Psychosocial predictors of change in sexual activity and sexual function after hysterectomy in women with pelvic pain.

BACKGROUND: Potential impact on sexual function is an often-cited concern for many patients considering hysterectomy. The existing literature indicates that sexual function remains stable to slightly improved for most patients who undergo hysterectomy, but most studies demonstrate a small subset of patients in whom sexual function declines after surgery. Unfortunately, there is a lack of clarity as to surgical, clinical, and psychosocial factors that may influence the likelihood of sexual activity after surgery or the magnitude and direction of change in sexual function. Although psychosocial factors are strongly associated with overall female sexual function, there is minimal data exploring the potential impact of these factors on the change in sexual function after hysterectomy. OBJECTIVE: This study aimed to evaluate the relationship between baseline psychosocial factors and both sexual activity and sexual function at 6 months after hysterectomy. STUDY DESIGN: Patients undergoing hysterectomy for benign, non-obstetric indications were prospectively recruited as part of an observational cohort study evaluating presurgical predictors of posthysterectomy outcomes on pain, quality of life, and sexual function. The Female Sexual Function Index was administered before hysterectomy and 6 months after surgery. Presurgical psychosocial assessments included validated self-reported measures of depression, resilience, relationship satisfaction, emotional support, and social participation. RESULTS: Complete data was available for 193 patients, of whom 149 (77.2%) reported sexual activity at 6 months after hysterectomy. In the binary logistic regression model examining sexual activity at 6 months, older age was associated with a lower likelihood of sexual activity (odds ratio, 0.91; 95% confidence interval, 0.85-0.96; P=.002). Higher relationship satisfaction before surgery was associated with a greater likelihood of sexual activity at 6 months (odds ratio, 1.09; 95% confidence interval, 1.02-1.16; P=.008). As expected, preoperative sexual activity was associated with a greater likelihood of postoperative sexual activity (odds ratio, 9.78; 95% confidence interval, 3.95-24.19, P<.001). Analyses using Female Sexual Function Index scores were limited to patients who were sexually active at both time points (n=132 [68.4%]). The total Female Sexual Function Index score did not change significantly from baseline to 6 months, but there were statistically significant changes in several individual domains of sexual function. Patients reported significant improvement in desire (P=.012), arousal (P=.023), and pain (P<.001) domains. However, significant decreases were reported in orgasm (P<.001) and satisfaction (P<.001) domains. The proportion of patients who met the criteria for sexual dysfunction was quite high (>60%) at both time points, but there was not a statistically significant change in the proportion from baseline to 6 months. In the multivariate linear regression model, there was no relationship between change in sexual function score and any of the variables examined, including age, endometriosis history, pelvic pain severity, or psychosocial measures. CONCLUSION: In this cohort of patients with pelvic pain undergoing hysterectomy for benign indications, both sexual activity and sexual function remained fairly stable after hysterectomy. Higher relationship satisfaction, younger age, and preoperative sexual activity were associated with a greater probability of sexual activity at 6 months after surgery. Psychosocial factors, such as depression, relationship satisfaction, and emotional support, and history of endometriosis were not related to change in sexual function among patients who were sexually active both before hysterectomy and at 6 months after surgery.

Effects of Pharmacologic Venous Thromboembolism Prophylaxis in Benign Hysterectomy.

STUDY OBJECTIVE: To evaluate whether the addition of pharmacologic prophylaxis to mechanical prophylaxis for venous thromboembolism (VTE) is associated with changes in perioperative outcomes in hysterectomy for benign indications. DESIGN: Retrospective cohort study. SETTING: Michigan Surgical Quality Collaborative database. PATIENTS: Patients who underwent hysterectomy between July 2012 and June 2015 when VTE prophylaxis data were collected. INTERVENTIONS: Patients who received mechanical prophylaxis alone were compared with those receiving dual prophylaxis (mechanical and pharmacologic). Minimally invasive surgeries (MIS) included laparoscopic, vaginal, robotic-assisted, and laparoscopic-assisted vaginal hysterectomies and were analyzed separately from abdominal (ABD) hysterectomy. MEASUREMENTS AND MAIN RESULTS: Propensity score matching was used to minimize confounding because of the differences in demographic and perioperative characteristics. The primary outcome was estimated blood loss (EBL). The secondary outcomes were operative time, postoperative blood transfusion, VTE, surgical site infection, reoperation, readmission, and death. There were 1803 matched pairs in the MIS analysis. In the ABD hysterectomy analysis, 2:1 matching was used with a total of 1168 patients receiving mechanical prophylaxis alone matched to 616 patients receiving dual prophylaxis. EBL was higher by 54.5 mL (95% confidence interval [CI], 16.9-92.1) in those receiving dual prophylaxis in the ABD hysterectomy analysis but did not differ between groups in the MIS analysis. Operative time was significantly longer with dual prophylaxis in both MIS (18.3 minutes; 95% CI, 13.8-22.8) and ABD (15.3 minutes; 95% CI, 9.0-21.6) surgical approaches. There was no difference in other secondary outcomes. CONCLUSION: The addition of pharmacologic prophylaxis to mechanical prophylaxis in benign hysterectomy was associated with longer operative time, regardless of surgical approach and increased EBL in ABD hysterectomy. Given very low rates of VTE, no difference in other perioperative outcomes, and possible harm, it seems reasonable to encourage individualized rather than routine use of pharmacologic prophylaxis in patients undergoing benign hysterectomy receiving mechanical prophylaxis.

Sexual function after hysterectomy according to surgical indication: a prospective cohort study.

BACKGROUND: Our aims were to describe characteristics of sexual function prior to and 6months following benign hysterectomy in patients with three common surgical indications, and to identify preoperative factors that influence the magnitude and direction of change in sexual function after the procedure. METHODS: This prospective observational cohort study enrolled women (n =80) undergoing hysterectomy for benign indications. Patients were categorised into three groups according to surgical indication: (1) pelvic pain (PP), (2) abnormal uterine bleeding (AUB), and (3) pelvic organ prolapse (POP). Primary outcome was Female Sexual Function Index (FSFI), which patients completed preoperatively and 6months postoperatively. RESULTS: The study included 80 patients, of whom 25.0% (n =20) had surgical indication of PP, 46.3% (n =37) of AUB, and 28.7% (n =23) of POP. PP patients experienced a significant improvement in overall sexual function, as well as orgasm and pain domains following hysterectomy. Significant improvements were not found in AUB and POP patients. In multivariate analysis, lower baseline sexual function (P <0.001), younger age (P =0.013), and pelvic pain<6months (P =0.020) were each independently associated with improvement in sexual function, but surgical indication was not significant. CONCLUSION: Individual patient factors including younger age, lower baseline sexual function, and short duration of pelvic pain are associated with a higher likelihood of improvement in sexual function after hysterectomy. Surgical indication does not appear to be predictive of postoperative sexual function once accounting for other factors.

Incidence and predictors of persistent pelvic pain following hysterectomy in women with chronic pelvic pain.

BACKGROUND: Chronic pelvic pain is a debilitating problem that afflicts 15% to 20% of women in the United States. Although more than 200,000 hysterectomies are performed annually for the treatment of chronic pelvic pain, previous studies indicate that 1 in 4 women undergo the discomfort and morbidity of hysterectomy without the relief of pain. The factors that predict treatment failure remain poorly characterized. OBJECTIVE: To describe the incidence of persistent pelvic pain 6 months following hysterectomy in women with chronic pelvic pain and determine whether a simple, self-reported measure of central sensitization is associated with a greater risk of persistent pelvic pain following hysterectomy. STUDY DESIGN: We conducted a prospective, observational cohort study of women undergoing hysterectomy at an academic tertiary care center for a benign indication. Patients with preoperative chronic pelvic pain, defined as average pelvic pain ≥3 on a 0 to 10 numeric rating scale for >3 months before hysterectomy, were included in this analysis. The patients completed validated assessments of pain, anxiety, depression, and centralized pain (using the 2011 Fibromyalgia Survey Criteria, 0-31 points) preoperatively and 6 months after hysterectomy. The demographic information, surgical history, intraoperative findings, and surgical pathology were abstracted from the electronic medical records. Multivariate logistic regression was used to identify the independent predictors of persistent pelvic pain 6 months following hysterectomy, defined as <50% improvement in pelvic pain severity. RESULTS: Among 176 participants with pelvic pain before hysterectomy, 126 (71.6%) were retained at 6 months, and 15 (11.9%) reported persistent pelvic pain. There was no difference in age (P=.46), race (P=.55), average pain severity during menses (P=.68), average overall pelvic pain (P=.10), or pain duration (P=.80) in those with and without persistent pelvic pain. Whereas intraoperative findings of endometriosis (P=.05) and uterine fibroids (P=.03) were associated with a higher incidence of persistent pain on univariate analysis, the surgical route (P=.46), pelvic adhesions (0.51), uterine weight (P=.66), and adenomyosis on histopathology (P=.27) were not related to the risk of persistent pain. Higher preoperative centralized pain scores (P=.01) but not depression (P=.64) or anxiety (P=.45) were more common in women with persistent pelvic pain. Multivariate logistic regression adjusting for age, preoperative pain severity, anxiety, depression, and operative findings of endometriosis and fibroids indicated that every 1-point increase in centralized pain before hysterectomy was associated with a 27% increase in the odds of persistent pelvic pain (odds ratio, 1.27; 95% confidence interval, 1.03-1.57) 6 months after surgery. CONCLUSION: Although the majority of women with chronic pelvic pain report considerable improvement in pain following hysterectomy, higher degrees of centralized pain before hysterectomy is a robust predictor of persistent pelvic pain.

Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment.

Patients with pelvic pain suffer from psychological conditions at a disproportionately high rate compared with their peers. We review environmental, genetic, inflammatory, and neurobiological factors that increase vulnerability to developing both of these conditions. We review treatment strategies for chronic pelvic pain in patients who have comorbid psychological conditions, including both nonpharmacologic and pharmacologic options.

McCall Culdoplasty during Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the feasibility and safety of a McCall culdoplasty at the time of total laparoscopic hysterectomy and to evaluate the differences in the total vaginal length, vaginal apex during Valsalva, and sexual function 12 months after McCall culdoplasty compared with standard cuff closure. DESIGN: A pilot randomized controlled, single-masked trial (Canadian Task Force classification I). SETTING: An academic tertiary care hospital. PATIENTS: Women undergoing total laparoscopic hysterectomy for benign indications from June 2013 to December 2013. INTERVENTIONS: Women were randomized (1:1) to McCall culdoplasty followed by standard cuff closure versus standard cuff closure. Patients underwent Pelvic Organ Prolapse Quantification examination and completed the Female Sexual Function Index immediately before surgery and at 6 months and 12 months postoperatively. The primary outcome was the operative time. Secondary outcomes included estimated blood loss, complications, total vaginal length, vaginal apex during Valsalva, and sexual function. MEASUREMENTS AND MAIN RESULTS: This study included 50 patients. The groups were similar in terms of preoperative and surgical characteristics. The operative time did not differ between the groups. The estimated blood loss and complications were also similar. The loss to follow-up was similar in both groups. Changes in the total vaginal length, vaginal apex during Valsalva, sexual function, and pain with intercourse did not differ between the groups. CONCLUSION: In this pilot study, the addition of McCall culdoplasty to standard cuff closure during total laparoscopic hysterectomy was not associated with an increase in operative time, estimated blood loss, or surgical complications. No differences in the total vaginal length or vaginal apex during Valsalva were observed at the 12-month follow-up. There were no differences in sexual dysfunction or dyspareunia. Given the well-established risk reduction for the development of apical prolapse with McCall culdoplasty during vaginal hysterectomy, this procedure may be a feasible and safe addition to total laparoscopic hysterectomy.

The Use of Opportunistic Salpingectomy at the Time of Benign Hysterectomy.

STUDY OBJECTIVE: To delineate the use of opportunistic salpingectomy over the study period, to examine factors associated with its use, and to evaluate whether salpingectomy was associated with perioperative complications. DESIGN: A retrospective cross-sectional study (Canadian Task Force classification II-2). SETTING: The Michigan Surgical Quality Collaborative. PATIENTS: Women undergoing ovarian-conserving hysterectomy for benign indications from January 2013 through April 2015. INTERVENTIONS: The primary outcome was the performance of opportunistic salpingectomy with ovarian preservation during benign hysterectomy. The change in the rate of salpingectomy was examined at 4-month intervals to assess a period effect over the study period. Multivariate logistic regression was performed to evaluate independent effects of patient, operative, and period factors. Perioperative outcomes were compared using propensity score matching. MEASUREMENTS AND MAIN RESULTS: There were 10 676 (55.9%) ovarian-conserving hysterectomies among 19 090 benign hysterectomies in the Michigan Surgical Quality Collaborative in the study period. The rate of opportunistic salpingectomy was 45.8% (n = 4890). Rates of opportunistic salpingectomy increased over the study period from 27.5% to 61.6% (p < .001), demonstrating a strong period effect in the consecutive 4-month period analysis. Salpingectomy was more likely with the laparoscopic approach (odds ratio = 3.48; 95% confidence interval, 3.15-3.85) and among women younger than 60 years of age (odds ratio = 1.60; 95% CI, 1.34-1.92). There was substantial variation in salpingectomy across hospital sites, ranging from 3.6% to 79.9%. Salpingectomy was associated with a 12-minute increase in operative time (p < .001), but there were no differences in the estimated blood loss or perioperative complications. CONCLUSION: The rates of salpingectomy increased significantly over the study period. The laparoscopic approach and younger age are associated with an increased probability of salpingectomy. Salpingectomy is not associated with increased blood loss or perioperative complications.

Reducing surgical site infections after hysterectomy: metronidazole plus cefazolin compared with cephalosporin alone.

BACKGROUND: Organisms that are isolated from vaginal cuff infections and pelvic abscesses after hysterectomy frequently include anaerobic vaginal flora. Metronidazole has outstanding coverage against nearly all anaerobic species, which is superior to both cefazolin and second-generation cephalosporins. Cefazolin plus metronidazole has been demonstrated to reduce infectious morbidity compared with either cefazolin or second-generation cephalosporins in other clean-contaminated procedures, which include both as colorectal surgery and cesarean delivery. OBJECTIVE: The purpose of this study was to evaluate whether the combination of cefazolin plus metronidazole before hysterectomy was more effective in the prevention of surgical site infection than existing recommendations of cefazolin or second-generation cephalosporin. STUDY DESIGN: This was a retrospective cohort study of patients in the Michigan Surgical Quality Collaborative from July 2012 through February 2015. The primary outcome was surgical site infection. Patients who were >18 years old and who underwent abdominal, vaginal, laparoscopic, or robotic hysterectomy for benign or malignant indications were included if they received 1 of the following prophylactic antibiotic regimens: cefazolin, second-generation cephalosporin, or cefazolin plus metronidazole. Multivariate logistic regression modeling was performed to evaluate the independent effect of an antibiotic regimen, and propensity score matching was used to validate the findings. RESULTS: The study included 18,255 hysterectomies. The overall rate of surgical site infection was 1.8% (n=329). The unadjusted rate of surgical site infection was 1.8% (n=267) for cefazolin, 2.1% (n=49) for second-generation cephalosporin, and 1.4% (n=13) for cefazolin plus metronidazole. After adjustment for differences in patient and operative factors among the antibiotic cohorts, compared with cefazolin plus metronidazole, we found the risk of surgical site infection was significantly higher for patients who received cefazolin (odds ratio, 2.30; 95% confidence interval, 1.06-4.99) or second-generation cephalosporin (odds ratio, 2.31; 95% confidence interval, 1.21-4.41). CONCLUSION: In this large cohort, the use of prophylactic cefazolin plus metronidazole resulted in lower surgical site infection rates after hysterectomy compared with cefazolin or second-generation cephalosporin.

The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do when surgery fails.

PURPOSE OF REVIEW: To provide an update on nonsurgical and nonpharmacologic strategies for the management of chronic pelvic pain (CPP). RECENT FINDINGS: Effective treatment of patients with CPP requires a multifaceted approach, with thoughtful consideration of surgical, pharmacologic, and nonpharmacologic strategies. Evidence for physical therapy and trigger point injections for treatment of myofascial components of CPP is increasing. Neuromodulation techniques, such as percutaneous tibial nerve stimulation and transcutaneous electrical stimulation, have limited but favorable preliminary data in patients with CPP. Behavioral strategies, such as exercise, cognitive behavioral therapy, and mindfulness, have demonstrated significant improvements in pain, function and quality of life in patients with a variety of chronic pain conditions and are promising avenues for future research in CPP. SUMMARY: Nonpharmacologic therapies are important adjuncts to surgical and pharmacologic treatment for CPP and should be considered integral to a comprehensive treatment approach.

Management considerations for patients with uterine fibroids and concurrent venous thromboembolism.

PURPOSE OF REVIEW: The purpose is to provide an update on management strategies for uterine fibroids in the setting of venous thromboembolism (VTE). RECENT FINDINGS: Uterine fibroids and VTE are independently associated with morbidity and increasing healthcare costs. Women with large uterine fibroids have a higher likelihood of VTE. Current strategies for stratifying patients with VTE take into account the nature of the VTE (i.e., truly provoked or unprovoked) and many patients may only require short-term anticoagulation. In those patients with risk factors for recurrent VTE, longer term anticoagulation may be required. SUMMARY: In women with large uterine fibroids, the likelihood of concurrent VTE increases. Peri and postoperative management should be determined based on patient-specific risk stratification, with the majority of patients requiring short-term anticoagulation. Further risk stratification may be required for patients with essentially an unprovoked VTE, and consultation with a thrombosis specialist is recommended.

Incentives for increasing prenatal care use by women in order to improve maternal and neonatal outcomes.

BACKGROUND: Prenatal care is recommended during pregnancy as a method to improve neonatal and maternal outcomes. Improving the use of prenatal care is important, particularly for women at moderate to high risk of adverse outcomes. Incentives are sometimes utilized to encourage women to attend prenatal care visits. OBJECTIVES: To determine whether incentives are an effective tool to increase utilization of timely prenatal care among women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the reference lists of all retrieved studies. SELECTION CRITERIA: Randomized controlled trials (RCTs), quasi-RCTs, and cluster-RCTs that utilized direct incentives to pregnant women explicitly linked to initiation and frequency of prenatal care were included. Incentives could include cash, vouchers, coupons or products not generally offered to women as a standard of prenatal care. Comparisons were to no incentives and to incentives not linked directly to utilization of care. We also planned to compare different types of interventions, i.e. monetary versus products or services. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion and methodological quality. Two review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS: We identified 11 studies (19 reports), six of which we excluded. Five studies, involving 11,935 pregnancies were included, but only 1893 pregnancies contributed data regarding our specified outcomes. Incentives in the studies included cash, gift card, baby carrier, baby blanket or taxicab voucher and were compared with no incentives. Meta-analysis was performed for only one outcome 'Return for postpartum care' and this outcome was not pre-specified in our protocol. Other analyses were restricted to data from single studies.Trials were at a moderate risk of bias overall. Randomization and allocation were adequate and risk of selection bias was low in three studies and unclear in two studies. None of the studies were blinded to the participants. Blinding of outcome assessors was adequate in one study, but was limited or not described in the remaining four studies. Risk of attrition was deemed to be low in all studies that contributed data to the review. Two of the studies reported or analyzed data in a manner that was not consistent with the predetermined protocol and thus were deemed to be at high risk. The other three studies were low risk for reporting bias. The largest two of the five studies comprising the majority of participants took place in rural, low-income, homogenously Hispanic communities in Central America. This setting introduces a number of confounding factors that may affect generalizability of these findings to ethnically and economically diverse urban communities in developed countries.The five included studies of incentive programs did not report any of this review's primary outcomes: preterm birth, small-for-gestational age, or perinatal death.In terms of this review's secondary outcomes, pregnant women receiving incentives were no more likely to initiate prenatal care (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.78 to 1.38, one study, 104 pregnancies). Pregnant women receiving incentives were more likely to attend prenatal visits on a frequent basis (RR 1.18, 95% CI 1.01 to 1.38, one study, 606 pregnancies) and obtain adequate prenatal care defined by number of "procedures" such as testing blood sugar or blood pressure, vaccinations and counseling about breastfeeding and birth control (mean difference (MD) 5.84, 95% CI 1.88 to 9.80, one study, 892 pregnancies). In contrast, women who received incentives were more likely to deliver by cesarean section (RR 1.97, 95% CI 1.18 to 3.30, one study, 979 pregnancies) compared to those women who did not receive incentives.Women who received incentives were no more likely to return for postpartum care based on results of meta-analysis (average RR 0.75, 95% CI 0.21 to 2.64, two studies, 833 pregnancies, Tau² = 0.81, I² = 98%). However, there was substantial heterogeneity in this analysis so a subgroup analysis was performed and this identified a clear difference between subgroups based on the type of incentive being offered. In one study, women receiving non-cash incentives were more likely to return for postpartum care (RR 1.26, 95% CI 1.09 to 1.47, 240 pregnancies) than women who did not receive non-cash incentives. In another study, women receiving cash incentives were less likely to return for postpartum care (RR 0.43, 95% CI 0.30 to 0.62, 593 pregnancies) than women who did not receive cash incentives.No data were identified for the following secondary outcomes: frequency of prenatal care; pre-eclampsia; satisfaction with birth experience; maternal mortality; low birthweight (less than 2500 g); infant macrosomia (birthweight greater than 4000 g); or five-minute Apgar less than seven. AUTHORS' CONCLUSIONS: The included studies did not report on this review's main outcomes: preterm birth, small-for-gestational age, or perinatal death. There is limited evidence that incentives may increase utilization and quality of prenatal care, but may also increase cesarean rate. Overall, there is insufficient evidence to fully evaluate the impact of incentives on prenatal care initiation. There are conflicting data as to the impact of incentives on return for postpartum care. Two of the five studies which accounted for the majority of women in this review were conducted in rural, low-income, overwhelmingly Hispanic communities in Central America, thus limiting the external validity of these results.There is a need for high-quality RCTs to determine whether incentive program increase prenatal care use and improve maternal and neonatal outcomes. Incentive programs, in particular cash-based programs, as suggested in this review and in several observational studies may improve the frequency and ensure adequate quality of prenatal care. No peer-reviewed data have been made publicly available for one of the largest incentive-based prenatal programs - the statewide Medicaid-based programs within the United States. These observational data represent an important starting point for future research with significant implications for policy development and allocation of healthcare resources. The disparate findings related to attending postpartum care should also be further explored as the findings were limited by the number of studies. Future large RCTs are needed to focus on the outcomes of preterm birth, small-for-gestational age and perinatal outcomes.

Association Between Nociplastic Pain and Pain Severity and Impact in Women With Chronic Pelvic Pain.

Exploring the relationship between nociplastic pain and the severity and impact of pelvic pain symptoms could lend insight into the heterogeneous symptom presentation and treatment response that complicates management of chronic pelvic pain. In this prospective cross-sectional study, we sought to evaluate relationships between degree of nociplastic pain, measured by the Fibromyalgia (FM) Survey Score, and multiple aspects of the chronic pelvic pain (CPP) experience, including severity, frequency, tenderness during pelvic myofascial exam, interference with daily life, and high-impact pain. The study included 303 women who presented to a tertiary referral clinic for chronic pelvic pain and endometriosis. Multiple measures of pelvic pain, including pain severity, frequency, interference, pelvic myofascial pain, and high-impact pain were examined in General Linear Models with FM Survey Score as the primary predictor of interest in models controlling for endometriosis, surgical history, use of opioids, body mass index, and patient age. Higher level of nociplastic pain was associated with greater pelvic pain severity, frequency, interference, and pelvic myofascial pain (all P < .05). For all models, degree of nociplastic pain was more strongly associated with pain outcomes than the presence of endometriosis, and use of opioids was the only stronger predictor of worse pain outcomes. The likelihood of high impact pain increased 7% for each additional point on the FM Survey Score. Degree of nociplastic pain was robustly associated with severity, frequency, and impact of pelvic pain, and was independent of the presence of endometriosis, history of surgical procedures for pelvic pain, age, and BMI. Trial registration: not applicable PERSPECTIVE: This article evaluates the impact of nociplastic pain on symptoms and functional status in chronic pelvic pain. These findings raise the possibility that a simple screening tool for nociplastic pain might provide clinically actionable information without the need for deep neurobiological phenotyping and may inform development of personalized management strategies.

Approach to Diagnosis and Management of Chronic Pelvic Pain in Women: Incorporating Chronic Overlapping Pain Conditions in Assessment and Management.

Chronic pelvic pain (CPP) is multifactorial in etiology and heterogeneous in presentation. Identification of all pain contributors is essential for successful management. Chronic overlapping pain conditions (COPCs) are a specified group of chronic pain conditions that commonly co-occur in patients. We briefly review individual COPCs and highlight risk factors and mechanisms that appear to be applicable across COPCs. We review evaluation and communication strategies that may help establish a productive therapeutic relationship between clinicians and patients. Management should include treatment of peripheral pain generators as well as co-occurring psychological conditions and central sensitization when present.

Lower Urinary Tract Symptoms in a Chronic Pelvic Pain Population.

OBJECTIVES: This study aimed to characterize the prevalence of lower urinary tract symptoms in a chronic pain population. METHODS: In this observational cohort study, patients referred to a female pelvic pain clinic completed several validated questionnaires assessing bladder symptoms, central sensitization, pain symptoms, depression, anxiety, and neuropathic pain. Patients diagnosed as having interstitial cystitis were excluded. Patient demographic characteristics and survey responses were compared across American Urological Association Symptom Index (AUA-SI) severity categories. Multivariable logistic regression was performed to identify independent predictors of moderate-to-severe AUA-SI scores. RESULTS: A total of 177 patients were included in the analysis. American Urological Association Symptom Index data showed that 48.8% of patients had mild, 31.2% had moderate, and 20.0% had severe symptoms. Patients reporting moderate or severe AUA-SI scores had higher mean Central Sensitization Inventory (CSI) scores (46.7 ± 16.0 vs 32.9 ± 13.8, P < 0.0001), McGill scores (median, 25 [interquartile range, 16-38] vs 13 [5-27]; P = 0.0003), Patient-Reported Outcomes Measurement Information System depression T-scores (median, 53.9 [interquartile range, 46.2-61.6] vs 51.2 [37.1-55.3]; P = 0.009), Pelvic Pain and Urgency/Frequency Symptoms Scale scores (18.4 ± 6.2 vs 12.5 ± 5.4, P < 0.0001), and Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs scores (median, 10.5 [interquartile range, 3.0-16.5] vs 6.0 [1.0-12.0]; P = 0.02). The odds of moderate-to-severe AUA-SI symptoms were higher with a positive PUF and CSI score and were lower with a diagnosis of vestibular pain. CONCLUSIONS: There is a high prevalence of lower urinary tract symptoms among patients with chronic pelvic pain. Vestibulodynia was associated with lower odds of bladder symptoms. High PUF and CSI scores were significantly associated with moderate-to-severe bladder symptoms.

Effects of Shared Decision Making on Opioid Prescribing After Hysterectomy.

OBJECTIVE: To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy. METHODS: We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation. RESULTS: Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P<.01), with no significant change in the number of requested refills (9.5% [n=15] vs 5.7% [n=14], P=.15). In the post-decision aid cohort, 76.6% of patients (n=121) chose fewer tablets than the guideline-allotted maximum. Approximately 76% of patients (n=102) reported having leftover tablets. CONCLUSION: This quality improvement initiative illustrates that a simple decision aid can result in a significant decrease in opioid prescribing without compromising patient satisfaction or postoperative pain management.

Pharmacological Management of Chronic Pelvic Pain in Women.

Chronic pelvic pain (CPP) is a multifaceted condition that often has both peripheral and central generators of pain. An understanding of neurobiology and neuropsychology of CPP should guide management. Successful treatment of CPP is typically multimodal, and pharmacologic treatment strategies include analgesics, hormonal suppression, anesthetics, antidepressants, membrane stabilizers, and anxiolytics. Evidence for these and other emerging pharmacologic therapies is presented in this article.

Patients' Knowledge and Perceptions of Morcellation.

BACKGROUND AND OBJECTIVES: Morcellation has received increased media and professional attention, but it remains unclear how much the average patient knows about this topic. We sought to evaluate patients' knowledge of morcellation, assess their perceptions of the risks and benefits, and determine how these perceptions affect their decision regarding the route of surgery. METHODS: Anonymous paper surveys were administered to 500 patients attending gynecologic appointments at the University of Michigan. Survey questions gathered demographic information and assessed knowledge of various surgical approaches for hysterectomy and myomectomy. Questions regarding patients' knowledge of morcellation explored various types of morcellation and the risks and benefits of this procedure. RESULTS: Of the 500 surveys administered, 396 patients answered at least 1 survey question resulting in a response rate of 79.2%. The mean ± SD age of respondents was 47.0 ± 14.1 years, 80.8% were white, and 83.1% had completed some college. Only 8.3% of patients reported that they had ever heard of morcellation. Even among women who were actively considering a hysterectomy or myomectomy (n = 33) or those who had undergone a hysterectomy or myomectomy (n = 98), only 12.1 and 7.1%, respectively, had heard of morcellation. Of those who had heard of morcellation (n = 32), only 9.4% correctly identified the definition in a multiple-choice question. Only 4.0% of women would choose an abdominal approach to avoid morcellation. CONCLUSIONS: Patients have very little knowledge about morcellation and most patients have never heard of the procedure. Very few patients would refuse morcellation and opt for an abdominal surgery instead.

Opioid Prescribing Patterns, Patient Use, and Postoperative Pain After Hysterectomy for Benign Indications.

OBJECTIVE: To quantify physician prescribing patterns and patient opioid use in the 2 weeks after hysterectomy at an academic institution and to determine whether patient factors predict postsurgical opioid use and pain recovery. METHODS: We conducted a prospective quality initiative study by recruiting all English-speaking patients undergoing hysterectomy for benign, nonobstetric indications at a university hospital between August 2015 and December 2015, excluding those with major medical morbidities or substance abuse. Before hysterectomy, patients completed the Fibromyalgia Survey, a validated measure of centralized pain. After hysterectomy, opioid use (converted to oral morphine equivalents) and pain scores (0-10 numeric rating scale) were collected by a daily diary and a structured telephone interview 14 days after surgery. Primary outcomes were total opioid prescribed and consumed in the 2 weeks after hysterectomy. Secondary outcomes included daily opioid use and daily pain severity for 14 days after hysterectomy. RESULTS: Of 103 eligible patients, 102 (99%) agreed to participate, including 44 (43.1%) laparoscopic, 42 (41.2%) vaginal, and 16 (15.7%) abdominal hysterectomies. Telephone surveys were completed on 89 (87%) participants; diaries were returned from 60 (59%) participants. Diary nonresponders had different baseline characteristics than nonresponders. Median amount of opioid prescribed was 200 oral morphine equivalents (interquartile range 150-250). Patients reported using approximately half of the opioids prescribed with a median excess of 110 morphine equivalents (interquartile range 40-150). The best fit model of total opioid consumption identified preoperative Fibromyalgia Survey Score, overall body pain, preoperative opioid use, prior endometriosis, abdominal hysterectomy (compared with laparoscopic), and uterine weight as significant predictors. Highest tertile of Fibromyalgia Survey Score was associated with greater daily opioid consumption (13.9 [95% CI 3.0-24.8] greater oral morphine equivalents at baseline, P=.02). CONCLUSION: Gynecologists at a large academic medical center prescribe twice the amount of opioids than the average patient uses after hysterectomy. A personalized approach to prescribing opioids for postoperative pain should be considered.