Current concepts of pelvic congestion and chronic pelvic pain.

Chronic pelvic pain in women is a common and disabling illness caused by numerous organic pathologies usually accompanied by varying psychological dysfunctions. Many patients may receive misdiagnosis, misdirected therapies, or do not seek help at all. Pelvic congestion may be responsible for pain in patients without more common diseases, such as endometriosis and pelvic adhesions, among others. Our view of this condition is evolving. In the United States, this medical condition remains controversial. More recent research from the United Kingdom has caused a fresh look at the diagnosis and treatment of chronic pelvic pain produced by pelvic congestion. Potentially, many patients may benefit from a reconsideration of this approach.

Peripheral neuropathies causing chronic pelvic pain.

Chronic pelvic pain is usually assumed to be visceral in origin by both patients and physicians. Because of the phenomenon of viscerosomatic convergence, it may be impossible to distinguish the origin without a meticulous history, physical examination, and nerve blocks. Error in diagnosis and treatment may lead to unhelpful surgery and poor results. Peripheral somatic neuropathies often mimic internal organ pathology. Similarly, visceral pathology can produce changes in peripheral somatic nerves that must also be addressed if maximum pain relief is to be attained. Awareness of peripheral neuropathies will favor more effective treatment for these patients.

Relationship of gynecologic surgery to constipation.

STUDY OBJECTIVE: To determine if women undergoing presacral neurectomy, hysterectomy, or other gynecologic surgery experience a greater frequency of constipation than those having no surgery. DESIGN: Concurrent, nonrandomized, retrospective study (Canadian Task Force classification II-2). SETTING: Tertiary medical care center with referral-based practice for the treatment of chronic pelvic pain. PATIENTS: Two hundred fifty-six women forming four groups based on surgical procedure: presacral neurectomy (66), hysterectomy (65), other gynecologic surgery (68), and no surgery (57). INTERVENTIONS: Laparoscopic presacral neurectomies. Other gynecologic surgery included laparoscopy, dilatation and curettage, laparoscopic resection of endometriosis, or any combination of these procedures. MEASUREMENTS AND MAIN RESULTS: Constipation was defined as decrease in frequency of spontaneous bowel movements. A statistically significant greater percentage of patients undergoing surgical procedures were more constipated than those having no surgery: presacral neurectomy, 31.8%; hysterectomy, 27.7%; other gynecologic surgery, 25%; and no gynecologic surgery, 10.5%. CONCLUSION: Pelvic surgery may cause parasympathetic nerve dysfunction leading to constipation. (J Am Assoc Gynecol Laparosc 6(1):75-78, 1999)

Laparoscopic treatment of genitofemoral neuralgia.

Chronic pain and tenderness in the groin, labia majora, and medial thigh can be caused by neuropathy of the genitofemoral nerve. Differentiation from ilioinguinal neuralgia by diagnostic blocks is crucial to selecting proper treatment. Three women with genitofemoral neuralgia underwent laparoscopic examination and treatment, thus avoiding laparotomy and flank incision.

Occult retrocervical endometriosis. A case report.

BACKGROUND: The retrocervical area of the pelvis is a particularly strategic location for dyspareunia-producing endometriotic lesions. Because this area is often hidden from view by the cervical bulge, it is necessary that close attention be paid to locating occult disease. CASE: A 35-year-old, white female underwent repeat laparoscopy for persistent dyspareunia. Occult retrocervical disease was found and exercised. CONCLUSION: Incomplete treatment may result if this area is not examined and biopsied.

Syndrome of inappropriate antidiuretic hormone after laparoscopic-assisted vaginal hysterectomy.

A 37-year-old woman undergoing laparoscopic-assisted vaginal hysterectomy experienced seizures and subsequent coma on the first postoperative day. Early recognition of the syndrome of inappropriate antidiuretic hormone with aggressive treatment and avoidance of hypoxia resulted in full recovery without sequelae. Menstruant women are 25 times more likely to die or suffer permanent brain damage from hyponatremic encephalopathy than menopausal women.

Effect of fluid instillation on postlaparoscopy pain.

One hundred thirty-seven patients participated in a randomized, double-blind study to determine what effect instillation of fluid at the conclusion of operative laparoscopy has on postoperative postural pain. The first phase examined pain intensity as related to closing pH, operative time and the surgeon. The second phase focused on the absence or presence of postural pain in the fluid and control groups. In phase 1, there was no significant relationship between pain and duration of surgery, closing pH or surgeon. In phase 2, 6 of 27 (22%) patients receiving postoperative fluid instillation experienced postural pain as compared to 19 of 25 (76%) in the control group (P < .001). Displacing the pneumoperitoneum by the instillation of 1-2 L of fluid at the conclusion of laparoscopy significantly decreased the frequency of subdiaphragmatic and shoulder pain on sitting or standing. This pain is probably produced by traction on the triangular or coronary ligaments of the liver due to loss of the suction effect by the diaphragm.

The role for laparoscopic presacral neurectomy.

This study was carried out to determine the efficacy of laparoscopic presacral neurectomy (LPSN) and to define its role in modern gynecology using a prospective consecutive cohort. One hundred three patients underwent LPSN, and 87 were included in this study. After LPSN, 91% of these 87 patients experienced some decrease in pelvic pain, and a majority of patients had 50% or greater reduction in pain score. There was a highly significant difference among the preoperative and postoperative pain levels (p less than 0.0001). Patients with pain of endometriosis (72), primary dysmenorrhea (5), and chronic pelvic inflammatory disease (10) responded with a decrease in pain score to this procedure. Complications included 1 patient with intraoperative bleeding, 2 with postoperative vaginal dryness, and 1 with constipation. We conclude that LPSN is as effective as that performed by laparotomy and should be offered to patients undergoing operative laparoscopy for central dysmenorrhea and pelvic pain. This procedure should be performed only by expert endoscopists experienced in the anatomy of this region.

Minimal incision Pereyra needle uterine suspension.

Ten patients underwent uterine suspension in conjunction with extensive operative laparoscopy or as primary treatment for deep thrust dyspareunia due to fixed uterine retroversion. Of the 10 patients, 9 had satisfactory relief of symptoms. The Pereyra needle allows the use of very small suprapubic incisions with little increase in operative morbidity or discomfort.

Recognition and treatment of persistent omphalomesenteric ligament. A report of two cases.

Two patients undergoing diagnostic laparoscopy for chronic pelvic pain were discovered to have persistent omphalomesenteric ligaments. Excision was accomplished with Silastic banding and electrocauterization. These fibrous ligaments should be removed to relieve symptoms and to prevent other serious bowel complications.

Childbirth after surgical repair of truncus arteriosus. A case report.

Pregnancy and delivery were accomplished in a woman with surgically repaired truncus arteriosus. The pregnancy was well tolerated, without significant cardiovascular ill effects. This is the first known report of such a case.

Pelviscopic adnexectomy.

Removal of fallopian tubes and ovaries through the laparoscope is a safe and efficient alternative to laparotomy. Seventeen patients undergoing this procedure are described. This approach should be considered for those patients requiring adnexal surgery provided that the operator is skilled in multiple puncture laparoscopy.

Sensitivity to heat and water loss at rest and during exercise in asthmatic patients.

We investigated the respiratory heat and water loss in 24 asthmatic patients who performed bicycle exercise while inspiring air conditioned to varying temperatures and water contents. Measurements of peak expiratory flow and forced expiratory volume in 1 s were made at rest, during and after exercise to determine changes in airways resistance. Respiratory heat and water loss were measured using rapid thermistors and a mass spectrometer to measure inspired and expired temperature and water vapour pressure. Exercise-induced asthma (EIA) was enhanced as the inspired water content of the air was reduced. However, there was a wide variation in sensitivity to the loss of heat and water between individual patients. This variability could not be accounted for by differences in body size. When patients inspired air conditioned to body temperature and fully saturated with water vapour, EIA was significantly reduced; however, half the patients still had an attack of asthma following exercise which had induced no significant loss of heat or water. It is suggested that the bronchoconstriction induced by water loss from the airways during exercise may be due to a change in osmolarity in the respiratory tract fluid.

Limitation of work performance in normal adult males in the presence of beta-adrenergic blockade.

The effect on work performance of a single oral dose of the cardio-selective beta-adrenoreceptor blocking agent, metoprolol, was compared with an equipotent dose of the non-selective agent, propranolol, in the same subjects. A number of biochemical and physiological variables including heart rate, oxygen consumption, ventilation, lactate, free fatty acid and glucose levels were measured. Following exercise in the presence of both active drugs, subjects complained of excessive leg fatique. For the group there was a significant reduction in the total work performed and the maximum heart rate achieved on both drugs. There was a significant correlation between plasma levels of metoprolol, reduction in total work performed and reduction in maximum heart rate. By contrast, after propranolol, there was a wide variation in work performed at a time when the reduction in maximum heart rate was similar for all subjects. This suggests for propranolol that a reduction in heart rate alone is an inappropriate guide to the impairment of work performance. There was a fail in the circulating level of free fatty acids at the end of exercise in the presence of both drugs and it is possible that this biochemical variable contributed to the decrease in work performance.

Successful management of pregnancy-induced pancytopenia.

The 46th case of known pregnancy-induced pancytopenia is reported. Pregnancy may play an etiologic role in this rare condition, but the specific mechanism is unknown. Maternal mortality is 63%, and fetal and neonatal wastage is 46%. The patient reported is a 24-year-old Oriental woman who delivered a healthy female infant. Her survival is attributed to conservative management with carefully timed packed cell and platelet transfusions.