Ropivacaine versus lidocaine infiltration for postpartum perineal pain: A systematic review and meta-analysis.

AIM: To systematically and meta-analytically examine the efficacy of ropivacaine versus lidocaine infiltration for controlling postpartum perineal pain secondary to spontaneous tear or selective episiotomy. METHODS: We searched four databases from inception to 20-September-2020. We included all relevant randomized and nonrandomized studies and assessed their risk of bias. We pooled data as standardized mean difference (SMD), weighted mean difference (WMD), or odds ratio (OR) with 95 % confidence intervals (95 % CIs). RESULTS: Four studies met the inclusion criteria (one and three studies were nonrandomized and randomized, respectively). There were 405 patients; 205 and 200 patients received lidocaine and ropivacaine, respectively. There was no significant difference between ropivacaine and lidocaine groups with regard to visual analogue scale (VAS) pain scores at suturing (WMD = -0.04, 95 % CI [-0.41, 0.32], P = 0.82), 2 h (SMD = -1.50, 95 % CI [-3.50, 0.50], P = 0.14), and 24 h (SMD = -0.40, 95 % CI [-1.15, 0.34], P = 0.29) post repair of perineal trauma. Proportion of patients with mild VAS pain score ≤3 at 24 h was significantly higher in the ropivacaine group (OR = 4.34, 95 % CI [2.03, 9.29], P < 0.001). Proportion of patients who did not require additional analgesia during the first 24 h post perineal repair did not significantly differ between both groups (OR = 2.44, 95 % CI [0.09, 68.21], P = 0.60). Ropivacaine group achieved higher maternal satisfaction (OR = 7.13, 95 % CI [3.63, 13.99], P < 0.001). CONCLUSIONS: During repair of postpartum perineal trauma, pain efficacy is relatively longer with ropivacaine but safety is not well investigated. High-quality and large-sized studies are needed to consolidate these findings.

Usefulness of an Intrapartum Ultrasound Simulator (IUSim™) for Midwife Training: Results from an RCT.

INTRODUCTION: We conducted a randomized study to determine whether a training session on a dedicated simulator (IUSim™) would facilitate the midwives in learning the technique of transperineal intrapartum ultrasound. METHODS: Following a 30-min multimedia presentation including images and videos on how to obtain and measure the angle of progression (AoP) and the head-perineum distance (HPD), 6 midwives with no prior experience in intrapartum ultrasound were randomly split into 2 groups: 3 of them were assigned to the "training group" and 3 to the "control group." The midwives belonging to the former group were taught to measure the 2 sonographic parameters during a 3-h practical session conducted on IUSim™ under the supervision of an expert obstetrician. In the following 3 months, all the 6 midwives were asked to independently perform transperineal ultrasound during their clinical practice and to measure on the acquired images either the AoP or the HPD. The sonographic images were examined in blind by the teaching obstetrician who assigned a 0-3 score to the image quality (IQS) and to the measurement quality (MQS). RESULTS: A total of 48 ultrasound images (24 patients) from 5 midwives were acquired and included in the study analysis. A midwife of the "training group" declined participation after the practical session. Independently from the randomization group, the image quality score (IQS + MQS) was significantly higher for the HPD compared with the AoP (2.5 ± 0.66 vs. 1.79 ± 1.14; p = 0.01). In the training group, the MQS of either AoP (2.66 ± 0.5 vs.1.46 ± 1.45. p = 0.038) and the HPD (2.9 ± 0.33 vs. 1.87 ± 0.83 p = 0.002) was significantly higher in comparison with the control group, while the IQS of both measurements was comparable between the 2 groups (1.91 ± 1.24 vs. 2.25 ± 0.865; p = 0.28). CONCLUSION: The use of a dedicated simulator may facilitate the midwives in learning how to measure the AoP and the HPD on transperineal ultrasound images.

Wound healing of metastatic perineal Crohn's disease using hyperbaric oxygen therapy: A case series.

BACKGROUND: Metastatic Crohn's disease (CD) is a rare manifestation of CD. It involves inflammatory skin lesions with histopathological findings (granulomas) similar to CD, without connection to the gastrointestinal tract. Hyperbaric oxygen therapy (HBO) has been suggested as a possible treatment option. OBJECTIVE: This study aimed to identify and treat a consecutive series of patients with biopsy-proven metastatic CD and monitor wound healing using prospectively acquired outcomes. METHODS: Pathology results of all patients with ongoing perineal wound-healing problems after proctectomy between 2005 and 2018 at the Amsterdam University Medical Centre were assessed for metastatic CD. Patients with a biopsy-proven diagnosis of perineal metastatic CD were offered HBO (40 daily sessions of 100% oxygen at 2.4 atmosphere absolute). Wound healing was monitored using photographs and standardised questionnaires (the Inflammatory Bowel Disease Questionnaire, EuroQol Visual Analogue Scale and the Female Sexual Function Index) at baseline and 1 and 3 months after HBO. RESULTS: Out of 13 patients in the cohort with persisting perineal wounds after proctectomy, six (46%) had biopsy results consistent with metastatic CD. Of these, three accepted treatment with HBO. All three patients were female. One patient had complete healing of her perineal wound; another patient showed initial improvement but had a flare of luminal and perineal disease at the 3-month follow-up. The third patient showed improvement solely in the questionnaires, with higher scores on all three questionnaires. CONCLUSION: A high rate of metastatic CD was found in patients with ongoing wound-healing problems after proctectomy, implying that the disease might not be as rare in these selected patients as previously thought. HBO might be beneficial in the treatment of metastatic CD.

Traditionally vs sonographically coached pushing in second stage of labor: a pilot randomized controlled trial.

OBJECTIVE: To investigate the usefulness of visual biofeedback using transperineal ultrasound to improve coached pushing during the active second stage of labor in nulliparous women. METHODS: This was a randomized controlled trial of low-risk nulliparous women in the active second stage of labor. Patients were allocated to either coached pushing aided by visual demonstration on transperineal ultrasound of the progress of the fetal head (sonographic coaching) or traditional coaching. Patients in both groups were coached by an obstetrician for the first 20 min of the active second stage of labor and, subsequently, the labor was supervised by a midwife. Primary outcomes were duration of the active second stage and increase in the angle of progression at the end of the coaching process. Secondary outcomes included the incidence of operative delivery and complications of labor. RESULTS: Forty women were recruited into the study. Those who received sonographic coaching had a shorter active phase of the second stage (30 min (interquartile range (IQR), 24-42 min) vs 45 min (IQR, 39-55 min); P = 0.01) and a greater increase in the angle of progression (13.5° (IQR, 9-20°) vs 5° (IQR, 3-9.5°); P = 0.01) in the first 20 min of the active second stage of labor than did those who had traditional coaching. No differences were found in the secondary outcomes between the two groups. CONCLUSION: Our preliminary data suggest that transperineal ultrasound may be a useful adjunct to coached pushing during the active second stage of labor. Further studies are required to confirm these findings and better define the benefits of this approach. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Visual biofeedback using transperineal ultrasound in second stage of labor.

OBJECTIVE: To assess the obstetric and psychological effects of visual biofeedback by transperineal ultrasound (TPU) during the second stage of labor. METHODS: This was a prospective, single-center observational study of low-risk nulliparous women with epidural analgesia undergoing vaginal delivery. Visual biofeedback using TPU was provided to 26 women during the second stage of labor. Pushing efficacy was assessed by the change in the angle of progression (AoP) at rest and during pushing efforts, before and after biofeedback. Obstetric outcomes included incidence of perineal tearing, mode of delivery and length of second stage of labor. Psychological outcomes were assessed by self-reported measures obtained during the postnatal hospital stay and included measures of perceived control and maternal satisfaction with childbirth, as well as level of maternal feelings of connectedness with the newborn. Obstetric and psychological results were compared with those of a control group of 69 women who received standard obstetric coaching from midwives. RESULTS: Pushing efficacy increased significantly following visual biofeedback by TPU (P = 0.01), as indicated by a significantly lower delta AoP before (mean, 22.2° (95% CI, 13.9-31.7°)) compared with after (mean, 35.2° (95% CI, 25.9-45.3°)) biofeedback. A significant association was found between visual biofeedback and an intact perineum following delivery (P = 0.03). No significant differences were found between the two groups with regard to mode of delivery or length of the second stage. Feelings of maternal connectedness with the newborn were significantly stronger (P = 0.003) in women who received visual biofeedback than in those who did not. However, perceived control during childbirth and maternal satisfaction with childbirth did not differ significantly between the biofeedback and control groups. CONCLUSIONS: This pilot study suggests that biofeedback using TPU may serve as a complementary tool to coached maternal pushing during the second stage of labor, with obstetric as well as psychological benefits. Further studies are required to confirm our findings and define the optimal duration of the intervention. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Impact of at-home self-rehabilitation of the perineum on pelvic floor function in patients with stress urinary incontinence: Results from a prospective study using three-dimensional ultrasound.

OBJECTIVE: Pelvic floor muscle training (PFMT) is the first step of treatment for stress urinary incontinence (SUI). Patients must perform self-retraining exercises of the perineal muscles at home in order to maintain the benefit of the physiotherapy. The aim of this study is to assess the benefit of a perineal electro-stimulator, using three-dimensional ultrasound, during this home-care phase. MATERIALS AND METHODS: A longitudinal prospective study was conducted between May 2012 and May 2013. All patients with de novo SUI benefited from PFMT followed by a self-maintenance of perineal rehabilitation at home with the Keat(®) Pro system. The primary endpoint was the biometric of the levator ani and it was assessed by three-dimensional perineal ultrasound at inclusion, after conventional rehabilitation and at the end of the study after self-rehabilitation. RESULTS: Ten patients were included. All patients (100%) showed a clinical improvement of SUI. The quality of life was significantly improved after PFMT vs. inclusion (P=0.014) and after self-rehabilitation vs. after PFMT (P=0.033). Levator ani muscles were significantly thicker after conventional rehabilitation than at baseline (P=0.004) and significantly thicker after self-rehabilitation than after PFMT (P=0.009). CONCLUSIONS: Conducting self-rehabilitation in addition to conventional PFMT objectively improves the perineal muscle building achieved after conventional rehabilitation.

[Descending perineum syndrome in children: Pathophysiology and diagnosis].

Objective: To propose a safer, simpler, and more exact method for the diagnosis of descending perineum syndrome (DPS). Material and Methods: A total of 194 patients aged 5 days to 15 years were examined and divided into 2 groups: Group 1 consisted of 65 patients without anorectal anomalies (AA); Group 2 comprised 129 patients, including 66 children with functional constipation, 55 with AA and visible fistulas, who were preoperatively examined, and 8 patients with anorectal angle (ARA), who were postoperatively examined. All the patients underwent irrigoscopy that was different from standard examination in the presence of X-ray CT contrast marker near the anus. Results and Conclusion: DPS is caused by puborectalis muscle dysfunction. A method was proposed to evaluate the status of the puborectalis muscle from the distance between the position of the ARA and the marker near the anus. This not only promotes an exacter estimate of DPS, but also allows refusal of defecography. The use of a barium enema with the minimum number of X-ray films decreases dose of ionizing radiation hazard and permits the use of this procedure not only in adults, but also in children with chronic constipation, fecal incontinence, and in AA for both pre- and postoperatively assessment of the causes of complications.

Does water delivery affect pelvic floor? Ultrasound evaluation of perineal function.

OBJECTIVE: The aim of the study is to analyse urethral mobility and excursion of the pubo-rectal angle, using perineal ultrasound, after normal vaginal delivery and water delivery. MATERIALS AND METHODS: A total of 52 primiparous women were enrolled: 25 who had delivery in water (W Group), 27 who had delivery without using water (NW Group). Every woman underwent perineal ultrasound assessment at 6 months after having given birth. The following parameters were assessed: urethral mobility during Valsalva's manoeuvre, movement of the puborectal sling angle during contraction of the levator ani muscle. RESULTS: Data obtained show that the urethral mobility during Valsalva's manoeuvre is higher in the W Group (34.9 degrees) in comparison to the NW Group (29.5 degrees), without statistically significant differences. The excursion of the pubo-rectal sling angle resulted lower in the W Group (8.7 degrees) than in the NW Group (11.0 degrees), without statistically significant differences. CONCLUSION: The present study found no statistically differences in pelvic floor, using perineal ultrasound, between water and "non-water" delivery.

Laparoscopically assisted anorectoplasty using perineal ultrasonographic guide: a preliminary report.

BACKGROUND/PURPOSE: As minimal invasive surgery, laparoscopically assisted anorectal pull-through has been reported with new devices. However, it is not easy to create an accurate pull-through canal (PTC) because of the narrow space between the urethra and puborectal sling. The authors describe a new method using perineal ultrasonography. METHODS: The rectourethral prostatic fistula was dissected laparoscopically. Externally, electrostimulation identified the center of the muscle contraction, over which a 1.2-cm skin incision was made, and the lower part of PTC was created by hemostat forceps guided by electrostimulation. An ultrasonographic probe applied to the perineum demonstrated the urethra, and the forceps was advanced behind the urethra into the pelvic cavity using the ultrasonographic guide. Anorectal pull-through was performed after dilatation of the PTC with dilators. RESULTS: The authors applied this procedure in 5 cases of male high and intermediate anomalies. Surgical damages to the urethra and the levator and vertical muscles were not encountered. Postoperative fluoroscopic study demonstrated good anterior angulation and intact contraction and relaxation of those muscles. CONCLUSION: The combination of laparoscopic dissection, pinpointing the center of anal sphincter by electrostimulation, and identification of the urethra by ultrasonographic images from the perineum facilitated creation of appropriate PTC in the muscle complex.

[Transvaginal electrical stimulation of the pelvic floor in the treatment of stress urinary incontinence: clinical and ultrasonographic assessment]. / Eletroestimulação transvaginal do assoalho pélvico no tratamento da incontinência urinária de esforço: avaliações clínica e ultra-sonográfica.

BACKGROUND: The purpose of this study was to evaluate the efficacy of transvaginal electrical stimulation on the treatment of women with stress urinary incontinence (SUI) in selected cases. METHODS: Twenty two women with primary stress urinary incontinence diagnosed by urodynamic study were submitted to transvaginal electrical stimulation. The mean age was 49 years old (range 22 to 74). The treatment consisted of two weekly sessions of stimulation, each 20 minutes long, during 8 weeks. Women were evaluated through history, clinical and urogynecological exam, weekly registration of frequency of urinary leakage, stress test and transperineal ultrasound before and after treatment. A pulse of 700 sec. was used, frequency of 50 Hz and intensity varying from 12 to 53 mA according to the women's sensitivity. RESULTS: Eighteen of 22 subjects (81.7%) were satisfied with electrical stimulation and frequency of urinary incontinence reduced significantly (p<0.01). Stress test was negative in 77.2% of the women after treatment. Valsalva leak-point pressure was higher in 14 (63.3%) women after treatment, although not reaching statistical significance (p=0.37). Bladder neck mobility did not change significantly before and after electrical stimulation (p=0.30). CONCLUSION: Transvaginal electrical stimulation of the pelvic floor is an effective and safe treatment to women with SUI without sphincter deficiency, with significant reduction of the frequency of urinary leakage.

The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle exercises.

Perineal ultrasound was used to detect and quantify levator activity by measuring the displacement of the internal urethral meatus against the inferoposterior margin of the symphysis pubis. Women who had previously been instructed in pelvic floor muscle exercises were more likely to contract the levator muscle when asked to do so than were those without previous instruction (P<0.0001). Of the 56 women who were unable to contract the pelvic floor on request, 32 (57%) eventually succeeded with visual ultrasound biofeedback. Pelvic floor muscle assessment and teaching can be used as an adjunct to the ultrasound assessment of urogynecologic patients, requiring at most 5 minutes. It allows quantification of lavator activity and can provide visual biofeedback, which is easily understood and readily accepted by women.

Prior transurethral resection does not increase morbidity following real-time ultrasound-guided prostate seed implantation.

PURPOSE: Patients with localized prostate cancer who had a prior open prostatectomy or transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) may be at risk for greater morbidity when treated with brachytherapy. This analysis examines the morbidity following brachytherapy using the real-time method to determine if patients with a history of TURP are at increase risk for developing complications. MATERIALS AND METHODS: An ultrasound-guided transperineal interactive prostate seed was implanted in 419 patients with T1-T2 prostate cancer. All patients were implanted using a peripheral weighting of sources (75%) with the interior sources placed at least 5 mm from the urethra. The patients were divided into two groups: group 1 consisted of 376 patients (89.7%) without a prior TURP, and group 2 consisted of 43 patients (10.3%) who had a TURP prior to their implant. The mean age, prostate-specific antigen level, Gleason score, clinical stage, prostate volume, isotope implanted, and number of patients treated with neoadjuvant hormone therapy were comparable for both groups. RESULTS: Median follow-up for group 1 was 12 months and for group 2 was 18 months. No patients suffered from radiation-related proctitis or cystitis in either group of patients. Two patients in group 2 implanted with iodine 125 and who had a history of two prior TURPs developed mild superficial urethral necrosis (SUN). The actuarial freedom from developing superficial urethral necrosis at 4 years was 84% in patients with a history of prior TURP. There were no episodes of SUN in group 1 and no cases of incontinence reported in either group of patients. The actuarial rate of potency was 78% at 2 years. CONCLUSION: Whereas other techniques of seed implantation report incontinence in patients who had a prior open prostatectomy or TURP, the real-time method combined with peripheral loading avoids this complication.

Patient position during cinedefecography. Influence on perineal descent and other measurements.

PURPOSE: This study was undertaken to assess the reproducibility of cinedefecography measurements and abnormal findings between the left lateral decubitus and seated positions. METHODS: Prospective patient evaluation included all patients who had lateral radiographs of the pelvis taken at rest, during squeezing, and pushing in both positions. Anorectal angle, perineal descent, and puborectalis length measurements were calculated for each set of radiographs. Pelvic floor dynamics during evacuation were measured as the changes between rest and pushing. Abnormal findings included both increased dynamic and fixed perineal descent, nonrelaxing puborectalis, and premature evacuation. RESULTS: One hundred five consecutive patients underwent cinedefecography. There were statistically significant differences between the positions with regard to anorectal angle (P < 0.0001), perineal descent (P = 0.0001), and puborectalis length (P = 0.0001). Dynamic changes of the anorectal angle, perineal descent, and puborectalis length were not significantly different (P > 0.05). However, 6 of 22 (27 percent) patients with fecal incontinence had premature evacuation severe enough to impede measurement only when seated (P = 0.05). CONCLUSION: Because of the statistically significant differences between the two positions, centers should always employ the same position for a given diagnostic group.

[Perineal hernia of the rectum (author's transl)]. / Hernie périnéale du rectum.

A case of perineal hernia of the rectum is presented; this case has been successfully treated by a fixation of the rectum to the sacrum by analogy with the treatment of the prolapsus of the rectum.