James L. Whiteside

Endometriosis-related pelvic pain: what is the evidence?

Introduction Endometriosis causes pain. The statement seems self-evident, yet behind it lies some important questions. How can we know endometriosis is the cause of pain in light of so many other equally plausible causes such as interstitial cystitis, irritable bowel syndrome or, myofascial syndromes to name just a few? Despite a plethora of studies on the pathogenesis, epidemiology, and management of endometriosis, the disease remains incompletely understood with significant knowledge gaps in the etiology and mechanisms of the associated pain. Any claim linking endometriosis with pain fails to account for the common experience that identical lesions can be found in symptomatic and asymptomatic women. Between 2% and 43% of asymptomatic women are found to have endometriosis. Furthermore, there does not appear to be any risk for patients with asymptomatic mild endometriosis to develop symptoms even after greater than 10 years. While 70% to 90% of women with chronic pelvic pain (CPP) have endometriosis, this does not definitively establish causation. Therefore, while we have come to assume the relationship between endometriosis and pain, what are the data to support this contention? The focus of this review is to establish an evidence-based link for these questions: What are the relationships between characteristics of endometriosis and pain? Does endometriosis cause pain?

Reliability and agreement of urodynamics interpretations in a female pelvic medicine center.

OBJECTIVE: To estimate the reliability and interobserver consistency of urodynamic interpretations of female bladder and urethral function. METHODS: Three urogynecologists and three female urologists at a tertiary care medical center reviewed masked, abstracted clinical and urodynamic information from 100 charts, selected for adequate completeness from a consecutive series of 135 women referred for urodynamic testing. For each of the 100 cases, the reviewers assigned International Continence Society filling and voiding phase diagnoses, and overall clinical diagnoses. Raw agreement proportions and weighted kappa chance-corrected agreement statistics (&kgr;) were used jointly to describe both reliability and interobserver agreement. Reliability was estimated from duplicate reviews, masked and separated by at least 4 months, of each case by each physician. Interobserver agreement was estimated from comparisons of all pairs of responses from different physicians. RESULTS: For clinical diagnosis of stress incontinence (present, absent, indeterminate), the within- and across-physician weighted &kgr;s were, respectively, 0.78 and 0.68. Corresponding results were 0.40 and 0.13 for detrusor overactivity without incontinence, 0.58 and 0.38 for detrusor overactivity with incontinence, and 0.51 and 0.26 for voiding dysfunction. Standard errors of each &kgr; were between 0.023 and 0.043. CONCLUSION: In our group, lower urinary tract diagnoses of stress urinary incontinence from both clinical and urodynamic data demonstrated substantial reliability and interobserver agreement. However, by conventional interpretation of &kgr;-statistics, reliability of diagnoses of detrusor overactivity or voiding dysfunction was only moderate, and interobserver agreement on these diagnoses was no better than fair. Urodynamic interpretations may not be satisfactorily reproducible for these diagnoses. LEVEL OF EVIDENCE: II-2

Laparoscopic management of the ovarian mass: a practical approach.

Laparoscopic management of a benign ovarian mass is regarded as the best surgical approach in many cases. Although several studies have found this approach to be safe and effective, surgeon preparation, technical skill, and technique are critical to obtain good patient outcomes. The purpose of this article is to review the preparatory evaluation and surgical technique for laparoscopic removal of a benign adnexal mass, including cases complicated by pregnancy or obesity.

Fibrin sealant for management of complicated obstetric lacerations.

BACKGROUND: Fibrin sealant commonly is used topically for hemostasis in cardiovascular surgery. Complicated vulvar and vaginal bleeding after vaginal delivery can be difficult to manage using traditional techniques. CASE: A 21-year-old primipara, after a spontaneous vaginal delivery of a twin gestation, was found to have expanding right labial swelling and ecchymosis extending from the superior part of the labia majora to the ischial fossa that was approximately 10 cm wide. Surgical exploration was pursued, but poor tissue quality limited the effectiveness of traditional hemostatic techniques. Prompt hemostasis was achieved with application of fibrin sealant. CONCLUSION: Fibrin sealant may be useful for hemostasis when traditional techniques fail in complicated lacerations of the vulva and vagina associated with obstetric delivery.

Transrectal mesh erosion remote from sacrocolpopexy: management and comment

Sacrocolpopexy is an effective treatment for advanced pelvic organ prolapse with predictable anatomic and functional outcomes. We describe a rare complication of mesh erosion into the rectum and subsequent multidisciplinary management. Multidisciplinary, experienced subspecialty care can address difficult complications of pelvic floor surgery with a minimally invasive approach.

The utility of urodynamic testing.

The utility of urodynamic testing has been questioned for decades. However, this diagnostic tool has been widely adopted in the evaluation of patients who suffer from urinary incontinence despite the associated costs to society. A review of the literature and the consensus of the authors with regard to the indications of urodynamic testing, its application as a diagnostic and prognostic tool, and its effect on surgical management and outcome are presented here.

Prohemostatic therapy: the rise and fall of aprotinin.

Aprotinin has been used clinically to enhance hemostasis for decades and was approved in the United States by the Food and Drug Administration in 1993 to reduce the transfusion requirement during coronary artery bypass surgery. Marketing of aprotinin ceased recently when observational studies and a randomized clinical trial reported increased cardiovascular toxicity in patients receiving this drug. The importance of prohemostatic therapy is reviewed in light of new information on long-term deleterious effects of blood transfusion, including increased risk of cardiovascular disease, malignancy, and infection possibly attributable to delivery of a load of red cell-derived redox-active iron. Weaknesses in design of clinical trials that failed to control adequately for such alternative mechanisms of toxicity complicate interpretation of risks versus benefits in clinical trials of aprotinin given to reduce transfusion requirement in the acute surgical setting. Properties and applications of aprotinin that may not have received sufficient attention in the decision to remove this drug from the therapeutic armamentarium are reviewed. Potential application of prohemostatic drugs, including aprotinin to special populations at risk for operative blood loss requiring transfusion, is illustrated by the description of nine patients with coagulopathies whose operative bleeding was managed effectively with aprotinin. This drug may remain safe and effective in patients at risk of bleeding with surgery. Beneficial effects of aprotinin seemingly unrelated to its prohemostatic properties, especially its apparent striking antineoplastic effects, warrant further study.

Vaginal rugae: measurement and significance

Objective To devise a validated measure of vaginal rugae and assess the relationships between vaginal rugae and important clinical parameters. Methods Two techniques of assessing vaginal rugae were developed and their inter-/intra-observer variability assessed. Examination variability was assessed using intraclass correlation and by way of an analysis of the absolute difference between the two rugal quantitations. After validating the assessment technique, the rugal quantitations of 88 women were compared to clinical parameters such as age, estrogen status, stage of prolapse, parity, history of anterior vaginal wall surgery, and body mass index. Linear regression analysis was used to assess the relationships between vaginal rugae score and these clinical parameters. Results The mean age and body mass index of the subjects were 56 years (standard deviation (SD) ± 13.8 years) and 30.4 kg/m2(SD ± 7.5 kg/m2), respectively. The median parity was 2 (range 0–11). A history of anterior vaginal wall surgery was present in 29% of subjects and 46% were estrogen-deficient. Scores for the two techniques to quantitate vaginal rugae were normally distributed. Both techniques demonstrated satisfactory interexaminer reliability. Increasing age and deficient estrogen status were found to be independent predictors of less vaginal rugae. Conclusions Vaginal rugae can be reliably quantitated. Loss of vaginal rugae is associated with estrogen deficiency and advancing age.

Intraperitoneal India ink deposits appearing as endometriosis in a patient with chronic pelvic pain.

BACKGROUND Visualization and biopsy of suspicious peritoneum can confirm endometriosis. Endoscopic India ink tattooing can lead to peritoneum that visually mimics endometriosis. CASE A woman with chronic pelvic pain and a history of treated endometriosis underwent diagnostic laparoscopy. Previously, a small bowel endoscopy had been performed to evaluate the pain. At laparoscopy, black peritoneal lesions were seen and biopsied due to concern for endometriosis. Pathology concluded the lesions to be carbon-based ink. Investigation revealed that tattoos placed during the small bowel endoscopy used India ink. CONCLUSION Endoscopic India ink tattooing used to demarcate an area of bowel for later identification can stain peritoneal surfaces and mimic endometriotic implants.

Informed Consent and the Use of Transvaginal Synthetic Mesh

In 2008 and again in July of this year, the U.S. Food and Drug Administration (FDA) issued safety communications regarding the use of transvaginally placed surgical mesh. These FDA communications have been the subject of much discussion in the literature. One issue raised by these communications and in the medical literature is the matter of informed consent. Informed consent is an established bioethical principle in modern health care, but it is evolving. The legal interpretations of informed consent are also in flux. A review of contemporary ethical and legal elements of informed consent is presented as it relates to the use of medical innovation, with a focus on transvaginally placed surgical mesh.