Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain.

AIM: Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy. DESIGN: Observational cross-sectional study. METHODS: Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated. RESULTS: Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first-degree tears and 273 (89.5%) always sutured second-degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69-15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39-9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46-8.79) were significantly more likely to adopt a restrictive use of episiotomy. CONCLUSIONS: There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Anatomic Subtype Differences in Extramammary Paget Disease: A Meta-Analysis.

Importance: Extramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management. Objective: To compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented. Data Sources: MEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022. Study Selection: Articles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded. Data Extraction and Synthesis: Abstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022. Findings: Most vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases). Conclusions and Relevance: The diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.

The REPAIR study: oral antibiotics to prevent infection and wound dehiscence after obstetric perineal tear-a double-blinded placebo controlled randomized trial.

BACKGROUND: Approximately 85% of women experience an obstetric tear at delivery and up to 25% subsequently experience wound dehiscence and/or infection. Previous publications suggest that intravenous antibiotics administrated during delivery reduces this risk. We do not know if oral antibiotics given after delivery can reduce the risk of wound dehiscence or infection. Our aim is to investigate whether three doses of oral antibiotics (amoxicillin 500 mg/clavulanic acid 125 mg) given after delivery can reduce the risk of wound dehiscence and infection in patients with a second-degree obstetric tear or episiotomy. METHODS: We will perform a randomized, controlled, double-blinded study including 221women in each arm with allocation 1:1 in relation to the randomization. The study is carried out at Department of Obstetrics & Gynecology, Herlev University Hospital, Copenhagen, Denmark. The women will be included after delivery if they have had a second-degree tear or episiotomy. After inclusion, the women will have a clinical follow-up visit after 1 week. The tear and healing will be evaluated regarding signs of infection and/or dehiscence. The women will again be invited for a 1-year clinical examination including ultrasound. Questionnaires exploring symptoms related to the obstetric tear and possible complications will be answered at both visits. Our primary outcome is wound dehiscence and/or wound infection, which will be calculated using χ2 tests to compare groups. Secondary outcomes are variables that relate to wound healing, as pain, use of painkillers and antibiotics, need for further follow-up, as well as outcomes that may be related to the birth or healing process, urinary or anal incontinence, symptoms of prolapse, female body image, and sexual problems. DISCUSSION: Reducing the risk of wound dehiscence and/or infection would decrease the number of control visits, prevent the need for longer antibiotic treatment, and possibly also decrease both short-term and long-term symptoms. This would be of great importance so the mother, her partner, and the baby could establish and optimize their initial family relation. TRIAL REGISTRATION: The conduction of this study is approved the 2/2-2023 with the EU-CT number: 2022-501930-49-00. CLINICALTRIALS: gov Identifier: NCT05830162.

Evaluation of perineal wound healing and pain outcomes after low-angle mediolateral episiotomy in women undergoing vaginal childbirth: A systematic review and meta-analysis.

The efficacy of episiotomy, particularly the angle of incision in mediolateral episiotomies, remains a significant area of inquiry in obstetrics. This meta-analysis aimed to evaluate the impact of low-angle mediolateral episiotomy on perineal wound healing and pain outcomes in women undergoing vaginal childbirth. Adhering to PRISMA guidelines, a systematic review was conducted using the PICO framework. Studies were selected based on predefined inclusion and exclusion criteria, focusing on randomised controlled trials (RCTs) involving low-angle mediolateral episiotomies. Comprehensive literature searches were performed across major electronic databases including PubMed, Embase, Web of Science and Cochrane Library. Data extraction and quality assessments were meticulously carried out by independent reviewers, employing the Cochrane Collaboration's risk of bias tool. A total of 1246 articles were initially identified, with 8 articles meeting the strict inclusion criteria for the final analysis. The meta-analysis revealed significant heterogeneity among studies regarding postoperative pain (p < 0.0001, I2 = 77.5%), and employed a random-effects model. Results showed that low-angle episiotomies significantly reduced postoperative pain (OR = 0.27, 95% CI: 0.17-0.42, p < 0.001), and increased first-degree healing rates (OR = 2.95, 95% CI: 2.20-3.96, p < 0.001) compared to traditional angles. Sensitivity analyses confirmed the stability of these findings, and no significant publication bias was detected. The analysis suggests that low-angle episiotomies can potentially reduce postoperative perineal pain and enhance wound healing. However, the limited number and varying quality of the included studies warrant cautious interpretation of these results. Further well-designed studies are needed to corroborate these findings and guide clinical practice.

Long-term outcomes analysis of flap-based perineal reconstruction.

BACKGROUND: High-risk patients undergoing abdominoperineal resection and pelvic exenteration may benefit from immediate flap reconstruction. However, there is currently no consensus on the ideal flap choice or patient for whom this is necessary. This study aimed to evaluate the long-term outcomes of using pedicled gracilis flaps for pelvic reconstruction and to analyze predictors of postoperative complications. METHODS: This was a retrospective review of a single reconstructive surgeon's cases between January 2012 and June 2021 identifying patients who underwent perineal reconstruction secondary to oncologic resection. Preoperative and outcome variables were collected and analyzed to determine the risk of developing minor and major wound complications. RESULTS: A total of 101 patients were included in the study with most patients (n = 88) undergoing unilateral gracilis flap reconstruction after oncologic resection. The mean follow-up period was 75 months. Of 101 patients, 8 (7.9%) developed early major complications, and an additional 13 (12.9%) developed late major complications. Minor complications developed in 33 patients (32.7%) with most cases being minor wound breakdown requiring local wound care. Most patients (n = 92, 91.1%) did not develop donor site complications. Anal cancer was significantly associated with early major complications, whereas younger age and elevated body mass index were significant predictors of developing minor wound complications. CONCLUSIONS: This study builds on our previous work that demonstrated the long-term success rate of gracilis flap reconstruction after large pelvic oncologic resections. A few patients developed donor site complications, and perineal complications were usually easily managed with local wound care, thus making the gracilis flap an attractive alternative to abdominal-based flaps.

Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor.

BACKGROUND: The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome. METHODS: A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups. RESULTS: Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001). CONCLUSIONS: This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.

Optimising recovery after perineal trauma: Implementation of an evidence-based patient-centred care and clinical practice guideline.

BACKGROUND: Perineal trauma and pain can affect the quality of life of women who experience vaginal birth. AIM: To investigate the effect of perineal care and pain management on women's postpartum recovery. METHODS: This was a Quasi-experimental study. In Phase 1 women were treated using our old postnatal perineal care management guideline. In Phase 2 an updated guideline was introduced (regular administration of icepacks and analgesia during the first 24-48 h postpartum). During Phase 1, pregnant women planning a vaginal birth completed a baseline questionnaire. Those who sustained perineal trauma completed a survey at 24-48 h, seven days and 12 weeks after birth. In Phase 2 we continued recruiting participants, using the same procedure, and investigated the efficacy of pain relief approaches using the new guideline. RESULTS: In Phase 1, 111 women (Group 1), and Phase 2, 146 women (Group 2) were recruited. No statistically significant differences were found between the two groups in terms of the women's pain catastrophising, their partner's responses to pain behaviours, or birth outcomes. At 24-48 h and seven days postpartum, women in Group 2 were less likely than women in Group 1 to be bothered by back or perineal pain, headache, sleeping difficulties and dizziness (p < 0.05). More women in Group 2 received regular paracetamol and perineal icepacks during their hospital stay, with less use of oxycodone in Group 2 than Group 1. CONCLUSION: The implementation of the guideline's recommendations was associated with decrease back and perineal pain, headache, sleeping difficulties and dizziness during the first seven days postpartum.

The severity of second-degree perineal tears and perineal pain during three months postpartum: A prospective cohort study.

BACKGROUND: Second-degree perineal tears are common and can vary widely in the extent of tissue trauma. Therefore, a better understanding of perineal pain based on tissue trauma severity in second-degree tears is needed. AIM: The primary aim of this study was to assess differences in perineal pain according to the severity of perineal tears, with a focus on subcategories of second-degree tears, during the first three months postpartum. The secondary aim was to assess the use of pain medication and breastfeeding patterns according to the severity of the second-degree tears. METHODS: In this observational cohort study, nulli- and multiparous women with singleton pregnancies were included during pregnancy. After birth, perineal tears were classified using the latest international classification system. In addition, second-degree tears were subcategorised according to percentage of damage to the perineum (<50 %=2A,>50 % but less than entire perineum=2B, affecting entire perineum, anal sphincter not involved=2C). Perineal pain, use of pain medication and breastfeeding patterns were assessed during a phone interview seven to ten days postpartum and through an electronic questionnaire three months postpartum. FINDINGS: Out of 880 vaginal births, 852 participants completed the phone interview and 715 answered the electronic questionnaire. During the first three months postpartum, women with 2C-tears reported statistically significantly higher pain scores and more frequent use of pain medication compared to women with 2A-tears. There was no statistically significant difference between the number of participants not breastfeeding between second-degree tear subcategories. CONCLUSION: Women with 2C-tears reported higher perineal pain scores and more use of pain medication compared to those with less severe tears during three months postpartum.

Primary perineal endometriosis - a case report and literature review.

Endometriosis is a common gynecological disease caused by the implantation of active endometrial cells outside the uterine cavity. In most cases, endometriosis occurs in the pelvic area, such as the ovary, Douglas' pouch, or uterine sacral ligament. Some rare cases of extrapelvic endometriosis can also occur in the perineum, urinary system, gastrointestinal tract, nervous system, chest, subcutaneous tissue, and skin. Endometriosis of the perineum is usually secondary to obstetric trauma, such as perineal laceration or episiotomy. To date, few cases of spontaneous perineal endometriosis have been reported. Herein, we report a rare case of spontaneous deep perineal endometriosis. Notably, the patient had typical symptoms of regular pain during menstruation with no history of delivery or perineal trauma. The patient recovered well after postoperative gonadotropin releasing hormone agonist injection.

The postnatal effects of perineal trauma on maternal psychological and emotional wellbeing: A longitudinal study.

OBJECTIVE: To examine the postnatal psychological health and parenting adjustment of primiparous women experiencing perineal trauma. STUDY DESIGN: Longitudinal cohort study assessing body image, perceptions of traumatic birth, psychological distress, perineal pain, impact upon parental tasks and mother-infant bonding at 6-12 weeks (n = 103) and 6-10 months postnatally (n = 91). Primiparous women were recruited following vaginal birth and perineal suturing in a UK-based maternity hospital. al. Comparisons made according to the objective classification of perineal trauma experienced; 1st/2nd degree tear, episiotomy, and Obstetric Anal Sphincter Injuries (OASI). RESULTS: At 6-12 weeks women with an episiotomy reported a more negative perception of their body image than those with OASI. Women with OASI or an episiotomy were more likely to have experienced birth as traumatic, and those with OASI reported more avoidance symptoms of post-traumatic stress and a greater negative impact on parenting tasks. At 6-10 months significantly more avoidance symptoms continued to be reported by those with OASI, whereas those with an episiotomy reported more anxiety related symptoms in general than those with OASI. CONCLUSIONS: OASI, whilst associated with traumatic birth and some early parenting impacts, may not be linked to general negative psychological outcomes when specialist routine follow-up care is provided. Psychological impacts for women with episiotomy may merit further input than currently provided. Consideration should be given with regards to widening the access to postnatal perineal care by extending the criteria for specialist follow up beyond those sustaining OASI.

Functional Anatomy of Urogenital Hiatus Closure: the Perineal Complex Triad Hypothesis.

INTRODUCTION: Urogenital hiatus enlargement is a critical factor associated with prolapse and operative failure. This study of the perineal complex was performed to understand how interactions among its three structures: the levator ani, perineal membrane, and perineal body-united by the vaginal fascia-work to maintain urogenital hiatus closure. METHODS: Magnetic resonance images from 30 healthy nulliparous women with 3D reconstruction of selected subjects were used to establish overall geometry. Connection points and lines of action were based on perineal dissection in 10 female cadavers (aged 22-86 years), cross sections of 4 female cadavers (aged 14-35 years), and histological sections (cadavers aged 16 and 21 years). RESULTS: The perineal membrane originates laterally from the ventral two thirds of the ischiopubic rami and attaches medially to the perineal body and vaginal wall. The levator ani attaches to the perineal membrane's cranial surface, vaginal fascia, and the perineal body. The levator line of action in 3D reconstruction is oriented so that the levator pulls the medial perineal membrane cranio-ventrally. In cadavers, simulated levator contraction and relaxation along this vector changes the length of the membrane and the antero-posterior diameter of the urogenital hiatus. Loss of the connection of the left and right perineal membranes through the perineal body results in diastasis of the levator and a widened hiatus, as well as a downward rotation of the perineal membrane. CONCLUSION: Interconnections involving the levator ani muscles, perineal membrane, perineal body, and vaginal fascia form the perineal complex surrounding the urogenital hiatus in an arrangement that maintains hiatal closure.

Image intensifier-guided transperineal prostate biopsy for patients without a rectum: novel technique.

INTRODUCTION: It is challenging to perform prostate biopsy in men with suspicion of prostate malignancy without a rectum to facilitate prostate biopsy. Nevertheless, such patients are presenting at an earlier stage, due to increased PSA testing in association with improved MRI imaging. We describe a novel technique for prostate biopsy in two such cases. TECHNIQUE: The patient is under General Anaesthesia and in lithotomy position. The patient is catheterised and a measured volume of contrast is inserted to the catheter balloon. By using anatomical surface landmarks, placing traction on the catheter to bring the balloon to the level of the bladder neck and using fluoroscopy, the distance to the apical prostate was estimated. This facilitates image intensifier guided trans-perineal prostate biopsy. OUTCOMES: A 67-year-old patient, with a history of panproctocolectomy for ulcerative colitis, presented with increasing PSA and a suspicious prostate on MP-MRI. The prostate couldn't be visualised on transperineal ultrasound and the patient was offered transperineal biopsy using image intensifier guidance. Several biopsy cores were taken and prostate cancer was diagnosed. The second patient was a 68-year-old who presented similarly, but with a history of panproctocolectomy for Crohn's disease. Using the above technique, biopsies were taken with low-risk prostate cancer diagnosed. Subsequently, due to rising PSA levels, a repeat set of prostate biopsies was taken 13 months later in an identical manner, upstaging his disease. There were no post-operative complications after any of the procedures. CONCLUSION: We review the literature and discuss several techniques available to sample the prostate in this patient cohort. We conclude that we have identified a safe and effective technique, which utilises commonly available equipment, to biopsy the prostate in the post proctectomy patient.

Radiation from the equine perineal region is low compared with the elbow and head 24 hours after bone scintigraphic examination.

The timing of follow-up radiography and ultrasound in horses that undergo skeletal scintigraphy for lameness investigation varies internationally and between equine hospitals. The prospective, one-group, pretest, posttest study aimed to estimate radiation levels from horses three and 24 h after injection of hydroxydiphosphonate labeled with metastable technetium (99mTc-HDP) and investigate which anatomical locations of the horse had higher radiation levels. Included were 46 horses referred for lameness investigation between June and December 2021. Radiation levels from the horse surface were measured using an electronic device from six anatomical locations (head, elbow, dorsum, ventrum, stifle, and perineum) at two time points and adjusted to three and 24 h after injection of 99mTc-HDP using the radioactive decay law. The radiation measured was significantly different in the various locations of the horses for both time points. At 3 h after injection of 99mTc-HDP, the ventrum had the highest radiation dose. At 24 h, the radiation emitted from the perineal region was significantly lower (P < .0001) than from the elbow and head, which had the highest values. There was a negative correlation between age and the radiation detected at 24 h postinjection (P = .02). Radiation from the perineal region was low compared with other regions of the horse 24 h postscintigraphy. Additional care should be taken around the ventrum area during the scintigraphy examination and around the elbow and head at 24 h postscintigraphy to minimize radiation to personnel.

Median and medial umbilical ligament repositioning for prevention of pelviperineal complications following abdominoperineal resection-a case series and novel technique.

INTRODUCTION: Pelviperineal complications after abdominoperineal resections are tough to treat. None of the available prophylactic methods has proven efficacy besides being technically challenging and expensive to perform. The present study aims to describe the technical details and short-term outcomes using mobilised umbilical ligaments to cover the pelvic inlet. TECHNIQUE: After completing the rectal resection, the bladder with umbilical ligaments is mobilised anteriorly into the space of Retzius until the free edge can reach the sacral midline. Hitching stitches are taken to fix the umbilical ligaments into the new position. Seven consecutive patients had the umbilical ligament flap used for pelvic inlet closure. RESULTS: Cross-sectional imaging on day 30 demonstrated the viable flap in all patients, and the small bowel descent was prevented. None of the seven patients had small bowel obstruction till day 90 after the operation. No patient required re-catheterisation, experienced major complications or wound infections that would necessitate re-intervention. CONCLUSION: Using mobilised umbilical ligaments hitched to the pelvic inlet is a technically safe and feasible procedure to prevent pelviperineal complications after APR.