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European Journal of Trauma and... Dec 2022Penetrating injuries to the perineum and associated pelvic organs have largely been reported in the military. Given the rarity of presentation and unique clinical... (Review)
Review
PURPOSE
Penetrating injuries to the perineum and associated pelvic organs have largely been reported in the military. Given the rarity of presentation and unique clinical characteristics of these injuries, we set out to address the gap in the literature in civilian settings.
METHODS
A systematic review of studies addressing penetrating perineal trauma from January 2000 to April 2021 was performed. Outcomes of interest were the epidemiology, associated injuries, management, follow-up, and patient outcomes.
RESULTS
26 studies were included in this review, reporting on a total of 2316 patients. Most injuries occurred in males (88.1%), with gunshot wounds (88.2%) representing the most common aetiology, followed by knife wounds (5.0%), impalement (3.1%), coital injuries/sexual assault (1.5%), and others (2.4%). Regarding associated injuries, anorectal (n = 1419, 69.4%), bladder (n = 351, 32.4%), penile (n = 282, 20.8%), scrotal (n = 375, 27.7%), and testicular (n = 229, 16.9%) occurred frequently. Bony injuries involved the pelvis (n = 88, 8.1%) and femoral fractures (n = 5, 0.5%), while soft-tissue injuries involved the inguinal region (n = 19, 1.6%) and buttocks (n = 14, 1.3%). Vascular injuries occurred in 79 (7.8%) patients. Regarding patient outcomes, 65 (4.8%) deaths were reported, and significant morbidity was detected with a mean injury severity score of 18.4 detected in the cohort. In terms of complications of injury, wound/infective complications (n = 135, 61.3%) and fistula formation/leakage (n = 16, 0.7%) featured prominently.
CONCLUSION
Penetrating perineal trauma in the civilian population poses a considerable challenge to clinicians, compounded by the potential for multisystem injury requiring involvement of different medical and surgical specialties.
Topics: Male; Humans; Wounds, Gunshot; Perineum; Wounds, Penetrating; Wounds, Stab; Injury Severity Score; Retrospective Studies
PubMed: 35262749
DOI: 10.1007/s00068-022-01908-z -
Posterior compartment prolapse and perineal descent: systematic review of available support devices.International Urogynecology Journal Nov 2023The aim of our study is to systematically review the literature about available devices facilitating perineal support during defecation in patients with obstructive... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of our study is to systematically review the literature about available devices facilitating perineal support during defecation in patients with obstructive defecation syndrome (ODS) and posterior pelvic organ prolapse (POP).
METHODS
We searched for the terms "defecat/ion or ODS" and" pessar/ies or device/aid/tool/perineal/perianal/prolapse and support" in MEDLINE, PubMed and Web of Science. Data abstraction was performed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis) guidelines. A two-stage inclusion was performed, selecting first on title and abstract and secondly the full text. For variables with sufficient data, a meta-analysis was performed using a random-effects model. Other variables were descriptively reported.
RESULTS
Ten studies out of 1332 were included for systematic review. The devices could be categorized into three groups: pessaries (n = 8), vaginal stent (n = 1) and external support device (n = 1). Methodology and data reporting is heterogeneous. Meta-analysis could be performed for the Colorectal-Anal Distress Inventory (CRADI-8) and Impact Questionnaire (CRAI-Q-7) in three pessary studies which showed a significant mean change. Significant improvement of stool evacuation was seen in two other pessary studies. The vaginal stent significantly decreases ODS. Subjective perception of constipation improved significantly using the posterior perineal support device.
CONCLUSION
All reviewed devices seem to improve ODS in patients with POP. There are no data on their efficacy with regard to perineal descent-associated ODS. There is a lack of comparative studies between devices. Studies are difficult to compare due to different inclusion criteria and evaluation tools.
Topics: Female; Humans; Pelvic Organ Prolapse; Constipation; Vagina; Anal Canal; Perineum; Pessaries
PubMed: 37074368
DOI: 10.1007/s00192-023-05508-2 -
BMC Pregnancy and Childbirth Nov 2015Because there is a lack of knowledge on the long-term consequences of maternal morbidity/near miss episodes on women's sexual life and function we conducted a systematic... (Review)
Review
BACKGROUND
Because there is a lack of knowledge on the long-term consequences of maternal morbidity/near miss episodes on women's sexual life and function we conducted a systematic review with the purpose of identifying the available evidence on any sexual impairment associated with complications from pregnancy and childbirth.
METHODS
Systematic review on aspects of women sexual life after any maternal morbidity and/or maternal near miss, during different time periods after delivery. The search was carried out until May 22(nd), 2015 including studies published from 1995 to 2015. No language or study design restrictions were applied. Maternal morbidity as exposure was split into general or severe/near miss. Female sexual outcomes evaluated were dyspareunia, Female Sexual Function Index (FSFI) scores and time to resume sexual activity after childbirth. Qualitative syntheses for outcomes were provided whenever possible.
RESULTS
A total of 2,573 studies were initially identified, and 14 were included for analysis after standard selection procedures for systematic review. General morbidity was mainly related to major perineal injury (3(rd) or 4(th) degree laceration, 12 studies). A clear pattern for severity evaluation of maternal morbidity could not be distinguished, unless when a maternal near miss concept was used. Women experiencing maternal morbidity had more frequently dyspareunia and resumed sexual activity later, when compared to women without morbidity. There were no differences in FSFI scores between groups. Meta-analysis could not be performed, since included studies were too heterogeneous regarding study design, evaluation of exposure and/or outcome and time span.
CONCLUSION
Investigation of long-term repercussions on women's sexual life aspects after maternal morbidity has been scarcely performed, however indicating worse outcomes for those experiencing morbidity. Further standardized evaluation of these conditions among maternal morbidity survivors may provide relevant information for clinical follow-up and reproductive planning for women.
Topics: Dyspareunia; Female; Humans; Maternal Health Services; Morbidity; Obstetric Labor Complications; Parturition; Perineum; Postpartum Period; Pregnancy; Sexual Dysfunction, Physiological
PubMed: 26596506
DOI: 10.1186/s12884-015-0742-6 -
Medicine and Science in Sports and... Mar 2021The purpose of this systematic review was to evaluate fetal and maternal pregnancy outcomes of elite athletes who had participated in competitive sport immediately... (Meta-Analysis)
Meta-Analysis
PURPOSE
The purpose of this systematic review was to evaluate fetal and maternal pregnancy outcomes of elite athletes who had participated in competitive sport immediately before conception.
METHODS
Online databases were searched up to March 24, 2020. Studies of any design and language were eligible if they contained information on the relevant population (pregnant women), exposure (engaged in elite sport immediately before pregnancy), and outcomes (birth weight, low birth weight, macrosomia, preterm birth, fetal heart rate and pulse index, cesarean sections, instrumental deliveries, episiotomies, duration of labor, perineal tears, pregnancy-induced low back pain, pelvic girdle pain, urinary incontinence, miscarriages, prenatal weight gain, inadequate/excess prenatal weight gain, maternal depression or anxiety).
RESULTS
Eleven unique studies (n = 2256 women) were included. We identified "low" certainty evidence demonstrating lower rates of low back pain in elite athletes compared with active/sedentary controls (n = 248; odds ratio, 0.38; 95% confidence interval, 0.20-0.73; I2 = 0%) and "very low" certainty evidence indicating an increased odds of excessive prenatal weight gain in elite athletes versus active/sedentary controls (n = 1763; odds ratio, 2.47; 95% confidence interval, 1.26-4.85; I2 = 0%). Low certainty evidence from two studies (n = 7) indicated three episodes of fetal bradycardia after high-intensity exercise that resolved within 10 min of cessation of activity. No studies reported inadequate gestational weight gain or maternal depression or anxiety. There were no differences between elite athletes and controls for all other outcomes.
CONCLUSIONS
There is "low" certainty of evidence that elite athletes have reduced odds of experiencing pregnancy-related low back pain and "very low"certainty of evidence that elite athletes have increased the odds of excessive weight gain compared with active/sedentary controls. More research is needed to provide strong evidence of how elite competitive sport before pregnancy affects maternal and fetal outcomes.PROSPERO Registration: CRD42020167382.
Topics: Abortion, Spontaneous; Athletes; Bias; Birth Weight; Delivery, Obstetric; Episiotomy; Female; Fetal Macrosomia; Heart Rate, Fetal; Humans; Infant, Low Birth Weight; Labor Stage, First; Labor Stage, Second; Low Back Pain; Pelvic Girdle Pain; Perineum; Pregnancy; Pregnancy Outcome; Premature Birth; Pulse; Sedentary Behavior; Urinary Incontinence; Weight Gain
PubMed: 32925496
DOI: 10.1249/MSS.0000000000002510 -
The Cochrane Database of Systematic... Dec 2014Manual rotation is commonly performed to increase the chances of normal vaginal delivery and is perceived to be safe. Manual rotation has the potential to prevent... (Review)
Review
BACKGROUND
Manual rotation is commonly performed to increase the chances of normal vaginal delivery and is perceived to be safe. Manual rotation has the potential to prevent operative delivery and caesarean section, and reduce obstetric and neonatal complications.
OBJECTIVES
To assess the effect of prophylactic manual rotation for women with malposition in labour on mode of delivery, and maternal and neonatal outcomes.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2014), the Australian and New Zealand Clinical Trials Registry (ANZCTR), ClinicalTrials.gov, Current Controlled Trials and the WHO International Clinical Trials Registry Platform (ICTRP) (all searched 23 February 2014), previous reviews and, references of retrieved studies.
SELECTION CRITERIA
Randomised, quasi-randomised or cluster-randomised clinical trials comparing prophylactic manual rotation in labour for fetal malposition versus expectant management, augmentation of labour or operative delivery. We defined prophylactic manual rotation as rotation performed without immediate assisted delivery.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study eligibility and quality, and extracted data.
MAIN RESULTS
We included only one small pilot study (involving 30 women). The study, which we considered to be at low risk of bias, was conducted in a tertiary referral hospital in Australia, and involved women with cephalic, singleton pregnancies. The primary outcome was operative delivery (instrumental delivery or caesarean section).In the manual rotation group, 13/15 women went on to have an instrumental delivery or caesarean section, whereas in the control group, 12/15 women had an operative delivery. The estimated risk ratio was 1.08 (95% confidence interval 0.79 to 1.49). There were no maternal or fetal mortalities in either groupThere were no clear differences for any of the secondary maternal or neonatal outcomes reported (e.g. perineal trauma, analgesia use duration of labour).In terms of adverse events, there were no reported cases of umbilical cord prolapse or cervical laceration and a single case of a non-reassuring or pathological cardiotocograph during the procedure.
AUTHORS' CONCLUSIONS
Currently, there is insufficient evidence to determine the efficacy of prophylactic manual rotation early in the second stage of labour for prevention of operative delivery. One additional study is ongoing. Further appropriately designed trials are required to determine the efficacy of manual rotation.
Topics: Adult; Analgesia, Obstetrical; Cesarean Section; Extraction, Obstetrical; Female; Humans; Labor Presentation; Obstetric Labor Complications; Perineum; Pilot Projects; Pregnancy; Version, Fetal
PubMed: 25532081
DOI: 10.1002/14651858.CD009298.pub2 -
The Cochrane Database of Systematic... Oct 2014One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and... (Review)
Review
BACKGROUND
One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.
OBJECTIVES
To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of retrieved articles.
SELECTION CRITERIA
Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed the trial reports for inclusion and risk of bias, extracted data and checked them for accuracy.
MAIN RESULTS
We identified and included one trial (147 women from a pre-planned sample size of 310 women) that compared the effect of prophylactic antibiotic (single-dose, second-generation cephalosporin - cefotetan or cefoxitin, 1 g intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears compared with placebo. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.12 to 0.96). However, the high failed-appointment rate may limit the generalisability of the results. The overall risk of bias was low except for incomplete outcome data. The quality of the evidence using GRADE was moderate for infection rate at two weeks' postpartum, and low for infection rate at six weeks' postpartum.
AUTHORS' CONCLUSIONS
Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.
Topics: Anal Canal; Anti-Bacterial Agents; Antibiotic Prophylaxis; Cefotetan; Cefoxitin; Cephalosporins; Delivery, Obstetric; Female; Humans; Intestinal Mucosa; Perineum; Pregnancy; Randomized Controlled Trials as Topic; Rectum; Rupture; Wound Infection
PubMed: 25289960
DOI: 10.1002/14651858.CD005125.pub4 -
Journal of Clinical Nursing Jul 2023To evaluate and quantify the best available evidence regarding risk factors for severe perineal lacerations. (Meta-Analysis)
Meta-Analysis Review
AIMS AND OBJECTIVES
To evaluate and quantify the best available evidence regarding risk factors for severe perineal lacerations.
BACKGROUND
Many studies have evaluated the risk factors for severe perineal lacerations. However, the results of those studies are inconsistent, and meta-analysis which thoroughly evaluates the risk factors for severe perineal lacerations is still lacking.
DESIGN
Systematic review and meta-analysis of cohort studies based on the PRISMA guideline.
METHODS
PubMed, Embase, the Cochrane Library, CINAHL, ClinicalTrials.gov, CNKI, Wanfang Data, VIP and SinoMed were systematically searched for cohort studies reporting at least one risk factor for severe perineal lacerations from 1 January 2000 to 2 June 2021. Two reviewers independently conducted quality appraisal by NOS scale and extracted data. Data synthesis was conducted via RevMan 5.3 using a random-effects or fixed-effects model.
RESULTS
A total of 47 studies with 7,043,218 women were included. The results showed that prior caesarean delivery (OR: 1.46, 95% CI 1.12-1.92) and pre-pregnant underweight (OR: 1.31, 95% CI 1.22-1.41) significantly increased the risk of severe perineal lacerations. The results also demonstrated that episiotomy was protective against severe perineal lacerations in forceps delivery (OR: 0.56, 95% CI 0.42-0.74), but not spontaneous vaginal delivery (OR: 1.30, 95% CI 0.81-2.07) or vacuum delivery (OR: 0.76, 95% CI 0.45-1.28). Nulliparity, foetus in occipitoposterior or occipitotransverse position, and midline episiotomy were also independent risk factors for severe perineal lacerations.
CONCLUSIONS
Severe perineal lacerations are associated with many factors, and evidence-based risk assessment tools are needed to guide the midwives and obstetricians to estimate women's risk of severe perineal lacerations.
RELEVANCE TO CLINICAL PRACTICE
This systematic review and meta-analysis identified some important risk factors for severe perineal lacerations, which provides comprehensive insights to guide the midwives to assess women's risk for severe perineal lacerations and take appropriate preventive measures to decrease the risk.
Topics: Pregnancy; Female; Humans; Lacerations; Perineum; Obstetric Labor Complications; Delivery, Obstetric; Parturition; Episiotomy; Cohort Studies; Risk Factors
PubMed: 35791260
DOI: 10.1111/jocn.16438 -
Ultrasound in Obstetrics & Gynecology :... Oct 2023The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective.
METHODS
We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool.
RESULTS
A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias.
CONCLUSION
Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Infant, Newborn; Female; Pregnancy; Humans; Anal Canal; Retrospective Studies; Prospective Studies; Delivery, Obstetric; Episiotomy; Anus Diseases; Perineum; Risk Factors; Obstetric Labor Complications
PubMed: 37329513
DOI: 10.1002/uog.26292 -
Annals of Physical and Rehabilitation... Sep 2018Pelvic floor fatigue is known by its clinical consequences (fecal incontinence, stress urinary incontinence, pelvic organ prolapse), but there are still few studies on... (Review)
Review
BACKGROUND
Pelvic floor fatigue is known by its clinical consequences (fecal incontinence, stress urinary incontinence, pelvic organ prolapse), but there are still few studies on the subject.
OBJECTIVE
This article presents an overview of the current knowledge of pelvic and perineal fatigue, focusing on its assessment and consequences in terms of evaluation and therapeutic strategies, to propose an evaluation that could be routinely performed.
METHODS
We performed a systematic review of the literature in MEDLINE via PubMed and Cochrane Library databases by using the keywords pelvic floor, muscular fatigue, physiopathology, stress urinary incontinence, pelvic organ prolapse, fecal incontinence, physical activity, and pelvic rehabilitation. We included reports of systematic reviews and retrospective and prospective studies on adult humans and animals in English or French published up to April 2018 with no restriction on start date.
RESULTS
We selected 59 articles by keyword search, 18 by hand-search and 3 specific guidelines (including the 2009 International Continence Society recommendations); finally 45 articles were included; 14 are described in the Results section (2 reviews of 6 and 20 studies, and 12 prospective observational or cross-over studies of 5 to 317 patients including 1 of animals). Perineal fatigue can be assessed by direct assessment, electromyography and spectral analysis and during urodynamics. Because pelvic floor fatigue assessments are not evaluated routinely, this fatigability is not always identified and is often falsely considered an exclusive pelvic floor weakness, as suggested by some rehabilitation methods that also weaken the pelvic floor instead of enhancing it.
CONCLUSION
Pelvic floor fatigue is not evaluated enough on a routine basis and the assessment is heterogeneous. A better knowledge of pelvic floor fatigue by standardized routine evaluation could lead to targeted therapeutic strategies.
Topics: Fecal Incontinence; Humans; Muscle Fatigue; Muscle Strength; Pelvic Floor; Perineum; Urinary Incontinence, Stress; Urodynamics
PubMed: 30017491
DOI: 10.1016/j.rehab.2018.06.006 -
BJOG : An International Journal of... Mar 2022There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors.
BACKGROUND
There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors.
OBJECTIVE
To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion.
SEARCH STRATEGY
We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019.
STUDY ELIGIBILITY CRITERIA
A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included.
DATA COLLECTION AND ANALYSIS
RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses.
RESULTS
We included 37 primary non-randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum-assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum.
CONCLUSIONS
LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis.
TWEETABLE ABSTRACT
Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively.
Topics: Cesarean Section; Female; Humans; Incidence; Pelvic Floor Disorders; Pregnancy; Vacuum Extraction, Obstetrical
PubMed: 34245656
DOI: 10.1111/1471-0528.16837