Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis.

Endometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often has a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists frequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing techniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, establishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and makes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients.

Surgical Management of Endometriosis Involving the Bladder and Ureter.

BACKGROUND: Endometriosis is a chronic, debilitating condition affecting up to 10% of reproductive-age women. Urinary tract endometriosis is found in 1%-6% of women diagnosed with pelvic endometriosis, with the most common sites being the bladder (70%-85%), ureter (9%-23%), and kidney (4%). Patients typically present with symptoms such as lower abdominal pain, dysuria, and urgency. Unfortunately, urinary tract endometriosis is often asymptomatic, potentially leading to silent obstructive uropathy and kidney failure. OBJECTIVE: To demonstrate a step-by-step approach for the surgical management of urinary tract endometriosis using conventional laparoscopy for partial cystectomy and robotic-assisted laparoscopy for ureteroneocystostomy. MATERIAL AND METHOD: Surgical video of 2 cases managed in an academic tertiary referral center for endometriosis. The first case was a 38-year-old Gravida 3, Para 3 with a history of hysterectomy who had an MRI which revealed a T2 hypointense bladder nodule consistent with endometriosis. Patient had significant urinary urgency, dysuria, and suprapubpic pain that improved but did not disappear after starting oral progestin therapy (5 mg of norethindrone). A cystoscopy was first performed to confirm MRI findings of bladder lesion and to delineate borders and depth of invasion. The second case was a 35-year-old nulliparous woman with chronic pelvic pain and primary infertility. The patient had a history of stage IV endometriosis with deep endometriosis into the bowel and extrinsic encasement of the ureters causing subsequent hydronephrosis requiring bilateral ureteral stents. She had continued daily pelvic pain despite of being on oral contraceptives for medical management of endometriosis. She subsequently underwent bilateral percutaneous nephrostomy tube placement to allow for ureteral rest prior to surgery. RESULTS: In the first case, conventional laparoscopy was utilized to perform bilateral ureterolysis, bladder mobilization, partial cystectomy for complete excision of the lesion, and 2-layered bladder closure. Use of indigo carmine assisted with ureteral orifice identification. In the second case, a cystoscopy was performed with injection of Indocyanine green to assist with ureteral identification. After ureterolysis, distal ureteric obstruction due to extensive disease was confirmed on laparoscopy and ureteroscopy. Bilateral ureteroneocystostomy with placement of Double-J ureteral stents was performed using a robotic-assisted approach. Each patient had an indwelling Foley catheter for bladder decompression during recovery. Pathology in both cases revealed endometriosis. Both patients had an uneventful postoperative course. A postoperative retrograde cystogram confirmed adequate repair prior to removal of each Foley catheter. Patient 2 had uncomplicated office stent removal 6 weeks postoperatively and had a normal renal ultrasound with no hydronephrosis 6 months postoperatively. CONCLUSION: Endometriosis is an increasingly common condition. It is important for gynecological surgeons to have the proper understanding of anatomy, surgical technique, and multidisciplinary care needed with urology for safe and complete excision of bladder and ureter endometriosis.

The association of endosalpingiosis with chronic pelvic pain.

BACKGROUND: Endosalpingiosis is a pathologic diagnosis of ectopic epithelium resembling the fallopian tubes. It has been described with clinical characteristics that are similar to endometriosis. The primary objective is to determine if endosalpingiosis (ES) has a similar association with chronic pelvic pain when compared to endometriosis (EM). METHODS: This is a retrospective case-control analysis of patients with a histologic diagnosis of endosalpingiosis or endometriosis at three affiliated academic hospitals between 2000 and 2020. All ES patients were included, and 1:1 matching was attempted to obtain a comparable EM cohort. Demographic and clinical data were obtained, and statistical analysis was performed. RESULTS: A total of 967 patients (515 ES and 452 EM) were included. ES patients were significantly older than EM patients (median age 52 vs. 48 years, P<0.001), but other demographic variables were similar. Fewer ES patients had baseline chronic pelvic pain than EM patients (25.3% vs. 47%, P<0.001), and patients with ES were less likely to undergo surgery for the primary indication of pelvic pain (16.1% vs. 35.4%, P<0.001). Pelvic pain as the surgical indication remained lower in the ES group in multivariable analysis (OR=0.49, P<0.001). There were similar rates of persistent postoperative pain between ES and EM groups (10.1% vs. 13.5%, P=0.109). CONCLUSIONS: Although endosalpingiosis can be associated with chronic pelvic pain, the incidence of pain is significantly lower than in patients who have endometriosis. These findings suggest that ES is a unique condition that differs from EM. Further research including long-term follow-up and patient-reported outcomes is imperative.

Interactive video module and simulated model for uterine manipulation during laparoscopic hysterectomy.

BACKGROUND: Hysterectomy is one of the most common gynecologic surgeries, with an increasing proportion of hysterectomies performed by a laparoscopic approach. Uterine manipulation is critical for patient safety and surgical efficiency; however, the most junior member of the surgical team assumes the responsibility of uterine manipulation, commonly without preparation. The objective of our study was to determine whether kinesthetic learning using a low-cost simulated pelvic model while learning the uterine manipulation maneuvers of a laparoscopic hysterectomy improves learning efficacy and application efficiency compared to an interactive video module alone. METHODS: Our randomized control trial at an academic medical center included forty first-year and second-year medical students. Participants were randomized to the intervention group that used a low-cost simulated pelvic model for kinesthetic learning during the video module or the control group who only had the interactive video module to learn the uterine manipulation maneuvers of a laparoscopic hysterectomy. RESULTS: Participants in the intervention group were less likely to make unnecessary movements with demonstration of both pelvic side walls (right wall: control 78.9%, intervention 42.9%, p < 0.027; left wall: control 94.7%, intervention 66.7%, p < 0.046), and this was more pronounced in novice first-year participants (p < 0.009). Additionally, participants in the intervention group reported higher perceived preparedness (100% versus 71.4% in control group, p < 0.037). However, there was no difference in verbal or physical cues required, time per task, or force used between the groups. CONCLUSION: Kinesthetic practice may not be required for learning the uterine manipulation maneuvers of a laparoscopic hysterectomy, but it may be beneficial for more novice learners and to increase learners' perceived preparedness. Our novel interactive video module alone may be sufficient to prepare learners to perform uterine manipulation maneuvers prior to the operating room.

Association Between Laparoscopic Appearance of Superficial Endometriosis, Positive Histology, and Systemic Hormone Use.

STUDY OBJECTIVE: To assess the association between laparoscopic appearance of superficial endometriosis lesions, histopathology, and systemic hormone use. DESIGN: Retrospective study. SETTING: Tertiary care academic medical center. PATIENTS: We identified 266 women who underwent laparoscopic surgery at an endometriosis center with excision of lesions consistent with possible superficial endometriosis between September 2015 and November 2018. INTERVENTIONS: Appearance of the peritoneal lesions was confirmed with review of surgical videos and correlated with each pathology specimen. Lesions were dichotomized on positive or negative pathology assessment. All pathology-positive lesions were further dichotomized by hormone use within 1 month of surgery. MEASUREMENTS AND MAIN RESULTS: A total of 841 lesions were biopsied from included subjects during the study period. Of those, 251 biopsies were negative, and 590 were positive for endometriosis on pathology assessment. Lesions had significantly higher odds of positive histology when they were red (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.17-2.48), white (OR, 1.99; 95% CI, 1.47-2.70), blue/black (OR, 2.98; 95% CI, 2.00-4.44), or puckering (OR, 9.78; 95% CI, 2.46-38.91) in appearance. The following combined characteristics had significantly higher odds of positive histology: white and blue (OR, 5.98; 95% CI, 2.97-12.02), red and white (OR, 2.22; 95% CI, 1.38-3.56), red and blue (OR, 4.11; 95% CI, 1.83-9.24), and clear and white (OR, 8.77; 95% CI, 1.17-66.02). Among positive biopsies, those with hormone exposure were more likely to have clear lesions than those without hormone use (OR, 3.36; 95% CI, 1.54-7.34) and were 2.89 times more likely to have clear and white lesions (95% CI, 1.07-7.85). CONCLUSION: Although lesions suspicious for endometriosis may have differing rates of positive pathology based on appearance, no lesion characteristic was able to exclude the possibility of endometriosis. In addition, hormone use may influence lesion appearance at the time of surgery, with clear lesions more prevalent. These data have implications for appropriate identification of endometriosis at the time of laparoscopy to ensure accurate diagnosis and complete treatment of disease.

The association of endosalpingiosis with gynecologic malignancy.

OBJECTIVE: Endosalpingiosis is a poorly understood condition of ectopic epithelium resembling the fallopian tubes. It has been described as an incidental pathology finding, a disease similar to endometriosis, and in association with malignancy. The objective of this study is to determine if endosalpingiosis (ES) has an increased association with gynecologic malignancy when compared to endometriosis (EM). METHODS: This is a retrospective case-control analysis of patients with a histologic diagnosis of endosalpingiosis or endometriosis at three affiliated academic hospitals between 2000 and 2020. All ES patients were included, and 1:1 matching was attempted to obtain a comparable cohort of EM patients. Demographic and clinical data were obtained, and statistical analysis was performed. RESULTS: A total of 967 patients (515 ES and 452 EM) were included. ES patients were significantly older than EM patients (median age 52 vs 48 years, p < 0.001). The ES group had significantly more cancer diagnoses at surgery than the EM group (40.1% vs 18.1%, p < 0.001); this difference persisted in a sub-analysis excluding patients with known or suspected malignancy (20.9% vs 5.6%, p < 0.001). ES patients had lower overall survival (10-year freedom from death: 77.0% vs 90.5%, p < 0.001). After adjusting for confounders, multivariable analysis showed that ES patients had increased cancer diagnosed at surgery (OR = 2.48, p < 0.001) and greater risk of death (OR = 1.69, p = 0.017). CONCLUSIONS: Endosalpingiosis was found concurrently with malignancy in 40% of cases, and this effect was preserved in multi-variable and sub-group analyses. Further research consisting of longer follow-up and exploration of molecular relationships between ES and cancer are forthcoming.

Excision of Deep Endometriosis of the Rectosigmoid: Individualizing Care to the Presenting Pathology.

STUDY OBJECTIVE: To highlight different surgical approaches for managing deep infiltrating endometriosis involving the rectosigmoid colon. DESIGN: Demonstration of specific surgical techniques with educational narrated video footage. SETTING: Bowel endometriosis is reported in 3.8% to 37% of patients with endometriosis [1]. Most commonly, the rectosigmoid colon is involved. Pelvic ultrasound and magnetic resonance imaging may be useful in diagnosis and for surgical planning [2]. Treatment options include observation, medications, or surgery. There are various surgical techniques that can be used for excision of deep infiltrating endometriosis involving the rectosigmoid colon. Serosal shaving, discoid resection, and complete resection are the possible types of surgical interventions that are demonstrated in this surgical education video at an academic medical center. Serosal shaving is used for lesions with minimal involvement of the muscularis. It can be done sharply or with electrosurgery and it is imperative to assess bowel integrity after shaving. Discoid resection is used for lesions with muscularis involvement, <3 cm in size, and encompassing less than one-third to a half of the bowel circumference. Full-thickness discoid bowel resection can be done in various ways including manual resection with primary suture closure, regular stapler transabdominally, or EEA stapler (Medtronic EEA Circular Stapler, Minneapolis, MN) transrectally. Segmental resection is used for lesions >3 cm in size, involving >50% of the bowel circumference, or for multifocal lesions. Various suture and stapler methods exist for this technique. INTERVENTIONS: Based on the imaging and intraoperative findings, a surgical technique was chosen and demonstrated. The types of surgical techniques demonstrated include laparoscopic serosal shaving, discoid resection with manual resection and primary suture closure, discoid resection with EEA stapler, and segmental resection. CONCLUSION: Knowledge of different surgical approaches to excise endometriosis is essential to appropriately address a patient's unique pathology. The choice of which surgical technique to use should include consideration of the location of the lesion, depth and circumference of involvement, and the number of nodules present.

Feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis.

PURPOSE: To evaluate the feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis (AWE). MATERIALS AND METHODS: A retrospective review of percutaneous cryoablation (CT or MR) of AWE was performed from January 2018 to December 2020. Eighteen patients were identified from an internal percutaneous ablation database. Technical success, complications, and outcomes were analyzed according to standard nomenclature. RESULTS: Patients comprised 18 females (mean age 36.9 years) who underwent 18 cryoablation procedures to treat 23 AWE deposits. Three of the 18 cases were performed under MR guidance, while the remaining 15 employed CT guidance. Technical success was achieved in all 18 cases (100%). Fifteen of 18 patients (83%) had biopsy proven AWE deposits prior to treatment. Hydrodisplacement was used to displace adjacent bowel, bladder, or neurovascular structures in 13/18 cases (72%). The mean number of probes used per case was 3. Sixteen of 23 (70%) of AWE deposits had imaging follow-up (median 85 days). Of the 16 lesions with imaging follow-up, 15 (94%) demonstrated no residual enhancement or T1 hyperintensity at the treatment site and 1 lesion (6%) demonstrated residual/progressive disease. At clinical follow-up, 13 of 14 (93%) patients reported improvement in AWE-related symptoms. Eleven patients had clinically documented pain scores before and after ablation and all demonstrated substantial symptomatic improvement. No society of interventional radiology (SIR) major complications were observed. CONCLUSIONS: Percutaneous cryoablation of AWE is feasible with a favorable safety profile. Further longitudinal studies are needed to document durable response over time.

Abdominal Ice after Laparoscopic Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the impact of abdominal ice packs on opioid use and pain control after laparoscopic hysterectomy DESIGN: Randomized controlled trial. SETTING: Academic tertiary care medical center. PATIENTS: Total of 142 adult women undergoing laparoscopic (either conventional or robotic) hysterectomy were randomized to control (n = 69) or intervention (n = 73). Exclusion criteria included preoperative opioid use, planned intensive care unit admission or same-day discharge, an incision ≥4 cm, and regional anesthesia use. INTERVENTIONS: Subjects in the intervention group had a large ice pack placed directly on the lower abdomen before leaving the operating room. The ice pack was maintained continuously for 12 hours postoperation, as desired thereafter until discharge, and continued use encouraged after discharge for up to 48 hours. MEASUREMENTS AND MAIN RESULTS: Total opioids administered postoperatively, while inpatient and after dismissal, were assessed in morphine milligram equivalents. Postoperative pain, as well as analgesia acceptability and side effects, were assessed using validated measures: Brief Pain Inventory and Overall Benefit of Analgesia Score. Median morphine milligram equivalent was lower in the intervention group than the controls from inpatient stay on the floor to completion of opioid use as an outpatient (22.5 vs 26.2) but was not statistically significant (p = .79). There was no significant difference between the groups in Brief Pain Inventory assessment of postoperative pain severity (p = .80) or pain interference (p = .36) or Overall Benefit of Analgesia Score total score (p = .88). Most patients in the intervention group were very satisfied with ice pack use (n = 51, 79.7%) and very likely to recommend it to friends or family (n = 54, 83.1%). There were no adverse events related to ice pack use. CONCLUSION: There was no significant difference in postoperative opioid use or pain assessment with ice pack use after laparoscopic hysterectomy. However, most of the subjects expressed high satisfaction specific to ice pack use and would recommend its use to others, suggesting potential desirability as adjunct therapy in postoperative pain control.

MRI impacts endometriosis management in the setting of image-based multidisciplinary conference: a retrospective analysis.

PURPOSE: The aim of the study was to quantify the value of pre-operative magnetic resonance imaging (MRI) in guiding surgical management of women with endometriosis. METHODS: Pre-operative discussion of patient management and review of imaging occurred for 136 patients with endometriosis in an MRI-based multidisciplinary conference co-directed by an abdominal radiologist and gynecologic surgeon. A tri-compartmental report template guided the systematic imaging review. Management changes made as a result of the conference were identified via retrospective chart review and classified as major, directly influencing the surgical procedure or approach, or minor, impacting the patient's medical management, therapies, or diagnostic evaluation. RESULTS: Of the 136 patients discussed in conference, a management change was identified in 18.4% (25 patients). Major changes occurred in 8.1% (11 patients) and minor changes in 13.2% (18 patients). The sum of major and minor management changes exceeded the total, as both major and minor management changes were made for 4 patients. CONCLUSION: Our findings demonstrate the ability of an MRI-based multidisciplinary conference to result in pre-operative management changes in approximately 1 of 5 pre-operatively reviewed women with endometriosis. Importantly, systematic review of the MRI facilitated management changes beyond that of the dictated report alone, which was available to clinicians prior to the conference. The study reflects the value of multidisciplinary interaction, with radiologists serving more directly as clinical consultants to surgical services, and suggests an opportunity to optimize the role of MRI in endometriosis management with standardized reports emphasizing surgically pertinent findings.

The role of imaging as a guide to the surgical treatment of endometriosis.

Minimally invasive surgery for complex endometriosis requires preoperative planning that intimately connects the gynecologic surgeon to the radiologist. Understanding the surgeon's perspective to endometriosis treatment facilitates a productive relationship that ultimately benefits the patient. We examine minimally invasive surgery for endometriosis and the key radiologic information which enable the surgeon to successfully negotiate patient counseling, preoperative planning, and an interdisciplinary approach to surgery.

Percutaneous cryoablation of abdominal wall endometriosis: the Mayo Clinic approach.

Abdominal wall endometriosis (AWE) is a rare form of endometriosis that often results in substantial pain and debility. The current treatment algorithm for AWE is not well established. The purpose of this review is to describe the Mayo Clinic experience with thermal ablation of symptomatic AWE as well as to review current imaging and interventional literature regarding the diagnosis and treatment of AWE.

Association between kissing and retropositioned ovaries and severity of endometriosis: MR imaging evaluation.

PURPOSE: To retrospectively investigate the relationship between ovarian positioning on pre-operative MR imaging and intra-operative staging of endometriosis. MATERIALS AND METHODS: Sixty-five women with suspected endometriosis who underwent pre-operative MRI and subsequent intra-operative staging of endometriosis formed the study group. A trained senior radiology resident and a board-certified staff radiologist experienced in endometriosis reviewed MR images for ovarian positioning and the presence of an endometrioma. The position of the ovaries was classified as (a) kissing when they were posterior to the uterus and in contact, (b) retropositioned when they were posterior to the uterus but not in contact, or (c) normal. Intra-operative staging of endometriosis (stage 0 to IV) was determined using the revised American Society for Reproductive Medicine classification system (rASRM) by a surgeon with expertise in endometriosis surgery. Correlation between ovarian positioning and endometriosis stage was evaluated with a logistical regression analysis. Sensitivity, specificity, and accuracy were calculated. RESULTS: MR images revealed kissing ovaries in 12 women, retropositioned ovaries in 17 women, and normally positioned ovaries in 36 women. At surgery, endometriosis stages 0, I, II, III, and IV were found in 13, 15, 6, 9, and 22 patients, respectively. The odds of stage IV endometriosis were eight times higher given kissing or retropositioned compared to normal ovaries, regardless of the presence of an endometrioma (p =0.01). Kissing and retropositioned ovaries had an accuracy of 82% for stage IV endometriosis, with 86% sensitivity and 79% specificity. All cases with kissing ovaries had stage III/IV endometriosis. CONCLUSIONS: Kissing and retropositioned ovaries on pre-operative MR images are associated with higher intra-operative rASRM stages of endometriosis.

Improving patient access through office hysteroscopy clinic redesign.

BACKGROUND AND OBJECTIVE: Patients with abnormal uterine bleeding (AUB) often require hysteroscopy as part of the diagnostic workup. The purpose of this study was to improve efficiency by shortening the time to patient appointment for office hysteroscopy. INTERVENTIONS: Preintervention, nurse practitioners (NPs) and gynecologists saw patients with abnormal uterine bleeding (AUB) separately. This created inefficiency for the patients, frequently requiring second visits for hysteroscopy. A new hysteroscopy clinic was designed to increase practice efficiency. A collaborative team model was created including consecutive visits with NPs and gynecologists. Each patient with AUB was first evaluated by an NP, followed immediately by a shorter visit with a gynecologist for office hysteroscopy as indicated. NPs managed other diagnostic evaluation and bleeding treatment if hysteroscopy was not warranted. Collaborative clinic staffing consisted of two NPs seeing patients with AUB paired with one gynecologist for procedural support. MEASUREMENTS AND RESULTS: Electronic records of 393 patients scheduled for AUB visits from January to June 2015 were evaluated for preintervention data. Postintervention, 647 patient records were reviewed from January to June of 2016. During the preintervention period, 30% of patients had a hysteroscopy appointment scheduled within 0-13 days from the initial visit for AUB. Postintervention, the wait time for appointments decreased, with 63% of patients scheduled within 0-13 days. Clinic redesign also resulted in an increase of 57.5% in appointment slots. No-show rates and appointment fill rates were not adversely affected. CONCLUSIONS: A collaborative team-based care model using NPs and gynecologists improved efficiency and access to office hysteroscopy services.

Comparison of routine pelvic US and MR imaging in patients with pathologically confirmed endometriosis.

PURPOSE: To estimate the benefit of pelvic magnetic resonance (MR) imaging after routine pelvic ultrasound (US) in patients with pathologically or surgically proven endometriosis. METHODS: Patients with surgically or pathologically proven endometriosis who had routine pelvic US followed by pelvic MR within 6 months prior to surgery were included. Patients were excluded if they had previously confirmed endometriosis, pregnancy, or surgery > 6 months after MR. The detection rate of endometriosis by pelvic US and MR was compared to the surgical/pathological reference standard. RESULTS: 83 female patients (mean age 40 ± 9) met inclusion criteria and had surgical/pathological confirmation of endometriosis. The mean time interval between pelvic US and MR was 33 ± 43 days, with 64 ± 69 days between MR examination and surgery. US detected endometriosis in 22% (18/83) of patients compared to 61% (51/83) for MR (p < 0.0001). 51% (33/65) of patients with a negative pelvic US exam had a positive MR. MR identified additional sites or sequela in the majority of patients with a positive US (14/18; 78%), including extraovarian locations [e.g., fallopian tubes 7/18 (39%), uterus 7/18 (39%), uterine ligaments 6/18 (33%), posterior cul de sac 5/18 (28%), pelvic side walls 5/18 (28%), abdominal wall 1/18 (6%)] and sequela [ovarian tethering 5/18 (28%), 6/18 (33%) bowel adhesive disease, posterior cul de sac obliteration 2/18 (11%), hydrosalpinx 2/18 (11%), and hydronephrosis 1/18 (6%)]. 3 T MR detected endometriosis in 33/46 (72%) patients compared to 18/37 (49%) for 1.5 T MR (p = 0.03). CONCLUSION: Pelvic MR imaging had a higher detection rate of surgically/pathologically proven endometriosis and provides more information about disease location and sequela compared to routine pelvic US.

Vaginal Diazepam for Nonrelaxing Pelvic Floor Dysfunction: The Pharmacokinetic Profile.

BACKGROUND: Vaginal diazepam is frequently used to treat pelvic floor tension myalgia and pelvic pain despite limited knowledge of systemic absorption. AIM: To determine the pharmacokinetic and adverse event profile of diazepam vaginal suppositories. METHODS: We used a prospective pharmacokinetic design with repeated assessments of diazepam levels. Eight healthy volunteers were administered a 10-mg compounded vaginal diazepam suppository in the outpatient gynecologic clinic. Serum samples were collected at 0, 45, 90, 120, and 180 minutes; 8, 24, and 72 hours; and 1 week following administration of a 10-mg vaginal suppository. The occurrence of adverse events was assessed using the alternate step and tandem walk tests, the Brief Confusion Assessment Method, and numerical ratings. Plasma concentrations of diazepam and active long-acting metabolites were measured. Pharmacokinetic parameters were calculated by standard noncompartmental methods. RESULTS: The mean peak diazepam concentration (Cmax) of 31.0 ng/mL was detected at a mean time (Tmax) of 3.1 hours after suppository placement. The bioavailability was found to be 70.5%, and the mean terminal elimination half-life was 82 hours. The plasma levels of temazepam and nordiazepam peaked at 0.8 ng/mL at 29 hours and 6.4 ng/mL at 132 hours, respectively. Fatigue was reported by 3 of 8 participants. CLINICAL IMPLICATIONS: Serum plasma concentrations of vaginally administered diazepam are low; however the half-life is prolonged. STRENGTHS & LIMITATIONS: Strengths include use of inclusion and exclusion criteria aimed at mitigating clinical factors that could adversely impact diazepam absorption and metabolism, and the use of an ultrasensitive LC-MS/MS assay. Limitations included the lack of addressing the efficacy of vaginal diazepam in lieu of performing a pure pharmacokinetic study with healthy participants. CONCLUSION: Vaginal administration of diazepam results in lower peak serum plasma concentration, longer time to peak concentration, and lower bioavailability than standard oral use. Providers should be aware that with diazepam's long half-life, accumulating levels would occur with chronic daily doses, and steady-state levels would not be reached for up to 1 week. This profile would favor intermittent use to allow participation in physical therapy and intimacy. Larish AM, Dickson RR, Kudgus RA, et al. Vaginal Diazepam for Nonrelaxing Pelvic Floor Dysfunction: The Pharmacokinetic Profile. J Sex Med 2019;16;763-766.

Transvaginal Ultrasound Vibro-elastography for Measuring Uterine Viscoelasticity: A Phantom Study.

The purpose of this research was to determine the feasibility of a transvaginal ultrasound vibro-elastography (TUVE) technique for generating and measuring shear wave propagation in the uterus. In TUVE, a 0.1-s harmonic vibration at a low frequency is generated on the abdomen of a subject via a handheld vibrator. A transvaginal ultrasound probe is used to measure the resulting shear wave propagation in the uterus. TUVE was evaluated on a female ultrasound phantom. The shear wave speeds in the region of interest of the uterus of the female ultrasound phantom were measured in the frequency range of 100-300 Hz. The viscoelasticity was analyzed based on the wave speed dispersion with frequency. The measurement of shear wave speed suggests that the uterus of this female ultrasound phantom is much stiffer than the human uterus. This research illustrates the feasibility of TUVE for generating and measuring shear wave propagation in the uterus of a female ultrasound phantom. We will further evaluate TUVE in patients, both normal controls and those with uterine diseases such as adenomyosis.

What makes a chronic pelvic pain patient satisfied?

Purpose: Caring for women with chronic pelvic pain (CPP) is challenging. There have been few studies on what factors patients consider to be important when being treated for their pelvic pain. This study sought to identify the key factors of the health care visit that contribute to patient's overall satisfaction with their care in a CPP clinic. Materials and methods: Between January 2015 and December 2016, new patients visiting a tertiary care CPP clinic were recruited to complete a patient satisfaction survey. Inductive thematic analysis was performed on response data regarding important factors that impact patient satisfaction with their visit/care. Results: Five themes of patient satisfaction identified included: providers with a compassionate and caring attitude, being listened to, clear communication with collaboration when needed, quality time spent with patient, and having a plan of care with recommendations. The theme regarding provider's compassion and listening skills was the most frequently identified. Pain relief was seldom mentioned as a source of patient satisfaction. Conclusions: The data suggest that a focus on empathic communication may make a meaningful difference in meeting the needs of women with CPP as well as strengthening the provider/patient relationship.

Hysteroscopic Morcellation Versus Resection for the Treatment of Uterine Cavitary Lesions: A Systematic Review and Meta-analysis.

This systematic review and meta-analysis compares hysteroscopic morcellation with electrosurgical resection to treat uterine cavitary lesions. A search of Ovid MEDLINE, Ovid Embase, Scopus, and Web of Science was conducted through August 18, 2015, for randomized controlled trials (RCTs) and prospective and retrospective studies, regardless of surgical indication and study language or sample size. Seven studies were eventually included (4 RCTs and 3 retrospective observational studies), enrolling 650 women. The meta-analysis showed that the total procedure time was significantly shorter for morcellation than for resection (weighted mean difference = 9.36 minutes; 95% confidence interval [CI], -15.08 to -3.64). When reviewing RCTs only, intrauterine morcellation was associated with a smaller fluid deficit and lower odds of incomplete lesion removal. This difference was not statistically significant in observational studies. There was no significant difference in the odds of surgical complications (odds ratio = 0.72; 95% CI, 0.20-2.57) or the number of insertions (weighted mean difference = -3.04; 95% CI, -7.86-1.78). In conclusion, compared with hysteroscopic resection, hysteroscopic morcellation is associated with a shorter operative time and possibly lower odds of incomplete lesion removal. The certainty in evidence was limited by heterogeneity and the small sample size.