The use of PROMIS and the RAND VSQ9 in chiropractic patients receiving care with the Webster Technique

IntroductionOur ongoing efforts to demonstrate effectiveness of care examined the quality of life (QoL) and patient satisfaction of chiropractic patients presenting for care in a PBRN.MethodsIn addition to socio-demographic and clinical care information, we examined visit-specific satisfaction and QoL using the RAND VSQ and PROMIS-29, respectively.ResultsOur study population was comprised of 126 subjects (average age = 39.68; 97 females). The majority of respondents presented with musculoskeletal complaints with an average mean duration of 7.188 years. The mean PROMIS-25 mean T Scores were: depression (47.80); pain interference (53.49); fatigue (51.02); physical function (49.02); satisfaction with social role (52.10); anxiety (50.14); and sleep disturbance (49.88). The VSQ9 mean score was 93.4% indicating high satisfaction.ConclusionsAdults attending care in a chiropractic PBRN were able to successfully complete the PROMIS29 and VSQ9 instruments. Future longitudinal studies should quantify the minimal clinically important difference in mean T score changes.     

Emergency Department Evaluation of Abdominal Pain in Female Adolescents

Study ObjectiveEvaluation of acute abdominal pain in an adolescent female patient should include consideration of all potential sources of pain, including gynecologic etiologies. The goal of our study was to determine the frequency of evaluation of gynecologic causes of abdominal pain in adolescent girls seen in a pediatric emergency department.Study DesignA retrospective review was performed of girls between 12 and 21 years of age presenting to the emergency department or urgent care centers at a single pediatric institution with the chief complaint of abdominal pain during 2016. Frequency analyses of demographic and clinical characteristics are presented.ResultsA total of 1082 girls presented with a chief complaint of abdominal pain. Menarche was documented in 85% of patients, sexual history in 52% of patients, and assessment of contraception use in 28%. Pregnancy testing was performed in 77%. Sexually transmitted infection (STI) testing was performed in 31%, and in only 73% of patients who reported being sexually active. Imaging was performed in 52%. In the subgroup of patients who reported being sexually active and presented with abdominal pain and vaginal discharge, only 37% had a pelvic examination performed. In multivariable modeling, Black patients were significantly more likely than White patients to have STI testing performed (adjusted risk ratio [aRR] = 1.39; confidence interval [CI] = 1.13-1.70) and to undergo a pelvic examination (aRR = 2.45; CI = 1.34-4.50), and less likely to undergo imaging (aRR = 0.69; CI = 0.59-0.81).ConclusionThe assessment of abdominal pain in adolescent girls should include gynecologic etiologies. Our results raise concerns that there are deficiencies in the evaluation of gynecologic sources of abdominal pain in girls treated at pediatric facilities, and evidence of potential racial disparities.     

The chiropractic care of a child with extremity tremors concomitant with a medical diagnosis of conversion disorder

ObjectiveTo describe the care of a patient with spinal and cranial dysfunctions and medically diagnosed with conversion disorder.Clinical featuresThe patient was an 11-yr-old girl presented by her parents with complaints of uncontrollable tremors of both arms and right leg. Conversion disorder was diagnosed following negative examination findings for an organic etiology. Prior to institutionalization, her parents requested a “second opinion” from a clinical psychologist that eventually led to chiropractic referral.Intervention and outcomeCare was provided using spinal manipulation to sites of spinal and cranial dysfunctions. With subsequent visit, the patient’s tremors improved. Following 12 chiropractic visits, the patient’s symptoms resolved. Long-term follow-up revealed continued resolution of the symptoms of tremors.ConclusionThis case report provides supporting evidence that patients with ballistic tremors of possible unknown organic etiology may benefit from chiropractic care. We support further research in this field.     

Gynecologic Issues of Adolescents with Down Syndrome,Autism, and Cerebral Palsy

Study ObjectiveThe gynecologic issues of adolescents with disabilities are understudied. The purpose of this study was to identify and compare the presenting complaints, treatments, and follow-up of adolescent girls with Down syndrome (DS), autism, and cerebral palsy (CP) presenting to a specialized gynecologic clinic for women with developmental disabilities.SettingOutpatient gynecology clinic.ParticipantsForty four adolescents (<21 y); 13 with DS, 14 with autism, and 17 with CP who presented to the clinic from 1999 to 2006.InterventionsNone.Main Outcome MeasuresA retrospective review of the electronic medical records to collect data on age at presentation to clinic, ethnicity, menstrual history, chief complaint, treatment, and follow-up.ResultsMean age at presentation to clinic was 15±3.5 years, and age of menarche was 12.5±2 years; age at menarche did not significantly differ between groups. The most frequent complaints were irregular bleeding (n=10) and mood/behavioral changes (n=6). Girls with autism were significantly (χ²=8.89, P=.012) more likely to present with behavioral issues than the other 2 groups. Initial management for the behavior issues in the autism group included nonsteroidal anti-inflammatory drugs (NSAID), oral contraceptives, and education.ConclusionThe most common gynecologic complaints of adolescent girls with DS, autism, and CP centered on menstruation and mood disorders. Patients with autism were more likely to present with behavioral issues related to the onset of periods.     

The Use of Norethisterone for the Treatment of Severe Uterine Bleeding in Adolescents: An Audit of Our Experience

Study ObjectiveThe purpose of this prospective study was to assess the effectiveness of norethisterone (NET) in the management of abnormal uterine bleeding (AUB) in adolescents in a tertiary care center.DesignThis was a prospective audit focused on administering high doses of NET in female adolescents with complaints of AUB.SettingWe included female adolescents who presented to our Emergency Gynecological Department or Adolescent Gynecological Outpatient Department from October 2016 to January 2019.ParticipantsThe study included 29 female adolescents aged 11-17 (mean, 13.14) years.InterventionsPatients were administered a daily dose of 10-30 mg, depending on the severity of the condition, bleeding duration, and patient weight.Main Outcome MeasuresCessation of vaginal bleeding.ResultsMean age at menarche of our patient sample was 11.4 years (range, 10.7-14 years). AUB presented at a mean time of 24.6 months after menarche (range, 0-79 months). Blood transfusion was deemed necessary in 9 patients. Bleeding stopped at a mean of 46.1 (range, 8-120) hours after onset of treatment with NET. No serious adverse events were reported with NET administration, with only 3 cases of minor side effects.ConclusionThe use of NET is an effective and reliable treatment option among adolescents for whom control of AUB is desired in the acute setting.     

Menstrual Dysfunction and Treatment Among Adolescents With Congenital Heart Disease

Study ObjectiveThis study describes menstrual dysfunction and treatment among adolescent and young adult (AYA) females with congenital heart disease (CHD).DesignData collected from a 1-time survey completed by AYA females (and mothers if AYA unable).SettingParticipants were recruited from pediatric cardiology clinics.ParticipantsFemale AYA with CHD, aged 14-21 years (N = 114).InterventionsNone.Main Outcome MeasuresThe questionnaire assessed sexual and reproductive health (SRH) concerns, behaviors, and management. Outcome measures were self-reported menstrual complaints, use of over-the-counter (OTC) pain relief medications for dysmenorrhea, reported visits with a clinician for a menstrual problem, and reported use of hormones for menstrual problems or birth control.ResultsMean age was 17.0 years (SD = 2.2). The majority of participants (83%) reported 1 or more menstrual complaints (67.5% cramping, 42.1% irregular menses, 46.5% heavy periods), and 88% reported any history of taking OTC medications for pain relief. Increased menstrual complaints were not associated with level of cardiac complexity, reported transplantation, or reported use of hormonal contraception. However, 32% of participants reported use of hormonal contraception for menstrual dysfunction. Combined oral contraceptive pills (COCs) were the most common; 2 of these women carried contraindications to estrogen.ConclusionsA large majority of AYA females with CHD reported menstrual dysfunction. Use of OTC medication for menstrual pain and inappropriate use of estrogen creates concerns that menstrual disorders may be unaddressed or addressed inappropriately. Thus, gynecological needs of adolescents with CHD may need to be specifically targeted by providers who feel comfortable with this population and their complex needs.     

Psychiatric illness presenting with a sexual complaint and management by psychotropic medications: a case report

IntroductionSexual medicine healthcare professionals, who do not normally examine men and women with psychiatric disorders, need to be aware that those with psychiatric disorders can and do present with sexual medicine problems. In particular, psychiatric individuals may present with a variety of delusions including those that have sexual content or sexual implications. The rare disorder of reverse delusional misidentification syndrome may be encountered in schizophrenic patients and may be best managed by the combined team effort of a sexual medicine specialist and psychiatrist.AimTo report a case study that reiterates the assessment and sexual medicine management of a female with sexual dysfunction who believed she was transforming into a male.MethodsCase report of a woman who attended an outpatient clinic in an academic medical center.ResultsA 60-year-old woman with a history of paranoid schizophrenia presented to a gynecologist for ovarian cancer screening. Evaluation revealed complaints that the patient’s ovaries were testes that produced sperm and her clitoris was a penis capable of erection and ejaculation. Gynecological examination revealed only atrophic vaginitis. The patient was treated with local minimally absorbed vaginal estrogens and referred for psychological assessment and counseling. Psychotropic medication compliance was encouraged, weekly psychotherapy was continued, and delusional symptoms were minimized.ConclusionSexual medicine healthcare providers should be prepared to manage sex health concerns of men and women with psychiatric disorders, including delusional misidentification syndrome, in conjunction with a psychiatrist. Krychman M, and Amsterdam A. Psychiatric illness presenting with a sexual complaint and management by psychotropic medications: A case report.     

Prepubertal Skene's Abscess

BackgroundSkene's glands are believed to be homologues of the prostate gland derived from the urogenital sinus.¹ Complications of Skene's glands occur most often in the third and fourth decades and are rarely seen in premenarchal females.CaseA 3-year-old presented to her pediatrician with a 9-day complaint of vulvar pain. Both pediatric and gynecologic office examination revealed an enlarged right labium majus and an erythematous area adjacent to the urethra. Examination under anesthesia revealed a Skene's gland abscess that was treated with incision and drainage. The patient experienced complete resolution of symptoms.ConclusionA Skene's gland abscess is rare among premenarchal girls. An abscess presenting in a patient complaining of pain can be successfully managed with incision and drainage.     

Sexual Functioning of Latino Women Seeking Outpatient Gynecologic Care

IntroductionA sample of Latino women from an ambulatory obstetrics and gynecology (Ob/Gyn) clinic were queried about their sexual functioning using the Changes in Sexual Functioning Questionnaire (CSFQ-14).AimTo assess the degree of self-reported sexual complaints in a sample of Latino women living in the United States; to assess if the prevalence of symptoms differs from one study of women living in Spain; and to determine if sexual complaints were associated with demographics, sexual/reproductive history, selected medications, or religious practices.Main Outcome MeasuresCSFQ-14 scores and demographic variables.MethodsCSFQ-14 questionnaire in an out-patient, bilingual Ob/Gyn clinic in Central Virginia.ResultsSeventy-one native Spanish-speaking patients (59% born in Mexico) completed the U.S. Spanish version of the CSFQ-14 and a short questionnaire for potential covariates. The mean age was 28.7 years (range 17–60). Birth place was outside of the United States for 95.8% (N = 67). Eighty percent of participants had children and 96% reported being currently sexually active. Low sexual functioning, as defined by a total CSFQ score of ≤41, was found in 26 (41.3%) participants. Taking medication for depression and/or anxiety was associated with lower sexual functioning (P = 0.03). Women who had children of any age living in the household were less likely to report low sexual functioning (P = 0.05; P = 0.01 when restricted to infants) than women without children living in the household. Thirteen of 68 women (19.1%) reported a history of physical and/or sexual abuse, but this was not associated with low sexual functioning. There was no association between self-reported religious affiliation or church attendance frequency and sexual complaints. Respondents in our sample had lower (i.e., worse sexual function) overall CSFQ scores compared with a sample of college students in Spain (P < 0.01), but higher (i.e., better sexual function) overall scores than workers in Spain (P < 0.04). On the subscales, our Latino population reported greater pleasure and less desire/interest than women who live in Spain.ConclusionsSelf-reported rates of low sexual functioning were common in this cross section of Latino women. Medical treatment of depression and/or anxiety was associated with lower functioning. Direct inquiry about the sexual health of U.S. Latino women presenting for routine health care may assist in the identification of sexual difficulties in this population. Hullfish KL, Pastore LM, Mormon AJA, Wernecke Y, Bovbjerg VE, and Clayton AH. Sexual functioning of Latino women seeking outpatient gynecologic care.     

Musculoskeletal Pain in Gynecologic Surgeons

ObjectiveTo describe the prevalence of musculoskeletal pain and symptoms in gynecologic surgeons.DesignProspective cross-sectional survey study (Canadian Task Force classification II-2).SettingVirtual. All study participants were contacted and participated via electronic means.ParticipantsGynecologic surgeons.InterventionsAn anonymous, web-based survey was distributed to gynecologic surgeons via electronic newsletters and direct E-mail.Measurements and Main ResultsThere were 495 respondents with complete data. When respondents were queried about their musculoskeletal symptoms in the past 12 months, they reported a high prevalence of lower back (75.6%) and neck (72.9%) pain and a slightly lower prevalence of shoulder (66.6%), upper back (61.6%), and wrist/hand (60.9%) pain. Many respondents believed that performing surgery caused or worsened the pain, ranging from 76.3% to 82.7% in these five anatomic regions. Women are at an approximately twofold risk of pain, with adjusted odds ratios (OR) of 1.88 (95% confidence interval [CI], 1.1–3.2; p = .02) in the lower back region, OR 2.6 (95% CI, 1.4–4.8; p = .002) in the upper back, and OR 2.9 (95% CI, 1.8–4.6; p = .001) in the wrist/hand region.ConclusionMusculoskeletal symptoms are highly prevalent among gynecologic surgeons. Female sex is associated with approximately twofold risk of reported pain in commonly assessed anatomic regions.     

Vulval Pain in Pediatric and Adolescent Patients

Study ObjectiveTo describe the experience of a tertiary pediatric and adolescent gynecology service that provides care to children and adolescents who present with vulval pain. Their presentation, associated symptoms, and management is described.DesignA retrospective analysis of all girls younger than 18 years of age who presented to the gynecology clinic of our tertiary referral Children’s Hospital between Jan 2010 and July 2016. Electronic medical records were reviewed and parameters recorded using a standardized data sheet.SettingGynecology clinic of a tertiary referral children’s hospital and private rooms of our director of gynecology.ParticipantsYoung women younger than 18 years who presented with symptoms suggestive of vulvodynia.Interventions and Main Outcome MeasuresPresenting symptoms, characteristics of associated features, treatment options, and treatment outcomes.ResultsForty-seven patients with a mean age of 11 years (range, 3-18 years) were identified. At the time of diagnosis 31/47 (65.9%) were premenarchal. Many presented with a symptom other than pain alone. In particular, 35/47 (74.4%) presented with coexisting or previous urinary symptoms. Of patients examined, most had positive cotton tip examination findings (16/17 (94.1%) and 11/13 (84.6%) for pre- and postmenarchal, respectively) with clinical inspection otherwise unremarkable.ConclusionChildren and adolescents with vulval pain have varied presentations. Many of the pre- and postmenarchal patients had coexisting urinary tract symptomatology at the time of diagnosis. This review of patients seen over 5.5 years at a pediatric tertiary referral center provides information on the presenting symptoms, examination features, and response to clinical management.     

A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions

BackgroundClitoral adhesions are characterized by adherence of preputial tissue to the glans clitoris and can be managed using a non-surgical approach in order to relieve symptoms of sexual dysfunction.AimTo evaluate efficacy and patient satisfaction associated with the non-surgical lysis procedure in order to determine if it is an appropriate treatment for symptomatic clitoral adhesions.MethodsThe non-surgical lysis procedure is performed by using a fine Jacobsen mosquito forceps to separate the plane between the prepuce and the glans of the clitoris, removing smegma and/or keratin pearls from underneath the adhesions and allowing for visualization of the entire glans. A chart review of 61 women that were treated for clitoral adhesions using the non-surgical lysis procedure at 1 sexual medicine practice was performed and an online survey was sent to these patients.Main Outcome MeasuresEncrypted survey responses were used to evaluate patient satisfaction as well as self-reported improvement in sexual functioning and pain before and after the procedure.Results41 survey responses were received out of 61 eligible (67% response rate). A large majority reported improvement in pain (76%), sexual arousal (63%), and ability to achieve orgasm (64%) and no participants reported worsening in these symptoms. Of the 16 women that reported the inability to orgasm from external clitoral stimulation prior to the procedure, 6 (38%) were able to do so afterwards. Seventy-one percent of respondents reported improvement in their satisfaction with sex and 83% reported being satisfied with their decision to have the procedure. Ninety-three percent of participants reported that they would recommend this procedure to a friend with clitoral adhesions.Clinical ImplicationsThe results of this study will help clinicians to recognize the non-surgical lysis procedure as a treatment option for clitoral adhesions.Strengths & LimitationsThis study is the first of its kind assessing a cohort of patients undergoing the non-surgical lysis procedure for clitoral adhesions. Its limitations include a small sample size from 1 clinic and lack of validated instrument to evaluate sexual function and pain before and after the procedure.ConclusionProviders should regularly examine the clitoris of patients with symptoms of sexual dysfunction in order to determine if they have clitoral adhesions. The non-surgical lysis procedure may be a viable therapeutic option for these patients that has demonstrated both satisfaction and symptom relief.Myers MC, Romanello JP, Nico E, et al. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. J Sex Med 2022;19:1412–1420.     

Enhanced Recovery After Surgery in Pediatric and Adolescent Gynecology: A Pilot Study

Study ObjectiveEnhanced recovery after surgery (ERAS) protocols have been successfully implemented in adult gynecology as well as adult and pediatric colorectal and urologic surgery with reduction in narcotic use, complications, return to the system (RTS), length of stay (LOS), and improved patient satisfaction. There are no studies evaluating the use of ERAS in pediatric and adolescent gynecology (PAG). The goals of this study are to present initial patient outcomes using ERAS in PAG patients undergoing intra-abdominal gynecologic surgery to prove efficacy, patient satisfaction, and decreased narcotic use.DesignAs a quality improvement measure in perioperative care, an ERAS protocol including preoperative, intraoperative, and postoperative components and a follow-up patient telephone call for pain assessment was implemented for all intra-abdominal gynecologic procedures. A retrospective study on implementation of ERAS components, outcomes, and patient satisfaction was then performed in participants meeting inclusion criteria.SettingLarge academic children's hospital.ParticipantsPatients <25 years of age who underwent laparoscopic (LSC) or open abdominal (XLAP) gynecologic surgery using an ERAS protocol by the PAG service over a 12-month period.InterventionsAn ERAS protocol including preoperative, intraoperative, and postoperative components and follow-up patient telephone call for pain assessment was implemented for all major gynecologic surgeries performed by the PAG service.Main Outcome MeasuresPatient satisfaction with the perioperative ERAS protocol along with components including pain management, narcotic use, LOS, RTS, and postoperative complications for various intra-abdominal gynecologic procedures.ResultsA total of 40 participants met inclusion criteria for the study. Thirty-four (85%) participants underwent LSC procedures and six (15%) underwent XLAP. Of the LSC patients, 95% were discharged on postoperative day 0, and all XLAP patients and one LSC patient were discharged on postoperative day 1. In all, 95% of patients were discharged from the hospital requiring only non-narcotic ERAS medications. There were no readmissions or postoperative complications. All patients were satisfied with their postoperative pain control at their follow-up telephone call and clinic visit.ConclusionImplementation of a pediatric-specific ERAS protocol in children and adolescents undergoing gynecologic surgery is feasible and safe, and leads to less narcotic use without an increase in complications or decrease in patient satisfaction.     

Prevalence of pelvic musculoskeletal disorders in a female chronic pelvic pain clinic

OBJECTIVE: To determine the prevalence of 2 musculoskeletal pain disorders among women presenting to a referral chronic pelvic pain clinic. STUDY DESIGN: This was a retrospective, cross-sectional study of 987 women (aged 14-79) presenting for evaluation from 1993 to 2000 at a university-based gynecologic chronic pelvic pain clinic. RESULTS: At the initial visit, all women completed standardized interviews and underwent a pelvic examination. Single-digit palpation of the levator ani and piriformis muscles was performed intravaginally. Among these women, 212 of 955 (22%) had tenderness of the levator ani muscles, while 128 of 943 (14%) had tenderness of the piriformis muscle (pain score > 3 of 10 on a visual analogue scale). Both levator ani tenderness and piriformis tenderness were associated with a higher total number of pain sites, previous surgery for pelvic pain, Beck Depression Inventory score, McGill Pain Inventory score and pain worsened with bowel movements (p < 0.05). CONCLUSION: Piriformis and levator ani pain are present in a significant proportion of female chronic pelvic pain patients. Further research into the natural course, diagnosis and treatment of pelvic musculoskeletal pain is needed to determine its true contribution to chronic pain.     

Surgical Treatment of the Solid Breast Masses in Female Adolescents

Study ObjectiveTo evaluate the histopathologic results of the excised solid breast masses in our clinic and to draw attention to breast masses in adolescents.DesignA retrospective chart review study and review of the literature.SettingThis study was conducted in Baskent University Adana Research Center between March 2003 and May 2011.ParticipantsPatients included 10 adolescent girls admitted to pediatric surgery clinic with the complaint of palpable breast mass who underwent surgical excision of the breast mass.Main Outcome MeasuresThe necessity of surgery in breast masses of female adolescents.Results10 female patients with an average age of 14 years were operated on for breast masses. A palpable mass in the breast and social anxiety were the cardinal complaints. Two patients had a family history of breast carcinoma. One patient had a history of neuroblastoma in remission. Histopathologic examination revealed 3 juvenile fibroadenomas, 1 conventional fibroadenoma, 3 tubular adenomas, and 3 phyllodes tumors.ConclusionsPalpable breast masses in adolescents are uncommon and are usually benign. The low malignancy risk and rarity of breast masses in childhood create a controversy as how to manage breast masses. Ultrasonography is the initial imaging modality to define the characteristics of the breast mass. Excisional biopsy and histopathologic examination is essential to rule out rare, but probable malignant, lesions in adolescents in selected patients such as maternal history of breast carcinoma, previous malignancy history in the patient, big size of the mass, and no regression on follow-up.     

The burden and determinants of dysmenorrhoea: a population-based survey of 2262 women in Goa, India

OBJECTIVE: To describe the prevalence and determinants of dysmenorrhoea, the most common menstrual complaint, in a community in India. DESIGN: Cross-sectional survey. SETTING: Catchment area of primary health centre in Goa, India. POPULATION: Three thousand women aged 18-45 years randomly selected. A total of 2494 women consented to participate (83.1%). METHODS: Eligible participants were asked standardised questions regarding menstrual complaints over the past 12 months, and socio-demographic, psychosocial and reproductive risk factors. Vaginal or urine specimens were collected for the diagnosis of reproductive tract infections. MAIN OUTCOME MEASURES: Dysmenorrhoea of moderate to severe intensity. RESULTS: A total of 2262 women were eligible. More than half reported dysmenorrhoea; moderate to severe dysmenorrhoea was reported by 755 participants (33.4%, 95% CI 31.4-35.4). There was a linear association between severity of pain and impact (medication and taking rest) and the onset of pain (premenstrual onset associated with more severe pain). On multivariate analyses, the risk of moderate-severe dysmenorrhoea was associated with the experience of violence (OR 2.23, 95% CI 1.5-34); other somatic complaints (OR 3.67, 95% CI 2.7-4.9 for highest somatoform symptom score category compared with the lowest); gynaecological complaints (non-menstrual lower abdominal pain: OR 1.78, 95% CI 1.3-2.3; dysuria: OR 1.98, 1.4-2.7); menorrhagia (OR 1.92, 95% CI 1.4-2.6); and illiteracy (OR 1.32, 95% CI 1.0-1.7). Having had a pregnancy (OR 0.53, 95% CI 0.4-0.7), older age of menarche (OR 0.70, 95% CI 0.5-0.9, for age >14 compared with <13 years) and older age (OR 0.43, 0.3-0.6 for age 40-50, compared with 18-24 years) were protective. CONCLUSIONS: The burden of dysmenorrhoea is greater than any other gynaecological complaint, and is associated with significant impact. Social disadvantage, co-morbidity with other somatic syndromes and reproductive factors are determinants of this complaint.     

Effects of neural mobilization in disorders associated with chronic secondary musculoskeletal pain: A systematic review and meta-analysis

PurposeTo evaluate the effect of neural mobilization (NM) in people with disorders associated with chronic secondary musculoskeletal pain due to persistent inflammation or diseases of the nervous system.MethodsA database search was conducted to select randomized controlled trials where NM, alone or within a multimodal protocol, was the main intervention for patients with neurological, autoimmune, or autoinflammatory disorders. The risk of bias and the certainty of evidence were assessed using the Cochrane Risk of Bias Tool for Randomized Trials and the GRADE approach. The primary outcome was pain intensity. Secondary measures were inflammatory biomarkers, range of motion and the level of spasticity.ResultsEleven studies were included (360 participants; 57% females). The most reported condition was arthritis, and the overall risk of bias was high in more than half of the studies. Pooled data showed a significant effect of NM, based on very low quality of evidence, on reducing pain intensity in people with systemic disorders (three studies: SMD = −0.58; 95% CI = −0.98, −0.18; p = 0.005), and the level of spasticity in individuals with brain or spinal cord injury (two studies: SMD = −0.85; 95% CI = −1.70, 0.00; p = 0.05).ConclusionsThere is scant and very low certainty of evidence to support that NM, compared to control interventions, may improve pain intensity and spasticity in patients with disorders associated with chronic secondary musculoskeletal pain. Further research with high methodological quality is needed to recommend for or against the use of NM in this population.     

Nonpalpable scarring of the penile septum as a cause of erectile dysfunction: an atypical form of Peyronie's disease

IntroductionMen with nonpalpable isolated septal scars (ISS) identified with color duplex ultrasonography (CDU) comprise a group of previously unrecognized patients with wide‐ranging sexual concerns.AimWe aim to identify the clinical characteristics of patients presenting with this atypical form of Peyronie’s disease characterized by the absence of palpable deformity.Materials and MethodsOf 482 consecutive patients who presented to a tertiary care erectile dysfunction (ED) clinic and underwent CDU after satisfying inclusion criteria, 27 (5.6%) men with nonpalpable ISS and no dorsal or ventral plaque were identified.Main Outcome MeasuresInternational Index of Erectile Function (IIEF), CDU, and clinical characteristics.ResultsThe median age of the men with nonpalpable ISS was 49 years. The length of time from onset of symptoms to presentation was 22 months, and the pretreatment IIEF score was 14. The remaining 455 men who underwent CDU were of similar age (48 years) but had a markedly lower IIEF score of 9.5 (statistical median). ISS patients presented with decreased penile rigidity (20), penile shortening (13), chronic pain with erection (13; mean 33 months), and the inability to maintain an erection (7). Fourteen men had failed phosphodiesterase‐5 inhibitor therapy, and four reported unsatisfactory results. Management options included retrial with oral agents, intracavernous pharmacotherapy, verapamil injections, and surgery.ConclusionsThe clinician should be suspicious for nonpalpable ISS in men with sexual concerns who present with decreased penile rigidity, length loss, and chronic pain with erection. Our findings support the use of CDU for this patient group, particularly when previous treatment has failed, because men with ISS had a greater likelihood of having no palpable deformity or curvature and ongoing penile pain. Bella AJ, Sener A, Foell K, and Brock GB. Nonpalpable scarring of the penile septum as a cause of erectile dysfunction: An atypical form of Peyronie’s disease. J Sex Med 2007;4:226–230.