Myofascial pelvic pain: the forgotten player in chronic pelvic pain.

PURPOSE OF REVIEW: In this review article, we discuss myofascial-related chronic pelvic pain, pathophysiology, symptomology, and management options. RECENT FINDINGS: Despite high prevalence of myofascial pelvic pain, screening is not routinely performed by providers. Treatment modalities include pelvic floor physical therapy, pelvic floor trigger point injections with anesthetics or botulinum toxin A and cryotherapy. Other adjunct modalities, such as muscle relaxants and intravaginal benzodiazepines, are used, but data regarding their effectiveness is sparse. SUMMARY: Myofascial pelvic pain is an important, though overlooked component of chronic pelvic pain. Multimodal, multidisciplinary approach including patient education, pelvic floor physical therapy, and trigger point injections is the mainstay of the management of myofascial pelvic pain.

Ultrasound findings in endometriosis: avoid hidden surprises.

OBJECTIVE: To discuss the steps to performing and interpreting ultrasound imaging for pelvic pain in women with suspicions of endometriosis. DESIGN: Educational video. SETTING: Specialized gynecologic ultrasound clinic. PATIENTS: Reproductive-age women with pelvic pain with findings suggestive of endometriosis. INTERVENTION: Transvaginal ultrasound imaging. MAIN OUTCOME MEASURES: A detailed discussion of findings suggesting endometriosis. RESULTS: There are four basic sonographic steps for examining women with pelvic pain, especially when there is suspicion of endometriosis. Step 1: routine evaluation of the uterus and adnexa (this includes uterine orientation, sonographic signs of adenomyosis, and the presence or absence of endometrioma). Step 2: evaluation of transvaginal sonographic markers for endometriosis, for example, site-specific tenderness and ovarian mobility. Step 3: assessment of anterior and posterior compartments using a real-time ultrasound-based "sliding sign"; and Step 4: assessment for deep endometriotic nodules in anterior and posterior compartments. Note: the bladder should contain a small amount of urine for anterior compartment evaluation. CONCLUSIONS: Ultrasound is a powerful and dynamic tool for evaluating pelvic pain with high sensitivity, specificity, and accuracy in diagnosing deep endometriosis. Ultrasound imaging is important not only for diagnosing but also to counsel patients properly, consent appropriately, and plan for interdisciplinary consultations.

Venous Thromboembolism in Metastatic Uterine Leiomyosarcoma: A Case Report and Review of the Literature.

We report an unusual case of extensive deep vein thrombosis (DVT) and pulmonary embolism (PE) in the setting of metastatic uterine leiomyosarcoma. Recognition of the associated sequelae of this condition may improve short- and long-term outcomes. A 56-year-old black female with a history of uterine leiomyosarcoma diagnosed incidentally after total abdominal hysterectomy for fibroid uterus without initiation of chemoradiation treatment presented to the emergency department complaining of generalized weakness and progressively worsening stridor for 2 weeks. The patient was experiencing shortness of breath, dysphagia, and hoarseness. Physical exam was remarkable for rhonchi but was otherwise normal. Diagnostic imaging via CT of the abdomen, pelvis, and chest revealed DVTs of the left common and external iliac veins, the superior mesenteric artery, multiple pulmonary emboli of the right pulmonary artery, several nodular lesions within the lungs, and scattered peritoneal necrotic lesions, which were suspicious for metastatic disease. Additionally, CT of the neck showed an exophytic mass protruding into the airway from the subglottic region and thyromegaly with bilateral thyroid lobe nodules. The patient was subsequently started on Eliquis and chemotherapy. The rarity of this case is rooted in the extent of the patient's DVTs and PEs secondary to hypercoagulability in metastatic cancer. This presentation should be further evaluated to exclude thrombophilias or underlying malignancies. Drawing from the lessons of this case will help guide future clinical management regarding the care of metastatic uterine leiomyosarcoma.

Deep Pelvic Side Wall Anatomy: A Case of Laparoscopic Management of Vaginal Vault Fistula to the Presacral Area.

STUDY OBJECTIVE: Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy [1-3]. DESIGN: Case presentation with showing anatomic structures in detail. SETTING: Tertiary academic teaching hospital. INTERVENTIONS: A 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension 9 years ago presented with fever and was found to have bacteremia. Abdomen and pelvic magnetic resonance imaging showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. Transgluteal drain placed with cultures growing Streptococcus constellatus and Gemella morbillorum. Blood cultures grew same bacteria. She was started on vancomycin, cefepime, and metronidazole and was transitioned to ceftriaxone with a plan for 6-week antibiotic course. Her blood sugar levels were well controlled during hospitalization with baseline insulin and moderate sliding scale. Physical therapy started preoperative and continued postoperative. She was managed with an interdisciplinary team of gynecologists, urogynecologists, orthopedic doctors, neurosurgeons, nutritionists, infectious disease doctors, endocrinologists, hematologists, rehabilitation specialists, and physical therapists. This video showcases laparoscopic resection of sacrospinous fistula tract. Postoperative pathology result showed squamous mucosa, submucosa, and deep soft tissue with a submucosal abscess surrounded by fibrosis, consistent with a fistula tract. CONCLUSION: Preoperative planning is of paramount importance in cases with multiple comorbidities. Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection. Knowing the precise anatomy of critical structures close to the area of interest is crucial.

Minimally invasive management of retained products of conception and the adherent placenta.

PURPOSE OF REVIEW: Retained products of conception (POC) may occur independently or as a consequence of placenta accreta spectrum (PAS). Managing these conditions depends on the clinical scenario, and in some cases, can involve the use of minimally invasive techniques. This review presents the role of hysteroscopy and laparoscopy in the treatment of retained POC and the adherent placenta. RECENT FINDINGS: Hysteroscopic resection of retained POC is reported to have favorable outcomes compared to blind dilation and curettage, including higher success rates and a lower risk of intrauterine adhesion formation. Hysteroscopic and laparoscopic techniques for managing PAS are limited to select cases where uterine preservation is desired, or a laparoscopic gravid or postpartum delayed hysterectomy is feasible. Data on these methods are limited to case reports. SUMMARY: A hysteroscopic approach is preferred over dilation and curettage for retained POC. Minimally invasive surgery may have a role in unique cases of PAS.

Minimally Invasive Surgical Techniques for Tissue Extraction.

STUDY OBJECTIVE: Morcellation is a technique to remove large specimens by means of small incisions and is commonly used in gynecologic procedures [1]. In this video, we demonstrate contained manual morcellation techniques in benign gynecologic surgeries. DESIGN: Stepwise demonstration of 4 techniques with narrated video footage. SETTING: Tertiary academic teaching hospital. INTERVENTIONS: This video showcases 4 contained manual morcellation techniques: abdominal extraction through an umbilical "mini-laparotomy" incision, abdominal extraction through a suprapubic "mini-laparotomy" incision, transvaginal extraction through the colpotomy, and transvaginal extraction through the posterior cul-de-sac with the uterus in place. A particular strategy should be selected on the basis of appropriate patient characteristics and surgical factors [2]. CONCLUSION: Minimizing risk during tissue extraction is critical to minimally invasive procedures. The morcellation techniques displayed in this video allow for tissue extraction through small incisions while reducing the risk of spreading an undiagnosed malignancy.

The Control of HIV After Antiretroviral Medication Pause (CHAMP) Study: Posttreatment Controllers Identified From 14 Clinical Studies.

Background: HIV posttreatment controllers are rare individuals who start antiretroviral therapy (ART), but maintain HIV suppression after treatment interruption. The frequency of posttreatment control and posttreatment interruption viral dynamics have not been well characterized. Methods: Posttreatment controllers were identified from 14 studies and defined as individuals who underwent treatment interruption with viral loads ≤400 copies/mL at two-thirds or more of time points for ≥24 weeks. Viral load and CD4+ cell dynamics were compared between posttreatment controllers and noncontrollers. Results: Of the 67 posttreatment controllers identified, 38 initiated ART during early HIV infection. Posttreatment controllers were more frequently identified in those treated during early versus chronic infection (13% vs 4%, P < .001). In posttreatment controllers with weekly viral load monitoring, 45% had a peak posttreatment interruption viral load of ≥1000 copies/mL and 33% had a peak viral load ≥10000 copies/mL. Of posttreatment controllers, 55% maintained HIV control for 2 years, with approximately 20% maintaining control for ≥5 years. Conclusions: Posttreatment control was more commonly identified amongst early treated individuals, frequently characterized by early transient viral rebound and heterogeneous durability of HIV remission. These results may provide mechanistic insights and have implications for the design of trials aimed at achieving HIV remission.

HIV-1 proviral landscapes distinguish posttreatment controllers from noncontrollers.

HIV posttreatment controllers (PTCs) represent a natural model of sustained HIV remission, but they are rare and little is known about their viral reservoir. We obtained 1,450 proviral sequences after near-full-length amplification for 10 PTCs and 16 posttreatment noncontrollers (NCs). Before treatment interruption, the median intact and total reservoir size in PTCs was 7-fold lower than in NCs, but the proportion of intact, defective, and total clonally expanded proviral genomes was not significantly different between the 2 groups. Quantification of total but not intact proviral genome copies predicted sustained HIV remission as 81% of NCs, but none of the PTCs had a total proviral genome greater than 4 copies per million peripheral blood mononuclear cells (PBMCs). The results highlight the restricted intact and defective HIV reservoir in PTCs and suggest that total proviral genome burden could act as the first biomarker for identifying PTCs. Total and defective but not intact proviral copy numbers correlated with levels of cell-associated HIV RNA, activated NK cell percentages, and both HIV-specific CD4+ and CD8+ responses. These results support the concept that defective HIV genomes can lead to viral antigen production and interact with both the innate and adaptive immune systems.

Frozen thawed embryo transfer cycles; A comparison of pregnancy outcomes with and without prior pituitary suppression by GnRH agonists: An RCT.

BACKGROUND: To perform an in-vitro fertilization cycle, pretreatment with gonadotropin-releasing hormone (GnRH) agonist is widely used as a part of controlled ovarian hyper-stimulation protocols to prevent endogenous luteinizing hormone surge and spontaneous ovulation. GnRH agonist pretreatment is relatively costly and there is a risk of hypo estrogenic side effect. It would also lengthen the preparation period until pituitary desensitization occurs. OBJECTIVE: Our study is aimed at evaluating the pregnancy outcome rate of frozen thawed embryo transfer with and without GnRH agonists pretreatment. MATERIALS AND METHODS: Women with documented infertility who were candidate for frozen thawed embryo transfer were recruited and randomly assigned to two groups. In group A (n=100), patients received GnRH agonist, Buserelin, to induce pituitary desensitization prior to endometrial preparation and embryo transfer. Individuals in group B (n=100) received steroid manipulation without prior down-regulation of the pituitary. Chemical pregnancy, implantation rate, clinical pregnancy and ongoing pregnancy were measured and statistically compared between the two groups. RESULTS: None of the outcome measures including clinical and chemical pregnancy rates, implantation rate, and ongoing pregnancy rate showed significant difference between the two groups. Similarly, the rate of miscarriage did not vary between the two groups. CONCLUSION: In this study, we found that removing the GnRH agonists pretreatment from the programmed cycles did not negatively influence the pregnancy outcome or implantation rate. Moreover, it will cause a considerable reduction in cost of assisted reproductive technology as well as adverse effects related to GnRH agonists, while having a favorable implantation and pregnancy outcomes.

A Comparative Study of Potassium Hydroxide versus CO2 Laser Vaporization in The Treatment of Female Genital Warts: A Controlled Clinical Trial.

BACKGROUND: Genital warts are the most common viral sexually transmitted disease affecting 1% of the population. A prospective, open-label controlled trial was performed to compare topical 5% potassium hydroxide (KOH) solution with CO2 laser in the treatment of female genital warts. METHODS: Seventy patients were enrolled in the study after convenience sampling. Right-sided lesions of the patients were treated by CO2 laser every 3 weeks. The left-sided lesions of the same patients were treated by topical 5% KOH solution twice a day using a toothpick with cotton wrap on the tip. The patients were visited at 3, 6, and 9 weeks after initiation of the treatment and followed up for 6 months after the last visit. RESULTS: Out of seventy patients, sixty three completed the study and were analyzed. A total of 56 KOH treated-patients (88.9%) showed complete response. On the other hand, 56 laser-treated patients (88.9%) presented complete clearing of the lesion. There was not any difference in response to both modalities of treatment. Complications of KOH solution and CO2 laser were 24% and 19% respectively (P>0.05), but serious adverse events were not observed. The patients under KOH treatment displayed a recurrence rate of 11.1% (7 cases), while the same patients with CO2 laser therapy demonstrated a recurrence rate of 7.9% (5 cases) (P=0.54). CONCLUSION: Topical 5% KOH solution was as effective as CO2 laser in the treatment of female genital warts. There was not any serious complication in the application of KOH solution. This could be used as a new treatment for genital warts. TRIAL REGISTRATION NUMBER: IRCT201412207848N1.

Determinants of Successful Non-Operative Management of Intra- Peritoneal Bleeding Following Blunt Abdominal Trauma.

OBJECTIVES:  To identify the  predictive factors of successful non-operative  management  of patients  with intraperitoneal bleeding following blunt abdominal trauma. METHODS: This was cross-sectional study being performed in our Level I trauma center in southern  Iran between 2010 and 2011. We included adult (>14 years) patients with blunt  abdominal trauma  and intra-peritoneal hemorrhage  detected by CT-Scan who were hemodynamically stable and did not  require any surgical intervention. Patients were managed conservatively in ICU. Those who required laparotomy during the study period were named as non-operative  management failure (NOM-F) while the other were non- operative management success (NOM-S). The baseline, clinical and laboratory characteristics were compared between two study groups in order to detect the predictors of successful NOM of intra-peritoneal bleeding. RESULTS: Overall we included 80 eligible patients among whom there were 55 (68.7%) men and 25 (31.3%) women with mean  age of 30.63.6± years. Finally, 43 (53.8%) were successfully managed conservatively (NOM-S) while 37 (46.2%) required laparotomy (NOM-F). We found that those who underwent emergency laparotomy had significantly higher EHb (p=0.016) and lower base deficit (p=0.005) when compared to those who were successfully managed conservatively. Those who required surgical intervention had significantly lower baseline systolic blood pressure (p<0.001) and higher shock index (p=0.002). The other parameters such as pulse rate and respiratory rate were comparable between two study groups. CONCLUSION: In patients with intra-peritoneal bleeding following blunt abdominal trauma, the most reliable predictive clinical and para-clinical factor of successful non-operative  management  are shock index and systolic blood pressure on arrival, base deficit and hemoglobin drop within first 12 hours of admission.