No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

[The influence of the comprehensive spa and health resort-based treatment on the system of hormonal regulation in the women presenting with gynecological pathology depending on the plasma prolactin level]. / Vliianie kompleksnogo sanatorno-kurortnogo lecheniia na sistemu gormonal'noi reguliatsii u zhenshchin s ginekologicheskoi patologiei v zavisimosti ot urovnia prolaktina.

AIM: The objective of the present study was to evaluate the influence of the comprehensive spa and health resort-based treatment on the system of hormonal regulation in the women presenting with bacterial vaginosis and concomitant chronic inflammatory diseases of the pelvic organs depending on the plasma prolactin level. MATERIAL AND METHODS: We investigated the indicators of hormonal regulation in 186 women suffering from bacterial vaginosis and concomitant chronic inflammatory diseases of the pelvic organs depending on the level of prolactin in blood plasma. The first group consisted of 128 women with the normal plasma prolactin levels whereas the second group was comprised of 58 women having hyperprolactinemia. The relevant laboratory data were obtained before and after peloid therapy. RESULTS: The application of the therapeutic peloids for the treatment of the women presenting with the normal level of prolactin in blood plasma was shown to contribute to the positive clinical dynamics of the patients' condition and have a modulating effect on the level of pituitary hormones as well as a stimulating effect on the function of the ovaries. The peloid therapy given to the women with hyperprolactinemia exacerbates the hormonal imbalance as a result of the increase of the initial level of prolactin, discoordination of the hormonal regulation at the level of the pituitary-ovarian system, and enhancement of the adrenal gland function regardless of the level of prolactin. CONCLUSION: The results of the study give evidence of the possibility to use the plasma prolactin level as an indicator of the effectiveness of the spa and health resort-based treatment of the women presenting with gynecological pathology. Moreover, they suggest the necessity of a differentiated approach to the application of the therapeutic peloids for the treatment of gynecological patients with the disturbances of the hormonal regulation taking into consideration the initial level of prolactin in the blood plasma and the presence of hyperprolactinemia prior to the prescription of the spa and health resort-based treatment including peloid therapy.

The approach to chronic pelvic pain in the adolescent.

Adolescents present to outpatient and acute care settings commonly for evaluation and treatment of chronic pelvic pain (CPP). Primary care providers, gynecologists, pediatric and general surgeons, emergency department providers, and other specialists should be familiar with both gynecologic and nongynecologic causes of CPP so as to avoid delayed diagnoses and potential adverse sequelae. Treatment may include medications, surgery, physical therapy, trigger-point injections, psychological counseling, and complementary/alternative medicine. Additional challenges arise in caring for this patient population because of issues of confidentiality, embarrassment surrounding the history or examination, and combined parent-child decision making.

Malnutrition and clinical outcome in gynecologic patients.

OBJECTIVES: An association between malnutrition and poor patient outcome has been established in various medical fields, but there is a general lack of data on the prevalence of malnutrition among gynecologic patients. Therefore an assessment of malnutrition is needed to detect malnourished patients in gynecology and initiate nutritional therapy if needed. STUDY DESIGN: Between 2011 and 2012 at our Gynecologic Department of a German University Hospital, 397 patients were evaluated regarding the risk of malnutrition and occurrence of complications during the time of hospitalization. The Nutritional Risk Screening (NRS) 2002 system was used to estimate the risk level for malnutrition. Of the 397 patients, 336 received surgery and 61 were treated conservatively. Patients were included independently of surgical intervention or age. The parameters for the clinical outcome were complications and time of hospitalization. RESULTS: A severe risk of malnutrition was diagnosed in 142 patients (35.8%) according to an NRS score of ≥3. Furthermore, a significantly higher complication rate among those patients who were at risk for malnutrition (NRS 1-2) (7.8%) or who were malnourished (NRS ≥3) (22.8%) was found (p<0.001 χ(2)). Regarding the length of stay (LOS) in hospital, the medial hospitalization time increased from 7 to 10 days when patients were malnourished (NRS score ≥3) (p<0.001). CONCLUSIONS: Malnutrition occurs frequently among gynecologic patients. Adequate perioperative nutritional supportive therapy should be considered in malnourished patients to improve their clinical outcome.

Spinal cord stimulation is an effective treatment for the chronic intractable visceral pelvic pain.

OBJECTIVE: Recent studies have demonstrated significant involvement of dorsal column pathways in transmission of visceral pelvic pain. Spinal cord stimulation (SCS) suppresses visceral response to colon distension in an animal model and therefore may be an effective therapy for chronic pelvic pain of visceral origin. We are reporting on the value of neurostimulation for chronic visceral pelvic pain in six female patients with the diagnosis of long-standing pelvic pain (history of endometriosis, multiple surgical explorations, and dyspareunia). DESIGN AND SETTINGS: Case-series report. All patients received repeated hypogastric blocks (in an average of 5.3 blocks) with a significant pain relief for a period ranging from 1 to 6 weeks. Three received neurolytic hypogastric block with the pain relief of 3, 8, and 12 months, respectively. Following psychological evaluation and clearance by our Multidisciplinary Committee on Implantable Devices, they all underwent SCS trial for 7-14 days. All patients received SCS systems with dual leads (Compact or Quad leads, Medtronic Inc., Minneapolis, MN, USA). RESULTS: The average follow-up was 30.6 months. Median visual analog scale pain score decreased from 8 to 3. All patients had more than 50% of the pain relief. Pain Disability Index changed from an average of 57.7 +/- 12 to 19.5 +/- 7. Opiate use decreased from an average 22.5 mg to 6.6 mg of morphine sulfate milligram equivalents per day. CONCLUSION: It appears that SCS may have a significant therapeutic potential for treatment of visceral pelvic pain.

[Psychosomatic complaints and utilisation of psychosomatic consultation services in gynecology and obstetrics]. / Psychosomatische Beschwerden und Anforderung psychosomatischer Konsile in der Frauenheilkunde.

The aim of this study was to identify symptoms of depression, anxiety and somatization disorder in gynecological and obstetrical inpatients by screening questionnaires and to compare this findings with utilisation of a psychosomatic consultation service. 517 patients were screened with HADS (anxiety and depression) and GBB-24 (somatic complaints). 28.7% had pathological and, in addition, 19.8% borderline scores in at least one scale. More than 40% had pathological or borderline scores even in a 4-week follow-up and emphasised that they would have preferred having psychosomatic support in hospital. In only 2.9% psychosomatic consultation service was requested. Physicians in the gynecology department rated anxiety depression and the patients' acceptance of psychological factors of their illness significantly lower than the patients themselves. Our results demonstrate that anxiety and depression in gynecological and obstetric patients are not only a momentary phenomenon. Physicians underestimate the need of psychosomatic consultation.

Long-term efficacy of nonsurgical urinary incontinence treatment in elderly women.

BACKGROUND: Although urinary incontinence affects up to 35% of community-dwelling elderly women, the long-term efficacy of conservative treatment in this population is unknown. METHODS: Between April 1991 and January 1994, 81 community-dwelling women over age 60 underwent nonsurgical incontinence treatment that included pelvic muscle exercises, bladder retraining, estrogen replacement, biofeedback, functional electrical stimulation, and pharmacologic therapy. Information about intercurrent medical problems, urogynecologic diagnoses, treatment recommendations, and provider-documented outcome were collected from medical records. We mailed structured questionnaires evaluating persistent incontinence, treatment efficacy, interval therapy, and quality of life to women who had last attended clinic at least one year previously. RESULTS: Fifty-three of 81 (65%) women, mean age (+/- SD) 76 +/- 8 years, returned the questionnaire. The mean follow-up interval was 21 +/- 8 months. At follow-up, 43% of women reported incontinence was not a problem or mild, 33% reported moderate incontinence, and 21% reported severe incontinence. When patients compared their initial with current incontinence severity, improvement was significant (p < .01). Genuine stress incontinence was diagnosed in 18 women, detrusor overactivity in 14, and mixed incontinence in 13. Improvement did not vary consistently by incontinence diagnosis. Older patients had more severe incontinence at presentation (r = .94, p = .02) and reported less improvement (r = .97, p < .01) than younger ones. However, the overall likelihood of improvement was greatest among patients with the most severe incontinence at presentation (r = .534, p < .001). Subjects considered pelvic muscle exercises, delayed voiding, and caffeine restriction most effective in reducing incontinence severity. CONCLUSIONS: Elderly women derive long-term clinical benefit from nonsurgical incontinence therapy. Younger patients and those with more severe incontinence are most likely to respond to treatment.

A prospective, multidisciplinary evaluation of premenopausal women with iron-deficiency anemia.

OBJECTIVE: The cause of iron deficiency anemia (IDA) in premenopausal women is often presumed to be menstrual blood loss. The purpose of this study was to determine the diagnostic value of a comprehensive gynecological and gastrointestinal evaluation in premenopausal women with IDA. METHODS: Nineteen premenopausal, nonpregnant women older than 18 yr of age with IDA defined by a hemoglobin < 12 gm/dl with serum ferritin < 10 ng/ml participated in the study. Evaluations included directed history and physical examination by a specialist in gynecology and a subspecialist in gastroenterology, esophagogastroduodenoscopy, colonoscopy, upper gastrointestinal radiography with small bowel follow-through, antiendomysial antibody, and fecal occult blood tests. RESULTS: Seven of 19 (37%) premenopausal women with IDA were diagnosed to have a gynecological cause of anemia by a specialist in that field. Although only four of these seven patients had digestive complaints, all but one (86%) were discovered to have gastrointestinal disease by upper endoscopy; findings were duodenal ulcer and Helicobacter pylori (H. pylori) gastritis (one), esophagitis and H. pylori gastritis (one), erosive esophagitis (one), gastric arteriovenous malformations (one), and nodular/erosive H. pylori gastritis (two). Fecal occult blood testing was positive in only two (29%) subjects; upper endoscopy revealed erosive esophagitis and gastric arteriovenous malformations. Twelve of the 19 (63%) premenopausal women with IDA were not diagnosed to have a gynecological source of anemia by a specialist in that field. Fecal occult blood testing was negative among all women tested and the only digestive complaint was heartburn (pyrosis) in seven. Each was identified to have esophagitis, duodenal ulcer, or gastritis by upper endoscopy. Colonoscopic examination of the 12 subjects without gynecologic etiology for IDA revealed pan colitis (one), diverticulosis (one), diverticulosis and melanosis coli (one), hyperplastic polyps (one), and nodular lymphoid aggregates (one). CONCLUSIONS: Significant upper gastrointestinal disease is identifiable among most premenopausal women with IDA (18 of 19 or 95%), even when careful evaluation by a specialist in gynecology suggests a gynecological source. Upper endoscopy should be considered in the evaluation of all premenopausal women with IDA expressing digestive complaints or in those with IDA refractory to iron supplementation. Lower endoscopic examination may be reserved for those women with symptoms or signs suggestive of colorectal disorders.

Office microlaparoscopy under local anesthesia in the diagnosis and treatment of chronic pelvic pain.

STUDY OBJECTIVE: To evaluate the safety of diagnostic and operative microlaparoscopy performed in the office under local anesthesia in the diagnosis and treatment of chronic pelvic pain. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: Office-based, free-standing private obstetrics and gynecology practice. PATIENTS: Twenty women with chronic pelvic pain. INTERVENTION: Diagnostic and operative microlaparoscopy performed under local anesthesia with conscious sedation. MEASUREMENTS AND MAIN RESULTS: All 20 patients had diagnostic microlaparoscopy and 19 had conscious pain mapping. Nine of 14 patients with endometriosis underwent fulguration of lesions and 7 of 8 with pelvic adhesions had lysis of adhesions. Four women with uterosacral ligament involvement had laparoscopic uterosacral nerve ablation. All patients tolerated office diagnostic and operative procedures without difficulty and had no complications. CONCLUSION: In selected women, several laparoscopic procedures traditionally done in a hospital or ambulatory surgery center under general anesthesia can be performed safely in the office laparoscopy suite under local anesthesia with conscious sedation.

[Symptomatic efficacy of clotrimazole combined with surgery in the treatment of recurring anal and genital condylomatosis in seropositive and AIDS patients]. / Efficacia sintomatica del clotrimazolo associato alla terapia chirurgica nel trattamento delle condilomatosi anali e genitali plurirecidivanti in pazienti sieropositivi ed affetti da AIDS. Comunicazione preliminare.

During their daily surgical activity in Hiv-positive and AIDS patients the authors have seen in surgical treatment of anogenital recurring acuminate condylomata (treated with diatermocoagulation) in 1995 that prescribing elotrimazole ointment in Candida albicans infection of the same regions there was and amelioration or the healing of the mycotic infection but also a net lowering of the condylomata and persistent latency (disease-free time) till to the next local recurrence. So they have hypothesized and antiviral and antiblastic effect of elotrimazole. Under this heading they have done a literature research discovering that in 1995, only some months ago, two fundamental works have been published on this intriguing topic. They demonstrate at an experimental level in mice a strong antiviral and antiblastic activity of clotrimazole. This new fascinating field is completely open to future research and the consequences at a therapeutic level will be of utmost importance.

Conference news highlights.

AIDS: Presentation summaries from two 1995 conferences dealing with AIDS, the Thirty-Fifth Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) and the Fourth Annual Women and HIV Conference, are presented. Highlights from ICAAC include discussions on HIV disease treatment issues, gynecologic concerns, obstetrics, and perinatal transmissions. Summaries from the Women and HIV Conference include a presentation on gynecologic care, how clinical trial data influence clinical practices, the implications from the ACTG 076 study on the effect of AZT on maternal-fetal transmission of HIV, and the use and success of traditional Chinese medicine.^ieng

Electrochemical therapy of pelvic pain: effects of pulsed electromagnetic fields (PEMF) on tissue trauma.

Unusually effective and long-lasting relief of pelvic pain of gynaecological origin has been obtained consistently by short exposures of affected areas to the application of a magnetic induction device producing short, sharp, magnetic-field pulses of a minimal amplitude to initiate the electrochemical phenomenon of electroporation within a 25 cm2 focal area. Treatments are short, fasting-acting, economical and in many instances have obviated surgery. This report describes typical cases such as dysmenorrhoea, endometriosis, ruptured ovarian cyst, acute lower urinary tract infection, post-operative haematoma, and persistent dyspareunia in which pulsed magnetic field treatment has not, in most cases, been supplemented by analgesic medication. Of 17 female patients presenting with a total of 20 episodes of pelvic pain, of which 11 episodes were acute, seven chronic and two acute as well as chronic, 16 patients representing 18 episodes (90%) experienced marked, even dramatic relief, while two patients representing two episodes reported less than complete pain relief.

[Genital bacterial infections associated with papillomavirus: value of screening and basis for treatment]. / Infections bactériennes génitales associées aux papillomavirus: intérêt du dépistage et base du traitement.

Genital bacterial and viral infections may be responsible of couple infertility and may be potentially oncogenic for genital lesions. Genital bacterial infection is associated with human papillomavirus infection in as much as 48% for men and 64% for women. The bacterias most frequently found are intracellular species (29%) and Gram-negative bacilli (14%). Treatment with specific antibiotics can reduce the frequency of infertility in both men and women. This treatment can also prevent therapeutic complications during treatment for papillomavirus infection.

[The treatment of the repercussion diencephalic syndrome in gynecology. Acupuncture therapy]. / Lechenie na reperkusionniia dientsefalen sindrom v ginekologiiata. Igloterapiia.

The obstetricians have to know the repercussion diencephalic syndrome because the diseases of genital organ can provoke it. Moreover its treatment is many difficult. The most efficient is earlier, complete and adequate treatment. Ordinary the treatment is symptomatic. The author presents 3 cases with repercussion diencephalic syndrome after gynaecology diseases treating with acupuncture and electroacupuncture: Liv1.7, CV1.3.6, Sp6.15. The effect is very good.

Ciprofloxacin treatment of chlamydial infections of urogenital tracts of women.

Ciprofloxacin was evaluated in chlamydial infections of the urogenital tracts of women treated with a dosage regimen of 500 mg orally twice a day for seven days. Of the 40 women evaluated, 30 were infected with Chlamydia trachomatis only, two were infected with Neisseria gonorrhoeae only, and a further eight had combined gonococcal and chlamydial infections. Ten were found to be harbouring Chlamydia trachomatis in the urethra as well as the cervix. Neisseria gonorrhoeae was eradicated from all patients with or without concomitant chlamydial infection. The overall chlamydial reisolation rates were 14% (5/35) four weeks after treatment and 23% (6/26) 11 weeks after treatment. The organism was not reisolated from the urethra of any of the patients after treatment. Ciprofloxacin was effective against Mycoplasma hominis, but almost completely ineffective against Ureaplasma urealyticum.

Severe chronic constipation of young women: 'idiopathic slow transit constipation'.

A series of 64 women complaining of severe constipation is described, in each of whom delayed elimination of markers from the colon was demonstrated but a barium enema was normal. All completed a detailed questionnaire and the responses are compared with those obtained in an age-matched series of healthy women with no bowel complaint. In each group 40 women also recorded in a manner suitable for analysis all food eaten over a period of seven days. The patients passed about one stool weekly with the aid of laxatives, and were greatly troubled by abdominal pain, bloating, malaise and nausea, to the extent that the symptoms were a major social disability and many lost time from work. Decreased bowel frequency and other symptoms were often first noticed around the age of puberty and slowly became worse until they were severe by the third decade. In a few, the symptoms began suddenly after an abdominal operation c-accident. Comparison with the control group showed no evidence that the patients had been underweight at any time or that they took less fibre; treatment with a bran supplement did not usually help them. The patients experienced rectal sensation before defaecation less often than the control subjects and they used digital pressure to assist defaecation more frequently. The women with constipation tended to have more painful and irregular menstrual periods, and there was an increased incidence of ovarian cystectomy and hysterectomy. Hesitancy in starting to pass urine was more common, as were some somatic symptoms such as cold hands or blackouts. Attention is drawn to this distinctive combination in young women of slow total gut transit time and a colon of normal width on barium enema, associated with abdominal, anorectal, gynaecological and somatic symptoms, as a disorder which can be disabling and particularly difficult to treat.

Rehabilitation principles in the care of gynecologic and obstetric patients.

Literature examining disabilities and rehabilitation in gynecologic and obstetric patients is limited. Among the musculoskeletal, vascular, neurologic, hormonal, and sexual problems described, pelvic floor laxity is the etiology for several dysfunctional states and is common to both parous and nonparous women. The focus of this paper is on one of the dysfunctional states--urinary stress incontinence--which in previous work had a reported incidence of 30% of all women and may affect up to 63% of postmenopausal women. This study, applying rehabilitation principles to diagnosis and treatment, found the incidence of stress incontinence to be 20 to 30% of women, pregnant or not, who did no specific pelvic floor exercise. A group of women, not pregnant, who did Kegel exercises for pelvic floor strengthening had only a 6% incidence of stress incontinence. There is a need to determine whether pelvic floor exercise, done effectively, could minimize this problem in postmenopausal women. Rehabilitation principles may be applied to the diagnosis and treatment of other disabling conditions in gynecology and obstetrics.