gynecology and Perinatology, Maribor University Clinical Center, Maribor, Slovenia, between January 1, 1993, and December 31, 2005. All women with CIN who required LETZ, based on histologic proof obtained by punch biopsy, were included. Ethics Committee approval was obtained and all participants were provided with a patient information leaflet. Informed consent was obtained from all patients eligible to take part in the study. All women underwent a standard gynecologic interview and preprocedure counseling. Before the procedure, an endocervical smear was taken for examination for genital pathogens. Swabs were collected in Amies transport medium for inoculation onto culture media for subsequent isolation of anaerobes, Streptococcus groups A–G, coliforms, Staphylococcus aureus, Neisseria gonorrhoeae, Trichomonas vaginalis, and Candida species. Surgery was performed under local anesthesia in an outpatient setting. Diathermy LETZ was performed using an Elektrotom 400 Unit (Berchtold, Tuttlingen, Germany) with loop devices ranging in size from 10 to 20 mm. The procedure was performed using a blended current with the cut frequency set at 40 W and the coagulation
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.11.015
28
D. Arko et al. / International Journal of Gynecology and Obstetrics 117 (2012) 27–29
frequency set between 20 and 40 W. The surface of the wound was electrocoagulated. All specimens were fixed with 10% formalin, serially sectioned, embedded in paraffin, processed with the standard overnight technique, and stained with hematoxylin and eosin. The incidence of different genital pathogens was calculated via microbiologic reports, with the possibility of patients harboring more than 1 kind of genital pathogen. On the instruction sheet, patients were asked to record on a daily basis any pain, discharge, or bleeding they experienced in the first 90 days following the procedure. These items were subjectively scored as 0 for none, 1 for mild, 2 for moderate, and 3 for severe. Three months after the procedure, participants returned for a follow-up visit. A gynecologic examination was performed, a cervical smear was taken, and the information sheets with recorded adverse effects were collected at this time. The χ 2 test was used to analyze infected and non-infected patients for significant differences in the occurrence and severity of pain, discharge, and bleeding. P b 0.05 was considered to be statistically significant. A mean score of symptoms of 0.0–1.0 was considered low, a score of 1.1–2.0 was moderate, and a score above 2.0 was severe.
Table 2 Incidence and intensity of symptoms among patients with and without genital pathogens following diathermy LETZ (n = 788)a.
3. Results
Abbreviation: LETZ, loop excision of the transformation zone. a Values are given as number (percentage). b χ2 = 0.675; P = 0.411. c χ2 = 0.031; P = 0.860. d χ2 = 3.444; P = 0.063.
Symptom Pain
Overall, 788 women were included in the study. Genital pathogens were present in 463 (58.8%) and absent in 325 (41.2%) cases. The most frequently isolated groups of microorganisms were group B β-hemolytic Streptococcus, α-hemolytic Streptococcus, Enterococcus species, and coliforms (Table 1). The frequency and severity of postoperative adverse effects among all participants are shown in Table 2. Pain was experienced by 199 (25.3%) women without genital pathogens and 298 (37.8%) women with pathogens (χ2 = 0.675; P > 0.05). Vaginal discharge was present in 181 (23.0%) patients without and 262 (33.2%) patients with positive cervical smears (χ2 = 0.031; P > 0.05). Bleeding was reported by 143 (18.1%) women without genital pathogens and 236 (29.9%) with pathogens (χ2 = 3.444; P > 0.05). The differences between the groups were not statistically significant. 4. Discussion Genital pathogens were present in the majority of women who were treated with LETZ during the study period. This is consistent with the results of studies that have shown a high prevalence of cervical pathogens in women who do not necessarily have any symptoms or inflammatory changes in their cervical smear [16–18]. There was a high incidence of subjective adverse effects (i.e. pain, discharge, or bleeding) following the procedure, although the majority of patients graded them as mild or moderate. A high incidence of adverse effects following LETZ was also described by the TOMBOLA group [6]. Among the 751 women who completed a questionnaire on after-effects 6 weeks after the procedure, 67% reported pain, 63% reported discharge, and 87% reported bleeding—higher frequencies
Table 1 Types of genital pathogens in women with cervical intraepithelial neoplasia (n = 788). Pathogen
No. (%)
Group B β-hemolytic Streptococcus α-hemolytic Streptococcus Enterococcus species Coliforms Coagulase-negative Staphylococcus Diphtheroids Gardnerella vaginalis Candida Staphylococcus aureus
107 82 80 79 68 63 59 51 31
(13.6) (10.4) (10.2) (10.0) (8.6) (8.0) (7.5) (6.5) (3.9)
Genital pathogens absent
Genital pathogens present
Absent Low Moderate Severe Any pain
126 73 97 29 199
(15.9) (9.3) (12.3) (3.7) (25.3)
165 109 152 37 298
(20.9) (13.8) (19.3) (4.7) (37.8)
Absent Low Moderate Severe Any discharge
144 56 99 26 181
(18.3) (7.1) (12.6) (3.3) (23.0)
201 103 128 31 262
(25.5) (13.1) (16.2) (3.9) (33.2)
Absent Low Moderate Severe Any bleeding
182 69 49 25 143 325
(23.1) (8.8) (6.2) (3.2) (18.1) (41.2)
227 119 78 39 236 463
(28.8) (15.1) (9.9) (4.9) (29.9) (58.8)
b
Discharge
Bleeding
All
Intensity
c
d
than in the present study. This is probably because of the length of follow-up: 6 weeks in the TOMBOLA trial and 3 months in the current study. A reduction of adverse effects after the 6th postoperative week is to be expected. By contrast, other studies have reported a much lower incidence of adverse effects after LETZ. Dunn et al. [19] performed a retrospective review of 557 charts and found the overall rate of acute complications occurring within 14 days of the procedure to be 9.7%. A complication rate of less than 10% has also been noted in other studies [20–23]. These differences may be partly caused by different definitions of complications and different data collection methods across the studies. Furthermore, all patients who did not complete in detail the part of the questionnaire about adverse effects were excluded from the present study, although it is likely that the majority of these patients did not have any adverse effects. The present results show no influence of genital tract infection on the incidence of adverse effects after LETZ. However, more patients experienced pain and discharge in the group harboring genital pathogens, although the differences were not statistically significant (P = 0.411 and P = 0.860, respectively). The same was true for postoperative bleeding, although the statistical difference in this case approached significance (P = 0.063). In a prospective randomized controlled trial, Chan et al. [13] investigated whether the topical use of tetracycline and amphotericin B after LETZ would reduce the incidence of complications. For the general population, they found no significant benefit of using an antimicrobial vaginal pessary, although a subgroup of women with positive endocervical or high vaginal swabs experienced significantly less bleeding in the 2nd week and less overall vaginal discharge when treated. No prophylactic or therapeutic antibiotics were used in the present study. Similarly, Gornall et al. [14] compared the severity of symptoms following LETZ among women treated postoperatively with a topical antiseptic agent with those of a control group without antiseptic treatment. They found no significant differences in postoperative morbidity between the groups and did not recommend prophylactic topical treatment. Moreover, Foden-Schroff et al. [15] discovered that the administration of prophylactic oral antibiotics after LETZ did not significantly decrease morbidity in terms of vaginal discharge.
D. Arko et al. / International Journal of Gynecology and Obstetrics 117 (2012) 27–29
Arko and Takac [24] investigated the potential correlation between Chlamydia trachomatis infection and bleeding following LETZ. They reported that C. trachomatis infection was rare and did not have an effect on postoperative bleeding. In conclusion, the results of the present study do not support the hypothesis that genital pathogens have a significant role in morbidity following LETZ. Conflict of interest The authors have no conflicts of interest. References [1] Montz FJ. Impact of therapy for cervical intraepithelial neoplasia on fertility. Am J Obstet Gynecol 1996;175(4 Pt 2):1129–36. [2] Prendiville W, Cullimore J, Norman S. Large loop excision of the transformation zone (LLETZ). A new method of management for women with cervical intraepithelial neoplasia. Br J Obstet Gynaecol 1989;96(9):1054–60. [3] Jordan J, Martin-Hirsch P, Arbyn M, Schenck U, Baldauf JJ, Anttila A, et al. Management of Abnormal Cervical Cytology. In: Arbyn M, Anttila A, Jordan J, Ronco G, Schenck U, Segnan N, et al, editors. European Guidelines for Quality Assurance in Cervical Cancer Screening. 2nd edition. Luxembourg: Office for Official Publications of the European Communities; 2008. p. 191–232. [4] Martin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO, Keep SL. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev 2010(6):CD001318. [5] Luesley D, Shafi M, Finn C, Buxton J. Haemmorhagic morbidity after diathermy loop excision: effect of multiple pre-treatment variables including time of treatment in relation to menstruation. Br J Obstet Gynaecol 1992;99(1):82–3. [6] TOMBOLA (Trial Of Management of Borderline and Other Low-grade Abnormal smears) GroupSharp L, Cotton S, Cochran C, Gray N, Little J, et al. After-effects reported by women following colposcopy, cervical biopsies and LLETZ: results from the TOMBOLA trial. BJOG 2009;116(11):1506–14. [7] Nam KH, Kim YT, Kim SR, Kim SW, Kim JW, Lee MK, et al. Association between bacterial vaginosis and cervical intraepithelial neoplasia. J Gynecol Oncol 2009;20(1): 39–43. [8] Vetrano G, Pacchiarotti A, Lombardi G, Cimellaro V, Verrico M, Carboni S, et al. Correlation between squamous intraepithelial lesions (SILs) and bacterial vaginosis. Eur J Gynaecol Oncol 2007;28(4):310–2. [9] Discacciati MG, Simoes JA, Lopes ES, Silva SM, Montemor EB, Rabelo-Santos SH, et al. Is bacterial vaginosis associated with squamous intraepithelial lesion of the uterine cervix? Diagn Cytopathol 2006;34(5):323–5.
29
[10] Lin L, Song J, Kimber N, Shott S, Tangora J, Aroutcheva A, et al. The role of bacterial vaginosis in infection after major gynecologic surgery. Infect Dis Obstet Gynecol 1999;7(3):169–74. [11] Persson E, Bergström M, Larsson PG, Moberg P, Platz-Christensen JJ, Schedvins K, et al. Infections after hysterectomy. A prospective nation-wide Swedish study. The Study Group on Infectious Diseases in Obstetrics and Gynecology within the Swedish Society of Obstetrics and Gynecology. Acta Obstet Gynecol Scand 1996;75(8):757–61. [12] Sarkar PK, Rodgers CA, Mannion P. A prospective study of the correlation between genital pathogens and morbidity following diathermy loop excision of the transformation zone. J Obstet Gynaecol 1997;17(1):82–5. [13] Chan KK, Tam KF, Tse KY, Ngan HY. The use of vaginal antimicrobial after large loop excision of transformation zone: a prospective randomised trial. BJOG 2007;114(8):970–6. [14] Gornall RJ, Beynon DW, Shepherd NJ, Boyd IE. Topical antiseptic agent after large loop excision of the transformation zone: results of a randomised controlled trial. J Obstet Gynaecol 1999;19(5):509–10. [15] Foden-Shroff J, Redman CW, Tucker H, Millinship J, Thomas E, Warwick A, et al. Do routine antibiotics after loop diathermy excision reduce morbidity? Br J Obstet Gynaecol 1998;105(9):1022–5. [16] Parsons WL, Godwin M, Robbins C, Butler R. Prevalence of cervical pathogens in women with and without inflammatory changes on smear testing. BMJ 1993;306(6886):1173–4. [17] Ravel J, Gajer P, Abdo Z, Schneider GM, Koenig SS, McCulle SL, et al. Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci U S A 2011;108(Suppl. 1): 4680–7. [18] Yamamoto T, Zhou X, Williams CJ, Hochwalt A, Forney LJ. Bacterial populations in the vaginas of healthy adolescent women. J Pediatr Adolesc Gynecol 2009;22(1):11–8. [19] Dunn TS, Killoran K, Wolf D. Complications of outpatient LLETZ procedures. J Reprod Med 2004;49(2):76–8. [20] Girardi F, Heydarfadai M, Koroschetz F, Pickel H, Winter R. Cold-knife conization versus loop excision: histopathologic and clinical results of a randomized trial. Gynecol Oncol 1994;55(3 Pt 1):368–70. [21] Wright Jr TC, Gagnon S, Richart RM, Ferenczy A. Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure. Obstet Gynecol 1992;79(2):173–8. [22] Herzog TJ, Williams S, Adler LM, Rader JS, Kubiniec RT, Camel HM, et al. Potential of cervical electrosurgical excision procedure for diagnosis and treatment of cervical intraepithelial neoplasia. Gynecol Oncol 1995;57(3):286–93. [23] Ljubojević N, Babić S, Audy-Jurković S, Jukić S, Hasić R, Radaković B, et al. Loop excision of the transformation zone (LETZ) as an outpatient method of management for women with cervical intraepithelial neoplasia: our experience. Coll Antropol 1998;22(2):533–43. [24] Arko D, Takac I. A prospective study of the correlation between Chlamydia trachomatis infection and secondary bleeding following large loop excision of the transformation zone (LLETZ). Wien Klin Wochenschr 2001;113(Suppl. 3): 11–3.
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
The role of genital pathogens in morbidity following diathermy loop excision of the transformation zone of the uterine cervix Darja Arko, Andraž Dovnik, Nina Fokter ⁎, Iztok Takač University Clinical Department of Gynecology and Perinatology, University Clinical Center Maribor, Maribor, Slovenia
a r t i c l e
i n f o
Article history: Received 12 August 2011 Received in revised form 3 November 2011 Accepted 21 December 2011 Keywords: Genital pathogens Loop excision of the transformation zone Morbidity Uterine cervix
a b s t r a c t Objective: To evaluate the role of genital pathogens in postoperative morbidity following diathermy loop excision of the transformation zone (LETZ) of the uterine cervix. Methods: Patients with cervical intraepithelial neoplasia (CIN) who underwent diathermy LETZ were included in a prospective study. Cervical swabs for genital pathogens were collected before the diathermy procedure. After surgery, women were followed-up regarding the occurrence and severity of postoperative pain, bleeding, and discharge. Results: Genital pathogens were present in 463 of 788 (58.8%) cases. The most frequently isolated groups of microorganisms were group B β-hemolytic Streptococcus, α-hemolytic Streptococcus, Enterococcus species, and coliforms. In patients with genital pathogens, postoperative pain was present in 298 (37.8%), discharge in 262 (33.2%), and bleeding in 236 (29.9%) cases. In patients without genital pathogens, 199 (25.3%) experienced pain, 181 (23.0%) discharge, and 143 (18.1%) bleeding. The differences between the 2 groups were not statistically significant (χ2 for pain= 0.675; χ2 for discharge = 0.031; χ2 for bleeding = 3.444; P > 0.05). Conclusion: Genital pathogens are very common among patients with CIN and do not affect the occurrence or severity of pain, discharge, or postoperative bleeding after diathermy LETZ. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction When offering a patient a given modality of therapy, healthcare providers are obligated to inform the patient of the adverse effects following that therapy [1]. Unfortunately, the type and probability of occurrence of such adverse effects are often unclear. Diathermy loop excision of the transformation zone (LETZ) has become the standard method of treatment for cervical intraepithelial neoplasia (CIN) [2,3] and, although it seems to be the surgical method with the least morbidity among the several techniques used in women with CIN [4], some postoperative adverse effects (e.g. bleeding, discharge, and pain) may appear following the procedure [5,6]. While opposing findings exist about the correlation between bacterial vaginosis and CIN [7–9], it has been shown that bacterial infection of the lower genital tract is strongly associated with the development of postoperative morbidity after abdominal hysterectomy [10,11]. There is also some evidence of the potential role of genital pathogens in morbidity after LETZ [12]. In addition, some studies have investigated the influence of prophylactic antibiotics on the incidence of complications after LETZ [13–15]; they found no indications for the routine use of such therapy.
⁎ Corresponding author at: University Department of Gynecology and Perinatology, University Clinical Center Maribor, Ljubljanska 5, 2000 Maribor, Slovenia. Tel.: + 386 2 321 2178; fax: + 386 2 321 2085. E-mail address: [email protected] (N. Fokter).
The aim of the present study was to investigate the occurrence and severity of postoperative adverse effects—including pain, discharge, and bleeding—among women undergoing LETZ, with and without the presence of genital pathogens of the uterine cervix. 2. Materials and methods The study included women who underwent LETZ at the University Clinical Department of Gynecology and Perinatology, Maribor University Clinical Center, Maribor, Slovenia, between January 1, 1993, and December 31, 2005. All women with CIN who required LETZ, based on histologic proof obtained by punch biopsy, were included. Ethics Committee approval was obtained and all participants were provided with a patient information leaflet. Informed consent was obtained from all patients eligible to take part in the study. All women underwent a standard gynecologic interview and preprocedure counseling. Before the procedure, an endocervical smear was taken for examination for genital pathogens. Swabs were collected in Amies transport medium for inoculation onto culture media for subsequent isolation of anaerobes, Streptococcus groups A–G, coliforms, Staphylococcus aureus, Neisseria gonorrhoeae, Trichomonas vaginalis, and Candida species. Surgery was performed under local anesthesia in an outpatient setting. Diathermy LETZ was performed using an Elektrotom 400 Unit (Berchtold, Tuttlingen, Germany) with loop devices ranging in size from 10 to 20 mm. The procedure was performed using a blended current with the cut frequency set at 40 W and the coagulation
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.11.015
28
D. Arko et al. / International Journal of Gynecology and Obstetrics 117 (2012) 27–29
frequency set between 20 and 40 W. The surface of the wound was electrocoagulated. All specimens were fixed with 10% formalin, serially sectioned, embedded in paraffin, processed with the standard overnight technique, and stained with hematoxylin and eosin. The incidence of different genital pathogens was calculated via microbiologic reports, with the possibility of patients harboring more than 1 kind of genital pathogen. On the instruction sheet, patients were asked to record on a daily basis any pain, discharge, or bleeding they experienced in the first 90 days following the procedure. These items were subjectively scored as 0 for none, 1 for mild, 2 for moderate, and 3 for severe. Three months after the procedure, participants returned for a follow-up visit. A gynecologic examination was performed, a cervical smear was taken, and the information sheets with recorded adverse effects were collected at this time. The χ 2 test was used to analyze infected and non-infected patients for significant differences in the occurrence and severity of pain, discharge, and bleeding. P b 0.05 was considered to be statistically significant. A mean score of symptoms of 0.0–1.0 was considered low, a score of 1.1–2.0 was moderate, and a score above 2.0 was severe.
Table 2 Incidence and intensity of symptoms among patients with and without genital pathogens following diathermy LETZ (n = 788)a.
3. Results
Abbreviation: LETZ, loop excision of the transformation zone. a Values are given as number (percentage). b χ2 = 0.675; P = 0.411. c χ2 = 0.031; P = 0.860. d χ2 = 3.444; P = 0.063.
Symptom Pain
Overall, 788 women were included in the study. Genital pathogens were present in 463 (58.8%) and absent in 325 (41.2%) cases. The most frequently isolated groups of microorganisms were group B β-hemolytic Streptococcus, α-hemolytic Streptococcus, Enterococcus species, and coliforms (Table 1). The frequency and severity of postoperative adverse effects among all participants are shown in Table 2. Pain was experienced by 199 (25.3%) women without genital pathogens and 298 (37.8%) women with pathogens (χ2 = 0.675; P > 0.05). Vaginal discharge was present in 181 (23.0%) patients without and 262 (33.2%) patients with positive cervical smears (χ2 = 0.031; P > 0.05). Bleeding was reported by 143 (18.1%) women without genital pathogens and 236 (29.9%) with pathogens (χ2 = 3.444; P > 0.05). The differences between the groups were not statistically significant. 4. Discussion Genital pathogens were present in the majority of women who were treated with LETZ during the study period. This is consistent with the results of studies that have shown a high prevalence of cervical pathogens in women who do not necessarily have any symptoms or inflammatory changes in their cervical smear [16–18]. There was a high incidence of subjective adverse effects (i.e. pain, discharge, or bleeding) following the procedure, although the majority of patients graded them as mild or moderate. A high incidence of adverse effects following LETZ was also described by the TOMBOLA group [6]. Among the 751 women who completed a questionnaire on after-effects 6 weeks after the procedure, 67% reported pain, 63% reported discharge, and 87% reported bleeding—higher frequencies
Table 1 Types of genital pathogens in women with cervical intraepithelial neoplasia (n = 788). Pathogen
No. (%)
Group B β-hemolytic Streptococcus α-hemolytic Streptococcus Enterococcus species Coliforms Coagulase-negative Staphylococcus Diphtheroids Gardnerella vaginalis Candida Staphylococcus aureus
107 82 80 79 68 63 59 51 31
(13.6) (10.4) (10.2) (10.0) (8.6) (8.0) (7.5) (6.5) (3.9)
Genital pathogens absent
Genital pathogens present
Absent Low Moderate Severe Any pain
126 73 97 29 199
(15.9) (9.3) (12.3) (3.7) (25.3)
165 109 152 37 298
(20.9) (13.8) (19.3) (4.7) (37.8)
Absent Low Moderate Severe Any discharge
144 56 99 26 181
(18.3) (7.1) (12.6) (3.3) (23.0)
201 103 128 31 262
(25.5) (13.1) (16.2) (3.9) (33.2)
Absent Low Moderate Severe Any bleeding
182 69 49 25 143 325
(23.1) (8.8) (6.2) (3.2) (18.1) (41.2)
227 119 78 39 236 463
(28.8) (15.1) (9.9) (4.9) (29.9) (58.8)
b
Discharge
Bleeding
All
Intensity
c
d
than in the present study. This is probably because of the length of follow-up: 6 weeks in the TOMBOLA trial and 3 months in the current study. A reduction of adverse effects after the 6th postoperative week is to be expected. By contrast, other studies have reported a much lower incidence of adverse effects after LETZ. Dunn et al. [19] performed a retrospective review of 557 charts and found the overall rate of acute complications occurring within 14 days of the procedure to be 9.7%. A complication rate of less than 10% has also been noted in other studies [20–23]. These differences may be partly caused by different definitions of complications and different data collection methods across the studies. Furthermore, all patients who did not complete in detail the part of the questionnaire about adverse effects were excluded from the present study, although it is likely that the majority of these patients did not have any adverse effects. The present results show no influence of genital tract infection on the incidence of adverse effects after LETZ. However, more patients experienced pain and discharge in the group harboring genital pathogens, although the differences were not statistically significant (P = 0.411 and P = 0.860, respectively). The same was true for postoperative bleeding, although the statistical difference in this case approached significance (P = 0.063). In a prospective randomized controlled trial, Chan et al. [13] investigated whether the topical use of tetracycline and amphotericin B after LETZ would reduce the incidence of complications. For the general population, they found no significant benefit of using an antimicrobial vaginal pessary, although a subgroup of women with positive endocervical or high vaginal swabs experienced significantly less bleeding in the 2nd week and less overall vaginal discharge when treated. No prophylactic or therapeutic antibiotics were used in the present study. Similarly, Gornall et al. [14] compared the severity of symptoms following LETZ among women treated postoperatively with a topical antiseptic agent with those of a control group without antiseptic treatment. They found no significant differences in postoperative morbidity between the groups and did not recommend prophylactic topical treatment. Moreover, Foden-Schroff et al. [15] discovered that the administration of prophylactic oral antibiotics after LETZ did not significantly decrease morbidity in terms of vaginal discharge.
D. Arko et al. / International Journal of Gynecology and Obstetrics 117 (2012) 27–29
Arko and Takac [24] investigated the potential correlation between Chlamydia trachomatis infection and bleeding following LETZ. They reported that C. trachomatis infection was rare and did not have an effect on postoperative bleeding. In conclusion, the results of the present study do not support the hypothesis that genital pathogens have a significant role in morbidity following LETZ. Conflict of interest The authors have no conflicts of interest. References [1] Montz FJ. Impact of therapy for cervical intraepithelial neoplasia on fertility. Am J Obstet Gynecol 1996;175(4 Pt 2):1129–36. [2] Prendiville W, Cullimore J, Norman S. Large loop excision of the transformation zone (LLETZ). A new method of management for women with cervical intraepithelial neoplasia. Br J Obstet Gynaecol 1989;96(9):1054–60. [3] Jordan J, Martin-Hirsch P, Arbyn M, Schenck U, Baldauf JJ, Anttila A, et al. Management of Abnormal Cervical Cytology. In: Arbyn M, Anttila A, Jordan J, Ronco G, Schenck U, Segnan N, et al, editors. European Guidelines for Quality Assurance in Cervical Cancer Screening. 2nd edition. Luxembourg: Office for Official Publications of the European Communities; 2008. p. 191–232. [4] Martin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO, Keep SL. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev 2010(6):CD001318. [5] Luesley D, Shafi M, Finn C, Buxton J. Haemmorhagic morbidity after diathermy loop excision: effect of multiple pre-treatment variables including time of treatment in relation to menstruation. Br J Obstet Gynaecol 1992;99(1):82–3. [6] TOMBOLA (Trial Of Management of Borderline and Other Low-grade Abnormal smears) GroupSharp L, Cotton S, Cochran C, Gray N, Little J, et al. After-effects reported by women following colposcopy, cervical biopsies and LLETZ: results from the TOMBOLA trial. BJOG 2009;116(11):1506–14. [7] Nam KH, Kim YT, Kim SR, Kim SW, Kim JW, Lee MK, et al. Association between bacterial vaginosis and cervical intraepithelial neoplasia. J Gynecol Oncol 2009;20(1): 39–43. [8] Vetrano G, Pacchiarotti A, Lombardi G, Cimellaro V, Verrico M, Carboni S, et al. Correlation between squamous intraepithelial lesions (SILs) and bacterial vaginosis. Eur J Gynaecol Oncol 2007;28(4):310–2. [9] Discacciati MG, Simoes JA, Lopes ES, Silva SM, Montemor EB, Rabelo-Santos SH, et al. Is bacterial vaginosis associated with squamous intraepithelial lesion of the uterine cervix? Diagn Cytopathol 2006;34(5):323–5.
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