Stuart Hart

Myofascial pain and pelvic floor dysfunction in patients with interstitial cystitis

Introduction and hypothesisThe objectives of this study are to investigate myofascial pain in patients with interstitial cystitis (IC) and to correlate myofascial exam findings with validated questionnaires.MethodsA retrospective chart review was performed on 186 patients with a diagnosis of IC from April 2007 to December 2008. Demographics, history and physical examination, and validated pelvic floor dysfunction questionnaire scores were extracted. The data was evaluated with SPSS for Windows using Spearmans rho, Mann–Whitney, and Kruskal–Wallis statistical analyses.ResultsMyofascial pain was demonstrated in 78.3% of IC patients with at least one myofascial trigger point, and 67.9% of patients had numerous areas of trigger points. Mild correlations were seen with trigger points and scores from the PUF, PFDI-20, and PFIQ-7 questionnaires.ConclusionsMyofascial pain is prevalent among IC patients and positively correlated with pelvic floor dysfunction scores. These findings support evaluation of pelvic floor myofascial pain in IC patients and suggest a possible benefit from pelvic floor therapy.

Abdominal sacral colpopexy mesh erosion resulting in a sinus tract formation and sacral abscess.

BACKGROUND: Complications associated with the use of synthetic mesh during an abdominal sacral colpopexy procedure include mesh infection and erosion into the vaginal vault and sacral osteomyelitis. CASE: This case report describes the management of an abdominal sacral colpopexy procedure that was complicated by postoperative vaginal mesh erosion, formation of a fistulous tract from the vaginal apex to the sacrum, and development of diskitis, osteomyelitis, and a sacral abscess. CONCLUSION: Treatment of a vaginal mesh erosion complicated by the formation of a sinus tract after abdominal sacral colpopexy should include extensive sinus tract resection in addition to complete mesh removal.

Dietary consumption triggers in interstitial cystitis/bladder pain syndrome patients.

Objectives: The aim of this study was to survey interstitial cystitis/bladder pain syndrome (IC/BPS) patients with a Web-based questionnaire to determine which consumables (foods, drinks, supplements/spices, and general food categories) truly exacerbate IC/BPS symptoms. Methods: The Interstitial Cystitis Association posted a Web link on its Web site offering its members participation in the Web-based questionnaire from April 2009 to February 2010. Members were asked questions on the effect of 344 different foods, drinks, supplements, condiments/spices, and general food categories on urinary frequency, urgency, and/or pelvic pain symptoms. Members were asked to score symptoms related to consumables on a symptom Likert scale of 0 to 5. Questions on ethnicity, education, symptom duration, seasonal allergies, irritable bowel syndrome, and specific diets were included. Results: There were 598 complete responses to the questionnaire, and 95.8% of the participants answered that certain foods and beverages affected their IC/BPS symptoms. Most items had no effect on symptoms. Items that made symptoms worse were citrus fruits, tomatoes, coffee, tea, carbonated and alcoholic beverages, spicy foods, artificial sweeteners, and vitamin C. Only calcium glycerophosphate (Prelief; AK Pharma, Inc, Pleasantville, NJ) and sodium bicarbonate (baking soda) had a trend toward improvement in symptoms. Conclusions: Interstitial cystitis diets do not have to be overly restrictive. It is recommended that patients with IC/BPS avoid citrus fruits, tomatoes, coffee, tea, carbonated and alcoholic beverages, spicy foods, artificial sweeteners, and vitamin C. The use of calcium glycerophosphate and/or sodium bicarbonate before consumption of these trigger consumables may also help reduce sensitivity.

National trends of adnexal surgeries at the time of hysterectomy for benign indication, United States, 1998-2011

OBJECTIVE We sought to investigate the most recent national trends of bilateral salpingectomy (BS) and bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy performed for benign indications. STUDY DESIGN We conducted a national cross-sectional analysis of all inpatient discharges for women aged ≥18 years who underwent a hysterectomy for benign indications from 1998 through 2011 using the largest publicly available all-payer inpatient database in the United States. We scanned International Classification of Diseases, Ninth Revision codes for an indication of specific bilateral adnexal surgeries, including BSO and BS. Joinpoint regression was used to characterize and estimate 14-year national trends in performing BSO and BS at the time of hysterectomy for benign indications, overall and in population subgroups. RESULTS During the study period, there were approximately 428,523 inpatient hysterectomy procedures performed annually for benign indications. Of these, >53% had no adnexal surgery performed during the same hospitalization, whereas 43.7% and 1.3% of those discharges had BSO and BS procedures, respectively. The rate of BSO was directly correlated with increasing age for patients <65 years. Conversely, we observed an inverse relationship between BS and patient age, with the BS rate among women aged <25 years twice that of women aged ≥45 years. From 1998 through 2001, there was a 2.2% increase in the rate of BSO per year (95% confidence interval, 0.4-4.0); however, this was followed by a consistent 3.6% (95% confidence interval, -4.0 to -3.3) annual decline in the BSO rate, from 49.7% in 2001 to 33.4% in 2011. National rates of BS among women undergoing hysterectomy for benign indications increased significantly throughout the study period, with an estimated 8% annual increase from 1998 through 2008, followed by a sharp 24% increase annually during the last 4 years of the study period. The BS rate nearly quadrupled in 14 years. CONCLUSION The type of adnexal surgery performed concomitantly with hysterectomy for benign indications has undergone a significant shift since 2001. Significantly more BS and less BSO procedures are being performed among gynecologic surgeons in the United States.

Laparoendoscopic Single-Site Combined Cholecystectomy and Hysterectomy

Laparoendoscopic single-site (LESS) surgery has gained increased acceptance among surgeons in various specialties. The universal nature of port placement in the umbilicus during LESS surgery may enable concomitant procedures to be performed in these surgical specialties via this single incision. This case report presents a 37-year-old woman who underwent concomitant LESS cholecystectomy and hysterectomy to treat a symptomatic fibroid uterus and symptoms of cholelithiasis. The surgical procedure was performed in approximately 3 hours without any complications, and the patient was discharge to home 18 hours after the procedure. This case demonstrates that increasingly complex concomitant procedures can be performed using a LESS surgical approach.

Trends in fetal monitoring through phonocardiography: Challenges and future directions

Abstract Monitoring the well-being of a fetus through Fetal Phonocardiography (FPCG) has been occurring for more than a century. Throughout history, there have been continuous advances in sensor development, data acquisition systems, and signal processing techniques. Despite these advancements, FPCG based point of care technologies are facing serious challenges in translating from basic research to clinical trials and commercialization. This is partly due to the noisy characteristic associated with FPCG, to the lesser clinical knowledge about fetal and maternal physiological profiles, to the unavailability of gold standard databases, and to the limited application of reliable signal processing techniques. In order to understand why FPCG continues to be underutilized, it is necessary to know about the existing standards of fetal monitoring, data collection trends, and the signal processing aspects. To serve this purpose, this paper will first provide an overview of the existing standards of fetal monitoring and then provide a comprehensive survey on Fetal Phonocardiography with focus on trends in data collection, signal processing techniques and synthesis models that have been developed to date. Finally, a set of guidelines will be proposed for future research and use in signal analysis, processing and modeling based on the outlined challenges.

Association between obesity and the trends of routes of hysterectomy performed for benign indications.

OBJECTIVE: To estimate the association between obesity and the recent trends of routes chosen for hysterectomy performed for benign indications in the United States. MATERIALS AND METHODS: Using the American College of Surgeons–National Surgical Quality Improvement Projects database, patients who underwent hysterectomy for benign indications from 2005 to 2011 were identified by International Classification of Diseases, 9th Revision codes and were categorized into total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH). The patients were divided into four subgroups according to body mass index (BMI) (less than 25, 25–29.9, 30–39.9, and 40 or greater). The data were analyzed using Students t test or &khgr;2 and Fishers exact test. RESULTS: A total of 18,810 patients underwent hysterectomy for benign indications during the study period: 9,852 (52.4%) were TAH, 5,146 (27.4%) TVH, 2,296 (12.2%) LAVH, and 1,516 (8.0%) TLH. The rates of TAH increased from 45.7% in patients with ideal body weight to 62% in morbidly obese patients (P<.001). The rate of TVH and LAVH decreased from 32.7% and 13.3% in patients with ideal body weight to 17.1% and 11.7% in morbidly obese patients, respectively (P<.001 and 0.04). The rate of TLH performed was independent of BMI (P=.61). Higher BMI was associated with longer operative time (P<.001) in all routes of hysterectomy. The rates of superficial and deep wound infections were higher with increasing BMI in patients undergoing TAH (P<.001) but not with TVH (P=.26), LAVH (P=1.0), or TLH (P=.48). CONCLUSION: Regarding hysterectomy performed for benign indications, increasing BMI was associated with increased rate of TAH and decreased rate of TVH and LAVH, but not the rate of TLH. Increasing BMI was associated with increased operative time for all subgroups and increased surgical site infection in the TAH group. LEVEL OF EVIDENCE: II

MRI-based segmentation of pubic bone for evaluation of pelvic organ prolapse.

Pelvic organ prolapse (POP) is a major womens health problem. Its diagnosis through magnetic resonance imaging (MRI) has become popular due to current inaccuracies of clinical examination. The diagnosis of POP on MRI consists of identifying reference points on pelvic bone structures for measurement and evaluation. However, it is currently performed manually, making it a time-consuming and subjective procedure. We present a new segmentation approach for automating pelvic bone point identification on MRI. It consists of a multistage mechanism based on texture-based block classification, leak detection, and prior shape information. Texture-based block classification and clustering analysis using K-means algorithm are integrated to generate the initial bone segmentation and to identify leak areas. Prior shape information is incorporated to obtain the final bone segmentation. Then, the reference points are identified using morphological skeleton operation. Results demonstrate that the proposed method achieves higher bone segmentation accuracy compared to other segmentation methods. The proposed method can also automatically identify reference points faster and with more consistency compared with the manually identified point process by experts. This research aims to enable faster and consistent pelvic measurements on MRI to facilitate and improve the diagnosis of female POP.

Levator ani subtended volume: a novel parameter to evaluate levator ani muscle laxity in pelvic organ prolapse

OBJECTIVE We describe a new parameter based on magnetic resonance 3-dimensional (3D) reconstructions proposed to evaluate levator ani muscle (LAM) laxity in women with pelvic organ prolapse (POP). STUDY DESIGN This is an institutional review board-approved, retrospective chart review of 35 women with POP, stages I-IV. The 3D Slicer software package was used to perform 2-dimensional and 3D measurements and the levator ani subtended volume (LASV) was described. Basically, the LASV represents the volume contained by LAM between 2 planes, which coincides with pubococcygeal line and H line. Correlations among measurements, ordinal POP stages, POP Quantification (POPQ) individual measurements, and validated questionnaires were performed. RESULTS The LASV differentiated major (III and IV) from minor (I and II) POPQ stages, which positively correlated to POP stages and POPQ individual measurements. CONCLUSION The LASV is a promising parameter to evaluate the LAM laxity.

Assessment of a semiautomated pelvic floor measurement model for evaluating pelvic organ prolapse on MRI

Introduction and hypothesisThe objective of this study was to assess the performance of a semiautomated pelvic floor measurement algorithmic model on dynamic magnetic resonance imaging (MRI) images compared with manual pelvic floor measurements for pelvic organ prolapse (POP) evaluation.MethodsWe examined 15 MRIs along the midsagittal view. Five reference points used for pelvic floor measurements were identified both manually and using our semiautomated measurement model. The two processes were compared in terms of accuracy and precision.ResultsThe semiautomated pelvic floor measurement model provided highly consistent and accurate locations for all reference points on MRI. Results also showed that the model can identify the reference points faster than the manual-point identification process.ConclusionThe semiautomated pelvic floor measurement model can be used to facilitate and improve the process of pelvic floor measurements on MRI. This will enable high throughput analysis of MRI data to improve the correlation analysis with clinical outcomes and potentially improve POP assessment.