Prolonged mental health sequelae among doctors and nurses involved in patient safety incidents with formal complaints and lawsuits.

We evaluated the presence of prolonged mental health sequelae in the aftermath of a patient safety incident and the impact of a formal complaint or lawsuit on these mental health sequelae in 19 hospitals and 2635 nurses and doctors. Of 2635 respondents, 983 (37.3%) reported a complaint and 190 (7.2%) reported a lawsuit. In both doctors and nurses prolonged mental health sequelae reflecting a stressor-related disorder were highly prevalent, each well over 20% overall. They were consistently more prevalent in case of a formal complaint or lawsuit. Lawsuits showed 2-, 3- and 4-fold increases in prevalence of mental health sequelae.

Sexual response in women with Mayer-Rokitansky-Küster-Hauser syndrome with a nonsurgical neovagina.

BACKGROUND: Sexual dysfunction is prevalent in women with Mayer-Rokitansky-Küster-Hauser syndrome after the creation of a neovagina. Insight into the physiologic response of the neovagina during sexual arousal is lacking, although this would help in the understanding of sexual function of these patients. The physiologic sexual response of the vagina can be measured objectively by vaginal photoplethysmography to assess vaginal blood flow. OBJECTIVE: Testing whether the physiologic and subjective sexual response in women with Mayer-Rokitansky-Küster-Hauser syndrome with a neovagina differs from the response in women with a natal vagina. STUDY DESIGN: Vaginal blood flow (vaginal pulse amplitude) and subjective sexual responses during neutral and erotic film viewing were assessed in premenopausal women with Mayer-Rokitansky-Küster-Hauser syndrome with a nonsurgically created neovagina (n=15) and were compared with responses of an age-matched control group (n=21). RESULTS: All women with Mayer-Rokitansky-Küster-Hauser syndrome had created their neovagina themselves by dilation. Women with Mayer-Rokitansky-Küster-Hauser syndrome showed a significantly smaller vaginal pulse amplitude compared with control subjects during neutral film viewing (P=.002). In both groups, vaginal pulse amplitude increased significantly during erotic film viewing, but this increase was significantly smaller in the Mayer-Rokitansky-Küster-Hauser syndrome group (P<.005). Levels of subjective sexual arousal did not significantly differ between the 2 groups (P>.2). CONCLUSION: Women with Mayer-Rokitansky-Küster-Hauser syndrome with a nonsurgically created neovagina showed a weaker vaginal blood flow response during visual sexual stimulation and poorer basal blood flow compared with control subjects. The differences in vaginal blood flow may be related to less vascularization and innervation of the neovagina compared with the natal vagina. The weaker vaginal sexual response can play a role in sexual dysfunction; however, despite the weaker vaginal response, women with Mayer-Rokitansky-Küster-Hauser syndrome did not differ in their level of subjective sexual arousal. Future studies may compare vaginal blood flow and subjective sexual response of women with Mayer-Rokitansky-Küster-Hauser syndrome with nonsurgically and surgically created vaginas.

Effects of Aversive Classical Conditioning on Sexual Response in Women With Dyspareunia and Sexually Functional Controls.

INTRODUCTION: In dyspareunia-a somatically unexplained vulvovaginal pain associated with sexual intercourse-learned pain-related fear and inhibited sexual arousal are supposed to play a pivotal role. Based on research findings indicating that enhanced pain conditioning is involved in the etiology and maintenance of chronic pain, in the present study it was hypothesized that enhanced pain conditioning also might be involved in dyspareunia. AIM: To test whether learned associations between pain and sex negatively affect sexual response; whether women with dyspareunia show stronger aversive learning; and whether psychological distress, pain-related anxiety, vigilance, catastrophizing, and sexual excitation and inhibition were associated with conditioning effects. METHODS: Women with dyspareunia (n = 36) and healthy controls (n = 35) completed a differential conditioning experiment, with one erotic picture (the CS+) paired with a painful unconditional stimulus and one erotic picture never paired with pain (the CS-). MAIN OUTCOME MEASURES: Genital sexual response was measured by vaginal photoplethysmography, and ratings of affective value and sexual arousal in response to the CS+ and CS- were obtained. Psychological distress, pain cognitions, and sexual excitation and inhibition were assessed by validated questionnaires. RESULTS: The two groups showed stronger negative affect and weaker subjective sexual arousal to the CS+ during the extinction phase, but, contrary to expectations, women with dyspareunia showed weaker differential responding. Controls showed more prominent lower genital response to the CS+ during acquisition than women with dyspareunia. In addition, women with dyspareunia showed stronger expectancy for the unconditional stimulus in response to the safe CS-. Higher levels of pain-related fear, pain catastrophizing, and sexual inhibition were associated with weaker differential conditioning effects. CONCLUSIONS: Pairing of sex with pain negatively affects sexual response. The results indicate that a learned association of sex with pain and possibly deficient safety learning play a role in dyspareunia. Both S, Brauer M, Weijenborg P, Laan E. Effects of Aversive Classical Conditioning on Sexual Response in Women With Dyspareunia and Sexually Functional Controls. J Sex Med 2017;14:687-701.

A retrospective study on persistent pain after childbirth in the Netherlands.

Reported prevalence rates of persistent postpartum pain (PPP) range from less than 1% to almost 20%. The aim of this study was to examine the prevalence of PPP in a Dutch cohort and to evaluate a possible causal role for specific risk factors on the development of chronic pain after childbirth. A questionnaire was sent to 960 postpartum women approximately 2 years after delivery. Primary outcome was pain that arose from childbirth at follow-up, and secondary outcomes included quality of life (QoL) and Hospital Anxiety and Depression Scale scores. Tested risk factors included mode of labor analgesia, history of negative effect, history of chronic pain, delivery route, parity, and ethnicity. A total of 495 (51.6%) women participated. At a mean time of 2.3 postpartum years, 7.3% of women reported any pain and 6.1% reported significant pain related to the delivery. Compared to spontaneous delivery, cesarean delivery provided protection against persistent pain (odds ratio, 0.12; 95% CI, 0.01-0.63, P<0.05). None of the other risk factors, including remifentanil use for labor pain, were of influence on the prevalence of persistent pain. Women with PPP experienced greater negative effects and had lower QoL scores compared to women without pain. In this cohort of Dutch patients, PPP is a serious problem with a great impact on the physical and mental health of women.

ISPOG European Consensus Statement - chronic pelvic pain in women (short version).

To date there is no international guideline on chronic pelvic pain available that focuses on medical, psychosomatic and psychological diagnostics and treatment of this complicated disease pattern. In this paper, a European working group, which was established in October 2010, aims to bridge this gap. The working group decided to use the current German guideline as source text and to transform it into a European consensus statement by deleting parts that apply only to the conditions of the German health system. The literature search included papers published up to and including December 2010, using Medline search and by adding some new search terms. This manuscript reports the essential facts of the above-mentioned consensus statement. Within this article we use the term "psychosomatic" as the integrated concept of medical and psychosocial aspects of a disease.

Sexual Response in Women with Type 1 Diabetes Mellitus: A Controlled Laboratory Study Measuring Vaginal Blood Flow and Subjective Sexual Arousal.

Previous studies have indicated that women with diabetes mellitus are at higher risk to develop sexual dysfunctions. In the current study, we hypothesized that lower genital arousal response-as a consequence of diabetes-related damage to nerves and blood vessels-might play a part in these higher prevalence rates. Vaginal blood flow, subjective sexual response, and clitoral sensitivity were compared between women with diabetes and healthy controls, and associations with diabetes complications were investigated. In pre- and postmenopausal women with type 1 diabetes (n = 42) and healthy controls (n = 46), vaginal blood flow was measured as vaginal pulse amplitude (VPA). VPA was assessed at rest, during erotic film viewing, and during vibrotactile clitoral stimulation. Subjective sexual arousal was measured using a questionnaire. Clitoral sensitivity was assessed by a vibration perception test. Data on diabetes complications were obtained from medical records, and neuropathy was assessed by quantitative sensory testing. VPA, subjective sexual arousal, and clitoral sensitivity were not significantly different between women with diabetes and controls. Nevertheless, women with diabetes who had retinopathy showed significantly lower VPA than women without retinopathy, and women with diabetes who had neuropathy showed significantly higher sensation thresholds for vibrotactile clitoral stimulation. The results do not support the hypothesis of a disrupted genital arousal response in women with diabetes. However, the observed associations between retinopathy and vaginal blood flow, and between neuropathy and clitoral sensitivity, suggest that diabetes-related complications might adversely affect the physiological basis of female sexual response.

A new device for simultaneous measurement of pelvic floor muscle activity and vaginal blood flow: a test in a nonclinical sample.

INTRODUCTION: Dyspareunia in women, defined as persistent or recurrent genital pain associated with sexual intercourse, is hypothesized to be related to (fear associated) pelvic floor hyperactivity and to diminished sexual arousal. Psychophysiological research to support these hypotheses is scarce and concentrates mostly on the role of either pelvic floor activity or sexual arousal. To investigate both factors, a measurement device that enables simultaneous assessment of pelvic floor muscle activity and genital sexual arousal would be most optimal. AIM: The aim of this study was to test a new vaginal device0-a vaginal photoplethysmograph with build-in surface electromyography (EMG)--that allows simultaneous assessment of pelvic floor muscle activity and vaginal blood flow. MAIN OUTCOME MEASURES: Genital arousal measured as vaginal pulse amplitude (VPA) and vaginal surface EMG. METHODS: Thirty-six sexually functional women participated. To investigate the sensitivity of the device for changes in genital blood flow and involuntary changes in pelvic floor activity, VPA and vaginal surface EMG were monitored during exposure to sexual and anxiety-evoking film clips. In addition, vaginal surface EMG was monitored during voluntary flick and hold contractions. RESULTS: VPA increased in response to the sexual film, and EMG values were significantly higher in response to the anxiety-evoking film. Higher EMG values in response to the anxiety film were associated with lower VPA. EMG during the instructed 3-second hold pelvic floor contractions showed, as expected, higher values during pelvic floor contractions with support of surrounding muscle groups, compared with pelvic floor muscles alone. CONCLUSION: The device is sensitive to changes in vaginal blood flow in response to sexual stimuli, and it is able to pick up small, involuntary changes in pelvic floor activity associated with anxiety. Also, the device is able to record changes in pelvic floor activity during voluntary pelvic floor contractions. This new device will be a valuable tool in further research on superficial dyspareunia.

[Reduction in chronic pelvic pain in women with less catastrophizing pain] / Vermindering van chronische buikpijn bij vrouwen die minder catastrofaal denken.

OBJECTIVE: To evaluate the course of chronic pelvic pain (CPP) symptoms in women and to explore factors associated with changes in pain intensity and adjustment to pain in the long term. DESIGN: Follow-up study. METHOD: All women who had visited a Chronic Pelvic Pain team of a university hospital in the past were invited to participate. All completed a set of questionnaires at their first visit and follow-up. RESULTS: Of the 131 women who met the inclusion criteria, 84 (64%) consented to participation in this follow-up study. After a mean follow-up period of 3 years, significant changes were found as regards a reduction in pain intensity, an improvement in adjustment to pain (i.e., physical well-being and depressive symptoms), a reduction in catastrophizing pain and an increase in perceived pain control. Neither sociodemographic, clinical nor pain-related variables were associated with these changes. Pain appraisals and pain coping strategies at baseline did not predict changes from baseline in pain intensity. A reduction in catastrophizing pain, however, was associated with a reduction in pain intensity and adjustment to pain, especially as regards physical well-being and depressive symptoms. CONCLUSION: After 3 years' follow-up, an improvement in pain intensity was observed in women with CPP, and this was not associated with baseline pain appraisals and coping strategies. A reduction in catastrophizing pain was related to better outcome in the long term.

Sexual functioning in women with chronic pelvic pain: the role of anxiety and depression.

INTRODUCTION: Chronic pelvic pain (CPP) in women is a long lasting and often disabling condition. It seems reasonable to expect that as a result of the pain, extreme fatigue and/or emotional problems, women with CPP may report a variety of sexual problems. AIM: The present study investigated differences in the report of sexual problems in women with CPP compared with healthy controls, and whether the association of CPP with sexual problems was moderated or mediated by somatic and psychological factors as manifested in women suffering from CPP. METHOD: One hundred fifty-four women with CPP and 58 age-matched controls completed self-report measures for sexual functioning, pain, physical impairment, anxiety, depression, and sexual and physical abuse. MAIN OUTCOME MEASURE: Golombok Rust Inventory of Sexual Satisfaction. RESULTS: Women with CPP reported higher levels of vaginistic complaints, sexual avoidance, nonsensuality and sexual dissatisfaction than healthy controls. Sexual problems were associated with anxiety, depression, and sexual abuse history but not with somatic factors as pain and physical impairment. Anxiety as well as depression, irrespective of the report of sexual abuse experiences, mediated the effect of CPP on sexual problems. Sexual abuse was a general predictor of sexual problems in both women with CPP and controls. CONCLUSIONS: Anxiety and depression constitute important factors in the evaluation of sexual problems in women with CPP.

Acute abdominal pain in women at an emergency department: predictors of chronicity.

BACKGROUND: Persistence of pain after acute abdominal pain has been encountered but predictors of chronicity are insufficiently known. AIMS: To assess the course of acute abdominal pain and to explore whether chronicity is predicted by baseline demographic and clinical variables. METHODS: A follow-up study was conducted on all consecutive women who had visited an emergency department of a secondary care teaching hospital for acute abdominal pain. After a mean of 2.3years 115 women (58%) completed questionnaires. RESULTS: At follow-up 34 women (30%) still suffered from abdominal pain complaints for more than 3months the past year. Low education level (Exp(B)=4.21, p=0.017) and having experienced abuse before the age of 16 (Exp(B)=3.14, p=0.016) were significantly and independently associated with chronicity. No other socio-demographic or clinical factors predicted the outcome. CONCLUSION: At a 2.3year follow-up period nearly one third of all women with acute abdominal pain still suffered from pain. Low education level and abuse at younger age showed to be risk factors for pain persistence.

A cognitive behavioural based assessment of women with chronic pelvic pain.

From population-based surveys, chronic pelvic pain (CPP) in women is a common condition with a spectrum of associated disability and distress. Those seen by gynaecologists in a referral setting often have substantial impairment of function and mood disturbance. Because in most cases, the aetiology of CPP cannot be explained and the range of effective interventions remains limited, treatment of CPP might easily result in a sense of frustration not only for the patient but also for the gynaecologist. To avoid this situation in clinical practice, a structured assessment of women suffering from CPP using a cognitive behavioural model, is suggested. This type of assessment provides information about the impact of CPP on a particular patient's daily life. It also facilitates referral for pain management. Future studies are needed to show further evidence of benefit of this approach for women with CPP.

Therapist-aided exposure for women with lifelong vaginismus: a replicated single-case design.

Vaginismus is commonly described as a persistent difficulty in allowing vaginal entry of a penis or other object. Lifelong vaginismus occurs when a woman has never been able to have intercourse. A replicated single-case A-B-phase design was used to investigate the effectiveness of therapist-aided exposure for lifelong vaginismus. A baseline period (Phase A) was contrasted with exposure + follow-up (Phase B), using random switching between phases. The main outcome measure (intercourse ability) was assessed daily for 24 weeks. Ten women participated. The exposure consisted of a maximum of three 2-hr sessions during 1 week at a university hospital. The participant performed vaginal penetration exercises on herself, in the presence of a female therapist. Two follow-up sessions were scheduled over a 5-week period. Nine of the 10 participants reported having intercourse after treatment, and in 5 of the 9, intercourse was possible within the 1st week of treatment. The results remained at 1-year follow-up. Furthermore, exposure was successful in decreasing fear and negative penetration beliefs posttreatment and at 3-month and 1-year follow-ups. Therapist-aided exposure appears to be an effective treatment for lifelong vaginismus.

Predictors of outcome in a cohort of women with chronic pelvic pain - a follow-up study.

BACKGROUND: Chronic pelvic pain (CPP) in women is a long-lasting condition. AIMS: To explore changes in pain intensity, adjustment to pain, pain appraisal and coping strategies as well as to evaluate whether baseline pain appraisals and coping strategies and their changes were associated with outcome in the long term. METHODS: A follow-up study was conducted on all consecutive women who had visited a CPP-team of a university hospital. After an average period of 3.2 years 64% of them (N=84) completed questionnaires at baseline and follow-up. RESULTS: A reduction in pain intensity (p<.001, d=.6), improvement in adjustment to pain (SF-36 Physical Component Summary (p<.001, d=.4) and depressive symptoms (p<.01, d=.2)), as well as a reduction in catastrophizing pain (p<.01, d=.4) and an increase in perceived pain control (p<.01, d=.3) were observed. Neither biographic nor clinical variables were related with these changes. Pain appraisal and coping strategies at baseline did not predict changes from baseline in pain intensity. However, baseline levels of perceived pain control correlated with a change in depressive symptoms (r=-.27, p<.05), also after adjustment for pain intensity at baseline (r=-.28, p<.05). Changes from baseline in levels of catastrophizing pain were associated with changes in pain intensity (r=.44, p<.01), SF-36 Physical Component Summary (r=-.34, p<.01) and depressive symptoms (r=.71, p<.01). CONCLUSION: At a 3 year follow-up, improvement in pain intensity in women with CPP was not associated with baseline pain appraisals and coping strategies. A reduction in catastrophizing was related to better outcome in the long term.

Request for operative reduction of the labia minora; a proposal for a practical guideline for gynecologists.

The increase in women's request for labia reduction surgery raises medical and ethical dilemmas for the gynecological surgeon. A bio-psycho-social approach is suggested; the problem is put forward from the perspective of the medical ethical principles and a practical guideline is proposed.

Management of chronic pelvic pain additional to tubal sterilization.

OBJECTIVE: A case series is presented to illustrate the dilemma in management of women with Chronic Pelvic Pain (CPP) additional to a tubal sterilization. METHODS: Between January 1999 and June 2007, five women consulted the Department of Gynecology for CPP additional to tubal sterilization with Filshie Clips (FCs). A biopsychosocial approach of the complaint was offered and laparoscopic removal of the clips was performed in all cases. The effectiveness of this management was assessed by a personal interview and a retrospective chart review. RESULTS: Two of the five patients refused an exploration of psychosocial factors possibly contributing to or maintaining the pain. During laparoscopic removal of the Filshie Clips no additional pathology was noted. At follow-up four women declared to have benefited from the removal procedure. CONCLUSION: If women present with CPP additional to sterilization with FCs in the absence of obvious pathology, gynecologists have to pay attention to the possibility of underlying psychosocial factors to this complaint. However, this attention can be in conflict with the woman's conviction that only removal of the clips will alleviate her pain. In that case, laparoscopic removal might be a component of the management.

Clinical course of chronic pelvic pain in women.

A follow-up study on a cohort of women with chronic pelvic pain (CPP) was conducted, to evaluate the clinical course and to identify factors associated with outcome. Participants were over 18 years of age and had initially visited a multidisciplinary CPP-team of a Gynaecological Department of a University Hospital. The course of chronic pelvic pain was evaluated using the Life Chart Interview (LCI) method. All participants completed questionnaires covering demographic and clinical characteristics, pain (McGill) and psychological distress (SCL-90) at baseline and follow up. The response rate was 60%. A survival analysis was conducted. After a mean follow-up period of 3.4 years, 18 women (25%) of the study sample (N=72) reported recovery from pelvic pain (i.e. pelvic pain for less than 3 months per year). Eight of these 18 women (11% of the total sample) reported no pain at all at follow up. Relapse of symptoms was not encountered. Not any demographic, clinical or pain related variable measured at baseline, nor any intervention between baseline and follow up, was associated with outcome. Our results indicate that chronic pelvic pain in women in secondary care is a longstanding condition. Further research is recommended to identify risk factors for persistence of symptoms.

Intraobserver and interobserver reliability of videotaped laparoscopy evaluations for endometriosis and adhesions.

OBJECTIVE: To determine the intra- and interobserver reliability of evaluations during videotaped laparoscopy, with real-time laparoscopy as the "gold standard." DESIGN: Prospective evaluation. SETTING: University hospital. PATIENT(S): Women who underwent laparoscopy for chronic pelvic pain, sterilization, or infertility workup. INTERVENTION(S): Real-time laparoscopies were videotaped and scored then later reassessed. MAIN OUTCOME MEASURE(S): Intra- and interobserver levels of agreement between evaluations for endometriosis and adhesions. RESULT(S): With the use of reassessments on 90 (videotaped) laparoscopies, the intra- and interobserver levels of agreement between the scorings for endometriosis were found to be substantial, except for ovarian implantations. A high agreement was found in the staging of endometriotic disease. The intra- and interobserver levels of agreement for scoring adhesions were only fair to moderate, and a substantial number of differences between measurements in adhesion total scores was found. No systematic difference between the number of disagreements was observed in either setting. CONCLUSION(S): Although special attention has to be given to the assessments of ovarian lesions, the evaluations of videotaped laparoscopies for endometriosis were reliable and justified the use of recorded findings. Because evaluations of adhesions during videotaped laparoscopy are not reliable, in some cases a second laparoscopy may need to be performed.

A cognitive-behavioral group program for women with vulvar vestibulitis syndrome (VVS): factors associated with treatment success.

The results of this prospective open clinical trial (N = 76) indicate that a cognitive-behavioral group program for women with vulvar vestibulitis syndrome (VVS) affects sexuality, pain control, vaginal muscle control, and vestibular pain and that these changes may mediate changes in pain during intercourse. Improvements in sexual functioning and vestibular pain during treatment seem to be particularly important factors in determining short and longer term treatment outcome. These findings are consistent with a cognitive-behavioral conceptualization of VVS.

Vulvar vestibulitis syndrome: an important factor in the evaluation of lifelong vaginismus?

The aim of the study was to investigate the prevalence of vulvar vestibulitis syndrome (VVS) in a sample of women suffering from lifelong vaginismus (N=91). Lifelong vaginismus is defined as "having a history of never having been able to experience penile entry of the vagina". The results with respect to VVS are compared with the results of women who are suffering from pain during intercourse (superficial dyspareunia) (N=84). Both patients groups were recruited from two treatment outcome studies. Using a standard physical examination, erythema was found in 77%, pain "on touch" in 69% and erythema and pain on the same location was seen in 56% of the patients with lifelong vaginismus. Furthermore, it was found that erythema (94%), pain (98%) and erythema and pain on the same location (92%) were more frequently found in patients with dyspareunia compared to women with lifelong vaginismus. It is concluded that pain is an integral part of the experiences in the majority of women with lifelong vaginismus.