OB-GYN-L Messages for September, 2004: Re: Granulation tissue

Re: Granulation tissue

From:

Terrence.Jones@kp.org

Wed Sep 22 16:08:47 2004

Agree with Steve, remove the pessary for now, she may end up in hosp with urosepsis secondary to ulceration. Might try putting in Estring ( sounds like she's likely to struggle with trauma from applicator secondary to introital stenosis) and continue topical ert, externally. Someone want to suggest to Pharmacia they market the ring in different sizes to accomplish both support and hormone delivery? After the epithelium has regenerated, if symptomatic prolapse, try placing the premarin cream in the apex, prior to re-insertion of the pessary, and with each cleaning. Periodically, you'll probably have to repeat this strategy (removal and regeneration) - tho it sounds like her problems were relatively recent. Lefort depends on the timing of "periodically", factoring in Patient's health and preference(s). tj

Steve & Eryl Raymond <eryl@intekom.co.za> Sent by: ob-gyn-l@obgyn.net 09/22/2004 01:27 PM Please respond to ob-gyn-l

To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net> cc: Subject: Re: Granulation tissue

This is not going to get better until the ring has been out for about 4 to 6 weeks. She really should have adequate oestrogenisation of her vagina before it is put back. Twice weekly Premarin cream is insufficient 0- should be daily. In fact for a month a course of oral Premarin would be a better idea. I think you should do a cystocoele repair or a LeFort procedure and dispense with the ring altogether. Steve

Rafael Haciski wrote:

> Question for the listers:
>
> I have an elderly pt. with post hysterectomy (many years ago) vaginal
> prolapse, who until now was satisfied with ring pessary.
> Over the course of last year she has developed sporadic vaginal
> bleeding - granulation tissue by appearance and biopsy. Initially
> cauterized with silver nitrate, but today a much greater area is seen
> (on both sides of vaginal walls, an at top of vault).
>
> The question concerns both treating the granulation tissue and vaginal
> prolapse.
> .. it seems too great an area for silver nitrate cauterization (prob.
> ~6 square cm)
> .. my concern in this frail pt. in using cautery (or cryo) is
> collateral injury to adjacent organs (rectum, bowel) and indeed poor
> healing leading to fistula formation.
> .. due to atrophy, her introitus is getting too painful for pessary
> removal and cleaning (lacerates each time, and she is using Premarin
> cream on the introitus 2-3 times weekly)
> .. LeFort procedure may be acceptable to her - she is thinking about
this >
> Any thoughts?
>
> Rafael C. Haciski MD FACOG
> Bradenton FL
>

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Agree with Steve, remove the pessary for now, she may end up in hosp with urosepsis secondary to ulceration. Might try putting in Estring ( sounds like she's likely to struggle with trauma from applicator secondary to introital stenosis) and continue topical ert, externally. Someone want to suggest to Pharmacia they market the ring in different sizes to accomplish both support and hormone delivery? After the epithelium has regenerated, if symptomatic prolapse, try placing the premarin cream in the apex, prior to re-insertion of the pessary, and with each cleaning. Periodically, you'll probably have to repeat this strategy (removal and regeneration) - tho it sounds like her problems were relatively recent. Lefort depends on the timing of "periodically", factoring in Patient's health and preference(s).  tj   <table width0%> <tr valign=top> <td> <td>Steve & Eryl Raymond <eryl@intekom.co.za> Sent by: ob-gyn-l@obgyn.net 09/22/2004 01:27 PM Please respond to ob-gyn-l <td>                To:        Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>         cc:                 Subject:        Re: Granulation tissue</table> This is not going to get better until the ring has been out for about 4 to 6 weeks.  She really should have adequate oestrogenisation of her vagina before it is put back.  Twice weekly Premarin cream is insufficient 0- should be daily.  In fact for a month a course of oral Premarin would be a better idea. I think you should do a cystocoele repair or a LeFort procedure and dispense with the ring altogether. Steve Rafael Haciski wrote: > Question for the listers: > > I have an elderly pt. with post hysterectomy (many years ago) vaginal > prolapse, who until now was satisfied with ring pessary. > Over the course of last year she has developed sporadic vaginal > bleeding - granulation tissue by appearance and biopsy.  Initially > cauterized with silver nitrate, but today a much greater area is seen > (on both sides of vaginal walls, an at top of vault). > > The question concerns both treating the granulation tissue and vaginal > prolapse. > .. it seems too great an area for silver nitrate cauterization (prob. > ~6 square cm) > .. my concern in this frail pt. in using cautery (or cryo) is > collateral injury to adjacent organs (rectum, bowel) and indeed poor > healing leading to fistula formation. > .. due to atrophy, her introitus is getting too painful for pessary > removal and cleaning (lacerates each time, and she is using Premarin > cream on the introitus 2-3 times weekly) > .. LeFort procedure may be acceptable to her - she is thinking about this > > Any thoughts? > > Rafael C. Haciski MD FACOG > Bradenton  FL >

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