Angus J.M. Thomson

Botulinum toxin type A for chronic pain and pelvic floor spasm in women: a randomized controlled trial.

OBJECTIVE: To estimate whether botulinum toxin type A is more effective than placebo at reducing pain and pelvic floor pressure in women with chronic pelvic pain and pelvic floor muscle spasm. METHODS: This study was a double-blinded, randomized, placebo-controlled trial. All participants presented with chronic pelvic pain of more than 2 years duration and evidence of pelvic floor muscle spasm. Thirty women had 80 units of botulinum toxin type A injected into the pelvic floor muscles, and 30 women received saline. Dysmenorrhea, dyspareunia, dyschezia, and nonmenstrual pelvic pain were assessed by visual analog scale (VAS) at baseline and then monthly for 6 months. Pelvic floor pressures were measured by vaginal manometry. RESULTS: There was significant change from baseline in the botulinum toxin type A group for dyspareunia (VAS score 66 versus 12; χ2=25.78, P<.001) and nonmenstrual pelvic pain (VAS score 51 versus 22; χ2=16.98, P=.009). In the placebo group only dyspareunia was significantly reduced from baseline (64 versus 27; χ2=2.98, P=.043). There was a significant reduction in pelvic floor pressure (centimeters of H2O) in the botulinum toxin type A group from baseline (49 versus 32; χ2=39.53, P<.001), with the placebo group also having lower pelvic floor muscle pressures (44 versus 39; χ2=19.85, P=.003). CONCLUSION: Objective reduction of pelvic floor spasm reduces some types of pelvic pain. Botulinum toxin type A reduces pressure in the pelvic floor muscles more than placebo. Botulinum toxin type A may be a useful agent in women with pelvic floor muscle spasm and chronic pelvic pain who do not respond to conservative physical therapy. Clinical Trial Registration: Australian Clinical Trials Registry, http://www.actr.org.au/, ACTRN012605000515695 LEVEL OF EVIDENCE: I

The use of botulinum toxin type A (BOTOX®) as treatment for intractable chronic pelvic pain associated with spasm of the levator ani muscles

In May 1999, a 34 year old woman presented to the pelvic pain diagnosis and treatment unit for assessment of her chronic pelvic pain. Her general health was good, with no history of sexual abuse or significant psychiatric disorder. Her gynaecological history included two caesarean deliveries, a miscarriage and a termination of her most recent pregnancy in 1993 complicated by a uterine perforation, requiring a subtotal hysterectomy. Following the procedure, she continued to have menstrual discharge every month, and significant pelvic pains including dysmenorrhoea (rated 5/10), dyspareunia (10/10), intermenstrual pain (7/10), but no dyschesia. She had no specific treatment for this pain and was managed by simple analgesia. Continued pain led to further evaluation, and a pelvic examination suggested left uterosacral endometriosis and a pelvic ultrasound indicated a probable endometrioma of the left ovary. In July 1999, a laparoscopy for resection of endometriosis and left salpingooophorectomy was performed and the diagnosis confirmed histologically. Following surgery, there was a reduction in dyspareunia (to 2/10) and intermenstrual pain (to 4/10) but a new symptom of severe dyschesia was reported (9/10). A flexible sigmoidoscopy was performed with no evidence of pathology and a second-look laparoscopy was undertaken in December 1999 and fibrotic tissue removed anterior to the rectum. Histologically, there was no residual endometriosis. During 2000, the patient reported worsening dyspareunia and constant non-menstrual pelvic pain. A range of medications was tried including paracetamol, non-steroidal anti-inflammatories, combined oral contraceptives, anxiolytics and antidepressants, with little or no effect. Pelvic examination revealed tenderness and spasm of the puborectalis and pubococcygeus muscles. Pelvic floor muscle manometry (perineometry) readings registered increased pelvic floor muscle resting tone of 48 cm (<30 cm H2O expected). Relaxation techniques and strategies for defecation and coitus were taught. Despite these, the pelvic pain, pelvic floor muscle tenderness and raised perineometry readings continued. In July 2000, the patient was given injections totalling 4 mL Xylocaine 1% (AstraZeneca, UK) to the puborectalis and pubococcygeus muscles bilaterally. This resulted in marked reduction in the pain and allowed easy pelvic examination and a reduction in the resting perineometry reading to 8 cm H2O. The local anaesthetic response was short-lived and within one to two weeks the chronic pelvic pain symptoms returned to pre-injection levels. During 2001, management of the pain symptoms continued with analgesics, anti-inflammatories, anxiolytics, antidepressants, physiotherapy and intermittent local anaesthetic injections to the pelvic floor muscles. The puborectalis and pubococcygeus spasm continued and the patient had significant discomfort with coitus. In June 2002, this patient received injections of botulinum toxin type A (BOTOXR, Allergan, Gordon, NSW, Australia) to the pelvic floor muscles in an attempt to reduce the muscle spasm and tenderness. The injections were performed under conscious sedation using a combination of propofol, midazolam and fentanyl, and were monitored by an anaesthetist. The woman was placed in a lithotomy position and the vulva was swabbed with an antiseptic. The muscles to be injected were located by digital vaginal palpation. The puborectalis was felt as a tight sling around the vagina, just distal from the hymenal ring. The needle was held in a near-horizontal plane, the vaginal mucosa pierced just inside the hymenal ring, within the posterior third of the hymenal opening. To inject the puborectalis muscle, the needle was directed slightly laterally and posteriorly for approximately 5–10 mm. The pubococcygeus has a more coronal angulation and is lateral and posterior to the puborectalis fibres. To inject the pubococcygeus muscles, the operator’s index finger was BJOG: an International Journal of Obstetrics and Gynaecology February 2005, Vol. 112, pp. 247–249

Endometrial integrin expression in women undergoing in vitro fertilization and the association with subsequent treatment outcome

OBJECTIVE To study the endometrial expression of three integrins (alpha v beta 3, alpha 4 beta 1, and alpha 1 beta 1) in women undergoing IVF-intracytoplasmic sperm injection (ICSI) treatment and assess whether they could be used to predict subsequent treatment success.Prospective observational study. Healthy volunteers in a large teaching hospital. PATIENT(S) Sixty-six patients attending for IVF-ICSI treatment. INTERVENTION(S) Timed endometrial biopsies were taken, during the implantation window at LH + 7-9 days, from women before IVF-ICSI treatment. MAIN OUTCOME MEASURE(S) Histological dating of endometrium and immunohistochemical staining intensity of alpha 4 beta 1, alpha v beta 3, and alpha 1 beta 1 integrins. The integrin levels were correlated with subsequent success rates. RESULT(S) There was a statistically significantly greater expression of alpha v beta 3 in the luminal epithelium of those patients who had successful treatment. However, treatment was successful in some patients with negative expression. CONCLUSION(S) Integrins are important markers of endometrial receptivity. There is an association between an in-phase endometrial biopsy, with positive luminal alpha v beta 3 integrin expression, and subsequent treatment success. However, the clinical value of assessing the endometrium before treatment has drawbacks, and further work needs to be done before this can be considered a clinically useful test.

The management of intrauterine synechiae

Purpose of review Intrauterine adhesions are a rare but significant cause of menstrual disturbance and infertility. Most cases are caused by uterine instrumentation. It is important for clinicians to understand the cause, diagnostic tools and rationale behind treatment. Recent findings Hysteroscopy is the gold standard for diagnosis and treatment of intrauterine adhesions. A combination of blunt and sharp dissection or electrosurgery is used by most units. Antibiotics and postoperative administration of estrogen ± progestogen is important in prevention of recurrence. The use of intrauterine contraceptive devices following synechiolysis is supported by some groups. Restoration of menstruation is highly successful (more than 90%), and pregnancy rates around 50–60% with live birth rates around 40–50% can be achieved. Summary Clinicians should maintain a level of suspicion of intrauterine adhesions and should investigate by hysteroscopy if necessary. Treatment should follow a protocol that incorporates sound hysteroscopic technique with antibiotic prophylaxis and postoperative hormonal therapy. Consideration should be given to the use of an intrauterine contraceptive device or Foley catheter for a short period.

SprayGel™ following surgery for Asherman's syndrome may improve pregnancy outcome

References Abrams P., Cardozo L., Fall M., Griffiths D., Rosier P., Ulmsten U. et al. (2002) The standardisation of terminology of lower urinary tract function. Report from the standardisation committee of the International Continence Society. Neurological Urodynamics, 21, 167 – 178. Hannestad Y.S., Rortveit G., Sandvik H. and Hunskar S. (2000) A community-based epidemiological survey of female urinary incontinence: the Norwegian EPICONT Study. Journal of Clinical Epidemiology, 53, 1150 – 1157. Harris W.J. (1995) Early complications of abdominal and vaginal hysterectomy. Obstetrical and Gynaecological Survey, 50, 795 – 805. Jarvis G.J. (1994) Surgery for genuine stress incontinence. British Journal of Obstetrics and Gynaecology, 101, 371 – 374. Kelleher C.J., Cardozo L.D., Khullar V. and Salvatore S. (1997) A new questionnaire to assess the quality of life of urinary incontinent women. British Journal of Obstetrics and Gynaecology, 104, 1374 – 1379. Kuuva N. and Nilsson G. (2002) A nationwide analysis of complications associated with tension free vaginal tape procedure. Acta Obstetricia et Gynaecologica Scandinavica, 81, 72 – 77. Nilsson C.G. and Kuuva N. (2001) The tension free vaginal tape procedure is successful in the majority of women with indications for surgical treatment of urinary stress incontinence. British Journal of Obstetrics and Gynaecology, 108, 414 – 419. Robinson D., Savvas M. and Cardozo L. (2003) An usual case of incontinence following hysterectomy. British Journal of Urology, 91, 727 – 728. Sandvik H., Hunskaar S., Vanik A., Bratt H., Seim A. and Hermstad R. (1995) Diagnostic classification of female urinary incontinence: an epidemiological study. Journal of Clinical Epidemiology, 48, 339 – 343.

Standardizing pneumoperitoneum for laparoscopic entry. Time, volume, or pressure: which is best?

STUDY OBJECTIVE To establish whether time, pressure, or volume is the most reliable indicator of adequate pneumoperitoneum and, hence, the best parameter to use for safe trocar entry. DESIGN Prospective cohort study (Canadian Task Force classification II-2). SETTING Department of Endogynecology, Royal Hospital for Women, Sydney, Australia. PATIENTS One hundred thirty-three consecutive patients having gynecologic laparoscopy were recruited for the study. Of these, 100 patients were included in the analysis, and 33 were excluded. INTERVENTION Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS After umbilical Veress needle entry, pressure and volume were recorded every 20 seconds until insufflation pressure of 20 mm Hg was reached. Following trocar entry, the gas was then expelled with the patient lying flat. The depth of pneumoperitoneum was measured at intra-abdominal pressure of 5, 10, 15, and 20 mm Hg. Random effects models were used to predict the depth of pneumoperitoneum based on pressure, time, and volume. A comparison was made of the standard deviation of pneumoperitoneum distance produced at pressure of 20 mm Hg (8.56 ± 0.59) compared with that produced by a volume of 3 L (4.96 ± 1.13). Compared with volume, pressure was significantly more reliable in estimating depth of pneumoperitoneum (p < .001) because it exhibited the least variance. Further comparison was made of the standard deviation of pneumoperitoneum distance produced at pressure of 20 mm Hg (8.56 ± 0.59) compared with that produced at 3 minutes (7.82 ± 1.19). Compared with time, pressure was significantly more reliable in depth of pneumoperitoneum (p < .001) because it exhibited the least variance. These results demonstrate that, compared with volume and time, pressure is the most reliable predictor of pneumoperitoneum depth because it exhibits the least variance (p < .001). CONCLUSION Pressure is the most reliable predictor of pneumoperitoneum before trocar entry in laparoscopic surgery.

Physical Properties of Electricity

Electricity is the flow of electrons through a conductor. The amount of current (amps) is related to the voltage (volts) pushing the electrons and the degree of resistance to flow (ohms). During their flow around a circuit, electrons can be used to create a number of useful byproducts such as heat and light. As electrons flow, they alter the charge of the matter they flow through, which may also generate electromagnetic effects.