Introduction. Nonpuerperal uterine inversion (NPUI) is a rare clinical problem with diagnostic and surgical challenges. The objective of our study was to review the literature on NPUI and describe causative pathologies, diagnosis, and different surgical options available for treatment. Materials and Methods. A comprehensive literature review was carried out on MEDLINE and Google Scholar databases to look for NPUI using the term “non-puerperal uterine inversion,” and further went through the cross-references of the published articles. Data are published case reports from 1911 to September 2018. Of the 153 published cases, 133 reports had adequate details of surgery for analysis. These reports were analyzed, concerning the clinical presentation, methods of diagnosis, and surgical treatment. Results. Mean age of the women was 46.3 years (standard deviation: 18, N = 153). Leiomyoma remained the commonest (56.2%) aetiology. While malignancies contributed to 32.02% of cases, 9.2% were idiopathic. High degree of clinical suspicion and identification of unique features on ultrasonography and magnetic resonance imaging enable prompt diagnosis. In cases of uncertainty, laparoscopy or biopsy of the mass was used to confirm the diagnosis. Hysterectomy or repositioning and repair of the uterus are the only treatment options available. The surgical methods implemented were analyzed in three aspects: route of surgical access, method of repositioning, and final surgical procedure undertaken. The majority (48.8%) had only abdominal access, while 27.1% had both abdominal and vaginal access. Haultain procedure was the most useful procedure for reposition (18.0%) of the uterus. The majority (39.7%) required abdominal hysterectomy with or without debulking of the tumour abdominally, while 15.0% had uterine repair after repositioning. We reviewed the different surgical techniques and described and proposed a treatment algorithm. Conclusions. Fibroids were the commonest cause for NPUI. Malignancies accounted for one-third of cases. A combined abdominal and vaginal approach, followed by hysterectomy or repair after repositioning, seems to be better for nonmalignant cases.

CONTEXT:Effects of zinc on male sexual competence are poorly understood.AIM:To study the effects of different doses of zinc on the sexual competence of males using a rat model.MATERIALS AND METHODS:Three subsets (eight in each subset) of sexually experienced adult male rats were supplemented with three different oral doses of zinc sulphate (a daily dose of 1 mg, 5 mg and 10 mg respectively) for two weeks. A subset of eight animals without zinc supplementation was used as the control group Sexual behavior was observed by placing them individually in cages with receptive females.STATISTICAL ANALYSIS:Data analysis was done using SPSS v10 for windows computer software.RESULTS:Supplementation of 5 mg of zinc/day for two weeks led to a prolongation of ejaculatory latency; 711.6 sec. (SEM 85.47) vs. 489.50 sec. (SEM 67.66), P < 0.05 and an increase in number of penile thrusting; 52.80 (SEM 11.28) vs. 26.50 (SEM 6.17), P < 0.05, compared to controls. The same group had elevated prolactin (PRL) and testosterone (T) levels compared to controls at the end of treatment period; PRL- 7.22 ng/dl (SEM 3.68) vs. 2.90 ng/dl (SEM 0.34) and T- 8.21 ng/ml (SEM 6.09) vs. 2.39 ng/ml (SEM 1.79), P < 0.05. In contrast, reduction of libido was evident in the same group, but this effect was not statistically significant (P > 0.05). However, partner preference index was positive and 5 mg zinc supplementation did not exert a significant adverse effect on the muscle strength and co-ordination. The subset of rats supplemented with 1 mg/day did not show a difference from the control group while supplementation with 10 mg/day led to a reduction of the libido index, number of mounts and intromissions.CONCLUSIONS:Zinc therapy improves sexual competence of male rats; the effect is dose dependent. Increase in the T levels is beneficial in this regard. However, increase in PRL is responsible for the reduced libido index. Further studies on pigs and monkeys are needed to evaluate the therapeutic use of zinc in sexual dysfunction.

RATIONALE:Current knowledge on the relationship between seminal zinc levels and different parameters of human semen is inconsistent.OBJECTIVES:To assess the relationship between seminal plasma zinc and semen quality using two markers; zinc concentration (Zn-C) and total zinc per ejaculate (Zn-T).DESIGN:The study was carried out as a cross-sectional study.SUBJECTS AND METHODS:Semen parameters of 152 healthy men undergoing evaluation for subfertility were assessed. Seminal plasma zinc levels were determined using flame atomic absorption spectrometry. Zn-C, expressed as μg/mL, was multiplied by ejaculated volume to calculate Zn-T. Mann Whitney U test and Chi-square test were used to compare the zinc levels between different seminal groups when appropriate. Correlations were observed with Pearson’s correlation of coefficient. Analysis was carried out using SPSS 10.0 for windows software.RESULTS:Zn-C was low in 23 (15%) samples, while in 32 (21%) of the samples Zn-T was abnormal. The number of subnormal samples was high in the low-zinc groups compared with the normal-zinc groups, 15 vs. 8 (P > 0.05) for Zn-C and 28 vs. 4 (P < 0.001) for Zn-T. Zn-C was significantly high in the asthenozoospermics compared with the normal motile group; 138.11 μg/mL (83.92) vs. 110.69 11 μg/mL (54.59) (P < 0.05). Zn-T was significantly low in samples with hyperviscosity compared with samples with normal viscosity; 220.06 μg (144.09) vs. 336.34 μg (236.33) (P < 0.05). Conversely, Zn-T was high in samples with low viability compared with those with normal viability; 437.67 μg (283.88) vs. 305.15 μg (221.19) (P < 0.05). Weak correlations were found between Zn and some semen parameters. However, the correlation was negative between pH and Zn-C (r = –0.193, P < 0.05) as well as Zn-T (r = –0.280, P < 0.01). On the other hand, correlations were positive between Zn-T and sperm count (r = 0.211, P < 0.05).CONCLUSION:Count, motility, viability, pH and viscosity are affected by variations of seminal plasma zinc. Seminal plasma Zn-T is the better marker for assessing the relationship between zinc and semen quality.

The validated Sinhala and Tamil translations of ICIQ-VS will be useful for assessing vaginal and sexual symptoms among women speaking Sinhala and Tamil.

Morbidly adherent placenta is a rare complication of human placentation that may threaten maternal life due to massive haemorrhage. Its incidence is increasing due to the rising caesarean section rates worldwide. A high degree of clinical suspicion coupled with ultrasonography, magnetic resonance imaging, and cystoscopy helps in antenatal diagnosis. Elective caesarean hysterectomy with a multidisciplinary approach is the conventional treatment for confirmed cases of morbidly adherent placenta. However more conservative fertility saving approaches are also used successfully. IntroductionMorbidly adherent placenta (MAP) occurs when there is a defect in the decidua basalis, resulting in an abnormal invasion of the placenta into the substance of the uterus. As a result, there is no clear plane of cleavage between the placenta and the underlying uterus. Depending on the extent of adherence and invasion of the placenta the condition is classified as placenta accreta (reaching the myometrium), placenta increta (into the myometrium) and placenta percreta (right through the myometrium to breach the serosa or beyond) 1 . In the literature the term "placenta accreta" is often used interchangeably as a general term to describe all three conditions. Morbidly adherent placenta is thought to be due to an absence or deficiency of Nitabush's layer or the spongiosus layer of the decidua. Benirschke et al suggested this to happen as a consequence of failure of reconstitution of the decidua basalis after repair of caesarean incision, thus resulting in absence of intervening decidual tissue between the invading trophoblast and the myometrium 2 . It has been proposed that the abnormality of the placental uterine interface leads to leakage of fetal alpha-fetoproteins into the maternal circulation resulting in elevated levels of maternal serum alpha-fetoproteins 3,4 . Management of morbidly adherent placenta R P Herath 1 , P S Wijesinghe