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Hernia : the Journal of Hernias and... Aug 2023A perineal hernia is a subtype of pelvic floor hernias, and especially primary perineal hernias are rare. No guideline exists on how to handle this type of hernia.... (Review)
Review
PURPOSE
A perineal hernia is a subtype of pelvic floor hernias, and especially primary perineal hernias are rare. No guideline exists on how to handle this type of hernia. Therefore, the primary aim of this scoping review was to investigate the surgical treatment options in adults for primary perineal hernias.
METHODS
This systematic scoping review included studies with original data on at least one adult operated for a primary perineal hernia. Studies from 1990 and forward were included to cover contemporary surgical techniques. Three databases were systematically searched: PubMed, Embase, and Cochrane CENTRAL. Furthermore, a snowball search was performed. The primary outcome was to narratively present details about the surgical techniques. The secondary outcomes were to give an overview of symptoms, diagnostics, intraoperative complications, and postoperative course.
RESULTS
Twenty-two case studies reported repairs on 22 patients suffering from primary perineal hernia. Common symptoms were pain and discomfort, and a bulge was often found during physical examination. Different diagnostic methods were used, and MRI-scans most often found an abnormality. Different surgical procedures can repair the condition, however, laparotomy and the use of a permanent mesh was the most common option. Far from all studies reported on outcomes, but no severe intraoperative event was reported, and the postoperative course was overall uneventful.
CONCLUSION
Primary perineal hernia is a very rare condition presenting with pain/discomfort and bulging and it can be visualized with different imaging modalities. Laparotomy with a permanent mesh was often used for repair, and the postoperative course was mostly uneventful.
Topics: Adult; Humans; Herniorrhaphy; Surgical Mesh; Hernia; Hernia, Abdominal; Laparotomy; Pain; Perineum
PubMed: 36840829
DOI: 10.1007/s10029-023-02760-9 -
Obstetrics and Gynecology Jan 2023To summarize the effectiveness and safety outcomes of medication abortion performed without prior pelvic examination or ultrasonogram ("no-test medication abortion").
OBJECTIVE
To summarize the effectiveness and safety outcomes of medication abortion performed without prior pelvic examination or ultrasonogram ("no-test medication abortion").
DATA SOURCES
We searched the MEDLINE, Scopus, Web of Science, Cochrane (including ClinicalTrials.gov), CINAHL, Global Index Medicus, and CAB Direct databases to identify relevant studies published before April 2022 using a peer-reviewed search strategy including terms such as "medication abortion" and "ultrasonography." We contacted experts in the field for unpublished data and ongoing studies.
METHODS OF STUDY SELECTION
We reviewed 2,423 studies using Colandr. We included studies if they presented clinical outcomes of medication abortion performed with mifepristone and misoprostol and without prior pelvic examination or ultrasonogram. We excluded studies with duplicate data. We abstracted successful abortion rates overall, as well as rates by gestational age through 63 days, 70 days and past 84 days. We abstracted complication rates, including the need for surgical evacuation, additional medications, blood transfusion, and ectopic pregnancy.
TABULATION, INTEGRATION AND RESULTS
We included 21 studies with a total of 10,693 patients with outcome data reported. The overall efficacy of no-test medication abortion was 96.4%; 93.8% (95% CI 92.8-94.6%) through 63 days of gestation and 95.2% (95% CI 94.7-95.7%) through 70 days of gestation. The overall rate of surgical evacuation was 4.4% (95% CI 4.0-4.9), need for additional misoprostol 2.2% (95% CI 1.8-2.6), blood transfusion 0.5% (95% CI 0.3-0.6), and ectopic pregnancy 0.06% (95% CI 0.02-0.15).
CONCLUSION
Medication abortion performed without prior pelvic examination or ultrasonogram is a safe and effective option for pregnancy termination.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42021240739.
Topics: Pregnancy; Female; Humans; Infant; Misoprostol; Abortifacient Agents; Abortion, Induced; Mifepristone; Pregnancy, Ectopic
PubMed: 36701607
DOI: 10.1097/AOG.0000000000005016 -
Journal of Personalized Medicine Nov 2022Uterine leiomyomas usually arise from the uterine body (95%), and rarely from the cervix (0.6%) or other urogenital sites. Lipoleiomyomas are benign, uncommon variants...
Uterine leiomyomas usually arise from the uterine body (95%), and rarely from the cervix (0.6%) or other urogenital sites. Lipoleiomyomas are benign, uncommon variants of leiomyomas (0.03-0.2%), histologically composed of smooth muscle cells and mature adipocytes; they usually occur in the uterine body and exceptionally in the cervix. We performed the first systematic literature review of cervical lipoleiomyomas (PRISMA guidelines), presenting five new cases. Including our series, thirty-one detailed cases were reported in the literature (mainly in Asia). The age range was 35-74 years, revealing a higher mean age than conventional cervical leiomyomas (46.5 vs. 39.4 years). Patients were usually multiparous (94%), typically complaining of vaginal bleeding (11/31, 36%), pelvic/abdominal pain (10/31, 32%), and/or urinary disturbances (6/31, 19%) 1 week to 10 months before presentation. Clinical examination revealed a pedunculated tumor (48%), or prolapse of ≥1 pelvic organs (16%). Twenty-four (77%) patients underwent total hysterectomy ± additional surgery; simple myomectomy/excision was performed in five (16%) cases. Only one (3%) of our cases recurred 2 years after partial excision; no evidence of disease was found 13 years after recurrence excision. Adipocytes occupied ≤50% of the tumor volume. Hyaline or myxoid changes and cartilaginous metaplasia were uncommon histological findings. Surgically challenging cases or pregnant patients may require expert gynecologists. Interventional radiology or conservative treatments were rarely proposed.
PubMed: 36579603
DOI: 10.3390/jpm12111852 -
Archivio Italiano Di Urologia,... Dec 2022Overactive bladder (OAB) symptoms of frequency, urgency and urge incontinence are frequently associated with known neurological diseases like multiple sclerosis (MS),... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Overactive bladder (OAB) symptoms of frequency, urgency and urge incontinence are frequently associated with known neurological diseases like multiple sclerosis (MS), spinal cord injury (SCI), Parkinson's disease (PD), stroke.
OBJECTIVE
The aim of our study was to review the efficacy of pharmacological and non-pharmacological treatments for neurogenic overactive bladder.
MATERIALS AND METHODS
We searched two electronic databases (PubMed and EMBASE) for randomized controlled trials focusing on pharmacological and non-pharmacological medical treatments for overactive bladder symptoms associated with neurological diseases published up to 30 April 2022.
RESULTS
A total of 157 articles were retrieved; 94 were selected by title and abstract screening; after removal of 17 duplicates, 77 records were evaluated by full-text examination. Sixty-two studies were finally selected. The articles selected for review focused on the following interventions: anticholinergics (n = 9), mirabegron (n = 5), comparison of different drugs (n = 3), cannabinoids (n = 2), intravesical instillations (n = 3), botulinum toxin (n = 16), transcutaneous tibial nerve stimulation (TTNS) (n = 6), acupuncture (n = 2), transcutaneous electrical nerve stimulation TENS (n = 4), pelvic floor muscle training (PFMT) (n = 10), others (n = 2). Anticholinergics were more effective than placebo in decreasing the number of daily voids in patients with PD (mean difference [MD]- 1.16, 95 % CI - 1.80 to - 0.52, 2 trials, 86 patients, p < 0.004), but no significant difference from baseline was found for incontinence episodes and nocturia. Mirabegron was more effective than placebo in increasing the cystometric capacity in patients with MS (mean difference [MD] 89.89 mL, 95 % CI 29.76 to 150.01, 2 trials, 98 patients, p < 0.003) but no significant difference was observed for symptom scores and bladder diary parameters. TTNS was more effective than its sham-control in decreasing the number of nocturia episodes (MD -1.40, 95 % CI -2.39 to -0.42, 2 trials, 53 patients, p < 0.005) but no significant changes of OAB symptom scores were reported. PFMT was more effective than conservative advice in decreasing the ICIQ symptom score (MD, -1.12, 95 % CI -2.13 to -0.11, 2 trials, 91 patients, p = 0.03), although the number of incontinence episodes was not significantly different between groups.
CONCLUSIONS
The results of the meta-analysis demonstrate a moderate efficacy of all considered treatments without proving the superiority of one therapy over the others. Combination treatment using different pharmacological and non-pharmacological therapies could achieve the best clinical efficacy due to the favorable combination of the different mechanisms of action. This could be associated with fewer side effects due to drug dosage reduction. These data are only provisional and should be considered with caution, due to the few studies included in metaanalysis and to the small number of patients.
Topics: Humans; Cholinergic Antagonists; Nocturia; Pelvic Floor; Randomized Controlled Trials as Topic; Treatment Outcome; Urinary Bladder, Neurogenic; Urinary Bladder, Overactive; Urinary Incontinence
PubMed: 36576454
DOI: 10.4081/aiua.2022.4.492 -
Journal of Ultrasonography Sep 2022The purpose of this study was to use ultrasonographic data to rule out and distinguish diseases that cause acute pelvic pain.
OBJECTIVE
The purpose of this study was to use ultrasonographic data to rule out and distinguish diseases that cause acute pelvic pain.
MATERIAL AND METHOD
The literature was reviewed using a systematic search of the databases Google Scholars and PubMed, as well as through hand searching. We looked through a total of 35 articles, but only 26 were selected after preliminary screening. Furthermore, 14 articles were left out because they required a membership, copyright clearance, or featured non-English references. There were a total of 12 articles included in the final revuew. Among all the study-related articles, only original research studies and one systematic review that sonographically explored the gynecological etiology of acute pelvic pain were selected.
RESULTS
Acute pelvic pain in women might be difficult to identify between gynecologic and non-gynecologic causes based solely on patient history and examination. Advanced imaging, like ultrasound, aids in determining the reason. Pelvic inflammatory disease can be difficult to diagnose, and clinicians should use a low threshold for starting presumptive treatment in order to avoid significant long-term effects such as infertility.
CONCLUSIONS
Pelvic pain can be acute, chronic or functional. Imaging investigations such as CT, ultrasonography, and MRI can assist in establishing a diagnosis. Particularly ultrasound scanning makes it possible to arrive at a diagnosis with a high degree of precision.
PubMed: 36482928
DOI: 10.15557/jou.2022.0030 -
Radiology Apr 2023Background US-indeterminate adnexal lesions remain an important indication for gynecologic surgery. MRI can serve as a problem-solving tool through the use of the... (Meta-Analysis)
Meta-Analysis
Background US-indeterminate adnexal lesions remain an important indication for gynecologic surgery. MRI can serve as a problem-solving tool through the use of the Ovarian-Adnexal Imaging Reporting and Data System (O-RADS) MRI lexicon, which is based on the ADNEX MR scoring system. Purpose To perform a systematic review and meta-analysis of the diagnostic performance of pelvic MRI interpreted using the ADNEX or O-RADS MRI stratification systems to characterize US-indeterminate adnexal lesions and of the category-wise malignancy rates. Materials and Methods A systematic literature search from May 2013 (publication of the ADNEX MR score) to September 2022 was performed. Studies reporting the use of pelvic MRI interpreted with the ADNEX or O-RADS MRI systems to characterize US-indeterminate adnexal lesions, with pathologic examination and/or follow-up as the reference standard, were included. Summary estimates of diagnostic performance were obtained with the bivariate random-effects model, while category-wise summary malignancy rates of O-RADS MRI 2, 3, 4, and 5 lesions were obtained with a random-effects model. Effects of covariates on heterogeneity and diagnostic performance were investigated through meta-regression. Results Thirteen study parts from 12 studies (3731 women, 4520 adnexal lesions) met the inclusion criteria. Diagnostic performance meta-analysis for 4012 lesions found a 92% summary sensitivity (95% CI: 88, 95) and a 91% summary specificity (95% CI: 89, 93). The meta-analysis of malignancy rates for 3641 lesions showed summary malignancy rates of 0.1% (95% CI: 0, 1) among O-RADS MRI 2 lesions, 6% (95% CI: 3, 9) among O-RADS MRI 3 lesions, 60% (95% CI: 52, 67) among O-RADS MRI 4 lesions, and 96% (95% CI: 92, 99) among O-RADS MRI 5 lesions. Conclusion Pelvic MRI interpreted with the Ovarian-Adnexal Reporting and Data System (O-RADS) MRI lexicon had high diagnostic performance for the characterization of US-indeterminate adnexal lesions. Summary estimates of malignancy rates in the O-RADS MRI 4 and O-RADS MRI 5 categories were higher than predicted ones. © RSNA, 2022 See also the editorial by Lee and Kang in this issue.
Topics: Female; Humans; Adnexal Diseases; Adnexa Uteri; Ovarian Neoplasms; Magnetic Resonance Imaging; Ultrasonography; Sensitivity and Specificity; Retrospective Studies
PubMed: 36413127
DOI: 10.1148/radiol.220795 -
Progres En Urologie : Journal de... Nov 2022To update the CCAFU recommendations for the management of muscle invasive bladder carcinoma (MIBC).
OBJECTIVE
To update the CCAFU recommendations for the management of muscle invasive bladder carcinoma (MIBC).
METHODS
A systematic review (Medline) of the literature from 2020 to 2022 was performed taking account of the diagnosis, treatment options and surveillance of NMIBC and MIBC, while evaluating the references with their levels of evidence.
RESULTS
MIBC is diagnosed after the most complete tumour resection possible. MIBC grading is based on CTU along with chest CT. Multiparametric pelvic MRI could be an alternative. Cystectomy with extensive lymphadenectomy is the gold standard treatment for non-metastatic MIBC. It should be preceded by platinum-based neoadjuvant chemotherapy in patients in good general health with satisfactory renal function. Enterocystoplasty is proposed in men and women in the absence of contraindications and when the urethral resection is negative on extemporaneous examination. Otherwise, transileal cutaneous ureterostomy is the recommended method of urinary diversion. Inclusion of all patients in an ERAS (Enhanced Recovery After Surgery) protocol is recommended. For metastatic MIBC, first line treatment with platinum-based chemotherapy (GC or MVAC) is recommended, if general health (PS>1) and renal function (clearance>60mL/min) so allow (only 50% of the cases). Pembrolizumab immunotherapy has demonstrated an overall survival benefit in second-line treatment.
CONCLUSION
Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and decision-making concerning MIBC treatment.
Topics: Humans; Male; Female; Urinary Bladder Neoplasms; Cystectomy; Neoadjuvant Therapy; Urologic Surgical Procedures; Muscles
PubMed: 36400480
DOI: 10.1016/j.purol.2022.07.145 -
Acute Medicine & Surgery 2022The aim of this review is to investigate the diagnostic accuracy or performance of contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) for... (Review)
Review
The aim of this review is to investigate the diagnostic accuracy or performance of contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) for acute pelvic inflammatory disease (PID) in an emergency care setting. We searched for studies on the diagnostic test accuracy of contrast-enhanced CT or MRI for women of reproductive age with acute abdominal pain using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform, and ClinicalTrials.gov. The reference standard was gynecological examinations by gynecologists using standard diagnostic criteria with or without laparoscopy or transcervical endometrial biopsy. Two reviewers undertook screening of records, data extraction, and assessment of the risk of bias in each included study using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate model was used for the meta-analysis. Of 2,619 screened studies, three studies investigating contrast-enhanced CT and one study investigating MRI were eligible, including a total 635 patients and with a median prevalence of acute PID of 29%. All of the included studies had a high risk of bias for a reference standard and had some applicability concerns. Contrast-enhanced CT had a pooled sensitivity of 0.79 (95% confidence interval [CI], 0.52-0.93) and specificity of 0.99 (95% CI, 0.94-1.00). Magnetic resonance imaging had a sensitivity of 0.95 (95% CI, 0.76-1.00) and specificity of 0.89 (95% CI, 0.52-1.00). Contrast-enhanced CT might serve as a practical alternative to gynecological examination in the diagnosis of acute PID in an emergency care setting, however, the evidence was uncertain. The evidence on MRI was also very uncertain.
PubMed: 36381955
DOI: 10.1002/ams2.806 -
The Cochrane Database of Systematic... Oct 2022Intentional endometrial injury is being proposed as a technique to improve the probability of pregnancy in women undergoing assisted reproductive technologies (ART) such... (Review)
Review
BACKGROUND
Intentional endometrial injury is being proposed as a technique to improve the probability of pregnancy in women undergoing assisted reproductive technologies (ART) such as in vitro fertilisation (IVF). Endometrial injury is often performed by pipelle biopsy and is a common gynaecological procedure with established safety. However, it causes a moderate degree of discomfort/pain and requires an additional pelvic examination. The effectiveness of this procedure outside of ART, in women or couples attempting to conceive via sexual intercourse or with intrauterine insemination (IUI), remains unclear.
OBJECTIVES
To assess the effectiveness and safety of intentional endometrial injury performed in infertile women or couples attempting to conceive through sexual intercourse or intrauterine insemination (IUI).
SEARCH METHODS
The Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Knowledge, and clinical trial registries were searched from inception to 21 May 2020, as were conference abstracts and reference lists of relevant reviews and included studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) that evaluated any kind of intentional endometrial injury in women planning to undergo IUI or attempting to conceive spontaneously (with or without ovarian stimulation (OS)) compared to no intervention, a mock intervention, or intentional endometrial injury performed at a different time.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures recommended by Cochrane. Primary outcomes were live birth/ongoing pregnancy and pain experienced during the procedure. Due to high risk of bias associated with many of the studies, primary analyses of all review outcomes were restricted to studies at low risk of bias. Sensitivity analysis including all studies was then performed.
MAIN RESULTS
We included 22 RCTs (3703 women). Most of these studies included women with unexplained infertility. Intentional endometrial injury versus either no intervention or a sham procedure The primary analysis was restricted to studies at low risk of bias, which left only one study included. We are uncertain whether endometrial injury has an effect on the probability of live birth, as only one study is included in the analysis and the confidence interval is wide (risk ratio (RR) 1.11, 95% confidence interval (CI) 0.78 to 1.59; 1 RCT, 210 participants). Evidence suggests that if the chance of live birth with no intervention/a sham procedure is assumed to be 34%, then the chance with endometrial injury would be 27% to 55%. When all studies were included in the sensitivity analysis, we were uncertain whether endometrial injury improves live birth/ongoing pregnancy, as the evidence was of very low quality (RR 1.71, 95% CI 1.32 to 2.21; 8 RCTs, 1522 participants; I² = 16%). Evidence suggests that if the chance of live birth/ongoing pregnancy with no intervention/a sham procedure is assumed to be 13%, then the chance with endometrial injury would be 17% to 28%. A narrative synthesis conducted for the other primary outcome of pain during the procedure included studies measuring pain on a zero-to-ten visual analogue scale (VAS) or grading pain as mild/moderate/severe, and showed that most often mild to moderate pain was reported (6 RCTs, 911 participants; very low-quality evidence). Timing of intentional endometrial injury Four trials compared endometrial injury performed in the cycle before IUI to that performed in the same cycle as IUI. None of these studies reported the primary outcomes of live birth/ongoing pregnancy and pain during the procedure. One study compared endometrial injury in the early follicular phase (EFP; Day 2 to 4) to endometrial injury in the late follicular phase (LFP; Day 7 to 9), both in the same cycle as IUI. The primary outcome live birth/ongoing pregnancy was not reported, but the study did report the other primary outcome of pain during the procedure assessed by a zero-to-ten VAS. The average pain score was 3.67 (standard deviation (SD) 0.7) when endometrial injury was performed in the EFP and 3.84 (SD 0.96) when endometrial injury was performed in the LFP. The mean difference was -0.17, suggesting that on average, women undergoing endometrial injury in the EFP scored 0.17 points lower on the VAS as compared to women undergoing endometrial injury in the LFP (95% CI -0.48 to 0.14; 1 RCT, 110 participants; very low-quality evidence).
AUTHORS' CONCLUSIONS
Evidence is insufficient to show whether there is a difference in live birth/ongoing pregnancy between endometrial injury and no intervention/a sham procedure in women undergoing IUI or attempting to conceive via sexual intercourse. The pooled results should be interpreted with caution, as the evidence was of low to very low quality due to high risk of bias present in most included studies and an overall low level of precision. Furthermore, studies investigating the effect of timing of endometrial injury did not report the outcome live birth/ongoing pregnancy; therefore no conclusions could be drawn for this outcome. Further well-conducted RCTs that recruit large numbers of participants and minimise bias are required to confirm or refute these findings. Current evidence is insufficient to support routine use of endometrial injury in women undergoing IUI or attempting to conceive via sexual intercourse.
Topics: Female; Humans; Pregnancy; Abortion, Spontaneous; Coitus; Fertilization in Vitro; Infertility, Female; Insemination; Live Birth; Pain; Pregnancy Rate
PubMed: 36278845
DOI: 10.1002/14651858.CD011424.pub4 -
Facts, Views & Vision in ObGyn Sep 2022Symptomatic obturator nerve endometriosis is a rare condition. In this paper, we aim to review and discuss the characteristics of obturator nerve endometriosis in light...
BACKGROUND
Symptomatic obturator nerve endometriosis is a rare condition. In this paper, we aim to review and discuss the characteristics of obturator nerve endometriosis in light of current literature.
METHODS
An electronic search was conducted using the PubMed/Medline database.
RESULTS
Symptomatic obturator nerve endometriosis is rare; only 8 cases have been reported in the literature. Symptoms including difficulty walking, weak thigh adduction and pain in the inner thigh, which are all related to obturator nerve function, could be seen in the case of the entrapment of the nerve by endometrial nodules. A history of recurrent symptoms during menstrual cycles and physical examination, combined with appropriate radiologic imaging, led to a suspicion of obturator nerve involvement.
CONCLUSION
Early diagnosis and surgical treatment of obturator nerve endometriosis is essential to minimise the nerve damage caused by recurrent cycles of bleeding and fibrosis, which are characteristics of endometriosis. The laparoscopic minimally invasive technique is feasible for the surgery of obturator nerve endometriosis. It offers the advantage of precise discrimination of vital structures and excellent access to deep anatomic sites.
WHAT IS NEW?
Obturator nerve endometriosis may be a severe cause of chronic pelvic pain in women of reproductive age. Treatment may be achieved surgically and in experienced hands, laparoscopic surgery would be the preferred choice.
PubMed: 36206796
DOI: 10.52054/FVVO.14.3.032