Lior Lowenstein

Postcesarean section pain prediction by preoperative experimental pain assessment.

Background Postcesarean section pain is a common cause of acute pain in obstetrics, yet pain relief and patient satisfaction are still inadequate in many cases. The present study was conducted to determine whether preoperative assessment of experimental pain perception by quantitative sensory tests could predict the level of postcesarean section pain. Methods Fifty-eight women who were scheduled for elective cesarean section were enrolled in the study. Heat pain threshold and magnitude estimation of suprathreshold pain stimuli at 44°–48°C were assessed for both algosity (the sensory dimension of pain intensity) and unpleasantness 1 or 2 days before surgery. The day after the operation, the women reported the level of pain at the surgical wound on a visual analog scale at rest and during activity. Regression analysis was performed to evaluate the usefulness of preoperative scores in predicting postcesarean section pain. Results Postoperative visual analog scale scores at rest and during activity significantly correlated with preoperative suprathreshold pain scores at 44°–48°C (r = 0.31–0.58 for algosity and r = 0.33–0.74 for unpleasantness). The stimulus of 48°C was found to be the best predictor of postoperative pain for both conditions (r = 0.434–0.527;P < 0.01). In contrast to suprathreshold pain stimuli, pain threshold was not correlated with postoperative pain. Conclusions The results show that a simple and quick preoperative test is useful in identifying those women who will experience greater pain after a cesarean section. This test may be suggested for caregivers to tailor the postoperative treatment to specific patient needs and to improve postoperative outcome and patient satisfaction.

Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review

Introduction and hypothesisThis study describes the incidence, risk factors, and treatments of graft erosion, wound granulation, and dyspareunia as adverse events following vaginal repair of pelvic organ prolapse with non-absorbable synthetic and biologic graft materials.MethodsA systematic review in Medline of reports published between 1950 and November 2010 on adverse events after vaginal prolapse repairs using graft materials was carried out.ResultsOne hundred ten studies reported on erosions with an overall rate, by meta-analysis, of 10.3%, (95% CI, 9.7 – 10.9%; range, 0 – 29.7%; synthetic, 10.3%; biological, 10.1%). Sixteen studies reported on wound granulation for a rate of 7.8%, (95% CI, 6.4 – 9.5%; range, 0 – 19.1%; synthetic, 6.8%; biological, 9.1%). Dyspareunia was described in 70 studies for a rate of 9.1%, (95% CI, 8.2 – 10.0%; range, 0 – 66.7%; synthetic, 8.9%; biological, 9.6%).ConclusionsErosions, wound granulation, and dyspareunia may occur after vaginal prolapse repair with graft materials, though rates vary widely across studies.

Graft use in transvaginal pelvic organ prolapse repair: A systematic review

OBJECTIVE: To estimate the anatomic and symptomatic efficacy of graft use in transvaginal prolapse repair and to estimate the rates and describe the spectrum of adverse events associated with graft use. DATA SOURCES: Eligible studies, published between 1950 and November 27, 2007, were retrieved through Medline and bibliography searches. METHODS OF STUDY SELECTION: To assess anatomic and symptomatic efficacy of graft use, we used transvaginal prolapse repair studies that compared graft use with either native tissue repair or repair with a different graft. To estimate rates of adverse events from graft use, all comparative studies and case series with at least 30 participants were included. For spectrum of adverse events, all study designs were included. TABULATION, INTEGRATION AND RESULTS: Eligible studies were extracted onto standardized forms by one reviewer and confirmed by a second reviewer. Comparative studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic-absorbable, synthetic nonabsorbable) and outcome (anatomic, symptomatic). We found 16 comparative studies, including six randomized trials, 37 noncomparative studies with at least 30 women, 11 case series with fewer than 30 women, and 10 case reports of adverse events. One randomized trial and one prospective comparative study evaluating synthetic, nonabsorbable graft use in the anterior compartment reported favorable anatomic and symptomatic outcomes with graft use. Data regarding graft use for posterior and apical compartments or for biologic or synthetic absorbable graft use in the anterior compartment were insufficient to determine efficacy. Rates and spectrum of adverse events associated with graft use included bleeding (0–3%), visceral injury (1–4%), urinary infection (0–19%), graft erosion (0–30%), and fistula (1%). There were insufficient data regarding dyspareunia, sexual, voiding, or defecatory dysfunction. CONCLUSION: Overall, the existing evidence is limited to guide decisions regarding whether to use graft materials in transvaginal prolapse surgery. Adequately powered randomized trials evaluating anatomic and symptomatic efficacy as well as adverse events are needed.

Vulvar vestibulitis severity—assessment by sensory and pain testing modalities

&NA; Vulvar vestibulitis syndrome (VVS) is a common cause of dyspareunia in pre‐menopausal women. Previous quantitative sensory test (QST) studies have demonstrated reduced vestibular pain thresholds in these patients. Here we try to find whether QST findings correlate to disease severity. Thirty‐five vestibulitis patients, 17 with moderate and 18 with severe disorder, were compared to 22 age matched control women. Tactile and pain thresholds for mechanical pressure and thermal pain were measured at the posterior fourcette. Magnitude estimation of supra‐threshold painful stimuli were obtained for mechanical and thermal stimuli, the latter were of tonic and phasic types. Pain thresholds were lower and supra‐threshold magnitude estimations were higher in VVS patients, in agreement with disease severity. Cut‐off points were defined for results of each test, discriminating between moderate VVS, severe VVS and healthy controls, and allowing calculation of sensitivity and specificity of the various tests. Our findings show that the best discriminative test was mechanical pain threshold obtained by a simple custom made ‘spring pressure device’. This test had the highest &kgr; value (0.82), predicting correctly 88% of all VVS cases and 100% of the severe VVS cases. Supra‐threshold pain magnitude estimation for tonic heat stimulation also had a high &kgr; value (0.73) predicting correctly 82% overall with a 100% correct diagnosis of the control group. QST techniques, both threshold and supra‐threshold measurements, seem to be capable of discriminating level of severity of this clinical pain syndrome.

Sexual Function is Related to Body Image Perception in Women with Pelvic Organ Prolapse

INTRODUCTION A previous study demonstrated that women seeking treatment for advanced pelvic organ prolapsed (POP) reported decreased self-perceived body image and decreased quality of life. AIMS To determine the relationship between: (i) sexual function and POP, (ii) self-perceived body image and POP; and (iii) sexual function and self-perceived body image in women with prolapse. METHODS After IRB approval, consecutive women with POP stage II or greater presenting for urogynecologic care at one of eight academic medical centers in the United States were invited to participate. In addition to routine urogynecologic history and physical examination, including pelvic organ prolapse quantification (POPQ), consenting participants completed three validated questionnaires: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to assess sexual function; Modified Body Image Perception Scale (MBIS) to assess self-perceived body image; Prolapse subscale of Pelvic Floor Distress Inventory (POPDI-6) to assess condition specific bother from POP. Pearsons correlations were used to investigate the relationship between independent variables. MAIN OUTCOME MEASURES Sexual function and modified body image score and its correlation with symptoms of POP. RESULTS Three hundred eighty-four participants with a mean age of 62 +/- 12 years were enrolled. Median POPQ stage was 3 (range 2-4). 62% (N = 241) were sexually active and 77% (N = 304) were post-menopausal. Mean PISQ-12, MBIS, and POPDI scores were (33 +/- 7, 6 +/- 5, 39 +/- 23, respectively). PISQ-12 scores were not related to stage or compartment (anterior, apical, or posterior) of POP (P > 0.5). Worse sexual function (lower PSIQ-12 scores) correlated with lower body image perception (higher MBIS scores) (rho = -0.39, P < 0001) and more bothersome POP (higher POPDI scores) (rho = -0.34, P < 0001). CONCLUSIONS Sexual function is related to a womans self-perceived body image and degree of bother from POP regardless of vaginal topography. Sexual function may be more related to a womans perception of her body image than to actual topographical changes from POP.

Changes in Sexual Function after Treatment for Prolapse Are Related to the Improvement in Body Image Perception

INTRODUCTION In a previous study, sexual function was related to a womans self-perceived body image and degree of bother from pelvic organ prolapse (POP). AIMS To evaluate sexual function, prolapse symptoms, and self-perceived body image 6 months following treatment for POP and to explore differences in body image perception and sexual function following conservative and surgical treatment for POP. METHODS After institutional review board approval, consecutive women with > or = stage II POP were invited to participate. In addition to routine urogynecologic history and physical examination, including Pelvic Organ Prolapse Quantification (POP-Q), the participants completed three validated questionnaires before, and 6 months after, treatment for POP: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Modified Body Image Perception Scale and Prolapse subscale of Pelvic Floor Distress Inventory to assess condition specific bother from POP. Main Outcome Measures. Changes in sexual function and body image perception following treatment for POP. RESULTS A total of 235 women with a mean age of 62 +/- 12 years returned for a 6-month follow-up. The majority of our participants had surgical repair for POP (88%). At 6-month follow-up visits, the patients reported significant improvement in sexual function from baseline (33 +/- 0.6 vs. 43 +/- 0.8, respectively P < 0.0001). Improvement in sexual function, as measured by PISQ-12, was not significant among sexually active patients treated with a pessary compared with those treated surgically (-2.5 +/- 5.5 vs. 11.5 +/- 1, respectively P < 0.0001). A multivariate linear regression model demonstrated that body mass index and changes in body image perception were the only independent factors associated with changes in PISQ score following POP treatment (beta = -0.5, P < 0.01 and beta = -0.4, P < 0.03, respectively). CONCLUSIONS Resolution of POP symptoms after treatment improves womens self-perceived body image and sexual function. Not surprisingly, pessary is less effective in improving sexual function compared with surgical repair of POP.

Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared With Laparoscopy and Laparotomy

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.

Patient-selected goals: the fourth dimension in assessment of pelvic floor disorders

The purpose of the study was to assess the relationship between self-expressed urogynecologic goals, symptoms, and treatment choice. Charts of women presenting for urogynecology consultation were reviewed. Demographics, diagnoses and responses to the pelvic floor distress inventory and medical, social, and epidemiologic aspects of aging questionnaires were recorded. Patients listed urogynecology goals before consultation. We categorized goals into five categories and then compared these categories by symptom type, severity, and treatment. Three hundred five women reported 635 goals (median 2, range 1–6). The number of goals listed per patient did not differ by age, race, comorbidities, or clinical diagnosis (p > 0.05). The most frequent goal category was symptoms (67%), followed by information seeking (12%), lifestyle (11%), emotional (4%), and “other” (6%). Women selecting non-surgical treatment were more likely to list information seeking as primary goal than those who chose surgery (p = 0.009). One third of participants expressed a primary non-symptom goal and were more likely to seek non-surgical therapy.

The relationship between obstructive sleep apnea, nocturia, and daytime overactive bladder syndrome in women.

OBJECTIVE The purpose of this study was to corroborate the association between obstructive sleep apnea (OSA) and nocturia in a clinical sample of urogynecologic patients and to explore whether night-time urine concentration predicts the presence of OSA. STUDY DESIGN Patients with nocturia and control subjects underwent a home sleep study, completed validated nocturia questionnaires, and provided evening and morning urine specimens that were analyzed for osmolarity. RESULTS Twenty-one patients with nocturia (16 of whom also had daytime overactive bladder [OAB] symptoms) and 10 control subjects were studied. OSA was present in 17 of 21 women (81%) with nocturia: 13 women (81%) with OAB, 4 women (80%) with nocturia/no OAB, and 4 control subjects (40%; P < .001). The percentage of rapid eye movement sleep time was correlated inversely with nocturic frequency (rho = -.51; P < .004). The presence of diluted nighttime urine in a patient with nocturia was 88% sensitive for the presence of OSA. CONCLUSION We should consider a diagnosis of OSA in all patients with nocturia, even those patients with daytime OAB.

Urogynecology and Sexual Function Research. How Are We Doing

INTRODUCTION Urinary incontinence (UI) and pelvic organ prolapse (POP) negatively impact health-related quality of life by affecting daily activities, body image, and sexual relationships. AIM To evaluate interest in sexual function (SF) research among urogynecologists. MAIN OUTCOME MEASURES The rate of abstracts presented at national meetings that dealt with SF over a 5-year period. METHODS We reviewed all abstracts presented as an oral podium, moderated poster, and nonmoderated posters at meetings of the Society of Gynecologic Surgeons (SGS) and American Urogynecologic Society (AUGS) between 2002 and 2007. Abstracts involving SF outcomes were categorized according to conference year, type of pelvic floor dysfunction, and type of intervention. The Friedman test was used to compare groups with respect to percentages. RESULTS During the study period, the number of abstracts related to SF increased significantly at both meetings. In 2002, there were no studies reported SF outcomes at the SGS meeting, and only 3% (four) of studies at AUGS meeting dealt with SF. Subsequently, in 2007, 10% (nine) and 9% (15) of the abstracts presented at the SGS and AUGS meetings, respectively, addressed SF (P < 0.001 and P < 0.003, respectively). The majority of the studies (60-70%) presented at both meetings investigated the relationship between SF and various surgical interventions for POP and stress UI. CONCLUSION Disorders of the female pelvic floor, such as UI and POP, can influence SF and satisfaction. Our study demonstrates that the awareness and interest of urogynecologists in this area have been increasing steadily. However, most pelvic floor research presentations still do not mention SF in their outcome. Since surgery alone cannot treat the majority of women with sexual dysfunction, there is a need for collaborative work among urogynecologists, gynecologists, female urologists, and sexual therapists.