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The Bone & Joint Journal May 2020Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It...
Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis. After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy. Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve. Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment. Cite this article: 2020;102-B(5):556-567.
Topics: Combined Modality Therapy; Diagnosis, Differential; Diagnostic Imaging; Electrodiagnosis; Humans; Medical History Taking; Physical Examination; Piriformis Muscle Syndrome; Pudendal Nerve; Sciatic Nerve; Sciatica
PubMed: 32349600
DOI: 10.1302/0301-620X.102B5.BJJ-2019-1212.R1 -
Medical Education Dec 2015An increasing number of graduating students are unable to competently and confidently perform a pelvic examination. Gynaecology teaching associates (GTAs) teach... (Meta-Analysis)
Meta-Analysis Review
CONTEXT
An increasing number of graduating students are unable to competently and confidently perform a pelvic examination. Gynaecology teaching associates (GTAs) teach technical and communication skills and offer immediate feedback. The objective was to perform a systematic literature review to assess whether teaching pelvic examinations using real women who are trained to give instructions on technique and feedback improves the competence, confidence and communication skills of trainees when compared with traditional teaching methods.
METHODS
MEDLINE, EMBASE, the Cochrane Library, CINAHL and the ISRCTN Register of Clinical Trials were searched using selected terminology. No language restrictions were applied. The selection criteria were randomised clinical trials (RCTs) and controlled studies that investigated the use of GTAs to teach students or health-related professionals the pelvic examination. Data evaluating study outcomes, along with methodological details, were extracted in duplicate. The outcomes measured were: self-reported confidence, assessed competence and assessed communication skills. The standard mean difference (SMD) was derived for each study where possible and heterogeneity across studies was quantified using the I(2) statistic. In the presence of substantial variation, the data were pooled using a random effects model.
RESULTS
Eleven studies with 856 participants were included: five RCTs and six observational studies. GTA training improved competence compared with other teaching methods and the finding of enhanced competence was consistent when the pooled analysis was restricted to RCTs. Communication skills were also improved with GTA teaching, but to a lesser degree, whereas no effect on student confidence was observed. Statistical heterogeneity was present for all outcomes when data were pooled.
CONCLUSION
Our findings suggest that GTA-based teaching of pelvic examination is associated with improvement in the competence and communication skills of trainees. However, further larger-scale studies with standardised relevant educational outcomes are needed to confirm these findings.
Topics: Adult; Clinical Competence; Education, Medical, Undergraduate; Female; Gynecological Examination; Gynecology; Humans; Outcome Assessment, Health Care; Patient Simulation
PubMed: 26611185
DOI: 10.1111/medu.12816 -
Radiography (London, England : 1995) Nov 2022The British Institute of Radiology (BIR) and American Association of Physicists in Medicine (AAPM) have recommended that gonad shielding is no longer used during pelvic... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The British Institute of Radiology (BIR) and American Association of Physicists in Medicine (AAPM) have recommended that gonad shielding is no longer used during pelvic X-ray examinations. The BIR guidance states that shielding may still be considered for use on males, but should not be used on females. This paper aimed to evaluate if this decision was supported by evidence from practice, by comparing the accuracy of gonad shield placement in paediatric males and females.
METHODS
A systematic review of databases including EMBASE, MEDLINE and PubMed was performed in February 2021. Studies were considered eligible if they provided data on the use of gonad shielding during pelvic X-ray examinations on male and female patients under the age of 18. Nine studies met the inclusion criteria and data extraction was performed. Quality appraisal was undertaken, and a meta-analysis of shielding accuracy was performed on seven studies.
RESULTS
The results from the meta-analysis (2187 total radiographs) demonstrated that female patients were significantly more likely (OR 1.38, 95% CI 0.88-1.87) than males to have gonad shields placed inaccurately (p value < 0.001).
CONCLUSION
Gonad shield placement on paediatric female patients is significantly less accurate than on males, and so the results support the AAPM and BIR guidance to stop the practice for females. Shield application may also be frequently inaccurate for males, but the review does not provide clear evidence for or against continuing the practice for males.
IMPLICATIONS FOR PRACTICE
Discontinuing the use of gonad shields in paediatric pelvic radiography on female patients is supported. Any continued use on male patients, or for reasons such as psychological reassurance, should be subject to enhanced training and audit to ensure benefits outweigh any risks.
Topics: Child; Female; Gonads; Humans; Male; Pelvis; Physical Examination; Radiation Protection; Radiography
PubMed: 35849887
DOI: 10.1016/j.radi.2022.06.009 -
Family Practice Jul 2019Urgent suspected cancer referral guidelines recommend that women with gynaecological cancer symptoms should have a pelvic examination (PE) prior to referral. We do not...
BACKGROUND
Urgent suspected cancer referral guidelines recommend that women with gynaecological cancer symptoms should have a pelvic examination (PE) prior to referral. We do not know to what extent GPs comply, their competency at PE, or if PE shortens the diagnostic interval.
OBJECTIVES
We conducted a systematic review of the use, quality and effectiveness of PE in primary care for women with suspected gynaecological cancer.
METHOD
PRISMA guidelines were followed. Three databases were searched using four terms: PE, primary care, competency and gynaecological cancer. Citation lists of all identified papers were screened independently for eligibility by two reviewers. Data extraction was performed in duplicate and independently. Paper quality was assessed using the relevant Critical Appraisal Skills Programme checklist. Emergent themes and contrasting issues were explored in a narrative ecological synthesis.
MAIN FINDINGS
Twenty papers met the inclusion criteria. 52% or less of women with suspicious symptoms had a PE. No papers directly explored GPs' competence at performing PE. Pre-referral PE was associated with reduced diagnostic delay and earlier stage diagnosis. Ecological synthesis demonstrated a complex interplay between patient and practitioner factors and the environment in which examination is performed. Presenting symptoms are commonly misattributed by patients and practitioners resulting in misdiagnosis and lack of PE.
CONCLUSION
We do not know if pre-referral PE leads to better outcomes for patients. PE is often not performed for women with gynaecological cancer symptoms, and evidence that it may result in earlier stage of diagnosis is weak. More research is needed.
Topics: Delayed Diagnosis; Female; Genital Neoplasms, Female; Guideline Adherence; Gynecological Examination; Humans; Primary Health Care
PubMed: 30265316
DOI: 10.1093/fampra/cmy092 -
The Journal of Maternal-fetal &... Nov 2020Given the increasing rate of cesarean delivery and request without maternal or fetal indication among pregnant women, this systematic review was conducted to obtain the...
Given the increasing rate of cesarean delivery and request without maternal or fetal indication among pregnant women, this systematic review was conducted to obtain the reasons for maternal request for elective cesarean section. We searched published studies from the first year of records through August 2018 in PubMed, Scopus, and Web of Science. The quality assessment of the studies was performed by the improved Newcastle-Ottawa Scale. Due to data heterogeneity; no meta-analysis was performed. Twenty-eight studies met the inclusion criteria and were included in the review. The results of studies on the reasons of maternal request for elective cesarean section were fear of labor pain, anxiety for fetal injury/death, fear of childbirth, urinary incontinence, pelvic floor and vaginal trauma, doctors suggestion, time of birth, experience of prior bad delivery, previous infertility, infertility, anxiety for gynecologic examination, anxiety for loss of control, avoid long labor, anxiety for lack of support from the staff, fear of fecal, emotional aspects, body weight of the infant at birth and abnormal prenatal examination. The results of studies on the demographic reasons of maternal request for elective cesarean section were advanced maternal age, parity, occupation, education, maternal obesity, family status, decreasing level of religiosity, household income, number of living children and age at marriage. Our study proposed that the comprehensive programs and the interventions of health promotion should be designed to reduce unnecessary cesarean section and improve the performance of vaginal delivery.
Topics: Cesarean Section; Child; Delivery, Obstetric; Elective Surgical Procedures; Female; Humans; Infant, Newborn; Parity; Parturition; Pregnancy; Pregnant Women
PubMed: 30810436
DOI: 10.1080/14767058.2019.1587407 -
Techniques in Coloproctology Dec 2017Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits over traditional techniques are largely unknown. The aim of this study was to compare detection and miss rates of pelvic floor abnormalities with MRD versus clinical examination and traditional fluoroscopic techniques.
METHODS
A systematic review and meta-analysis was conducted in accordance with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were accessed. Studies were included if they reported detection rates of at least one outcome of interest with MRD versus EITHER clinical examination AND/OR fluoroscopic techniques within the same cohort of patients.
RESULTS
Twenty-eight studies were included: 14 studies compared clinical examination to MRD, and 16 compared fluoroscopic techniques to MRD. Detection and miss rates with MRD were not significantly different from clinical examination findings for any outcome except enterocele, where MRD had a higher detection rate (37.16% with MRD vs 25.08%; OR 2.23, 95% CI 1.21-4.11, p = 0.010) and lower miss rates (1.20 vs 37.35%; OR 0.05, 95% CI 0.01-0.20, p = 0.0001) compared to clinical examination. However, compared to fluoroscopy, MRD had a lower detection rate for rectoceles (61.84 vs 73.68%; OR 0.48 95% CI 0.30-0.76, p = 0.002) rectoanal intussusception (37.91 vs 57.14%; OR 0.32, 95% CI 0.16-0.66, p = 0.002) and perineal descent (52.29 vs 74.51%; OR 0.36, 95% CI 0.17-0.74, p = 0.006). Miss rates of MRD were also higher compared to fluoroscopy for rectoceles (15.96 vs 0%; OR 15.74, 95% CI 5.34-46.40, p < 0.00001), intussusception (36.11 vs 3.70%; OR 10.52, 95% CI 3.25-34.03, p = 0.0001) and perineal descent (32.11 vs 0.92%; OR 12.30, 95% CI 3.38-44.76, p = 0.0001).
CONCLUSIONS
MRD has a role in the assessment of pelvic floor dysfunction. However, clinicians need to be mindful of the risk of underdiagnosis and consider the use of additional imaging.
Topics: Cystocele; Defecography; Female; Fluoroscopy; Humans; Intussusception; Magnetic Resonance Imaging; Pelvic Floor; Physical Examination; Rectal Prolapse; Rectocele
PubMed: 29094218
DOI: 10.1007/s10151-017-1704-y -
World Journal of Emergency Surgery :... Oct 2020Pelvic fractures are common among blunt trauma patients, and timely and accurate diagnosis can improve patient outcomes. However, it remains unclear whether physical... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Pelvic fractures are common among blunt trauma patients, and timely and accurate diagnosis can improve patient outcomes. However, it remains unclear whether physical examinations are sufficient in this context. This study aims to perform a systematic review and meta-analysis of studies on the diagnostic accuracy and clinical utility of physical examination for pelvic fracture among blunt trauma patients.
METHODS
Studies were identified using the MEDLINE, EMBASE, and CENTRAL databases starting from the creation of the database to January 2020. A total of 20 studies (49,043 patients with 8300 cases [16.9%] of pelvic fracture) were included in the quality assessment and meta-analysis. Two investigators extracted the data and evaluated the risk of bias in each study. The meta-analysis involved a hierarchical summary receiver operating curve (ROC) model to calculate the diagnostic accuracy of the physical exam. Subgroup analysis assessed the extent of between-study heterogeneity. Clinical utility was assessed using decision curve analysis.
RESULTS
The median prevalence of pelvic fracture was 10.5% (interquartile range, 5.1-16.5). The pooled sensitivity (and corresponding 95% confidence interval) of the hierarchical summary ROC parameters was 0.859 (0.761-0.952) at a given specificity of 0.920, which was the median value among the included studies. Subgroup analysis revealed that the pooled sensitivity among patients with a Glasgow Coma Scale score ≥ 13 was 0.933 (0.847-0.998) at a given specificity of 0.920. The corresponding value for patients with scores ≤ 13 was 0.761 (0.560-0.932). For threshold probability < 0.01 with 10-15% prevalence, the net benefit of imaging tests was higher than that of physical examination.
CONCLUSION
Imaging tests should be performed in all trauma patients regardless of findings from physical examination or patients' levels of consciousness. However, the clinical role of physical examination should be considered given the prevalence and threshold probability in each setting.
Topics: Fractures, Bone; Humans; Pelvic Bones; Physical Examination; Wounds, Nonpenetrating
PubMed: 33008428
DOI: 10.1186/s13017-020-00334-z -
Medical Education Apr 2010There are recognised difficulties in teaching and assessing intimate examination skills that relate to the sensitive nature of the various examinations and the anxiety... (Review)
Review
OBJECTIVES
There are recognised difficulties in teaching and assessing intimate examination skills that relate to the sensitive nature of the various examinations and the anxiety faced by novice learners. This systematic review provides a summary of the evidence for the involvement of real patients (RPs) and simulated patients (SPs) in the training of health care professionals in intimate examination skills.
METHODS
For the review, 'intimate examinations' included pelvic, breast, testicular and rectal examinations. Major databases were searched from the start of the database to December 2008. The synthesis of findings is integrated by narrative structured to address the main research questions, which sought to establish: the objectives of programmes involving RPs and SPs as teachers of intimate examination skills; reasons why SPs have been involved in this training; the evidence for the effectiveness of such training programmes; the evidence for measures of anxiety in students learning how to perform intimate examinations; how well issues of sexuality are addressed in the literature; any reported negative effects of involvement in teaching on the patients, and suggestions for practical strategies for involving patients in the teaching of intimate examination skills.
RESULTS
A total of 65 articles were included in the review. Involving patients in teaching intimate examination skills offers advantages over traditional methods of teaching. Objective evidence for the effectiveness of this method is demonstrated through improved clinical performance, reduced anxiety and positive evaluation of programmes. Practical strategies for implementing such programmes are also reported.
CONCLUSIONS
There is evidence of a short-term positive impact of patient involvement in the teaching and assessment of intimate examination skills; however, evidence of longer-term impact is still limited. The influences of sexuality and anxiety related to such examinations are explored to some extent, but the psychological impact on learners and patients is not well addressed.
Topics: Breast; Clinical Competence; Competency-Based Education; Education, Medical; Educational Measurement; Female; Humans; Male; Patient Participation; Pelvis; Physical Examination; Problem-Based Learning; Rectum; Testis
PubMed: 20444070
DOI: 10.1111/j.1365-2923.2009.03608.x -
International Urogynecology Journal Jul 2021Pregnancy and childbirth are considered risk factors for pelvic organ prolapse (POP). The long latency between obstetric events and morbidity hinders the establishment... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Pregnancy and childbirth are considered risk factors for pelvic organ prolapse (POP). The long latency between obstetric events and morbidity hinders the establishment of cause-effect relationships. Recently, intermediate outcomes such as organ descent and levator avulsion (LA) have been identified. We aimed to assess the effect of obstetric events on symptoms and signs of POP and on LA.
METHODS
We systematically reviewed the literature by searching PubMed/MEDLINE, Embase and Cochrane Library. We included studies in women examining associations between obstetric events and symptoms and signs of POP and LA, assessed through questionnaires, clinical examination and pelvic floor imaging. Two reviewers evaluated the studies for eligibility and for methodological quality/susceptibility to bias. We extracted study results and clustered them by outcome: symptoms of POP (sPOP), clinical findings of POP (cPOP) and LA. When appropriate, we performed a random-effect meta-analysis and reported the summary odds ratios (OR) with 95% confidence intervals. Heterogeneity across studies was assessed using the I statistic.
RESULTS
The first vaginal delivery was a risk factor for POP as measured by sPOP (OR: 2.65 [1.81-3.88]), cPOP (OR: 4.85 [2.15-10.94]) and in association with LA (OR: 41.6 [4.13- 419.41]). Forceps delivery was a risk factor for POP as measured by sPOP (OR: 2.51 [1.34-4.69]), cPOP (OR: 1.68 [1.21-2.34]) and in association with LA (OR: 5.92 [3.75-9.34]). Birth exclusively by caesarean was protective for sPOP (OR: 0.38 [0.29-0.51]) and for cPOP (OR: 0.29 [0.20-0.41]) and it did not confer any additional risk compared to nulliparity.
CONCLUSIONS
This review confirms a strong aetiological link between vaginal birth and POP, with the first vaginal and forceps delivery being the main determinants.
Topics: Delivery, Obstetric; Female; Humans; Nuclear Proteins; Parity; Pelvic Floor; Pelvic Organ Prolapse; Pregnancy; Repressor Proteins; Risk Factors
PubMed: 33704536
DOI: 10.1007/s00192-021-04724-y