The relationship between laparoscopic disease, pelvic pain and infertility; an unbiased assessment.

OBJECTIVES: To measure the relationship between laparoscopically detected pelvic pathology and pelvic pain or infertility. METHODS: Women undergoing diagnostic laparoscopy either for the investigation of pelvic pain, for sterilisation or for the investigation of infertility were studied. The indication for surgery was recorded before laparoscopy. At operation a series of 35-mm slide photographs were taken of the pelvis and later scored by two independent assessors without knowledge of the indication for surgery. RESULTS: Satisfactory photographs were obtained in 298 women. Minimal endometriosis was not associated with pain (adjusted OR 1.3; 0.5-2.8), although moderate disease was non-significantly so (2.5; 0.4-7.1). Severe disease was significantly more common and never occurred in patients being sterilised (P = 0.02). The odds of pain were not increased in the presence of dilated veins > 9 mm diameter (OR 1.1; 0.4-3.2) or adhesions (OR 0.6; 0.2-4.7). The odds of infertility were non-significantly increased in the presence of minimal and moderate endometriosis (OR 2.0; 0.8-5.3, and OR 4.2; 0.6-25 respectively) and again significantly more common in the presence of advanced disease (P = 0.002). The odds of infertility tended to be lower in the presence of severely dilated veins (OR 0.2; 0.032-1.2). There was no clear effect of adhesions (OR 0.9; 0.1-5.9). CONCLUSIONS: The long established associations between severe endometriosis and pelvic pain, and between endometriosis in general and infertility are confirmed. However there is little or no association between minimal endometriosis, pelvic adhesions or dilated pelvic veins and pain. Previously reported associations may have been an artefact of the surgeon's knowledge of the indication for operation when assessing the pelvis.

The Dalkon syndrome--a rare condition?

A patient who presented acutely with severe pelvic sepsis related to Dalkon shield is reported. Although the Dalkon syndrome has been described (Tatum HJ, Connell EB. Intrauterine contraception. Duvant: Creative Informatics, 1985) the term is not widely used and controversy surrounds this condition. However, the condition may still present to the modern day gynaecologist.

Which is more painful? A randomized trial comparing loop with laser excision of the cervical transformation zone.

We compared the pain of excisional cervical surgery by the laser or loop diathermy (LLETZ) in a randomised controlled clinical trial. Eighty women with CIN III were recruited from a laser colposcopy clinic specifically adapted to run randomized trials. They were scheduled for excision of their cervical transformation zone and both groups were matched for age, parity, and size of lesion. We measured linear analogue pain scores, subjective pain scores, and operative time. The laser and loop diathermy inflicts similar discomfort and there is no detectable difference between the median pain scores of women in either group (P = 0.99). However, in the hands of an experienced surgeon it takes 4 min extra to excise the cervical transformation zone with a laser compared to loop diathermy. The average time from sitting in the chair to the end of the procedure was 13.02 min (SD 3.65) for the group allocated diathermy surgery compared to 17.30 min (SD 5.33) for a laser excision log transformed t(log transformed data) = 3.7 (P < 0.001).

Who finds cervical laser therapy painful?

To identify women who find outpatient laser cervical surgery painful we designed a prospective observational study correlating surgical pain with multiple variables. The pain scoring systems were validated by comparing the subjective linear analogue score with an objective scoring method. The pain of surgery was compared with age, parity, acute anxiety scores, psychological state, premenstrual syndrome scores, phase of the menstrual cycle, contraceptive use, menstrual history, nature of the lesion, and intraoperative bleeding. Anxious women with no children suffered most. Nulliparity, acute preoperative anxiety, and a history of dysmenorrhea independently predict high pain scores. Young women and those using the combined oral contraceptive pill also find laser surgery more painful but this is because they are less likely to have delivered children and more likely to suffer from dysmenorrhea. Psychological state, premenstrual syndrome score, phase of the menstrual cycle, type of surgery, and perioperative bleeding have no predictive value. We suggest that nulliparous women and dysmenorrhea sufferers who are anxious about outpatient surgery but ambivalent about hospital admission should be offered cervical surgery under general anesthesia. Parous women who do not suffer from dysmenorrhea can be reassured that outpatient laser treatment should be tolerable.

Is transcutaneous electrical nerve stimulation of any value during cervical laser treatment?

OBJECTIVE: To assess the value of transcutaneous electrical nerve stimulation (TENS) during cervical laser therapy. DESIGN: Randomized three arm controlled clinical trial comparing (i) TENS, (ii) local anaesthetic and (iii) TENS plus local anaesthetic (direct infiltration of 2% lignocaine and 0.03 iu/ml octopressin). SETTING: Colposcopy Unit adapted to run randomized trials. SUBJECTS: 100 women with CIN and no previous experience of cervical surgery. MAIN OUTCOME MEASURE: Visual linear analogue pain scores. RESULTS: The median pain score associated with TENS was greater than the score associated with local anaesthesia (23% compared with 17%; P = 0.1). Combining TENS with local anaesthesia did not further reduce pain scores. CONCLUSION: Although there was considerable consumer satisfaction with TENS it provided no additional pain relieving effect in addition to direct infiltration of lignocaine and it is inferior to lignocaine alone. We are unable to advocate the use of TENS for laser treatment of the cervix.

The correlation between dysmenorrhea and the pain experienced during laser ablation of a cervical lesion.

Twenty women undergoing colposcopically directed laser evaporation of a cervical intraepithelial neoplastic (CIN) lesion were recruited. Using a linear analog scale they scored the pain associated with a normal period when not using contraception. Under standardized conditions and without any analgesia or local anesthesia their transformation zone was ablated to a depth of approximately 6 mm by an independent operator. Pain was assessed 10 min after the procedure by the same technique as that used for the measurement of dysmenorrhea. There is a direct correlation (r = 0.7) between the discomfort of dysmenorrhea and discomfort at colposcopy. This allows the operating colposcopist to predict which patients are most likely to experience discomfort during laser evaporation of a cervical lesion.

A new way to expose endocervical lesions at colposcopy.

If there are atypical cells on a cytological smear and if the squamo-columnar junction can not be visualized during a colposcopic examination, then in order to exclude an early invasive cancer in the nonvisualized area within the endocervix it is mandatory to perform a diagnostic cone biopsy. A woman with abnormal cervical cytology and an unsatisfactory colposcopic examination who refused a cone biopsy was offered Lamicel in an attempt to expose the entire transformation zone. After 4 hr the sponge was removed and colposcopy repeated. The lesion and the squamo-columnar junction was then fully visible and she was spared a cone biopsy.

Using Lamicel to expose high cervical lesions during colposcopic examinations.

Women with abnormal cervical cytology and an unsatisfactory colposcopic examination were offered Lamicel in an attempt to expose the entire transformation zone. The sponge, which softens, dilates and effaces the cervix, was passed intracervically in 41 patients in whom the entire squamocolumnar junction could not be seen. After 3-4 h the sponge was removed and colposcopy repeated. In 29 of the 41 patients the lesion and the squamocolumnar junction were now fully visible. Twenty-five of these patients were spared a cone biopsy.

The efficacy of paracervical injections of lignocaine before laser ablation of the cervical transformation zone. A randomized placebo-controlled double-blind clinical trial.

In a prospective double-blind randomized placebo-controlled clinical trial the efficacy of paracervical lignocaine was compared with saline in reducing pain in 70 women undergoing laser ablation of the cervical transformation zone. Paracervical lignocaine had no significant measurable effect on reducing the pain experience during the laser procedure. The mean subjective visual linear analogue pain score in the lignocaine and saline groups was 27% (95% CI 17 to 38) and 30% (95% CI 24 to 41) respectively (t = 1.0; P = 0.35). The median (quartiles) objective pain scores for the same groups were 0 (0-2) and 0 (0-1) respectively (P = 0.58).

Invasive carcinoma of one cervix in a uterus didelphys. Case report.

A patient is described with invasive squamous carcinoma developing in one cervix in a didelphic uterus with double cervix and vagina completely separated by a vaginal septum.

Neurofibromatosis and pregnancy.

Ten patients with neurofibromatosis were studied in 27 pregnancies. Two of the patients had evidence of pre-eclampsia in their first pregnancy but not in subsequent ones. In all other pregnancies, no adverse features were noted. It would seem that neurofibromatosis is not specifically associated with any obstetric complications. The need for further reporting of cases is stressed.

The wounded uterus: pregnancy after hysterotomy.

Despite contraceptive advice, a high proportion of patients who have had a pregnancy terminated by hysterotomy became pregnant again within a short space of time. Fifty-three such pregnancies have been studied, and a substantial risk of rupture of the uterus was demonstrated in 14 cases where the scar was thin. Rupture, impending rupture, or presumptive rupture occurred in three of these cases. Nevertheless successful vaginal delivery occurred in about 80% of cases. The infants so produced were often small for dates. Due weight should be given to the risks of subsequent early pregnancy and uterine rupture before terminating a pregnancy by the operation of hysterotomy without sterilization.