Management of chronic pelvic pain.

Chronic pelvic pain (CPP) is a common complaint of women presenting for gynecologic and primary care. Evaluation of CPP requires obtaining a careful history including not only obstetrical and gynecologic information but also screening for gastrointestinal, urologic, musculoskeletal, and neurological disorders. A detailed physical examination is also necessary. Management of CPP depends largely on the cause. Gynecologic causes include endometriosis, pelvic inflammatory disease, adhesive disease, pelvic congestion syndrome, ovarian retention syndrome, ovarian remnant syndrome, adenomyosis, and leiomyomas. Some non-gynecologic causes are interstitial cystitis/painful bladder syndrome, irritable bowel syndrome, pelvic floor tension myalgia, and abdominal myofascial pain syndrome. Treatments may be directed toward specific causes or may be targeted to general pain management. The most effective therapy may involve using both approaches. The diagnosis and treatment of each of the above disorders, and the management of CPP itself, is discussed.

Fracture of the acetabulum in a 14-year-old patient: 20-year review.

A case report of 14-year old female with an acetabular fracture involving the anterior column and posterior column-posterior wall is presented here and the findings on 20-year follow-up are described.

Transcervical or intraperitoneal analgesia for laparoscopic tubal sterilization: a randomized controlled trial.

OBJECTIVE: To test the effectiveness of analgesia administered transcervically through a uterine manipulator compared with direct topical application to the fallopian tubes for relief of postoperative pain after interval laparoscopic tubal sterilization. METHODS: Sixty-one women who had laparoscopic sterilization were enrolled in a randomized, double-masked clinical trial comparing analgesia with 75 mg of bupivacaine administered through a uterine manipulator with 75 mg of bupivacaine applied directly to the fallopian tubes through a secondary trocar. Results were evaluated using visual analog scale pain levels, time of administration of analgesics, total analgesics required, and recovery room times. We calculated that a sample size of 60 women would detect a 30% difference in pain levels with a power of 80% at a significance level of .05. RESULTS: In the 59 women who completed the study, there were no differences in the two groups in pain levels, amounts of medications used, or times to administration of postoperative analgesia. Mean recovery room time was shorter in the group given analgesia transcervically, but that difference was not statistically significant. CONCLUSION: There were no significant differences in postoperative pain relief between transcervical administration and topical application of analgesia for laparoscopic tubal sterilization.

Conscious pain mapping by laparoscopy in women with chronic pelvic pain.

OBJECTIVE: To evaluate the findings and outcomes of laparoscopic conscious pain mapping in women with unsuccessfully treated chronic pelvic pain. METHODS: Fifty consecutive women with at least one prior procedure for chronic pelvic pain had conscious pain mapping. Operative findings and clinical outcomes were documented. Preoperative and postoperative pain levels were evaluated using visual analog scales. RESULTS: Conscious pain mapping was successful in 35 cases (70%). Twenty-nine patients had 42 specific positive sites, and six patients had diffuse visceroperitoneal pelvic tenderness. Adhesions and endometriosis accounted for 45% of positive lesions or sites. About half of women with endometriosis or adhesions mapped pain specifically to those lesions. For endometriosis, histologic but not visual diagnosis predicted positive mapping. Specific viscera accounted for 36% of positively mapped sites. Diagnoses of chronic visceral pain syndrome were suggested by the findings in 16 (46%) patients whose mapping was successful. Mean +/- standard deviation visual analog scale pain levels were 8.7 +/- 1.2 preoperatively and 5.5 +/- 3.7 postoperatively. Twenty-two women (44%) had decreased pain postoperatively and eight (16%) were pain-free. CONCLUSION: Conscious pain mapping can be done with reasonable success in women with prior surgical evaluations and treatments for chronic pelvic pain. Chronic visceral pain syndrome, adhesions, and endometriosis were the most common diagnoses.

An evidence-based medicine approach to the treatment of endometriosis-associated chronic pelvic pain: placebo-controlled studies.

OBJECTIVE: Use an evidence-based medicine (EBM) approach to evaluate the evidence regarding efficacy of treatment of endometriosis-associated chronic pelvic pain (CPP) in placebo-controlled randomized clinical trials (RCT). DESIGN: Review of six randomized, controlled trials (Canadian Task Force classification I). SETTING: University of Rochester School of Medicine and Dentistry. Patients. Three hundred eighty-one women with endometriosis enrolled in placebo-controlled randomized clinical trials. Intervention. A MEDLINE search of published medical articles from January 1976, to January 1998. MEASUREMENTS AND MAIN RESULTS: Six placebo-controlled randomized clinical trials were found that addressed the treatment of pelvic pain associated with endometriosis and met validity criteria; one was a study of surgical treatment, two of medical therapies, and three of combined surgical and medical treatments. They clearly show that laparoscopic surgery and medical treatment with medroxyprogesterone acetate, danazol, or nafarelin are more effective than placebo. Evidence for efficacy of leuprolide acetate is weaker. At 6 months, absolute decreases in pain scores are quite similar with surgical or medical treatment. Medical therapy after surgical treatment significantly reduced pain, but six months after it was stopped there was no difference between women treated and not treated postoperatively. CONCLUSIONS: Although either surgical or medical treatment of endometriosis in women with CPP is clearly indicated, pain relief of 6 or more months' duration can be expected in only 40 to 70% of women with endometriosis-associated CPP.

The role of laparoscopy as a diagnostic tool in chronic pelvic pain.

More than 40% of laparoscopies are performed for the diagnosis of chronic pelvic pain (CPP). Although laparoscopic evaluation is sometimes considered a routine part of the evaluation, ideally the decision to perform a laparoscopy should be based on the patient's history, physical examination and findings of non-invasive tests. About 65% of women with CPP have at least one diagnosis detectable by laparoscopy and it is common to attribute causality to this diagnosis. Endometriosis is diagnosed in one-third of laparoscopies for CPP. Endometriosis requires histological confirmation to assure an accurate diagnosis. Adhesions are diagnosed in about one-quarter of laparoscopies. Ovarian cysts, hernias, pelvic congestion syndrome, ovarian remnant syndrome, ovarian retention syndrome, post-operative peritoneal cysts and endosalpingiosis are other diagnoses that can be made laparoscopically in some cases. Laparoscopic conscious pain mapping has the potential to improve the accuracy of laparoscopy as a diagnostic tool in CPP.

A randomized, controlled trial of a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) versus penile nerve block for pain relief during circumcision.

OBJECTIVE: We set out to compare a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) to dorsal penile nerve block with lidocaine for anesthesia during circumcision. STUDY DESIGN: In a double-blind study, term newborns were randomized to local anesthetic cream and sodium chloride solution dorsal penile nerve block (n = 31) or to placebo cream and lidocaine dorsal penile nerve block (n = 29). Pain was assessed by determination of heart rate, respiratory rate, and behavioral distress scoring. Group differences were evaluated with repeat-measures analyses of variance. RESULTS: Distress scores and heart rates were significantly higher in the eutectic mixture group than in the lidocaine group. Respiratory rates were higher in the eutectic mixture group but did not reach statistical significance. CONCLUSIONS: Distress scores and heart rates were significantly higher in infants treated with the anesthetic mixture than in infants treated with lidocaine. Dorsal penile nerve block with lidocaine is a more efficacious means of providing anesthesia for neonatal circumcision than the mixture of local anesthetics.

Physiologic stability of newborns during cup- and bottle-feeding.

BACKGROUND: To prevent breastfeeding problems, cup-feeding has been recommended as a method of providing medically necessary supplemental feedings to breastfed infants. OBJECTIVES: To compare amounts ingested, administration time, and infant physiologic stability during cup-, bottle-, and breastfeeding. DESIGN/METHODS: A total of 98 term, healthy newborns were randomized to either cup-feeding (n = 51) or bottle-feeding (n = 47). The heart (HR), respiratory (RR), and oxygen (O(2)) saturation rates were monitored on these infants and 25 breastfed newborns during 1 feeding. Differences in amounts ingested and administration times were evaluated with t tests and physiologic data with repeat measures analysis of variance. RESULTS: There were no significant differences in administration time, amounts ingested or overall HR, RR, and (O(2)) saturation rates, between cup and bottle groups. Breastfed infants had longer administration times and lower overall HR, RR, and higher O(2) saturation as compared with cup- and bottle-fed infants. CONCLUSIONS: Administration times, amounts ingested, and infant physiologic stability do not differ with cup- and bottle-feeding. Breastfeeding takes longer than cup- or bottle-feeding, but infants experience less physiologic variability. These data support cup-feeding as an alternative to bottle-feeding for supplying supplements to breastfed infants.

Operative laparoscopic treatment of ovarian retention syndrome.

STUDY OBJECTIVE: To evaluate the ability to treat ovarian retention syndrome (ORS) by operative laparoscopy. DESIGN METHODS: Retrospective observational analysis (Canadian Task Force classification II-2). SETTING: Pelvic pain referral practice in an university-affiliated community hospital. PATIENTS: Thirty consecutive women with ORS. INTERVENTION: Operative laparoscopy. MEASUREMENTS AND MAIN RESULTS: Salpingo-oophorectomy or oophorectomy was completed laparoscopically in 26 women; conversion to laparotomy was necessary in 4 (13.3%). Mean operating time was 159 +/- 63 minutes, mean blood loss was 119 +/- 152 ml, and mean hospital stay was 1.1 +/- 1.4 days. Complications occurred in four patients (13. 3%); in two (6.6%) they were intraoperative. The mean time interval between hysterectomy and symptoms of ORS was 6.4 +/- 4.6 years. Mean preoperative duration of pain was 40.11 +/- 41.3 months. Of 27 patients with adequate follow-up, 13 (48%) were pain free postoperatively with a mean follow-up of 12.9 +/- 8.2 months. Fourteen women (52%) had recurrent pain with mean time to recurrence of 8.8 +/- 10 months. Mean visual analog pain scores were 7.5 +/- 2. 4 preoperatively and 2.3 +/- 3.1 postoperatively (p <0.001). Endometriosis at time of surgery was associated with a significantly higher risk of recurrent pelvic pain (relative risk = 2.3, 95% confidence intervals 1.1, 5.1). Ovarian preservation was significantly related to recurrence of pain (RR = 2.6, 95% CI 1.52, 4.53) and risk of repeat surgery (RR = 4.4, 95% CI 1.69, 11.33). CONCLUSIONS: Ovarian retention syndrome can usually be treated by laparoscopy. Removal of both ovaries, if present, may be necessary to prevent recurrent pain. In our series, 48% of women experienced prolonged relief. (J Am Assoc Gynecol Laparosc 6(3):297-302, 1999)

A survey of gynecologists' attitudes regarding decision making in the management of non-cancerous conditions that frequently result in hysterectomy.

OBJECTIVE: To explore attitudes of practicing gynecologists regarding making treatment decisions for patients with benign uterine conditions frequently treated with hysterectomy. DESIGN: Mailed survey. PARTICIPANTS: 66 gynecologists practicing in the Greater Rochester, New York, area. INTERVENTIONS: After reading brief vignettes, respondents indicated how they would treat patients with chronic pelvic pain, uterine leiomyomas, and abnormal uterine bleeding, and rated the importance of 24 considerations in making their treatment decisions on a 1-to-5 scale ranging from not important to extremely important. RESULTS: Fourteen considerations (58%) had group mean importance ratings higher than 3. Exploratory factor analysis identified four factors that accounted for 96% of the variance. Respondent gender, practice type, graduation from a U.S. vs a non-U.S. medical school, and opinion regarding roles of doctor and patient in making treatment decisions were associated with significant differences in factor scores. CONCLUSIONS: Gynecologists' attitudes toward hysterectomy decisions are complex, multifactorial, and variable. Depending on the extent to which these attitudes affect treatment decisions, differences among gynecologists in their clinical decision making processes could account for a substantial amount of the regional variability in hysterectomy use.

The effects of early pacifier use on breastfeeding duration.

OBJECTIVE: To evaluate the effects of pacifier use and the timing of pacifier introduction on breastfeeding duration, problems, and frequency. METHODS: A cohort of 265 breastfeeding mother-infant dyads was followed prospectively. Maternal interviews were conducted at delivery, 2, 6, 12, and 24 weeks, and thereafter every 90 days until breastfeeding ended. Information was obtained regarding pacifier use, infant feeding, use of supplemental foods and breastfeeding frequency, duration, and problems. The effect of pacifier introduction by 6 weeks of age on breastfeeding duration was evaluated with Kaplan-Meier and Cox proportional hazards models. The effect of the timing of pacifier introduction (

Hereditary form of parkinsonism--dementia.

In four generations of a family, 13 members were afflicted with an autosomal dominant disorder characterized by young age at onset, early weight loss, and rapidly progressive dopa-responsive parkinsonism, followed later by dementia and, in some, by hypotension. Intellectual dysfunction began with subjective memory loss and objective visuospatial dysfunction and was followed later by decline of frontal lobe cognitive and memory functions. Neuropathological examination in 4 autopsied cases showed neuronal loss in the substantia nigra and locus ceruleus and widespread Lewy bodies, many of them in the cerebral cortex; those in the hypothalamus and locus ceruleus were often of bizarre shapes. Other findings were vacuolation of the temporal cortex, unusual neuronal loss and gliosis in the hippocampus (CA 2/3), and neuronal loss in the nucleus basalis. There were no neuritic plaques, neurofibrillary tangles, or amyloid deposits. Positron emission tomography in 3 patients showed decreased striatal uptake of fluorodopa. Neurochemical analysis of an autopsied brain showed a pronounced decrease in choline acetyltransferase activity in the frontal and temporal cortices and hippocampus and a severe depletion of striatal dopamine with a pattern not typical of classic Parkinson's disease.

Management of tubal prolapse after hysterectomy.

Uterine tube prolapse into the vaginal vault is an uncommon complication after hysterectomy, and our 6 patients bring to 90 the number of cases reported in the literature. Symptoms consist almost exclusively of vaginal bloody discharge and/or leukorrhea, persistent pelvic pain, and dyspareunia. Surgical treatment must be individualized according to the patient's symptoms. In our series, sexually active women with pelvic pain and dyspareunia had the best outcome when a combined laparoscopic and vaginal approach was used.

Reaction of residents to a teaching collaborative practice.

Using the team concept, certified nurse-midwives, nurse practitioners, and physician assistants help educate physicians in an obstetrics and gynecology residency program and help to create a balance between education and service. This program is well received by the physicians in graduate medical education, and the majority indicate they will work within a collaborative model of practice.

Neonatal circumcision and pain relief: current training practices.

OBJECTIVE: We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure. METHODS: Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%). RESULTS: Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02-0.08] or obstetrical (OR, 0.14; 95% CI, 0.08-0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3-110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4-306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7-7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7-4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties. CONCLUSIONS: Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.

Direct laparoscopic cannula insertion at the left upper quadrant.

We evaluated the efficacy and safety of direct left upper quadrant (LUQ) cannula insertion for laparoscopic surgery in 23 women with prior pelvic surgery, compared with direct umbilical cannula insertion in a control group of 81 patients. Generally, the laparoscope was retained at the LUQ site throughout the operative procedure. Cannula insertions at the LUQ were successful in the first attempt in 22 patients, compared with a single successful attempt in 78 of 81 umbilical insertions. Nine women had anterior abdominal wall adhesions that extended to the umbilical area. Seven had either a prior midline (1) or Pfannenstiel (6) incision; all seven had direct LUQ cannula insertions. Two patients with umbilical adhesions had no prior surgery. Of the three complications, two were related to cannula insertions and both were in the control group. There were no bowel injuries. More experience is required to prove that LUQ cannula insertion accomplishes its intended aim of avoiding bowel or omental injuries due to adhesions in women with prior abdominopelvic surgery, but initial results were favorable.

Laparoscopic lateral ovarian transposition before radiation treatment of Hodgkin disease.

More than one-half of women treated with pelvic radiation therapy for malignant disease experience premature ovarian failure. Preservation of ovarian function by repositioning the ovaries out of the irradiation field is suggested in all women of reproductive age. This repositioning generally is done by moving the ovaries either medially so they are posterior to the uterus, or laterally so they are in the paracolic gutters. Laparoscopic medial transposition has been reported, with mixed results. A woman underwent successful laparoscopic lateral transposition before irradiation for stage IIIa Hodgkin disease. A review of published cases suggests that this is preferable to medial transposition.