Amos Adelowo

Botulinum Toxin Type A (botox) for Refractory Myofascial Pelvic Pain

Objective To assess intralevator botulinum toxin type A (Botox) injections for refractory myofascial pelvic pain with short tight pelvic floor. Methods Retrospective cohort study of all women with intralevator Botox injection (100–300 Units) from 2005 through 2010 for refractory myofascial pelvic pain. Primary outcomes were self-reported pain on palpation and symptom improvement. Secondary outcomes included postinjection complications and a second injection. Pain was assessed during digital palpation of the pelvic floor muscles using a scale of 0 to 10, with 10 being the worst possible pain. Follow-up occurred at less than 6 weeks after injection and again at 6 weeks or more. Data are presented as median (interquartile range) or proportion. Results Thirty-one patients met eligibility criteria; 2 patients were lostto follow-up and excluded. The median age was 55.0 years (38.0–62.0 years). Before Botox injection, the median pain score was 9.5 (8.0–10.0). Twenty-nine patients (93.5%) returned for the first follow-up visit; 79.3% reported improvement in pain, whereas 20.7% reported no improvement. The median pain with levator palpation was significantly lower than before injection (P<0.0001). Eighteen women (58.0%) had a second follow-up visit with a median pain score that remained lower than before injection (P<0.0001). Fifteen (51.7%) women elected to have a second Botox injection; the median time to the second injection was 4.0 months (3.0–7.0 months). Three (10.3%) women developed de novo urinary retention, 2 patients (6.9%) reported fecal incontinence, and 3 patients (10.3%) reported constipation and/or rectal pain; all adverse effects resolved spontaneously. Conclusions Intralevator injection of Botox demonstrates effectiveness in women with refractory myofascial pelvic pain with few self-limiting adverse effects.

Management of vesicovaginal fistulae: a multicenter analysis from the Fellows' Pelvic Research Network.

Objectives Vesicovaginal fistulae (VVF) are the most commonly acquired fistulae of the urinary tract, but we lack a standardized algorithm for their management. The purpose of this multicenter study was to describe practice patterns and treatment outcomes of VVF in the United States. Methods This institutional review board–approved multicenter review included 12 academic centers. Cases were identified using International Classification of Diseases codes for VVF from July 2006 through June 2011. Data collected included demographics, VVF type (simple or complex), location and size, management, and postoperative outcomes. &khgr;2, Fisher exact, and Student t tests, and odds ratios were used to compare VVF management strategies and treatment outcomes. Results Two hundred twenty-six subjects were included. The mean age was 50 (14) years; mean body mass index was 29 (8) kg/m2. Most were postmenopausal (53.0%), nonsmokers (59.5%), and white (71.4%). Benign gynecologic surgery was the cause for most VVF (76.2%). Most of VVF identified were simple (77.0%). Sixty (26.5%) VVF were initially managed conservatively with catheter drainage, of which 11.7% (7/60) resolved. Of the 166 VVF initially managed surgically, 77.5% resolved. In all, 219 subjects underwent surgical treatment and 83.1% of these were cured. Conclusions Most of VVF in this series was managed initially with surgery, with a 77.5% success rate. Of those treated conservatively, only 11.7% resolved. Surgery should be considered as the preferred approach to treat primary VVF.

Practice patterns regarding management of rectovaginal fistulae: A multicenter review from the fellows' pelvic research network

Objectives Rectovaginal fistulae (RVFs) are often debilitating and there are no established treatment algorithms. We sought to describe current diagnosis and management strategies for RVFs across the United States. Methods This institutional review board–approved multicenter retrospective study included 12 sites. Cases were identified using International Classification of Diseases, Ninth Revision codes during a 5-year period. Demographics, management, and outcomes of RVF treatment were collected. Results Three hundred forty-two charts were identified; 176 (52%) met criteria for inclusion. The mean (SD) age was 45 (17) years. Medical history included hypertension (21%), cancer (17%), Crohn disease (11%), and diabetes (7%). Rectovaginal fistulae were often associated with obstetric trauma (42%), infection/inflammation (24%), and cancer (11%). Overall, most RVFs were primary (94%), small (0.5–1.5 cm; 49%), transsphincteric (31%), and diagnosed via vaginal and rectal (60%) examination. Eighteen percent (32/176) were initially managed conservatively for a median duration of 56 days (interquartile range, 29–168) and 66% (21/32) of these resolved. Almost half (45%) of RVFs treated expectantly were tiny (<0.5 cm). Eighty-two percent (144/176) of subjects were initially managed surgically and 81% (117/144) resolved. Procedures included simple fistulectomy with or without Martius graft (59%), transsphincteric repair (23%), transverse transperineal repair (10%), and open techniques (8%), and 87% of these procedures were performed by urogynecologists. Conclusions In this large retrospective review, most primary RVFs were treated surgically, with a success rate of more than 80%. Two thirds of RVFs managed conservatively resolved spontaneously, and most of these were tiny (<0.5 cm). These success rates can be used in counseling to help our patients make informed decisions about their treatment options.

Do symptoms of voiding dysfunction predict urinary retention

Objectives We assessed the relationship between symptoms of voiding dysfunction and elevated postvoid urinary residual (PVR). Methods Cross-sectional study of women presenting for initial evaluation from February through July 2011. Charts were reviewed for demographics, voiding dysfunction symptoms, and examination findings. Urinary retention was defined as PVR of 100 ml or more. Data are presented as median (interquartile range) or proportion; test characteristics are reported with 95% confidence intervals. Results Of 641 eligible women, 57 women (8.9%) had urinary retention. Of these, 32 women (56.1%) had at least one symptom of voiding dysfunction, most commonly, sensation of incomplete emptying (30.1%). Sensitivity and positive predictive values of voiding dysfunction symptoms were low. Of 254 women reporting voiding symptoms, most (87.5%) had PVR of less than 100 ml and were significantly more likely to have other pelvic floor symptoms and findings. Conclusions Patients’ symptoms do not predict urinary retention. Postvoid urinary residual should be measured, and other causes of voiding dysfunction symptoms should be considered.

Underlying Factors Contributing to the Delay in Patients Seeking Care for Pelvic Floor Dysfunction

Objective: To investigate barriers and variables associated with the delay in seeking urogynecologic care by women with pelvic floor dysfunction. Methods: Cross sectional study of 300 new patients presenting for outpatient evaluation of pelvic floor dysfunction from August 2011 through March 2012. Patients were mailed a survey prior to initial visit. Delay in seeking care was defined as 12 months or more from symptom manifestation, persistence or recurrence after prior intervention, or being informed about the condition to time of visit. Data are presented as proportion or mean (±standard deviation). Comparisons were made using chi-square and t tests. Results: Two hundred and thirty one (77.0%) surveys were returned. Mean age was 55.9 years (± 17.4). Majority (91.3%) were Caucasian, 57.4% sexually active, and 96.1% saw a health care provider annually. Commonly reported causes were child birth (32.6%) and aging (23.4%). Delay was seen in 140 women (61.4%). Of these, 81 (57.9%) had been previously asked about symptoms by their primary care provider. The most common reason reported for delay was “Did not have time to care for myself” (19.8%). There was no statistically significant difference in level of education (p=0.86), annual health care visits (p=0.74), and sexual activity (p=0.28) between women with and without delay. However, women who delayed seeking care were more likely to report increased symptom severity (p=0.005) and to have been asked about symptoms (p=0.01). Conclusion: There is significant delay in seeking care with an urogynecologist. Additional resources are needed to promote patient and primary care provider awareness.

The Role of Preoperative Urodynamics in Urogynecologic Procedures

Urodynamic studies refer to any tests that provide objective information about lower urinary tract function with the goal of evaluating bladder and urethral function. Pre-operative urodynamic testing is commonly performed prior to urogynecologic procedures for urinary incontinence and pelvic organ prolapse. Although the utility of preoperative urodynamics testing before urogynecologic procedures have been challenged in the literature, the preoperative utilization of urodynamic testing in women with complex voiding dysfunction or associated conditions such as prolapse or urethral diverticulum is still considered important for surgical planning and pre-operative counseling.

Rectovaginal fistula repair using a disposable biopsy punch.

Objectives To describe a novel surgical technique for complete excision of a rectovaginal fistula tract using a disposable biopsy punch during a transvaginal rectovaginal fistula repair and to present our initial surgical experience. Methods Description of 4 cases of simple rectovaginal fistulas and an innovative surgical technique for the complete excision of the fistula tract using a disposable biopsy punch. Results Successful 3-, 9-, and 12-month follow-up of 4 cases with simple rectovaginal fistulas after transvaginal rectovaginal fistula repair using a novel approach for complete fistula tract excision with a disposable biopsy punch and layered nonoverlapping suture closure. Demographic information reported included age, parity, medical and surgical history, as well as fistula characteristics including size, location, presenting symptoms, and duration of symptoms. We describe our operative technique with picture description. Conclusion This novel approach using a disposable punch biopsy device to complete excision of simple rectovaginal fistula tracts during a transvaginal rectovaginal fistula repair can help with achieving a successful surgical outcome.

The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial

Objective To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery. Methods We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms. Results One hundred fifty-three participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P⩽0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At 2 weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0–4.0) days. Conclusions Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function. LEVEL OF EVIDENCE I

Assessing Adequacy of Cervical Core Specimens From Extirpated Uteri: Implications for Laparoscopic Supracervical Hysterectomy With Transcervical Coring

STUDY OBJECTIVE To describe the histopathologic adequacy of cervical specimens after ex vivo excision of the cervical canal with cervical coring. DESIGN Descriptive study (Canadian Task Force classification III). SETTING Community medical center with university affiliation. INTERVENTION Endocervical coring. MEASUREMENTS AND MAIN RESULTS Eleven cervical core samples from hysterectomy specimens were evaluated. Cervical coring was performed using classic intrafascial supracervical hysterectomy instruments: 15 mm for 6 specimens and 20 mm for 5 specimens. Mean patient age was 49 years, and median (range) parity was 2 (0-3). Three patients (27.3%) were postmenopausal. In most patients (72.7%) leiomyomas and abnormal uterine bleeding was the indication for hysterectomy, and 3 patients (23.3%) had uterovaginal prolapse. The most common cervical pathologic diagnosis was chronic cystic cervicitis (72.7%). Histopathologic presence of the entire cervical transformation zone was present in all 11 cervical core samples. Endocervical glands were absent in the radial margins of all samples. Endometrial glands were absent in the radial margins in 7 samples (63.6%). There was no statistically significant difference in age, parity, cervical remnant, and cervical core dimensions between both core sizes (p > .05). CONCLUSION Cervical coring to remove the endocervical canal during hysterectomy resulted in adequate removal of endocervical glands and endometrial glands in most cases, using either the 15-mm or 20-mm classic intrafascial supracervical hysterectomy instrument.