[Postpartum ovarian vein thrombophlebitis: diagnosis, treatment and follow-up. Retrospective study over 10 years]. / Thrombophlébites pelviennes du post-partum : diagnostic, traitement et suivi. Etude rétrospective sur 10ans.

INTRODUCTION: Postpartum ovarian vein thrombosis (POVT) is a rare but serious postpartum complication that can be life-threatening due to its embolic and septic risks. The clinical and paraclinical diagnosis is difficult because of the non-specific signs and the absence of a gold standard for imaging. There is no consensus in the literature on the treatment and follow-up of these patients. The primary objective was to specify the clinical and paraclinical signs suggestive of POVT in order to improve the diagnostic delay. The secondary objectives were to describe the extent of POVT and the proposed immediate therapeutic management. METHODS: This was a 10-year retrospective study in a type III maternity hospital, from January 2010 to December 2019, where all patients with an imaging-confirmed diagnosis of POVT were included. We analysed the clinical and paraclinical data and the follow-up of the patients. RESULTS: We included 9 patients with a diagnostic confirmation by imaging. The mean time from first symptoms to diagnosis was 3.3 days (±3.5 days), and only 2 patients (22.2 %) had been diagnosed with POVT before imaging. All patients received curative anticoagulation and 77.8 % (n=7) received antibiotic therapy for POVT. Two patients had a complicated form, 1 with a pulmonary embolism and 1 with a urinary tract compression requiring a urinary diversion with a double J catheter. Five patients (55.6 %) had a thrombophilia check-up. CONCLUSION: The diagnosis of POVT is difficult and needs to be evoked in front of a painful symptomatology or a fever in postpartum. It can be made by ultrasound, but the injected CT scan specifying the specific search for a POVT remains the imaging examination of choice in order to confirm the diagnosis and eliminate differential diagnoses. Under curative anticoagulation and broad-spectrum antibiotic therapy, the clinical course is generally very favourable. A consultation with an internist makes it possible to define instructions for a subsequent pregnancy.

[Pelvic fracture and urogenital dysfunction in women: A literature review]. / Fracture du pelvis et conséquences urogénitales chez la femme : revue de la littérature.

INTRODUCTION: The consequences of a pelvic fracture on pelvic statics and sexuality in women are often overlooked and relegated to secondary care. OBJECTIVE: To carry out a state of knowledge on disorders of pelvic statics and sexuality in patients with a history of pelvic fracture: incidence, risk factors, management. METHODS: Literature review on the Pubmed, Medline, Embase and Cochrane database using the following keywords and MeSH terms: pelvis floor dysfunction, urinary dysfunction, sexual dysfunction, pelvic organ prolapse, in association with the terms pelvic fracture, pelvic trauma. RESULTS: Among the 270 initial articles, 21 were selected. Finally, one retrospective cohort study has evaluated the impact of pelvic fracture on the onset of a genital prolapse, 2 comparative retrospective studies and one prospective study focused on the impact of pelvic fracture on lower urinary tract symptoms. One comprehensive review studied pelvic fracture and sexuality outcomes. The incidence of prolapse following pelvic fracture could not be identified. The incidence of lower urinary tract symptoms varies between 21 and 67% with a significant difference for urinary urgency without leakage (P=0.016) and SUI (P=0.004). The incidence of sexual disorders varies between 21 and 62% with a predominance of dyspareunia. The mechanism of the trauma is thought to be a contributing factor, as well as the damage of the pubic symphysis (RR 4.8 95% CI 2.0-11.2). CONCLUSION: The evaluation of urogenital, sexual and anorectal dysfunctions following trauma to the pelvis has so far been little explored in the literature. Future prospective studies are to be carried out to improve patient care.

[Impact of hysterectomy on urinary incontinence: A systematic review]. / Impact de l'hystérectomie sur l'incontinence urinaire : revue de la littérature.

INTRODUCTION: The impact of a hysterectomy on urinary incontinence is a controversial subject in the literature. OBJECTIVE: To evaluate the prevalence and incidence of urinary incontinence after a hysterectomy as well as associated risk factors such as the type of hysterectomy, the surgical approach, urodynamic criteria and uterine disease. STUDY DESIGN: We conducted a systematic review in Pubmed database with the following keywords and MeSH term: hysterectomy, urinary incontinence. RESULTS: A total of 1340 articles were retrieved, 42 articles were selected for the final text analysis. The results of the different studies were heterogeneous. Hysterectomy seemed to increase the rate of sphincter deficiency (VLPP<60mmH2O for 20% of cases versus 1,7% without hysterectomy, P=0.003). The vaginal route could increase the incidence of UI with OR of 2.3 (95%CI 1.0-5.2). Subtotal hysterectomy appears to increase UI with a 0,74 RR for total hysterectomy (95%CI 0.58-0.94). A radical hysterectomy with nerve conservation would preserve urinary functions, unlike pelvic radiotherapy, which is responsible for irreversible nerve damage by demyelination and bladder fibrosis.

[Pelvic and perineal pain after genital prolapse: A literature review]. / Douleur pelvi-périnéales et prolapsus génital : revue de la littérature.

INTRODUCTION: Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex. MATERIALS ET METHODS: A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery. RESULTS: Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex. CONCLUSION: Pelvic pain after genital prolapse surgery is still obscure to this day.

Chronic pelvic pain and rectal prolapse invite consideration of enterocele.

AIM: Data on the pathogenesis and symptoms of enterocele are limited. The objectives of this study were to determine the clinical phenotype of patients with enterocele, to highlight the main functional and/or anatomical associations and to improve the accuracy of the preoperative assessment of pelvic floor disorders. METHOD: A total of 588 patients who were referred to a tertiary unit for an anorectal complaint completed a self-administered questionnaire and underwent physical examination, anorectal manometry and defaecography. Using defaecography, enterocele was defined as a radiological hernia of the small bowel into an enlarged rectovaginal space. One hundred and thirty-five patients with enterocele were age- and gender-matched with 270 patients without enterocele. Factors associated with enterocele were assessed using univariate and multivariate analysis models. RESULTS: Patients with enterocele were less frequently obese than patients without enterocele (8/135 vs 36/270; P = 0.02) and more frequently had a past history of pelvic surgery (51/135 vs 75/270; P = 0.04). They complained more frequently of pelvic pain on bearing down (29/135 vs 24/270; P = 0.003), anal procidentia (37/135 vs 46/270; P = 0.01) and more frequently had irritable bowel syndrome (83/135 vs 131/270; P = 0.01) and severe constipation according to the Kess score (104/135 vs 182/270; P = 0.04). Anorectal function was comparable between the two groups. Patients with enterocele had more frequent rectoceles and overt rectal prolapses than patients without enterocele. CONCLUSIONS: Enterocele should be investigated in patients with chronic pelvic pain, overt rectal prolapse and/or a past history of pelvic surgery.

[Uterine preservation or not during prolapse surgery: Review of the literature]. / Préserver ou non l'utérus en cas de chirurgie du prolapsus : revue de la littérature.

OBJECTIVE: To evaluate the impact of hysterectomy in case of genital prolapse on the anatomical and functional results, and on per and post operative complications compared with uterine preservation. MATERIAL AND METHODS: We conducted a review of the Pubmed, Medline, Embase and Cochrane literature using the following terms and MeSH (Medical Subject Headings of the National Library of Medicine): uterine prolapse; genital prolapse; prolapse surgery; vaginal prolapse surgery; abdominal prolapse surgery; hysterectomy; hysteropexy; sacrocolpopexy; surgical meshes; complications; sexuality; neoplasia; urinary; incontinence; cancer. RESULTS: Among the 168 abstracts studied, 63 publications were retained. Whatever performance of hysterectomy or not, anatomical and functional results were similar in abdominal surgery (sacrocolpopexy) (OR=2.21 [95% CI: 0.33-14.67]) or vaginal surgery (OR=1.07 [95% CI: 0.38-2.99]). There was no difference in terms of urinary symptoms or sexuality after surgery. Hysterectomy was associated to a higher morbidity (bleeding, prolonged operating time, longer hospital stay), to an increased risk of mesh exposure particularly in case of total hysterectomy (8.6%; 95% CI: 6.3-11). CONCLUSION: In the absence of evidence of superiority in terms of anatomical and functional outcomes, with an increased rate of complications, concomitant hysterectomy with prolapse surgery should probably not be performed routinely.

[Definition, epidemiology and risk factors of obstetric anal sphincter injuries: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. / Définitions, épidémiologie et facteurs de risque des lésions périnéales du 3e et 4e degrés. RPC Prévention et protection périnéale en obstétrique CNGOF.

OBJECTIVES: The aim of this review was to agree on a definition of the obstetric anal sphincter injuries (OASIS), to determine the prevalence and risk factors. METHODS: A comprehensive review of the literature on the obstetric anal sphincter injuries (OASIS), establishment of levels of evidence (NP), and grades of recommendation according to the methodology of the recommendations for clinical practice. RESULTS: To classify obstetric anal sphincter injuries (OASIS), we have used the WHO-RCOG classification, which lists 4 degrees of severity. To designate obstetric anal sphincter injuries, we have used the acronym OASIS, rather than the standard French terms of "complete perineum" and "complicated complete perineum". OASIS with only isolated involvement of the EAS (3a and 3b) appears to have a better functional prognosis than OASIS affecting the IAS or the anorectal mucosa (3c and 4) (LE3). The prevalence of women with ano-rectal symptoms increases with the severity of the OASIS (LE3). In the long term, 35-60% of women who had an OASIS have anal or fecal incontinence (LE3). The prevalence of an OASI in the general population is between 0.25 to 6%. The prevalence of OASIS in primiparous women is between 1.4 and 16% and thus, should be considered more important than among the multiparous women (0.4 to 2.7%). In women with a history of previous OASIS, the risk of occurrence is higher and varies between 5.1 and 10.7% following childbirth. The priority in this context remains the training of childbirth professionals (midwives and obstetricians) to detect these injuries in the delivery room, immediately after the birth. The training and awareness of these practitioners of OASIS diagnosis improves its detection in the delivery room (LE2). Professional experience is associated with better detection of OASIS (LE3) (4). Continuing professional education of obstetrics professionals in the diagnosis and repair of OASIS must be encouraged (Grade C). In the case of second-degree perineal tear, the use of ultrasound in the delivery room improves the diagnosis of OASIS (LE2). Ultrasound decreases the prevalence of symptoms of severe anal incontinence at 1 year (LE2). The diagnosis of OASIS is improved by the use of endo-anal ultrasonography in post-partum (72h-6weeks) (LE2). The principal factors associated with OASIS are nulliparity and instrumental (vaginal operative) delivery; the others are advanced maternal age, history of OASIS, macrosomia, midline episiotomy, posterior cephalic positions, and long labour (LE2). The presence of a perianal lesion (perianal fissure, or anorectal or rectovaginal fistula) is associated with an increased risk of 4th degree lacerations (LE3). Crohn's disease without perianal involvement is not associated with an excess risk of OASIS (LE3). For women with type III genital mutilation, deinfibulation before delivery is associated with a reduction in the risk of OASIS (LE3); in this situation, deinfibulation is recommended before delivery (grade C). CONCLUSION: It is necessary to use a consensus definition of the OASIS to be able to better detect and treat them.

[Interest of infiltration of Impar node in rebel vulvodynia: About a series of 8 cases]. / Intérêt de l'infiltration du ganglion Impar dans les vulvodynies rebelles : à propos d'une série de 8 cas.

INTRODUCTION: Vulvodynia is a common and debilitating disease, for which treatments are often of limits efficacy. As the Impar node receives nociceptive afferents from pelvis and perineum, it is a potential therapeutic target to treat pain in this region. The objective of the study was to evaluate the relevance of ropivacaine Impar node infiltration in patients suffering from rebel vulvodyny. METHODS: This was a retrospective, single-center study. The Impar node infiltrations were performed by a single operator in eight patients suffering from rebel vulvodynia. Ropivacaine and iopamidol were administered in prone position with a lateral approach under scanner. The anaesthetic diagnostic block of the Impar node was positive in all eight patients included in the study. Thereafter these patients benefited of 2 additional therapeutic infiltrations. Subsequently, an infiltration of the node with 100UI of botulinum toxin was performed in two patients with a bilateral approach under scanner. The analgesic efficacy was evaluated by a Visual Analogic Scale (VAS) before, immediately after, and at day 15 following the infiltration. A subjective evaluation of pain comprising the percentage of overall improvement and duration of analgesic efficacy was performed after the third infiltration. RESULTS: Comparison of the VAS before and immediately after the Impar block showed in the first anesthetic block a significant decrease in pain median VAS from 51/100 to 16/100 (P=0.01). Similarly, for the second block, VAS decreased from 52.5/100 to 15/100 (P=0.02). The maximal pain reported on Day 15, was significantly lower after the third infiltration than that after the first (P=0.03). Five patients reported an overall improvement in their quality of life of over 50%, which lasted an average of six weeks. A long lasting effectiveness was obtained in the two patients who benefited of the botulinum toxin. CONCLUSION: The infiltration of Impar node is an interesting technique for patients suffering of rebel vulvodynia. LEVEL OF EVIDENCE: 4.

[Oxytocin and postpartum depression]. / L'ocytocine et la dépression du post-partum.

INTRODUCTION: Postpartum depression (PPD) is prevalent (about 10%) with a major impact on the mother and child health. At the hormonal level, poor regulation of oxytocin rate has a key role in depression. Recently, oxytocin has been used on psychiatric therapy, intranasal or intravenously, particularly in mood disorders. But, in obstetrics, this molecule is administered during childbirth. The objective of this study was to determine if intravenous administration of oxytocin could influence thymic state of the mother in the postpartum period. METHODS: Literature review, after consultation of Pubmed and Sciencedirect databases, with the following keywords: oxytocin, postpartum depression, pregnancy, social behavior. RESULTS: The effects of oxytocin in the PPD are part of a multifactorial mechanism (hormonal and social) that influences the hormonal effects of oxytocin. Oxytocin use in therapeutic was able to give conclusive results in psychiatry, the way and the optimal method of administration are not known. PPD is associated with administrated oxytocin during labour. Physiopathology remains unknown. CONCLUSION: It is possible that oxytocin administered during childbirth is related with the onset or worsening of the PPD without defining if it's a cause or a consequence.