Self-reported natural history of recurrent prolapse among women presenting to a tertiary care center

ObjectiveTo describe the characteristics of recurrent pelvic organ prolapse (POP).MethodsA convenience sample of patients presenting with recurrent POP symptoms between October 2007 and February 2010 completed questionnaires. The survey focused on timing of recurrence(s), symptoms, and demographics.ResultsNinety-seven women completed questionnaires. Thirty-four (35.1%) had undergone multiple prior treatments. Overall, 23 of 76 (30.3%) women had not informed their surgeon of the recurrence. Twenty-seven of 59 (45.8%) women reported that their symptoms were the same as before treatment, whereas 23 of 59 (39.0%) reported more severe symptoms. POP was considered to be persistent if symptoms returned within 3 months, and recurrent if symptom relief exceeded 3 months. After primary surgery, 28 of 79 (35.4%) cases were considered to be persistent, whereas 51 (64.6%) cases were recurrent. Similar percentages were seen after second and third treatments.ConclusionOverall, 35% of participants experienced early return of symptoms. Almost one-third of participants had not informed their surgeon of the recurrence, indicating that there may not be an accurate self-assessment of outcome in the absence of careful follow-up.     

Predictive factors for failure of pelvic arterial embolization for postpartum hemorrhage

ObjectiveTo assess the efficacy of pelvic embolization in women with postpartum hemorrhage (PPH) and to determine factors associated with embolization failure.MethodsIn a retrospective observational study, data were analyzed from 98 consecutive women who underwent pelvic embolization for intractable PPH between January 2007 and November 2009 at Beaujon Hospital, Clichy, France. Women with persistent PPH despite pelvic embolization were compared with women who had cessation of hemorrhage and attained hemodynamic stability.ResultsAmong the 98 women, 66 (67.3%) had been transferred from another hospital after delivery. Pelvic arterial embolization failed to control PPH in 8 (8.2%) women. On univariate analysis, factors significantly associated with embolization failure were the presence of placenta accreta (P < 0.005), hemoglobin level (P < 0.05), prothrombin time (P < 0.04), fibrinogen level (P < 0.03), red blood transfusion (P < 0.02), number of packed red blood cell units transfused (P < 0.05), and fresh-frozen plasma transfusion (P < 0.02). Hospital-to-hospital transfer with a notable time interval between delivery and embolization was not associated with increased risk of failure.ConclusionPredictive factors significantly associated with failed pelvic arterial embolization were the presence of placenta accreta, biologic factors, and transfusional factors. Delay due to inter-hospital transfer did not affect the outcome of embolization.     

Sexual Function and Quality of Life in Women with Urinary Incontinence Treated by a Complete Pelvic Floor Rehabilitation Program (Biofeedback,Functional Electrical Stimulation,Pelvic Floor Muscles Exercises,and Vaginal Cones)

IntroductionUrinary incontinence (UI) is a debilitating condition that can cause discomfort, embarrassment, loss of confidence; it can lead to withdrawal from social life, and adversely affects physical and mental health, sexual function and quality of life (QoL) in women.AimThe aim is to determine the impact of combined pelvic floor rehabilitation (PFR) on UI, female sexual dysfunction, and QoL.Main Outcome MeasuresFemale Sexual Function Index questionnaire (FSFI) and King's Health Questionnaire (KHQ).MethodsSixteen patients with UI were selected and underwent a complete PFR program (biofeedback, functional electrical stimulation, pelvic floor muscles exercises, and vaginal cones). Patient filled out the FSFI questionnaire and the KHQ at the baseline and at follow-up.ResultsAfter PFR none of the patients reported urine leakage during sexual activity. Resolution of incontinence was achieved in 13 (81.25%) women. Only three (18.75%) patients had positive 1-hour pad test after the treatment. There was significant difference between pad test leakage before and after the PFR (P < 0.001).The mean Stamey incontinence score was 1.37 ± 0.5 at the baseline vs. 0.25 ± 0.57 at the follow up (P < 0.001). Before PFR, FSFI total score ranged from 25.8 to 2 (mean 14.65 ± 6.88), after treatment the FSFI total score ranged from 36 to 2 (mean 22.65 ± 9.5) (P < 0.001). The improvement of the scores in the six FSFI domains, 5 months after the conclusion of PFR, was statistically significant (desire, arousal, lubrication, orgasm, satisfaction, and pain). All the nine domains in the KHQ presented a low average score after treatment and the improvements were statistically significant.ConclusionsPFR led to a significant difference in the daily use of pads, 1-hour pad test, and Stamey incontinence scores. The treatment caused an improvement in patient's QoL index and sexual function. Rivalta M, Sighinolfi MC, Micali S, De Stefani S, and Bianchi G. Sexual function and quality of life in women with urinary incontinence treated by a complete pelvic floor rehabilitation program (biofeedback, functional electrical stimulation, pelvic floor muscles exercises, and vaginal cones).     

Sexualité féminine après chirurgie pour endométriose pelvienne profonde

ObjectivesThe aim of this study is to assess the impact on sexuality of the surgical treatment in patients with symptomatic deep pelvic endometriosis.Patients and methodsThe design is a single-center cohort prospective study including all patients with symptomatic pelvic endometriosis and regular sexual activity who underwent surgery between October 2009 and September 2010. Sexual function was evaluated by the “Brief Index of Sexual Functioning for Women” (BISF-W) questionnaire translated and validated in French, including a global evaluation by the Composite Score (CS). Pain symptoms related to endometriosis were evaluated by the Visual Analog Scale (VAS) and the simple Verbal Rating Scale (VRS). Questionnaires were answered before surgery. A standardized mid and long-term postoperative follow-up was performed to compare sexuality and pain symptoms.ResultsTwenty women were included in the study. Mean follow-up was 23.3 months. When compared to a French reference population, global preoperative sexual function was significatively deteriorated (CS = 14.3 ± 10.8 vs 32.2 ± 12.6; P < 0.001), especially for arousal, frequency of sexual activity, pleasure and orgasm. Significant improvements in sex life were observed after surgery at the long-term follow-up (CS = 33.0 ± 11.7 vs 14.3 ± 10.8; P = 0.02). and sexual function was similar to the reference population (CS = 33.0 ± 11.7 vs 32.2 ± 12.6; P = 0.806). At the mid-follow-up, a significant improvement in the intensity of dysmenorrhoea, non-cyclic pelvic pain, dyspareunia and bowel symptoms were observed on the VAS. At the long-term follow-up, dysmenorrhoea and dyspareunia were significatively ameliorated. Pelvic pain recurrence related to endometriosis was 13.3%.Discussion and conclusionSurgical management of deep pelvic endometriosis in symptomatic patients improves sexual life at the long term follow-up. Deep dyspareunia pain decreases significantly, although other conditions are involved in the improvement of sexual function.     

Long-term results of prolapse recurrence and functional outcome after vaginal hysterectomy

ObjectiveTo evaluate the incidence of prolapse and prolapse-related symptoms following vaginal hysterectomy.MethodsData were reviewed from women who underwent vaginal hysterectomy between 1988, and 1995, at St George's Hospital, London, UK, and attended long-term follow-up. Outcome measures included a questionnaire for prolapse, urinary, bowel, and sexual symptoms; and a vaginal examination.ResultsAmong 94 women attending long-term evaluation, the mean follow-up time was 100.7 months (range 67.0–156.0 months). Before vaginal hysterectomy, urgency was noted among 23 (24.5%), urge incontinence among 11 (11.7%), and stress incontinence among 8 (8.5%) women. At follow-up, these symptoms were observed among 23 (24.5%), 13 (13.8%), and 6 (6.4%) women, respectively. De novo urge incontinence and de novo stress incontinence were observed among 3 (3.2%) and 2 (2.1%) women, respectively. Vaginal examination data were compared for 70 women, of whom 18 (25.7%) had grade 1, 40 (57.1%) had grade 2, and 6 (8.6%) had grade 3 uterine prolapsed before surgery. Postoperatively, vaginal vault prolapse occurred in 7 (10.0%) women and correlated with degree of posterior prolapse (P = 0.007), but not with severity of uterine descent (P = 0.205) or previous prolapse surgery (P = 0.573).ConclusionThe incidence of post-hysterectomy vault prolapse correlated with the degree of preoperative rectocele.     

Efficacy of letrozole in treatment of endometriosis-related pain

ObjectiveTo evaluate the efficacy of aromatase inhibitor (letrozole) in the treatment of endometriosis-related pain.Patients and methodA total of 20 women with Stage IV endometriosis presented with endometriosis-related pain refractory to previous treatment or recurrence after such treatment have been included in the study. All women were treated with oral administration of letrozole 2.5 mg in addition to elemental calcium 1000 mg and vitamin D 880 IU daily for a total treatment duration of 6 months. Baseline (pre-treatment), monthly during treatment, at end of treatment and 6 months after completion of treatment; all patients were evaluated for the presence and intensity of pain (including dysmenorrhea, deep dyspareunia and chronic pelvic pain) using a 100 mm visual analog scale (VAS).ResultsMean age was 30.9 years with 80% of patients were NP. Half of patients presented with dysmenorrhea. Patients previously received oral contraceptives (50%), GnRH agonists (25%) and Medroxyprogesterone acetate (25%) or underwent laparotomy with ovarian cystectomy (20%) or exploration 30%). At the end of treatment (6 months after start treatment) mean VAS dropped from 7.65 at start of therapy to 6.1 (p-value < 0.005). Six months later (12 months after start of therapy), further significant drop of mean VAS has been reported (from 6.1 to 4).ConclusionLetrozole (aromatase inhibitor) has shown to be effective in the treatment of endometriosis-related pain with substantial improvement of pain with no recurrence of pain for 6 months after completion of treatment.     

Pelvic Floor Tenderness in the Etiology of Superficial Dyspareunia

ObjectiveTo calculate the prevalence of pelvic floor tenderness in the population of women with pelvic pain and to determine its implications for symptoms of pelvic pain.MethodsWe conducted a retrospective review of patients with pelvic pain at a tertiary referral centre. Pelvic floor tenderness was defined as levator ani tenderness on at least one side during single digit pelvic examination. The prevalence of pelvic floor tenderness in this cohort of women with pelvic pain was compared with the prevalence in a cohort of women without pain attending a gynaecology clinic. In the women with pelvic pain, multiple regression was performed to determine which variables were independently associated with pelvic floor tenderness.ResultsThe prevalence of pelvic floor tenderness was 40% (75/189) in the cohort with pelvic pain, significantly greater than the prevalence of 13% (4/32) in the cohort without pain (OR 4.61; 95% CI 1.55 to 13.7, P = 0.005). On multiple logistic regression, superficial dyspareunia (OR 4.45; 95% CI 1.86 to 10.7, P = 0.001), abdominal wall pain (OR 4.04; 95% CI 1.44 to 11.3, P = 0.005), and bladder base tenderness (OR 4.65; 95% CI 1.87 to 11.6, P = 0.001) were independently associated with pelvic floor tenderness. Pelvic floor tenderness was similarly present in women with or without underlying endometriosis.ConclusionPelvic floor tenderness is common in women with pelvic pain, with or without endometriosis, and is a contributor to superficial dyspareunia. Pelvic floor tenderness was also associated with abdominal wall pain and bladder base tenderness, suggesting that nervous system sensitization is involved in the etiology of pelvic floor tenderness.     

Changes in Sexual Function after Treatment for Prolapse Are Related to the Improvement in Body Image Perception

IntroductionIn a previous study, sexual function was related to a woman's self-perceived body image and degree of bother from pelvic organ prolapse (POP).AimsTo evaluate sexual function, prolapse symptoms, and self-perceived body image 6 months following treatment for POP and to explore differences in body image perception and sexual function following conservative and surgical treatment for POP.MethodsAfter institutional review board approval, consecutive women with ≥stage II POP were invited to participate. In addition to routine urogynecologic history and physical examination, including Pelvic Organ Prolapse Quantification (POP-Q), the participants completed three validated questionnaires before, and 6 months after, treatment for POP: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Modified Body Image Perception Scale and Prolapse subscale of Pelvic Floor Distress Inventory to assess condition specific bother from POP.Main Outcome MeasuresChanges in sexual function and body image perception following treatment for POP.ResultsA total of 235 women with a mean age of 62 ± 12 years returned for a 6-month follow-up. The majority of our participants had surgical repair for POP (88%). At 6-month follow-up visits, the patients reported significant improvement in sexual function from baseline (33 ± 0.6 vs. 43 ± 0.8, respectively P < 0.0001). Improvement in sexual function, as measured by PISQ-12, was not significant among sexually active patients treated with a pessary compared with those treated surgically (–2.5 ± 5.5 vs. 11.5 ± 1, respectively P < 0.0001). A multivariate linear regression model demonstrated that body mass index and changes in body image perception were the only independent factors associated with changes in PISQ score following POP treatment (β = ?0.5, P < 0.01 and β = ?0.4, P < 0.03, respectively).ConclusionsResolution of POP symptoms after treatment improves women's self-perceived body image and sexual function. Not surprisingly, pessary is less effective in improving sexual function compared with surgical repair of POP. Lowenstein L, Gamble T, Sanses TVD, van Raalte H, Carberry C, Jakus S, Pham T, Nguyen A, Hoskey K, and Kenton K for the Fellow's Pelvic Research Network. Changes in sexual function after treatment for prolapse are related to the improvement in body image perception.     

Persistent Sexual Dysfunction Impairs Quality of Life after Cardiac Transplantation

IntroductionThe impact of sexual dysfunction (SD) on mental and physical health after heart transplantation (HTx) has not been established.AimWe investigated the relationship of SD on quality of life (QoL), physical and mental health, and depressive symptoms after HTx.Main Outcome MeasuresWe evaluated SD according to the International Index of Erectile Dysfunction and the Female Sexual Function Index. QoL, physical and mental health were assessed using: 1) Short Form 12 Health Survey Questionnaire, 2) Quality of Life Enjoyment and Satisfaction Questionnaire—Short Form, and two depressive symptoms questionnaires: 1) Beck Depression Inventory-II and 2) Quick Inventory Depressive Symptomatology-Self Report.MethodsWe enrolled patients who were greater than 6 months post HTx. Patients unable to read English, had pelvic surgery or trauma, urogenital abnormalities, or sexually inactive were excluded.ResultsOut of 79 subjects that were screened, 33 men and 6 women participated (mean age 61.4 + 11.4). Response rates were at least 82% for all questionnaires. Overall prevalence of SD was 61%, with 78% of men being affected and 50% of women. There was no significant difference in measures between genders. HTx recipients with SD reported significantly worse QoL on measures of physical health when compared to those without SD. After HTx, patients suffering from SD had significantly worse general health (P = 0.02) and physical health (P = 0.02), including physical functioning (P = 0.01) and physical role limitation (P = 0.01). In contrast, mental health and depressive symptoms after HTx were not significantly different between those with and without SD.ConclusionsAfter HTx a high prevalence of SD remains among both men and women. Patients with SD had worse general and physical health but not depressive symptoms when compared to those without SD. The contributing factors may be more related to physical rather than psychological causes. Phan A, IsHak WW, Shen B-J, Fuess J, Philip K, Bresee C, Czer L, and Schwarz ER. Persistent sexual dysfunction impairs quality of life after cardiac transplantation.     

Quality of life and emotional distress in early stage and locally advanced cervical cancer patients: a prospective, longitudinal study

ObjectivesThis prospective, longitudinal study investigates QoL issues and emotional distress in early stage cervical cancer (ECC) patients undergoing radical surgery (RS) and in locally advanced cervical cancer (LACC) patients triaged to chemoradiation (CT/RT) followed by RS.MethodsThe Global Health Status scale of EORTC QLQ-C30 (GHS), the EORTC QLQ-CX24 (CX24) and the Hospital Anxiety and Depression Scale (HADS) questionnaire were administered at baseline, and after 3, 6, and 12 months from surgery. For LACC patients QoL assessment was also performed after CT/RT. Statistical analysis was performed by the ANOVA for repeated measures and the Between Subject test.ResultsIn ECC and LACC patients, the GHS scores improved over time (5.5% difference in mean scores compared to baseline in ECC, and 7.0% difference in mean score compared to baseline in LACC patients). An early worsening of lymphedema scores was documented in ECC cases (14.6% difference in mean values compared to baseline, p value = 0.001), and in LACC patients (difference up to 28.3% of mean values, value = 0.0001). Menopausal symptoms persistently worsened over time reaching > 15% difference of mean values compared to baseline in both groups. Sexual activity scores markedly improved both in ECC and LACC patients (difference of mean score values compared to baseline was 16.5% in ECC, and 6.7% in LACC patients). Both ECC and LACC patients experienced an improvement of anxiety scores.ConclusionsLymphedema and menopausal symptoms were the most disabling treatment-related sequelae; the amount of QoL issues and their multifaceted aspects require the cooperation of multidisciplinary teams.     

Aromatase inhibitor “letrozole” versus progestin “norethisterone” in women with simple endometrial hyperplasia without atypia: A prospective cohort trial

ObjectiveTo evaluate the effectiveness of the aromataze inhibitor “letrozole” to progestin “norethisterone” for women with simple endometrial hyperplasia without atypia.Subjects and methodsOne hundred women with a histo-pathological diagnosis of simple endometrial hyperplasia without atypia were divided into two groups: Groups A and B. Group A included 50 patients who received a daily 5 mg dose of letrozole for three successive months. Group B included the other 50 patients who received norethisterone 10 mg daily by non-stop regimen for 3 months. All patients in both groups were reevaluated after treatment. Women diagnosed with progressive or persistent endometrial hyperplasia at the second curettage were asked to continue on the same medication for another 3 months. Transvaginal sonography as well as serum estradiol level measurement were performed before the start of treatment and 3 months after treatment.ResultsDespite that there was no statistically significant difference between the two groups as regards the proportion of women whose endometrial sample revealed resolution, regressing or persistence after 3 months of treatment. However, endometrial thickness was significantly thinner in women who received letrazole than in women who received norethisterone (mean difference 0.12 mm, 95% CI: 0.22–0.01, P = 0.02). Serum E2 level was significantly lower in the Group A compared to Group B (mean difference 9.1 pg, 95% CI: 13.74–4.45, P < 0.001).ConclusionLetrozole is as effective as norethisterone for women with abnormal uterine bleeding due to endometrial hyperplasia without atypia.     

140 exéresis de lesiones de cérvix con asa de diatermia. Márgenes,tabaco y persistencia

ObjectiveTo evaluate the factors that influence in the cervix lesion persistence after removingDesignRetrospective studySubjets140 patients who suffered diathermy loop excisional procedures of cervix lesionsResultsThe half age was 37.5 (19–74); 72.5% smokers. Persistence in patients with margins affections was 31.3% at sixth months, in front of 17.2% with free margins (15 of 87) (OR: 2.18; CI: 0.6–7.2) (p = 0.2). Two lesions persisted eighteen month later (cure in 96.1%), both cases with free margins. After 6 months the lesion persisted in 26.5% in smokers, versus 13.3% in non smokers (OR: 2.34; CI: 0.5–11.8) (p = 0.3). The two patients with persistence after 18 months were smokers. 19.3% of high degree lesions persisted after 6 months and 3.9% after 18 months; 29.4% of low degree persisted after 6 months and no case of low degree persisted after 18 months (p = 0.8)ConclusionsThe persistence of the lesion after eighteen months did not depend on the affectation of the resection margins, of the histology neither of the smoking habit. It is not necessary the later surgery in the patients that have incomplete resection of a lesion of the uterine cervix, and only the pursuit with cytology and colposcopia can justify the reintervention     

Role of MR imaging in surgical planning and prediction of successful surgical repair of pelvic organ prolapse

ObjectiveTo determine the role of magnetic resonance imaging (MRI) in surgical planning for females with pelvic organ prolapsed (POP) and to determine the clinical utility of MR imaging in predicting successful surgical repair.MethodsFifteen patients with different varieties of pelvic floor dysfunction and 15 nulliparous females as control subjects were studied by magnetic resonance imaging (static and dynamic). Intraoperative findings related to POP were correlated to MRI findings. In the symptomatic patients, magnetic resonance imaging was repeated within 6–12 months after surgery.ResultsPreoperative MRI and operative findings showed a significant correlation in all types of prolapse, except rectocele. On the other hand preoperative pelvic examination and operative findings were significantly correlated for cystocele, rectocele and vaginal cuff prolapse (r = 0.75, P < 0.008). Preoperative magnetic resonance imaging added information that changed the management in 40% of symptomatic women. Postoperative magnetic resonance imaging showed normal pelvic floor in asymptomatic patients (n = 13). Abnormal imaging findings were found in patients with persistent postoperative or de novo complaints (n = 2).ConclusionMagnetic resonance imaging can accurately localize pelvic floor defects, evaluate success or failure of surgical procedures, predict the need for more extensive reconstruction, and identify complications.     

The Levonorgestrel Intrauterine System is an Effective Treatment in Women with Abnormal Uterine Bleeding and Anticoagulant Therapy

ObjectiveTo evaluate the efficacy of levonorgestrel intrauterine systems (LNG-IUS) in obese women with AUB on anticoagulant therapy.DesignProspective observational case series (Canadian Task Force Classification II-3).SettingUniversity affiliated teaching hospital.PatientsPremenopausal women on Warfarin therapy.InterventionsFrom January 2002 through January 2007, 10 women were identified from the senior author's clinical practice (G.A.V.). After clinical assessment, including Papanicolaou smear, endometrial biopsy, and pelvic sonography, the LNG-IUS was placed to treat their AUB.Measurements and Main ResultsThe median and range of age, parity, and body mass index were 45 years (34-49), 1 (0-4), and 38 kg/m² (26-52), respectively. All women were receiving warfarin therapy (4-12.5 mg/d) for previous venous thromboembolism. Some patients had additional comorbid conditions and were at high risk for traditional medical or surgical therapies. After placement of the LNG-IUS, all women reported menstrual reduction at 3 and 6 months. By 12 months, 1 woman with large fibroids expelled the LNG-IUS and was treated with transfemoral uterine artery embolization. Two women had amenorrhea, and 7 had hypomenorrhea. At 2 to 5 years, 1 woman expelled the LNG-IUS and hysterectomy indicated extensive adenomyosis in a 195-g uterus, and 1 woman had hysteroscopic endometrial ablation, 4 were menopausal, 2 had amenorrhea, and 1 had hypomenorrhea. In the 5 women with uterine fibroids measuring 4.2 to 147 cm³, the fibroids were reduced in volume by approximately 75% in 2, were no longer detectable in 1, were subsequently shown to be adenomyoma in 1, and required uterine artery embolization in 1.ConclusionIn properly assessed and selected obese, premenopausal women with AUB receiving warfarin therapy and at high risk for traditional therapies, the LNG-IUS was an effective treatment in 70% of patients.     

Sexual function after radical hysterectomy for early-stage cervical cancer

IntroductionFor early-stage cervical cancer, treatment with radical surgery appears effective with excellent survival. However, the treatment is associated with significant morbidities. Sexual dysfunction is the leading cause of symptom-induced distress after the treatments for early-stage cervical cancer. There has been no study that evaluates the effect of surgical treatments for cervical cancer on sexual function in the Eastern/Asian patients.AimTo examine the effect of radical hysterectomy on postoperative sexual function in women with early-stage cervical cancer.Main Outcome MeasuresThe visual analog score on seven aspects of sexual function: overall satisfaction with sexual intercourse, sexual desire, vaginal lubrication, vaginal elasticity, orgasmic satisfaction, patient-perceived partner satisfaction, and associated anxiety.MethodsThirty patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy at the Chiang Mai University Hospital were recruited. All of the patients were interviewed by questionnaire on sexual function at preoperative hospital admission and then at 3 and 6 months after surgery. Relevant clinical and pathologic data were also prospectively collected.ResultsThe mean age of the patients was 45.3 ± 6 years (range 28–59). Seven (23%) of the patients were postmenopausal. Almost all (97%) had FIGO stage IB1 disease. Fourteen (46.7%) patients had bilateral salpingo-oophorectomy, and one (3.3%) patient had unilateral salpingo-oophorectomy. Squamous-cell carcinoma and adenocarcinoma were diagnosed in 83% and 17%, respectively. At 3 and 6 months after operation, 63% and 93% of the patients had sexual intercourse, respectively. Considering the overall sexual satisfaction, the patient-rated visual analog score appeared comparable at preoperative and 6-month postoperative assessment (4.2 ± 2.5 vs. 3.6 ± 2.2, P > 0.05).ConclusionRadical hysterectomy using the current technique has a minimal short-term impact on sexual function. A comparative study with long-term follow-up would provide clearer information on permanent effect of radical hysterectomy on sexual function. Jongpipan J, and Charoenkwan K. Sexual function after radical hysterectomy for early-stage cervical cancer.     

Is transobturator suburethral sling effective for treating female urodynamic stress incontinence with low maximal urethral closure pressure?

ObjectiveTo assess retrospectively the efficacy and safety of MONARC (American Medical Systems) transobturator suburethral slings in the treatment of female urodynamic stress incontinence with and without low maximal urethral closure pressure (MUCP).Materials and MethodsSeventy-three women with urodynamic stress incontinence, fitted with the transobturator suburethral sling at a medical center in central Taiwan, participated in the study. Objective postoperative evaluations, including a 1-hour pad test, cough stress test, uroflowmetry, and residual urine volume, were conducted 6 months after operation. Subjective outcomes were evaluated by telephone interview. Charts were reviewed for perioperative complications, urinary retention, and requirements for postoperative medication for symptoms of urgency. The mean follow-up was 48 months.ResultsObjective cure rate was 80.8% (dry pad test and negative stress test), 82.4% for MUCP less than 30 cmH₂O, and 80.4% for MUCP greater than 30 cmH₂O (p = 1.000). Mean pad weight gain changed from 25.8 g preoperatively to 1.8 g postoperatively (p < 0.05). There was no significant change in urinary flow rate or residual volume. Subjectively, 98.6% of subjects experienced complete improvement; only one patient found no improvement. Very few perioperative complications occurred. Immediate postoperative difficulty in voiding occurred in 6.8% of patients. Postoperative de novo urgency was 2.7%.ConclusionsThe MONARC transobturator suburethral sling is a safe and highly effective treatment for stress urinary incontinence even in women with low MUCP at a mean follow-up of 48 months. Evaluation of the outcomes after a longer follow-up period is necessary.     

Depressive symptoms,anxiety, and quality of life in women with pelvic endometriosis

ObjectiveTo assess depressive symptoms, anxiety and quality of life in women with pelvic endometriosis.Study designA prospective study of 104 women diagnosed with pelvic endometriosis. The Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HAM-D) were used to evaluate depressive symptoms; the Spielberger State-Trait Anxiety Inventory (STAI) and the Hamilton Rating Scale for Anxiety (HAM-A) to evaluate anxiety symptoms; and the short (26-item) version of the World Health Organization Quality Of Life instrument (WHOQOL-BREF) to evaluate quality of life.ResultsOf the patients evaluated, 86.5% presented depressive symptoms (mild in 22.1%, moderate in 31.7%, and severe in 32.7%) and 87.5% presented anxiety (minor in 24% and major in 63.5%). Quality of life was found to be substandard. Age correlated positively with depressive symptoms, as determined using the BDI (P = 0.013) and HAM-D (P = 0.037). There was a positive correlation between current pain intensity and anxiety symptoms, as assessed using the STAI (state, P = 0.009; trait, P = 0.048) and HAM-A (P = 0.0001). The complaints related to physical limitations increased in parallel with the intensity of pain (P = 0.017). There was an inverse correlation between duration of treatment and quality of life (P = 0.017). There was no correlation between psychiatric symptoms and endometriosis stage.ConclusionsA rational approach to endometriosis should include an evaluation of the emotional profile and quality of life. That approach would certainly reduce the functional damage caused by the endometriosis.     

Clinical presentation and epidemiology of female genital tuberculosis in eastern Sudan

ObjectiveTo describe the epidemiology and clinical presentation of female genital tuberculosis (FGTB) among women in eastern Sudan.MethodsA cross-sectional survey was conducted at Kassala Maternity Hospital, Sudan, from January 1 to December 31, 2010.ResultsOf the 2778 women presenting with various gynecologic symptoms, 44 suspected cases of FGTB were identified. Granulomatous tissue reactions were observed in 25 of the suspected FGTB cases, yielding an incidence of 0.9%. The majority (20/25; 80%) of these patients presented with chronic pelvic and lower abdominal pain; however, 68.0% (17/25) presented with pelvic mass, cyst and/or abscess; 48.0% (12/25) had dyspareunia; 40.0% (10/25) were infertile; 28% (7/25) had menstrual dysfunction; 20.0% (5/25) had dysmenorrhea; and 4.0% (1/25) experienced postmenopausal bleeding. Body mass index, residence, and educational level were significantly different between women diagnosed with FGTB and those where FGTB was excluded (P values = 0.02, 0.03, and 0.01, respectively). However, no significant differences were found in age and Bacillus Calmette-Guérin vaccination status.ConclusionClinical suspicion may facilitate and improve the detection of FGTB, with chronic pelvic pain identified as the predominant clinical presentation among women in eastern Sudan.     

Is Hysterectomy Necessary for Laparoscopic Pelvic Floor Repair? A Prospective Study

Study ObjectiveTo evaluate whether the addition of hysterectomy to laparoscopic pelvic floor repair has any impact on the short-term (perioperative) or long-term (prolapse outcome) effects of the surgery.DesignA controlled prospective trial (Canadian Task Force classification II–1).SettingPrivate and public hospitals affiliated with a single institution.PatientsA total of 64 patients with uterovaginal prolapse pelvic organ prolapse quantification system stage 2 to 4 had consent for laparoscopic pelvic floor repair from January 2005 through January 2006 (32 patients in each treatment arm). Patients self-selected to undergo hysterectomy in addition to their surgery.InterventionsPatients were divided into group A (laparoscopic pelvic floor repair with hysterectomy) or group B (laparoscopic pelvic floor repair alone). All patients had laparoscopic pelvic floor repair in at least 1 compartment, whereas 52 patients had global pelvic floor prolapse requiring multicompartment repair. Burch colposuspension and/or additional vaginal procedures were performed at the discretion of the surgeon in each case.Measurements and Main ResultsSymptoms of prolapse and pelvic organ prolapse quantification system assessments were collected preoperatively, perioperatively, and at 6 weeks, 12 months, and 24 months postoperatively. Validated mental and physical health questionnaires (Short-Form Health Survey) were also completed at baseline, 6 weeks, and 12 months. No demographic differences occurred between the groups. Time of surgery was greater in group A (+35 minutes), as was estimated blood loss and inpatient stay, although the latter 2 results had no clinically significant impact. No difference between groups was detected in the rate of de novo postoperative symptoms. At 12 months, 4 (12.9%) patients in group A had recurrent prolapse as did 6 (21.4%) patients in group B. At 24 months these figures were 6 (22.2%) and 6 (21.4%), respectively. These differences were not statistically significant (p = .500 at 12 months and .746 at 24 months). In the group not having hysterectomy, 4 (14.3%) of 28 patients had cervical elongation or level-1 prolapse by the 12-month assessment.ConclusionThe addition of total laparoscopic hysterectomy to laparoscopic pelvic floor repair adds approximately 35 minutes to surgical time with no difference in the rate of perioperative or postoperative complications or prolapse outcome. Leaving the uterus in situ, however, is associated with a risk of cervical elongation potentially requiring further surgery. Laparoscopic pelvic floor repair is successful in 80% of patients at 2 years.     

Complications after double-barreled wet colostomy compared to separate urinary and fecal diversion during pelvic exenteration: Time to change back?

ObjectiveTo assess complications associated with double-barreled wet colostomy (DBWC) in the first six months after pelvic exenteration as compared to separate urinary and fecal diversion (SUD).MethodsA single institution retrospective chart review was conducted of all patients who underwent a pelvic exenteration between 2000 and 2011. Patients were included if the procedure involved at least a urinary diversion and a perineal phase. Patient demographics and complications in the first 6 months after surgery were recorded.ResultsThirty-three patients met inclusion criteria (12 DBWC and 21 SUD). The majority of patients had recurrent cervical cancer (58%) followed by vaginal, vulva, and endometrial cancer. All patients had previously received radiation. 10/12 patients with a DBWC and 67% of SUD had pelvic reconstruction. Median length of stay (LOS) was shorter for DBWC (14.5 vs. 20 days, p = .01). Median operating times were shorter for DBWC (610 vs. 702 minutes, p = .04). No urinary conduit or anastomotic bowel leaks occurred in the DBWC group compared to 5 (24%) and 2 (9.5%), respectively, in the SUD group (p = .06 for any leak). 58% of the DBWC and 62% of the SUD group required re-operation, and there were no 30-day peri-operative deaths.ConclusionsDBWC can be performed safely at the time of pelvic exenteration. We found reduced operating times, shorter LOS, and a trend toward fewer urinary conduit and/or bowel anastomotic leaks in DBWC exenteration patients. DBWC may be favorable over more technically challenging SUD in this heavily radiated population that generally has a limited overall survival.