Intracoital pain, syncope and collapse

This can be caused if the ovarian follicle is about to ovulate.  Any minimum frictional  contact will cause ovulation and continued bleeding and rarely it can cause bleeding.

usually the origin of the pain = site of pathology.
Bleeding in these scenarios is secondary to ovulation.  The collected blood usually stays around the ovary 

Cervical effacement & dilatation

Intractable intracoital pain, syncope and collapse during sexual intercourse

Vaginal hysterectomy first steps

Hand drawn diagram

Vaginal hysterectomy steps

Non PID causes of Ectopic pregnancy

Many patients ask me whenever I met up a client with a diagnosis of Ectopic pregnancy, what is the cause and why did this happen?
My usual answer use to be asymptomatic PID.
But my observations are that, eventhough PID may be the common cause of Ectopic pregnancy, but many took it by surprise. So that made me to keep a close eye on Non PID causes of Ectopic pregnancy.
If the Ectopic pregnancy is on the right side, then chronic appendicitis with adhesions should be thought of.
If the Ectopic pregnancy is on the left or right, then active endometriosis should be thought of.

Vaginal hysterectomy -- Tips and tricks

The most important step in vaginal hysterectomy is safe dissection of the bladder and pouch of Douglas.

1. The initial incision on cervix begins circumferentially at the reflection of the vaginal mucosa onto the cervix.
2. The position and depth of this circumferential incision is very important because they determine access to appropriate planes that will lead to opening of Utero vescial fold of peritoneum and Pouch of Douglas peritoneum.
3. Anteriorly appropriate location of the incision is at the site of the bladder reflection. The lower end of bladder reflection on the prolapsed cervix is indicated by a CREASE or SULCUS formed in the vaginal mucosa when the cervix is pushed slightly inward or back into the vagina. This can also be achieved by moving the cervix in and out of the vagina and at the same time try and identify the sulcus or the groove between the vagina and bladder reflection bulge. If this location is still not identified, one should make the incision low rather than high to avoid the potential bladder injury. Downward traction on the cervix and counter-traction by the retractors help to determine the appropriate depth of the incision. This incision should be continued down to the cervical stroma. Once the appropriate depth of the incision is reached, the vaginal tissue will fall away from the underlying cervical tissue because there is distinct plane between these two tissues.