Effect of a new pelvic stabilizer (T-POD®) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures

Background

Pelvic fractures, often the result of high energy blunt trauma, are associated with severe morbidity and mortality. A new pelvic stabilizer (T-POD^®) provides secure and effective simultaneous circumferential compression of the pelvis.

Methods

In this study we describe 15 patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the T-POD^®. Before and 2 min after applying the T-POD^®, heart rate and blood pressure were measured. An X-ray before and directly after applying the T-POD^® was made to measure the effect on reduction in symphyseal diastasis.

Results

Application of the T-POD^® reduced the symphyseal diastasis with 60% (p = 0.01). The mean arterial pressure (MAP) increased significant from 65.3 to 81.2 mm Hg (p = 0.03) and the heart rate declined from 107 beats per minute to 94 (p = 0.02). Out of ten patients in whom the circulatory response before and after the T-POD^® was recorded, seven were good responders, one had a transient response and two responded poor.

Conclusion

In the acute setting, the T-POD^® device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. The T-POD^® is therefore an effective and easy to use device in (temporarily) stabilizing the pelvic ring in haemodynamically unstable patients.     

Association between pelvic floor muscle trauma and pelvic organ prolapse 20 years after delivery

Introduction and hypothesis

It is known that pelvic floor muscle trauma (PFMT) after vaginal delivery is associated with pelvic organ prolapse (POP) symptoms (sPOP) and signs (POP-Q ≥2) in patient populations. Our aims were to establish the prevalence and investigate a possible association between PFMT and sPOP and POP-Q ≥2 in healthy women 20 years after their first delivery.

Methods

During 2013 and 2014 we conducted a cross-sectional study among 847 women who delivered their first child between 1990 and 1997. Women responded to a postal questionnaire and were offered a clinical examination including prolapse grading and pelvic floor ultrasonography. The main outcome measures were sPOP, POP-Q ≥2 and PFMT, defined by levator avulsion or a levator hiatal area on Valsalva manoeuvre of >40 cm² on ultrasonography.

Results

Of the 847 eligible women, 608 (72 %) were examined. Data on POP symptoms, POP-Q stage, levator avulsion and levator hiatal area were available in 598, 608, 606 and 554 women, respectively, and of these 75 (13 %) had sPOP, 275 (45 %) had POP-Q ≥2, 113 (19 %) had levator avulsion and 164 (30 %) had a levator hiatal area >40 cm². Levator avulsion was associated with POP-Q ≥2 with an odds ratio (OR) of 9.91 and a 95 % confidence interval (CI) of 5.73 – 17.13, and with sPOP (OR 2.28, 95 % CI 1.34 – 3.91). Levator hiatal area >40 cm² was associated with POP-Q ≥2 (OR 6.98, 95 % CI 4.54, – 10.74) and sPOP (OR 3.28, 95 % CI 1.96 – 5.50).

Conclusion

Many healthy women selected from the general population have symptoms and signs of POP 20 years after their first delivery, and PFMT is associated with POP-Q ≥2 and sPOP.

     

Does pelvic hematoma on admission computed tomography predict active bleeding at angiography for pelvic fracture?

Pelvic angiography plays an increasing role in the management of pelvic fractures (PFs). Little has been written regarding the size of pelvic hematoma on admission computed tomography (CT) and how it relates to angiography results after PF. This is a retrospective review of trauma patients with PF who underwent an admission abdominal/pelvic CT scan and pelvic angiography from 2001 to 2003. CT pelvic hematoma was measured and classified as minimal or significant based on hematoma dimensions. Presence of a contrast blush on CT scan was also documented. Thirty-seven patients underwent an admission CT scan and went on to pelvic angiography. Of the 22 patients with significant pelvic hematoma, 73 per cent (n = 16) had bleeding at angiography. Fifteen patients had minimal pelvic hematoma, with 67 per cent (n = 10) showing active bleeding at angiography. In addition, five of six patients (83%) with no pelvic hematoma had active bleeding at angiography. Six patients had a blush on CT scan, with five of these (83%) having a positive angiogram. But, 22 of 31 (71%) patients with no blush on CT scan had bleeding at angiography. The absence of a pelvic hematoma or contrast blush should not alter indications for pelvic angiography, as they do not reliably exclude active pelvic bleeding.     

The pelvic digit ��eleventh finger��

Described as asymptomatic and an incidental finding on a plain x-ray film, the “pelvic digit” is a rare congenital anomaly. A 35-year-old man is of a rare symptomatic pelvic digit that warranted surgical excision. Its importance lies in its differentiation from acquired abnormalities due to trauma such as myositis ossificans and avulsion injuries of pelvis. If this entity is kept in mind, unnecessary investigations or interventions can be avoided.     

Gigantic ureteral diverticulum or pelvic cyst?

Ureteral diverticulum is a rare anomaly, and very few reported cases concerning it can be found in literature. We report a 3.5-year-old boy who presented with urinary tract infection, rare voiding, and straining during voiding. Ultrasonography and magnetic resonance imaging showed a cystic pelvic mass. At surgical intervention, however, a massive ureteral cystic structure communicating both with the ureteropelvic and ureterovesical portion of the ureter was observed. Finding the presence of a smooth muscle layer, the pathologist confirmed this to be a true diverticulum. The fact that fenoterol (which was used for the prevention of preterm labor in the boy's mother) significantly decreases frequency and amplitude of upper urinary tract contractions suggests that fenoterol treatment might have influenced the occurrence of this abnormality.     

Vaginal wind – a new pelvic symptom

The aim of this study was to evaluate the risk factors, investigations and treatments for vaginal wind. A prospective longitudinal study was carried out at a tertiary care referral centre at St Georges Hospital, London. Six consecutive women with symptomatic vaginal air were enrolled in the study, which used a comprehensive questionnaire for vaginal air, prolapse, urinary, bowel and sexual symptoms, vaginal examination following the Standardized ICS Scoring System for prolapse, physiotherapist evaluation, and analysis of the treatment. Main outcome measureswere the effect of the patients age, weight, parity, mode of delivery, fetal weight, and the treatment (conservative and surgical) on the frequency of vaginal wind. The mean age of the six women was 32.8±9.9 years (range 21–52), the mean BMI was 23.1±5.5 (range 15.2–32.2), all women were premenopausal and five were parous. The mean estimated frequency of the symptoms was 20.0±8.1 per day (range 10–40). All the patients completed a course of pelvic floor physiotherapy and one patient had a posterior repair and later a Fenton operation without improvement. A modified Bard pessary was the main form of treatment and resolved the symptoms in two women. Vaginal wind causes significant distress and embarrassment to sufferers. Further information on risk factors, evaluation and treatment modalities should be obtained. Editorial Comment: The authors describe a rare but extremely embarrassing problem in women. Although vaginal air has been described with other conditions, such as enterovaginal fistula, inflammatory bowel disease, radiation therapy and pelvic malignancy, this is the first report of this problem in women with pelvic floor dysfunction. Further studies are needed to determine the true prevalence of this condition and the best modality of therapy.     

Can sex survive pelvic floor surgery?

Introduction/hypothesis  

Sexual function in women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI) is adversely affected, but data reporting sexual function following surgery are limited. We aimed to determine effect of pelvic reconstructive surgery on sexual function and to evaluate effect of additional continence procedures.     

Surgical management of pelvic Ewing��s sarcoma

Background:

Despite advances in adjuvant therapy, Ewing’s sarcoma of the pelvis remains an anatomic site with a poor prognosis due to its relative inaccessibility, complex anatomy, and limited reconstructive options available. This study evaluates the role of surgery in the management of patients with pelvic Ewing’s sarcoma who also have received conventional radiation therapy and chemotherapy.

Materials and Methods:

From July 1990 to July 2006, we received 10 patients with Ewing’s sarcoma of pelvis at our center. Nine patients were in stage II B and one in Stage III at the time of presentation to us. All patients underwent surgical resection after preoperative chemotherapy with or without radiotherapy, which was given at the discretion of the referral center. Reconstruction was attempted using plate osteosynthesis in four patients, SS wires and screws in three patients, free fibular strut graft in one patient, and none was done in two patients.

Results:

Functional outcome assessed by Enneking’s criteria revealed excellent outcome in two patients, good outcome in five patients, and poor outcome in two patients. At a mean followup of 10.3 years, seven patients remained free from the disease, and three patients died. The 5- and 10-year cumulative survival (Kaplan Meier method) was 63% and 34%, respectively.

Conclusion:

This study demonstrates that surgery plus chemotherapy and radiation therapy is helpful for treating patients with pelvic Ewing’s sarcoma, particularly in achieving local control.     

Women’s experiences of doing long-term pelvic floor muscle exercises for the treatment of pelvic organ prolapse symptoms

Introduction and hypothesis

This study investigated women’s experiences of doing prescribed pelvic floor muscle exercise (PFME) after participation in the Pelvic Organ Prolapse Physiotherapy (POPPY) trial. The aim was to understand post-supervised treatment adherence to PFME and to inform future advice for women being treated for pelvic organ prolapse (POP).

Methods

Five women were purposively selected from the New Zealand branch of the multi-centre, multi-national POPPY trial and took part in a semi-structured interviews about their experiences of PFME. The interviews were subjected to an interpretative phenomenological analysis (IPA).

Results

Three core themes were identified in the analysis. The first theme, “Patterns of PFME behaviour”, described exercise characteristics and behaviours. The second theme, “Influences on PFME maintenance cycles”, captured the participants’ responses to and evaluations of their exercise practice and related PFME self-efficacy. The “cycle” referred to the changing influences on exercise behaviour. The third theme, “Family as priority”, was expressed in terms of either putting family first or successfully combining the priorities of family and self.

Conclusion

This study revealed the importance of family in influencing PFME patterns and behaviours in the treatment of POP. It is possible that identifying strategies to help women reach their PFME goals within the context of their families will promote more successful PFME adherence. The importance of family when prescribing exercise for women with other chronic health conditions is also worth exploring.     

Hip and pelvic fractures and sciatic nerve injury

Objective:To investigate te influence of hip and pelvic fracture,especially acetanbular fracture complicated by sciatic nerve injury on clinical features and prognosis of sciatic nerve injury.Methods:From January 1987 to January 2000,17 patients(14 male and 3 female) who had hip and pelvic fractures complicated by sciatic nerve injury were treated with operative reduction and internal fixation and followed up from 10 months to 5 years.The average age was 38 years(ranging 23-56 years).The left extremities were involved in 11 patients and the right in 6.Twelve patients underwent primary exploration and neurolysis and 5 patients underwent secondary operation.Results:Preperativelys,8 patients were treated with large doses of oral narcotics to control their severe sciatic pain.Three of the 8 patients underwent patient-controlled analgesia and epidural analgesin.After operation,excellent and good rates of reduction and functional recovery of sciatic nerve were 94.1% and 88% respectively.Four patients still had sciatic pain and 2 patients failed to recover.Sciatic nerve function improved within 3-6 months after surgery in 11 patients.Conclusions:Hip and pelivic fractures can result in sciatic nerve injury,especially common peroneal nerve injury and prognosis is poor.Open reduction and internal fixation combined with nerve exploration and neurolysis should be used as early as possible for severe sciatic pain.     

Composite pelvic exenteration: Is it worthwhile?

Background In locally advanced pelvic cancer, tumor fixation to the bony pelvis is regarded as unresectable and often inoperable. Few data exist regarding the futility or utility of pelvic exenteration with en bloc resection of involved portions of the bony pelvis. Methods Thirty-four of 625 patients undergoing radical pelvic procedures had an en bloc resection of pelvic organs with portions of the bony pelvis. There were 19 female and 15 male patients, and the median age was 59 years. Primary neoplasms included 19 rectal, 6 cervicouterine, 4 anal, 3 vaginal, 1 sarcoma, and 1 penile. All but three patients underwent preoperative pelvic irradiation. Pelvic exenterations were posterior in 7 patients, anterior in 3, supralevator in 3, and total in 21 patients. Pelvic bony resections included portions of the sacrum-coccyx in 18 patients, ischium in 5, pubic symphysis in 4, and ischial pubic rami in 4, and hemipelvectomy was performed in 3. Results Surgical morbidity occurred in 67.6% (23) of 24 patients. Median follow-up was 37 months. Pelvic or perineal tumor recurrence was concurrent with distant metastases in 9 patients (26.4%); 6 (17.6%) had only distant relapse, and 2 (5.8%) died with local recurrence alone. Overall cancer-related mortality rate was 50%. Five-year overall and cancer-specific survival rates were 44% and 52%, respectively. Conclusions Substantial survival can be accomplished for patients whose tumors are fixed to limited portions of the bony pelvis. These procedures are still associated with substantial morbidity, but operative mortality is infrequent.     

Breathing with the pelvic floor? Correlation of pelvic floor muscle function and expiratory flows in healthy young nulliparous women

Introduction and hypothesis

The aim of this cross-sectional study was to determine correlations between pelvic floor muscle (PFM) function and expiratory function in healthy young nulliparous women.

Methods

In 40 volunteers, PFM function was assessed by vaginal palpation. Forced expiration patterns were evaluated visually and by palpation of the suprapubic insertion region of the anterolateral abdominal muscles. Forced vital capacity (FVC) and forced expiratory flows (FEF) were determined by spirometry.

Results

Incremental positive correlation was found between voluntary PFM contraction strength and forced expiratory flow at 25%, 50% and 75% (FEF_25%, FEF_50%, FEF_75%) of the FVC, respectively. Positive correlation was also found between PFM contraction strength and forced expired volume in 1 s (FEV₁). No correlation was found between PFM contraction strength and FVC or peak expiratory flow (PEF).

Conclusions

Despite some limitations of this study, the observed correlation between PFM contraction strength and forced expiratory flows may serve as theoretical background for a potential role of coordinated abdominal and PFM training in diseases with expiratory flow limitations.