ABSTRACT
Background: Ovarian torsion is a gynecologic emergency that requires surgical intervention to avoid functional loss of the ovary. Our objective was to determine predictors of ovarian preservation in the setting of torsion, primarily time from initial presentation to surgery. Method(s): We conducted a retrospective cohort study of women aged 12-40 who presented to the Emergency Department (ED) at a single institution between 2008 and 2021 and had surgical confirmation of torsion. Cases were identified using diagnosis codes for ovarian torsion, and we performed chart review to confirm inclusion criteria. We compared ovarian preservation by time to surgery after ED presentation. Covariates included age, parity, sonographic doppler flow, presence of ovarian mass, intraoperative attempt at detorsion, intraoperative concern for necrosis, and night or weekend presentation. We considered the potential effect of COVID-19 pandemic on time to surgery. We assessed predictive factors for ovarian preservation based on preoperative sonographic findings and patient characteristics using multivariable logistic regression. Institutional IRB approved a waiver of consent. Result(s): We identified 60 surgical cases of confirmed ovarian torsion, of which 25 underwent oophorectomy (42%). The median time from initial presentation in ED to surgery was 8.6 hours (IQR: 5.9-12.9;8.3 hours in preserved versus 8.7 in removed;p=0.68). When time to surgery was < 4 hours (n=6), the ovary was preserved in 83% of cases, compared to 56% when time to surgery was >=4 hours (n=54;p=0.39). When time to surgery was < 8 hours (n=28), 61% had ovarian preservation compared to 56% at >=8 hours (n=32;p=0.73) (Figure). The COVID-19 pandemic was not associated with a longer time to surgery (n=7). Ovarian preservation was significantly more likely with present doppler flow on sonographic exam (60% vs 27%;p=0.02). Preservation was less likely with necrosis suspected intraoperatively (20% vs 84%;p< 0.01). Detorsion was attempted in 64% of cases, resulting in preservation of 35% of necrotic-appearing ovaries. 76% of cases underwent oophorectomy based on intraoperative concern for necrosis;however, only 48% of ovarian specimens had necrosis confirmed on pathology. Age, parity and night or weekend ED admission were not associated with ovarian preservation. Conclusion(s): Predictors with the greatest likelihood of ovarian preservation after torsion include surgical goal time of < 4 hours after ED presentation, present doppler flow on sonographic exam, and attempt at detorsion intraoperatively despite necrotic appearance. Intraoperative methods to confirm ovarian viability would reassure surgeons. The surgical decision for oophorectomy may be based on factors unrelated to functional loss of the ovary. Supporting Figures or Tables https://www.abstractscorecard.com/uploads/Tasks/upload/19245/RGXGDRUQ-1375800-1-ANY(2).docxCopyright © 2023
ABSTRACT
Introduction: Stress urinary incontinence (SUI) occurs in part due to a weakened urethral rhabdosphincter. Yoga and Pilates are low-impact workouts that use bodyweight as resistance, and limited evidence shows these exercises improve pelvic muscle strength and decrease incontinence episodes. Objective: The study objective was to evaluate the effect of an 8-week web-based yoga-Pilates exercise program on SUI severity as measured by the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) and secondarily to evaluate the potential mechanism of action for yoga-Pilates through ultrasound measurement of the urethral rhabdosphincter cross-sectional area (CSA). We hypothesized that yoga-Pilates would decrease SUI severity and cause hypertrophy of the urethral rhabdosphincter. Methods: This was a prospective interventional cohort study from November 2020 through September 2021. The intervention was an 8-week home yogaPilates web-based video that tracked and prompted participation. Participants with SUI underwent in-person visits pre/post-intervention during which they completed quality of life and severity surveys and underwent pelvic exam, including POP-Q, cough stress test, Brink pelvic floor strength score, and resting 3-dimensional transperineal ultrasound [1]. Ultrasound images were masked and measured post-collection. The rhabdosphincter is located in the middle third of the urethra, so 5 CSA measurements were taken: at the midpoint and then at 2.5 mm and 5 mm cranial and caudal from the midpoint [1]. The urethral CSA was determined by subtracting luminal/submucosal area from total urethral area (Figure 1). Pre/post 24-hour voiding diaries and an automated video viewing log were also collected. The study was powered to detect a mean change of 2.0 ± 4.0 ICIQ UI-SF score units and a mean CSA increase of 0.25 ± 0.6 cm2 with 48 compliant participants. All pre/post- intervention changes were analyzed using paired t-tests with a null change of zero. Results: 78 women, ages 46.6 + 10.4 years, enrolled. 60 women completed the study. The cohort was predominantly premenopausal (67%), vaginally parous (65%), and had done yoga (76%) and/or Pilates (44%) in the past. 73% of the completers performed the exercises at least 3x/week. The ICIQ-UI SF score improved from 9.5 (95% CI 8.7-10.4) to 7.1 (95% CI 6.3-7.9) post-intervention (P < 0.001). The number of incontinence episodes decreased post-intervention from 1 (IQR 1-3) to 1 (IQR 0-1) (P < 0.001). The Brink score also improved from 7.1 (95% CI 6.6-7.7) to 7.7 (95% CI 7.2-8.2) (P = 0.013). Participants were very satisfied with the online exercises. The majority (83%) of completers also reported they were “a little better”, “much better”, or “very much better” on patient global impression of improvement. There were no significant changes in urethral measurements from pre- to post-intervention. Conclusions: Although there were no changes in the urethral rhabdosphincter, this web-based yoga-Pilates exercise program improved symptoms of SUI and decreased number of incontinence episodes in women with SUI over 8 weeks. Web-based yoga-Pilates offers women with SUI a nonsurgical treatment that can be performed at home, which is beneficial in the ongoing COVID-19 pandemic.