Subjective and objective outcomes of botulinum toxin type A treatment in vestibulodynia: pilot data.

OBJECTIVE: To collect pilot data on the efficacy of intramuscular botulinum toxin type A (BTX/A) injection into the levator ani muscles to relieve coital pain, reduce pelvic floor tension and instability, and reduce vestibular hyperalgesia in vestibulodynia. STUDY DESIGN: Two subjects meeting diagnostic criteria for vestibulodynia were treated with 20 units and 40 units of BTX/A at 12-week intervals. Outcomes included a visual analogue scale (VAS), weekly coital pain diaries, surface electromyography (sEMG) and a vulvar algesiometer. RESULTS: BTX/A modestly reduced coital pain in 1 patient and was ineffective in the other. Pelvic floor hypertonicity and variability were markedly reduced in both patients, but negligible changes occurred in vestibular hyperalgesia. The patient with greater pelvic floor tension had more of a reduction in diary-rated coital pain 2 weeks after the injection (29% vs. 9%) and on the VAS at 12 weeks (15% vs. 3%). CONCLUSION: BTX/A injections may be effective in reducing coital pain in vestibulodynia with levator ani tenderness but have little effect on vestibular allodynia. The relationship between pelvic floor hypertonicity and decreased coital pain suggests that vestibulodynia may be a variant of chronic regional pain syndrome. The dose and volume of BTX/A injected may be related to the degree of relief.

Anal incontinence in women presenting for gynecologic care: prevalence, risk factors, and impact upon quality of life.

OBJECTIVE: The purpose of this study was to estimate the prevalence and impact upon quality of life of anal incontinence (AI) in women aged 18 to 65. STUDY DESIGN: Consecutive women presenting for general gynecologic care were given a bowel function questionnaire. Women with AI were prompted to complete the Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL). RESULTS: The cohort was composed of 457 women with a mean age of 39.9 +/- 11 years. AI prevalence was 28.4% (95% CI 24.4-32.8). After logistic regression, IBS (OR 3.22, 1.75-5.93), constipation (OR 2.11, 1.22-3.63), age (OR 1.05, 1.03-1.07), and BMI (OR 1.04, 1.01-1.08) remained significant risk factors. The mean FISI score was 20.4 +/- 12.4. Women with only flatal incontinence scored higher, and women with liquid loss scored lower on all 4 scales of the FIQL. CONCLUSION: AI is prevalent in women seeking benign gynecologic care, and liquid stool incontinence has the greatest impact upon quality of life.

Is a resident's score on a videotaped objective structured assessment of technical skills affected by revealing the resident's identity?

OBJECTIVE: The purpose of this study was to determine whether knowledge of resident's identity affects the evaluation of surgical skills. STUDY DESIGN: During an objective structured assessment of technical skills, 33 residents in obstetrics and gynecology who performed 10 surgical skills were videotaped with two digital cameras simultaneously. One camera videotaped "hands only," concealing resident identity; the other camera videotaped from the "waist up," revealing identity. Residents wore opaque gowns and gloves. Four faculty reviewers with previous clinical experience with the residents scored the "hands only" videos first. The scoring was based on the total of a global rating scale and a task-specific checklist. RESULTS: The combined scores for all reviewers was significantly different between the two views (P=.03). When the video tapes were analyzed individually, two reviewers scored the views differently; one reviewer scored higher, whereas the other reviewer scored lower. CONCLUSION: Bias can occur in evaluation of surgical skills but is dependent on the individual reviewer. Resident identification can alter the score, depending on the evaluator.