Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) study.

OBJECTIVE: Among women diagnosed with pelvic inflammatory disease, we examined the associations between hormonal or barrier methods of contraception and upper genital tract infection or inflammation. METHODS: Participants were 563 patients from a treatment trial for pelvic inflammatory disease. All had pelvic pain; pelvic organ tenderness; and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. Contraceptive use within the prior 4 weeks was compared among women with baseline upper genital tract gonorrhea or chlamydia, women with endometritis without upper genital tract gonorrhea or chlamydia, and women with neither upper genital tract gonorrhea or chlamydia nor endometritis. RESULTS: Inconsistent condom use was significantly and independently associated with a 2 to 3 times elevated risk for upper genital tract infection. Upper genital tract gonorrhea or chlamydia was not significantly associated with use of oral contraceptives, use of medroxyprogesterone, condoms used consistently, nor other barrier methods. CONCLUSION: No hormonal or barrier contraceptive method was related to a reduction in upper genital tract disease among women with clinical pelvic inflammatory diseases.

Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study.

BACKGROUND: Douching has been related to risk of pelvic inflammatory disease (PID). GOAL: To examine the association between douching and PID in a large, multicenter, clinical trial of PID after adjustment for race/ethnicity. STUDY DESIGN: Interviews were conducted with 654 women who had signs and symptoms of PID. Vaginal Gram stains and upper genital tract pathology/cultures were obtained from all the women. Women with evidence of plasma cell endometritis and/or gonococcal or chlamydial upper genital tract infections were compared with women who had neither endometritis nor upper genital tract infection. RESULTS: Women with endometritis or upper genital tract infection were more likely to have douched more than once a month or within 6 days of enrollment than women who never douched. These associations remained after adjustment for confounding factors, after analysis of black women only; and among women with normal or intermediate vaginal flora but not bacterial vaginosis. CONCLUSION: Among a predominantly black group of women with clinical PID, frequent and recent douching was associated with endometritis and upper genital tract infection.

Effects of pubovaginal sling procedure on patients with urethral hypermobility and intrinsic sphincteric deficiency: would they do it again?

OBJECTIVE: This study was undertaken to assess the cure rate of stress urinary incontinence, long-term effects on other lower urinary tract symptoms, and quality of life in a cohort of patients who underwent pubovaginal sling procedures for treatment of incontinence related to intrinsic sphincteric deficiency and urethral hypermobility. STUDY DESIGN: This was a retrospective analysis of 57 patients with 90% follow-up who underwent pubovaginal autologous fascial sling procedures for stress urinary incontinence related to urethral hypermobility and intrinsic sphincteric deficiency. Objective postoperative urodynamic evaluation was performed in 34 (60%) of the cases. Telephone interviews to assess quality-of-life parameters were performed in all cases. RESULTS: The mean follow-up period was 42 months and the median follow-up period was 34 months, with a range of 0.5 to 134 months. The age at the time of the sling procedure ranged from 18 to 84 years, with a median parity of 3.0 (range, 0-6). Preoperative body mass index ranged from 19.5 to 39.1 kg/m(2). Five percent of patients had detrusor instability before the operation. Forty-one percent (41%) of the patients who underwent postoperative urodynamic evaluation had voiding dysfunction. The postoperative objective cure rate for stress urinary incontinence was 97%. Of all patients 88% indicated that the sling had improved the quality of life, 84% indicated that the sling relieved the incontinence in the long-term, and 82% would choose to undergo the procedure again. CONCLUSION: Construction of a pubovaginal sling is an effective technique for relief of severe stress urinary incontinence. Voiding dysfunction is a common side effect. Despite this problem, a significant number of patients would elect to undergo the procedure again.

Neurologic disease presenting as chronic pelvic pain.

Neurologic disease as a cause of chronic pelvic pain may be more common than previously reported. We report three cases wherein patients with complaints of pelvic pain were subsequently found to have neurologic disease involving the lumbosacral spine. In all three cases, the presenting features were complaints of cyclic or noncyclic lower abdominal pain attributed to endometriosis, pelvic inflammatory disease, or uterine fibroids. When conventional therapies failed to resolve the pain, magnetic resonance imaging (MRI) of the lumbosacral spine showed a neoplasm in one patient and disk herniation in two patients. Evolving lumbar disk disease or intradural neoplasms in the upper lumbar area can produce symptoms interpreted as pelvic pain. Symptoms consistent with radiculopathy occurred late in the course of each of the three cases reported.

The association of interleukin 6 with clinical and laboratory parameters of acute pelvic inflammatory disease.

OBJECTIVE: We sought (1) to determine whether interleukin 6 levels are increased in plasma and cervical secretions and endometrial tissue obtained from women with a clinical diagnosis of pelvic inflammatory disease, (2) to determine whether interleukin 6 levels in these sample sites reflected the clinical severity of acute infection, and (3) to determine whether interleukin 6 levels in endometrial tissue obtained from these women were higher in the presence of histologic endometritis. STUDY DESIGN: We performed a prospective pilot study on 20 women with a clinical diagnosis of pelvic inflammatory disease (patients) and then compared them with 20 women presenting to the gynecology clinic without pelvic complaints (control subjects). Interleukin 6 levels were measured by enzyme-linked immunologic testing in plasma, cervical secretions, and endometrial biopsy specimens. RESULTS: Cervical interleukin 6 levels were higher in patients than control subjects (median, 317 vs 111 pg/mL; P =.003). Among women with pelvic inflammatory disease, statistically significant positive correlations were noted between the clinical severity score and the erythrocyte sedimentation rate (r = 0.45; P =.04), the clinical severity score and the white blood cell count (r = 0.49; P =.03), the plasma interleukin 6 levels and the erythrocyte sedimentation rate (r = 0.55; P =.02), and the plasma interleukin 6 levels and the white blood cell count (r = 0.54, P =.01). Endometrial tissue interleukin 6 levels were also higher in patients with versus those without histologic endometritis (median, 427 vs 17 pg/mL; P =.004). CONCLUSION: In this pilot study interleukin 6 levels in cervical secretions were significantly higher in women with pelvic inflammatory disease versus those without pelvic inflammatory disease. In women with pelvic inflammatory disease, endometrial tissue samples with histologic evidence of endometritis were observed to have higher levels of interleukin 6. Interleukin 6 may be a useful adjunct to the clinical diagnosis of pelvic inflammatory disease.

Design of the PID Evaluation and Clinical Health (PEACH) Study.

This paper describes the PID Evaluation and Clinical Health Study (PEACH), a multicenter, randomized clinical trial designed to compare treatment with outpatient and inpatient antimicrobial regimens among women with pelvic inflammatory disease (PID). PEACH is the first trial to evaluate the effectiveness and cost-effectiveness of currently recommended antibiotic combinations in preventing infertility, ectopic pregnancy, chronic pelvic pain, recurrent PID, and other health outcomes. It is also the largest prospective study of PID ever conducted in North America. We describe the PEACH study's specific aims, study organization, patient selection criteria, conditions for exclusion, data collected upon entry, randomization and treatment, adherence measures, follow-up activities, quality-of-life measures, outcomes, and statistical analyses. In the first 11 months of enrollment (March 1996-January 1997), 312 women were randomized. Of eligible women, 59% consented to enroll. Participating women are primarily black (72%) and young (mean age 24 years). After a median of 5.5 months of follow-up, we were in contact with 95% of study participants. The PEACH study will provide a rationale for selecting between inpatient and outpatient antibiotic treatment, the two most common treatment strategies, for PID.

Laparoscopic and psychologic evaluation of women with chronic pelvic pain.

OBJECTIVE: Pelvic pain can account for up to 40 percent of laparoscopies performed by gynecologists. This report compares the psychological profiles and efficacy of laparoscopic surgery at long-term follow-up in a series of laparoscopy-positive and laparoscopy-negative patients with chronic pelvic pain. METHOD: A retrospective chart review was performed on patients diagnosed with chronic pelvic pain combined with postoperative written questionnaires and self-rating scales. These questionnaires were used to assess long-term post laparoscopy follow-up of the physical and psychological status of women with positive findings at laparoscopy compared to those women with negative findings. RESULTS: There were no statistically significant demographic differences between respondents and nonrespondents. In the respondents, no statistically significant differences were noted even with long-term follow-up when comparing responses of the laparoscopy-positive and laparoscopy-negative groups on the above questionnaires. CONCLUSION: Though reporting modest improvement in pelvic pain since laparoscopy, both groups reported a high incidence of anxiety, depression, physical worries, and marital/sexual problems.

Sexual function after sacrospinous ligament fixation for vaginal vault prolapse.

OBJECTIVE: To determine if sacrospinous ligament fixation predisposes to dyspareunia or if vaginal narrowing secondary to repair of associated defects is causative. STUDY DESIGN: We interviewed and examined 36 heterosexual patients preoperatively and at follow-up 15-79 months postoperatively. We inquired specifically as to sexual activity or inactivity and whether sexual function had improved or declined since surgery. RESULTS: Postoperatively, sexually active patients reported either an improvement or no change in sexual function unless vaginal narrowing occurred. Vaginal narrowing caused apareunia in three postoperative patients. Death of the partner was the most common reason for sexual inactivity preoperatively or postoperatively. CONCLUSION: Sacrospinous ligament fixation did not predispose to dyspareunia unless vaginal narrowing due to repair of associated defects was present.

Long-term failure of pelvic floor musculature exercises in treatment of genuine stress incontinence.

This report evaluates the motivation of a group of patients to continue a program of pelvic floor musculature exercises as conservative therapy for genuine stress incontinence. Fourteen women with urodynamically documented genuine stress incontinence had subjective improvement; nine of them showed objective improvement after 4 weeks of supervised pelvic floor musculature exercises. These patients were questioned 5 years later as to continence status, performance of pelvic floor musculature exercises, and subsequent surgery for incontinence. Ten of 14 patients responded: four have had anti-incontinence surgery and remain continent; five have not had surgery, do not perform pelvic floor musculature exercises, and continue to have stress incontinence. One patient continues to perform pelvic floor musculature exercises and has stress incontinence with a full bladder. Thus, only one patient out of 10 remained sufficiently motivated to perform pelvic floor musculature exercises after 5 years, even though all patients in this series had improvement after a 4-week course of supervised exercises.

Recurrent pelvic support defects after sacrospinous ligament fixation for vaginal vault prolapse.

BACKGROUND: Multiple studies have shown sacrospinous ligament fixation to be highly effective therapy for vaginal vault prolapse. Several authors have suggested that the marked vaginal retroversion subsequent to sacrospinous ligament fixation may predispose to recurrent pelvic support defects in the anterior fascial segment, resulting in cystocele or urethrocele, or both. STUDY DESIGN: Thirty-six patients, 46 to 86 years of age, were examined at six weeks postoperatively and at long-term follow-up evaluation 15 to 79 months (median of 42 months) after sacrospinous ligament fixation and repair of associated pelvic support defects. The examinations, by an unbiased examiner, were done to identify and grade recurrent pelvic support defects. RESULTS: At the six week postoperative visit, one patient had a small enterocele, and none of the patients demonstrated vaginal vault prolapse. At the long-term follow-up visit, 33 (92 percent) of the patients had cystoceles, six (17 percent) had rectoceles, two (6 percent) had enteroceles, and three (8 percent) demonstrated recurrent vaginal vault prolapse. Most cystoceles were small and asymptomatic. CONCLUSIONS: A high rate of success in the treatment of prolapse of the upper vagina by sacrospinous ligament fixation was observed. Pelvic support defects at long-term follow-up evaluation occurred more commonly in the anterior fascial segment. Retroversion and fixation of the upper vagina predisposes the anterior fascial segment to excess pressure and a higher incidence of cystocele than could be attributed to the effects of aging and menopause.

Enterocele: a review.

An enterocele is a hernia of the small intestine into the vagina. First described in 1736, it is an uncommon but potentially quite symptomatic clinical entity. Despite increased interest in enterocele during the past 50 years, there are few large series reported, and follow-up on surgical results has generally been poor. Many enteroceles follow vaginal or abdominal hysterectomy. Various surgical techniques for repair of enterocele are presented herein, including the classical repairs by Ward and Moschcowitz. Because enterocele frequently coexists with vaginal vault prolapse, contemporary procedures for simultaneous repair are described. Emphasis is placed upon prophylactic vaginal vault suspension and cul-de-sac obliteration at the time of abdominal or vaginal hysterectomy. The complications of failure to recognize enterocele are spontaneous vaginal evisceration, although rare, and progressive symptomatology. Attempted repair may also engender complications, some life-threatening.