Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Sawsan As-Sanie, MD, MPH David I. Eisenstein, MDMichael Hibner, MD, PhD Nima R. Patel, MD, MSBethany D. Skinner, MD John F. Steege, MD
Plenary 7: Pelvic Pain
DISCUSSANTS
MODERATOR
Nita A. Desai, MD, MBA
CO-MODERATOR
Nima R. Patel, MD, MS
Noor M. Abualnadi, MD Joelle Aoun, MDInsiyyah Patanwala, MD Mallory A. Stuparich, MDSmitha Vilasagar, MD Golnar Vazirabadi, MD
Professional Education Information Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Catechol‐O‐Methyltransferase (COMT) Genetic Polymorphisms in Women with Vulvodynia I. Patanwala .................................................................................................................................................. 4 Diagnosis of Occult Hernia in Women with Unexplained Chronic Pelvic Pain J. Aoun .......................................................................................................................................................... 7 Pre‐Operative Risk Factors for Increased Postoperative Pain after Benign Hysterectomy N.M. Abualnadi .......................................................................................................................................... 11 Correlation between Frequency of Urinary Symptoms and Clinical and Image‐Based Indexes of Interstitial Cystitis in a Prospective Cohort of Patients with and without Interstitial Cystitis G. Vazirabadi .............................................................................................................................................. 14 Video: Laparoscopic Ovarian Vein Ligation for Treatment of Pelvic Congestion Syndrome S. Vilasagar ................................................................................................................................................. 16 Video: Presacral Neurectomy: Relevant Anatomy and Strategies for Success M.A. Stuparich ............................................................................................................................................ 17 Cultural and Linguistics Competency ......................................................................................................... 18
Plenary 7: Pelvic Pain
Moderator: Nita A. Desai Co-Moderator: Nima R. Patel
Discussants: Sawsan As-Sanie, David I. Eisenstein, Michael Hibner,
Nima R. Patel, Bethany D. Skinner, John F. Steege
Faculty: Noor M. Abualnadi, Joelle Aoun, Insiyyah Patanwala, Mallory A. Stuparich, Smitha Vilasagar, Golnar Vazirabadi
Chronic pelvic pain is a common symptom for which women seek gynecologic care and continues to be a challenging entity to treat. This session will provide an update on surgical modalities for evaluating and treating pelvic pain, highlight the multimodal etiology, and identify possible risk factors that may influence postoperative pain in benign gynecologic surgery. Learning Objectives: At the conclusion of this course, the participant will be able to: 1) Identify anatomical landmarks for performing laparoscopic surgical interventions for chronic pelvic pain; 2) discuss the role of genetic mutation, interstitial cystitis, and occult hernia in chronic pelvic pain; and 3) consider the role of pre-operative risk factors on postoperative pain.
Course Outline 2:15 Catechol-O-Methyltransferase (COMT) Genetic Polymorphisms in Women
with Vulvodynia I. Patanwala
2:21 Discussant B.D. Skinner
2:25 Diagnosis of Occult Hernia in Women with Unexplained Chronic Pelvic Pain J. Aoun
2:31 Discussant J.F. Steege
2:35 Pre-Operative Risk Factors for Increased Postoperative Pain after Benign Hysterectomy N.M. Abualnadi
2:41 Discussant N.R. Patel
2:45 Correlation between Frequency of Urinary Symptoms and Clinical and Image-Based Indexes of Interstitial Cystitis in a Prospective Cohort of Patients with and without Interstitial Cystitis G. Vazirabadi
2:51 Discussant D.I. Eisenstein
2:55 Video: Laparoscopic Ovarian Vein Ligation for Treatment of Pelvic Congestion Syndrome S. Vilasagar
3:01 Discussant S. As-Sanie
3:05 Video: Presacral Neurectomy: Relevant Anatomy and Strategies for Success M.A. Stuparich
3:11 Discussant M. Hibner
3:15 Adjourn
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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Noor M. Abualnadi* Joelle Aoun* Sawsan As-Sanie Consultant: Myriad Genetics Lab Nita A. Desai* David I. Eisenstein Speakers Bureau: AbbVie Michael Hibner* Insiyyah Patanwala*
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Nima R. Patel* Bethany D. Skinner* John F. Steege* Mallory A. Stuparich* Golnar Vazirabadi* Smitha Vilasagar* Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.
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Catechol-O-Methyltransferase Genetic Polymorphisms in Women with VulvodyniaInsiyyah Patanwala, MD, Fellow
Advanced and Minimally Invasive Gynecology
Florida Hospital, Orlando
November 17th, 2016
I have no financial relationships to disclose.
Audience Objectives
Explain how vulvodynia is diagnosed and classified
Describe the function of catechol-O-methyltransferase (COMT) and how it may affect pain sensitivity
Discover whether a specific COMT genetic polymorphism is more common among women with vulvodynia
Background
Vulvodynia is defined as vaginal or vulvar stabbing or burning pain of at least three months duration that can be spontaneous or provoked, that has no other discernible cause (i.e. infection, injury, etc)
The etiology of vulvodynia is unclear and thought to be multi-factorial
Catechol-O-methyltransferase (COMT) is an enzyme that metabolizes neurotransmitters involved in transmission of pain signals
A single nucleotide polymorphism in the COMT gene at position 158 in exon 3 results in the substitution of methionine for valine in the final protein which leads to reduction in enzyme function
This polymorphism has been associated with increased pain sensitivity, therefore the objective of this investigation was to determine if this COMT polymorphism is associated with vulvodynia
Methods
Women with and without vulvodynia were recruited from five clinical centers across the country
Participants completed study questionnaire and underwent a gynecologic examination
Buccal swab was then collected for genetic testing and shipped to Weill Cornell Medicine for analysis
Analysis
Genetic comparison is considered more accurate among participants of the same race
Given that >70% of our cases were Caucasian, we only completed final data analysis for controls and cases that were Caucasian for more accurate results
The numbers of subjects in each minority group were too low to complete an accurate analysis, therefore they are not included in the following tables/graphs
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ResultsCOMT genotypes and allele frequencies in women with vulvodynia and controls
Genotype Allele Vulvodynia Control
N = 167 N = 107
____________________________________________________________________________________
H,H 55 (32.9%)a 23 (21.5%)
H,L 81 (48.5%) 57 (53.2%)
L,L 31 (18.6%) 27 (25.2%)
H 191 (57.2%)b 103 (48.1%)
L 143 (42.8%) 111 (51.9%)
______________________________________________________________________________________
aP = 0.0543, Odds ratio (OR) = 1.793, 95% confidence interval (CI) 1.021, 3.149
bP = 0.0435, OR = 1.439, 95% CI 1.020, 2.030
Results
0
10
20
30
40
50
60
70
Primary Vulvodynia Secondary Vulvodynia Controls
% o
f Pa
tient
s
COMT Allele Frequency
H L
p=0.034
ResultsInfluence of COMT gene polymorphism on pain perception vulvodynia
Genotype Allele Vulvar Pain
Daily 1-2x/week <1 week Only with sex None
N = 78 N = 3 N= 22 N = 64 N = 107
_________________________________________________________________________________________________________________
H,H 23 (29.5%) 1 (33.3%) 7 (31.8%) 26 (40.6%)a 23 (21.5)
H,L 35 (44.9%) 2 (66.7%) 11 (50.0%) 32 (50.0%) 57 (53.2%)
L,L 20 (25.6%) 0 4 (18.2%) 6 (5.1%)b 27 (25.2%)
H 81 (51.9%) 4 (66.7%) 25 (56.8%) 84 (65.6%)c 103 (48.1%)
L 75 (48.1%) 2 (33.3%) 19 (43.2%) 44 (34.4%) 111 (51.9%)
_____________________________________________________________________________________________________________________
aP = 0.0090 vs. none, OR = 2.499 , 95% CI 1.267, 4.930
bP = 0.0153 vs. none, OR = 0.3065, 95% CI 0.1189, 0.7903
cP = 0.0017 vs. none, OR = 2.057 , 95% CI 1.308, 3.236
Conclusions Contrary to our hypothesis, women with vulvodynia do not have a higher
prevalence of the L allele compared to women without vulvodynia, therefore low enzyme activity due to the SNP at position 158 (rs4680) is not implicated in the pathophysiology of vulvodynia
Surprisingly, certain sub-groups of women with vulvodynia actually have a higher prevalence of the high enzyme activity genotype and the reason for this is unclear
A major limitation of our study is that we could not recruit many minorities despite diverse clinic locations, likely reflecting a disparity in health care. Thus our conclusions can only be applied to Caucasian women.
Future Directions Measurement of COMT enzyme levels in women with vulvodynia may more
accurately reflect COMT function
Determining the prevalence of other COMT genetic polymorphisms, such as its 3 major haplotypes, among women with vulvodynia, would provide a more comprehensive genetic analysis
More research in minority populations is imperative
ReferencesAndersen S, Skorpen F. Variation in the COMT gene: implications for pain perception and pain treatment. Pharmacogenomics. Apr 2009;10(4):669-684.
Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? Journal of the American Medical Women's Association (1972). Spring 2003;58(2):82-88.
Lamvu G, Nguyen RH, Burrows LJ, et al. The Evidence-based Vulvodynia Assessment Project. A National Registry for the Study of Vulvodynia. The Journal of reproductive medicine. May-Jun 2015;60(5-6):223-235.
Reed BD, Harlow SD, Sen A, et al. Prevalence and demographic characteristics of vulvodynia in a population-based sample. American journal of obstetrics and gynecology. Feb 2012;206(2):170 e171-179.
Wesselmann U, Bonham A, Foster D. Vulvodynia: Current state of the biological science. Pain. Sep 2014;155(9):1696-1701.
Zubieta JK, Heitzeg MM, Smith YR, et al. COMT val158met genotype affects mu-opioid neurotransmitter responses to a pain stressor. Science (New York, N.Y.). Feb 21 2003;299(5610):1240-1243
Acknowledgements
Georgine Lamvu, MD, MPH Jessica Feranec, MD
Department of SurgeryOrlando VA Medical CenterOrlando, Florida
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Thank you for listening!Questions?
6
Diagnosis of Occult Hernia in Women with Unexplained
Chronic Pelvic Pain
Presenter: Joelle Aoun, MD, MIGS
Henry Ford Hospital
Department of Minimally Invasive Gynecologic Surgery
I have no financial relationships to disclose
“In Women, Hernias May Be
Hidden Agony” New York Times, May 16, 2011, by Jane Brody
“Laura Sweet was an active 42-year-old saleswoman […] when the agony first started — debilitating, flaring pains in her pelvis that lasted for days and recurred periodically [resulting] in many visits to the emergency room, referrals to various specialists, wrong diagnoses and a daily cocktail of painkillers”.
OBJECTVES
At the conclusion of this activity, the participant will be better able to:
Evaluate women with unexplained chronic pelvic pain and focal inguinal tenderness for the presence of occult hernia
Identify the role and accuracy of ultrasound imaging in the diagnosis of occult hernia
CHRONIC PELVIC PAIN Affects 15% of women during their reproductive years with
significant impact on quality of life, work productivity and healthcare utilization (ref 10-13).
Accounts for 10% of outpatient gynecological consultations and 40% of laparoscopies in the United States (ref 10)
HERNIAS Have been shown to cause chronic pelvic pain (ref 3)
Typically non-palpable and clinically occult in women, and thus more difficult to diagnose as compared to men. (ref 3)
Further investigation with imaging may be indicated in women with high levels of suspicion for occult hernia prior to proceeding to surgery or additional management (ref 5)
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IMAGING The most reliable and cost effective diagnostic modality in
the evaluation of suspected occult hernia in women is not standardized
Limited recent literature examined the role of ultrasound and other imaging tools in the diagnosis of occult hernia; results are conflicting and very few studies included a female only cohort (ref 4 to 8, 15 to 16)
RELEVANCE
As Gynecologists we are likely to see those patients before other specialties due to the pelvic location of their pain
Recognizing women with a high clinical suspicion for occult hernia and offering the proper evaluation is of significant importance in order to prevent delays in diagnosis and prolonged sufferings of women with chronic pelvic pain
METHODS
Design:Retrospective chart review. Approved by the IRB
Setting: Pelvic Pain Clinic at a university-affiliated tertiary medical center in Southeast Michigan. This clinic is multidisciplinary and consists of an Obstetrician and Gynecologist, a pain psychologist, and physical therapists trained in pelvic floor physiology
METHODSStudy population:All women seen between Jan 2005-Jul 2012 at the Pelvic Pain clinic for unexplained chronic pelvic pain with ALL the following inclusion criteria:
1. History that points to an inguinal source of pain2. Physical examination demonstrating focal inguinal tenderness on
standing and supine abdominal exam and/or on retro-inguinal palpation during bimanual exam
3. NO evidence of hernia or bulge on physical examination4. Documentation of a musculoskeletal ultrasound to evaluate for the
presence of a hernia
Intervention:All musculoskeletal ultrasounds were performed by a single sonographer.
A standard imaging protocol was used to assess the inguinal and upper thigh soft tissue anatomy at rest and with provocative maneuvers.
Hernia was diagnosed when fat or visceral tissue was visualized protruding into the inguinal anatomy from within a visceral source.
RESULTS 96 women met the inclusion criteria and were included
All 96 women had a standardized musculoskeletal ultrasound to evaluate for the presence of an occult hernia
The ultrasound was suggestive of a hernia diagnosis in 53% of women (51/96)
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Patients with an ultrasound diagnosis of hernia were significantly older than patients with a negative ultrasound (41± 13 years vs 34 ±11 years , respectively, p = 0.005)
They also were more likely to have a history of arthritis as compared to patients with no evidence of hernia on ultrasound (p = 0.02)
All 51 patients with positive ultrasound findings were referred to general surgery
69% (35/51) underwent surgical evaluation Patients who underwent surgical evaluation had higher pain
metrics on their Brief Pain Inventory as compared to patients who did not have the surgery
Of those, 97% (34 patients) had a confirmed diagnosis of hernia at the time of surgery
SUMMARY In this retrospective analysis of a female clinic population
with unexplained chronic pelvic pain and focal inguinal tenderness, we found evidence to support that:
The diagnosis of occult hernia on soft tissue ultrasound was found in around half of the cases
The ultrasound results were highly correlated with surgical findings (PPV of 97%)
TAKE HOME MESSAGE Women with chronic pelvic pain and a physical examination
pointing to focal inguinal pain, in the absence of other clear etiologies, warrant an evaluation to rule out the presence of an occult hernia.
While no clear guidelines exist in the literature, we believe that imaging should be an essential part of this evaluation before proceeding to surgery
We believe that a musculoskeletal ultrasound is a valuable initial imaging modality due to its high predictive value, low cost and noninvasiveness. In patients with negative results on ultrasounds, in the absence of clear etiology, and a highly suggestive physical examination, an MRI might aid in diagnosis
REFERENCES1. Prevalence of chronic pelvic pain among women: an updated review. Ahangari A. Pain Physician. 2014
Mar-Apr;17(2):E141-7
2. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. Latthe P et al. BMC Public Health. (2006)
3. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Mathias SD et al. Obstet Gynecol. (1996)
4. Chronic pelvic pain: a challenge. Gomel V. J Minim Invasive Gynecol. 2007 Jul-Aug;14(4):521-6
5. Perry CP, Echeverri JD, Hernias as a cause of chronic pelvic pain in women. JSLS. 2006 Apr-Jun;10(2):212-5
6. Role of imaging in the diagnosis of occult hernias. Miller J et al. JAMA Surg. (2014)
1. Role of Sonography in Clinically Occult Femoral Hernias. Brandel DW, Girish G, Brandon CJ, Dong Q, Yablon C, Jamadar DA. J Ultrasound Med. 2016 Jan;35(1):121-8
2. The role of ultrasound in the management of patients with occult groin hernias. Alabraba E, Psarelli E, Meakin K, Quinn M, Leung M, Hartley M, Howes N. Int J Surg. 2014;12(9):918-22
3. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Robinson A et al. Surg Endosc. (2013)
4. The role of ultrasound scan in the diagnosis of occult inguinal hernias. Light D, Ratnasingham K, Banerjee A, Cadwallader R, Uzzaman MM, Gopinath B. Int J Surg. 2011;9(2):169-72
5. The positive predictive value of diagnostic ultrasound for occult herniae. Bradley M et al. Ann R Coll Surg Engl. (2006)
ACKNOWLEDGEMENTS
Jonathan Shaw, BS
Wayne State University, Detroit, Michigan
David Eisenstein, MD
Department of Minimally Invasive Gynecologic Surgery
Henry Ford Hospital, West Bloomfield, Michigan
Ziv Tsafrir, MD
Department of Gynecology Oncology
Sourasky Medical Center, Tel Aviv, Israel
9
THANK YOU
10
Presenter: Noor M. Abualnadi, MD
University of Michigan‐Ann Arbor
Pre‐Operative Risk Factors for Increased Postoperative Pain
After Benign Hysterectomy
DISCLOSURES:
I have no financial relationships to disclose.
OBJECTIVES:
• Identify patient characteristics associated with increased post‐operative pain
• Recognize pre‐operative management can impact post‐operative pain
• Describe how post‐operative pain can impact post‐operative course
Value in Healthcare:
• Importance of VAS scores
– Goal < 7
• Joint Commission on Accreditation of Healthcare Organizations Pain Management Program
What do we know?
Chronicpain
Female
Non‐minimally invasive technique
Duration of surgery
Younger age
METHODS:
• Statewide collaborative of 52 teaching and community hospitals
• All payers• Standardized data collection
methodology• 30 day postoperative
outcomes• Funded by Blue Cross/Blue
Shield of Michigan
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RESULTS:
Hysterectomy routes in MSQC database
Abdominal
Vaginal
Laparoscopic
n= 7,02064.2%
n= 2,60523.8%
n= 1,31212.0%
Total Hysterectomies: 10,937
RESULTS:
Abdominal Vaginal Laparoscopic P value
Mean VAS score 4.18 3.58 3.87 .002
Mean POD#1 VAS scores
Present Not present P value
Chronic pelvic pain 3.89 3.34 .002
Prior pelvic surgery 3.62 3.2 .001
Private Insurance 3.74 3.44 .002
RESULTS:
0%
10%
20%
30%
Tobacco use, p <.001Smoker Non‐smoker
21%
12%
0%
5%
10%
15%
20%
25%
Race, p<.001White Non‐white
21%
13%
0%
20%
40%
60%
80%
Age, <.0001<50 years Non‐smoker ≤50 years
74%
26%
0%
20%
40%
60%
80%
Surgical time, p<.001<2 hours ≥ 2 hours
41%
26%
59%
RESULTS:
Post‐operative complications
Presentation to ED within 30 days
Yes No P value
Presentation to ED
948 (8.7%) 9,662 (88%)
Mean VAS score 4.24 3.46 .001
Re‐admission within 30 days
Yes No P value
Re‐admission 364 (3.3%) 10,229 (93.5%)
Mean VAS score 4.31 3.5 .001
CONCLUSION:
• Elevated post‐hysterectomy VAS scores are associated with certain patient characteristics.
• These patients may be at higher risk for post‐operative complications.
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REFERENCES:1. Berry, Patricia. et al. The New JCAHO Pain Standards: Implications for pain management nurses.
Pain Management Nursing 2000; 1(1):3 –12.
2. Mei W., Seeling M., Franck M., Radtke F., Brantner B., Wernecke K., Spies C. Independent risk factors for postoperative pain in need of intervention early after awakening from general anaesthesia. European Journal of Pain 2010; 14: 149.e1–149.e7. doi:10.1016/j.ejpain.2009.03.009
3. Gerbershagen H., Pogatzki‐Zahn E., Aduckathil S., Peelen L., Kappen T., Van Wijck J., KalkmanC., Meissner W.; Procedure‐specific Risk Factor Analysis for the Development of Severe Postoperative Pain. Anesthesiology 2014;120(5):1237‐1245. doi: 10.1097/ALN.0000000000000108.
4. Ip H., Abrishami A. , Peng P. , Wong J., Chung F.; Predictors of Postoperative Pain and Analgesic Consumption: A Qualitative Systematic Review. Anesthesiology 2009;111(3):657‐677. doi: 10.1097/ALN.0b013e3181aae87a.
5. Caumo W., Schmidt AP., Schneider CN., Bergmann J., Iwamoto CW., Adamatti LC., Bandeira D., Ferreira M. Preoperative predictors of moderate to intense acute postoperative pain in patients undergoing abdominal surgery. Acta Anaesthesiologica Scandinavica 2002;46: 1265–1271. doi:10.1034/j.1399‐6576.2002.461015.x
ACKNOWLEDGEMENTS:
Erika L. Mowers, MD, Neil S. Kamdar, Daniel Morgan, MD, and Sawsan As‐Sanie, MD, MPH
University of Michigan‐Ann Arbor
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Vazirabadi G, MD
Dept of Obstetrics, Gynecology and Women's Health
St. Louis University
Disclosures
I have no financial relationships to disclose.
Objectives
By the end of this lecture, the listener should be able to:
Describe the correlation between frequency of symptoms of Interstitial Cystitis (IC) and clinical and procedure‐based indexes of IC
Explain the role of cystoscopy with hydrodistention in the diagnosis
Contextualize the results of this study within the framework of previous literature
Interstitial Cystitis: An Overview
Persistent or recurrent chronic pelvic pain, pressure or discomfort perceived to be related to the urinary bladder accompanied by at least one other urinary symptom such as an urgent need to void or urinary frequency (Doggweiler R ICS 2016).
IC is difficult to study as there are no objective tools that have been validated for diagnosis (Davis 2014)
Recently the role of cystoscopy with hydrodistension for diagnosis of IC has been called into question (Wennevik GE 2016, Messing 1997, Erickson AUA 2011)
Study Design
Design: Prospective interventional cohort study with blinded image review
Setting: Participants were recruited from an academic urogynecologic and minimally invasive gynecologic practice
Participants:
patients scheduled to have routine gynecologic and urogynecologic procedures involving cystoscopy or cystoscopy with hydrodistension (CwHD).
224 of the 269 women initially enrolled had complete data sets and are included in this analysis.
Interventions:
Participants completed questionnaires including the IC Symptom Index (ICSI)
Physicians performing cystoscopy with hydrodistention were asked pre‐operatively to rate likelihood of patients having IC and post‐operatively to assign a final (Yes/No) diagnosis of IC.
All patients initially underwent cystoscopy with hydrodistension
A panel of three urogynecologists evaluated de‐identified batched picture sets.
Questionnaires and Indexes of Interstitial Cystitis
Interstitial Cystitis Symptom Index (O’Leary MP 1997)
Frequency of 4 key IC symptoms
Frequency, Urgency, Nocturia, Burning/Pain/Discomfort
Clinical Indexes
Initially scheduled procedure
Physician expectancy
Procedure Based Indexes
Composite diagnosis by physician performing CwHD
Diagnosis based on blinded image review
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Frequency of Component Symptoms of ICSI by Clinical Indexes of IC
ICSI
Symptom
Frequency of Symptom
Scheduled Procedure (N) Physician Expectancy (N)
Cystoscopy CwHD P‐value Not
Likely
Likely Very
Likely
P‐value
Frequency Not at all or <1 Time in 5 34 19
<0.05
35 16 2
0.08
<Half or about Half the
Time
38 34 32 31 7
>Half the Time or
Almost Always
44 50 39 45 8
Urgency Not at all or <1 Time in 5 57 36
0.10
56 30 5
<0.05
<Half or about Half the
Time
29 35 28 29 7
>Half the Time or
Almost Always 30 32
23 32 5
Nocturia Not at all or <1 Time in 5 46 31
0.07
43 29 4
0.26<Half or about Half the
Time
17 27 16 24 4
>Half the Time or
Almost Always
55 45 49 39 9
Burning/
Pain/
Discomfort
Not at all 82 26
<0.001
76 28 1
<0.001
Once or a Few
Times/ week
26 31 21 30 5
Often, Usually, or
Almost Always 9 46
10 34 11
Frequency of Component Symptoms of ICSI by Procedural Indexes of IC
ICSI
Symptom
Frequency of
Symptom
Physician Final Diagnosis (N) Image Based Diagnosis (N)
IC No IC P‐value Positive Equivocal Negative P‐value
Frequency Not at all or <1 Time in
512 40
0.16
8 5 40
0.17
<Half or about Half the
Time28 41 22 4 44
>Half the Time or
Almost Always34 59 27 3 60
Urgency Not at all or <1 Time in
530 62
0.44
24 6 62
0.59
<Half or about Half the
Time19 44 15 5 40
>Half the Time or
Almost Always 24 35
17 1 43
Nocturia Not at all or <1 Time in
521 55
0.21
14 7 55
0.07<Half or about Half the
Time19 25 17 1 24
>Half the Time or
Almost Always34 62 26 4 67
Burning/
Pain/
Discomfort
Not at All 25 80
<0.01
22 6 78
0.28
Once or a Few Times/
week21 35 16 4 36
Often, Usually, or
Almost Always 28 26
19 2 31
Composite ICSI Score by Clinical and Procedural Based Indexes of Interstitial Cystitis
P Value
Clinical Indexes Scheduled
Procedure
[Cystoscopy only
N=120]
8 (0, 20)*
[CwHD N= 104]
11 (1, 20) <0.01
Physician
Expectancy
[Not likely N= 110]
8 (0, 20)
[Likely N= 93]
11.5 (1, 20)
[Very Likely N= 17]
13 (4, 20) <0.001
Procedural Based
Indexes
Physician
Composite
Diagnosis
[IC N= 75]
11 (1, 20)
[No IC N= 144]
9 (0, 20) 0.18
Image Based
Diagnosis
[Positive N= 58]
10 (1, 20)
[Equivocal N=12]
6.5 (0, 20)
[Negative N= 148]
9 (0 20) 0.17
*Average composite ICSI score and range of scores
Discussion
Cystoscopic findings correlate poorly with individual symptoms and with ICSI score
Reliance on cystoscopic findings might lead to under‐diagnosis of IC
While ICSI components do correlate with clinical indexes of IC, ICSI overall appears to be a poor diagnostic tool for IC
Our related study found a significant relationship between severity of burning/ pain/ discomfort and all four clinical and procedure‐based indexes of IC
Bogart 2007, Clemens 2015, Lai 2012
Citations
Bogart, Laura M., Sandra H. Berry, and J. Quentin Clemens. “Symptoms of Interstitial Cystitis, Painful Bladder Syndrome and Similar Diseases in Women: A Systematic Review.”The Journal of Urology 177, no. 2 (February 2007): 450–56. doi:10.1016/j.juro.2006.09.032.Clemens, J. Quentin, Daniel J. Clauw, Karl Kreder, John N. Krieger, John W. Kusek, H. Henry Lai, Larissa Rodriguez, et al. “Comparison of Baseline Urological Symptoms in Men and Women in the MAPP Research Cohort.” The Journal of Urology 193, no. 5 (May 2015): 1554–58. doi:10.1016/j.juro.2014.11.016.Davis, N. F., C. M. Brady, and T. Creagh. “Interstitial Cystitis/painful Bladder Syndrome: Epidemiology, Pathophysiology and Evidence‐Based Treatment Options.” European Journal of Obstetrics, Gynecology, and Reproductive Biology 175 (April 2014): 30–37. doi:10.1016/j.ejogrb.2013.12.041.Doggweiler, Regula, Kristene E. Whitmore, Jane M. Meijlink, Marcus J. Drake, Helena Frawley, Jørgen Nordling, Philip Hanno, et al. “A Standard for Terminology in Chronic Pelvic Pain Syndromes: A Report from the Chronic Pelvic Pain Working Group of the International Continence Society: Chronic Pelvic Pain Syndromes.” Neurourology andUrodynamics, August 2016. doi:10.1002/nau.23072 Hanno, Philip M., David Allen Burks, J. Quentin Clemens, Roger R. Dmochowski, Erickson, Deborah, Fitzgerald, Mary Pat, John B. Forrest, et al. “AUA Guideline for the Diagnosis and Treatment of Interstitial Cystitis/bladder Pain Syndrome.” The Journal of Urology 185, no. 6 (June 2011): 2162–70. doi:10.1016/j.juro.2011.03.064.Lai, H. Henry, Carol S. North, Gerald L. Andriole, Gregory S. Sayuk, and Barry A. Hong. “Polysymptomatic, Polysyndromic Presentation of Patients with Urological Chronic Pelvic Pain Syndrome.” The Journal of Urology 187, no. 6 (June 2012): 2106–12. doi:10.1016/j.juro.2012.01.081.Messing, E., D. Pauk, A. Schaeffer, M. Nieweglowski, L. M. Nyberg, J. R. Landis, Y. L. Cook, and L. J. Simon. “Associations among Cystoscopic Findings and Symptoms and Physical Examination Findings in Women Enrolled in the Interstitial Cystitis Data Base (ICDB) Study.” Urology 49, no. 5A Suppl (May 1997): 81–85.O’Leary, M. P., G. R. Sant, F. J. Fowler, K. E. Whitmore, and J. Spolarich‐Kroll. “The Interstitial Cystitis Symptom Index and Problem Index.” Urology49, no. 5A Suppl (May 1997): 58–63.Wennevik, Gjertrud E., Jane M. Meijlink, Philip Hanno, and Jørgen Nordling. “The Role of Glomerulations in Bladder Pain Syndrome: A Review.” The Journal of Urology 195, no. 1 (January 2016): 19–25. doi:10.1016/j.juro.2015.06.112.
Thank YouGavard J, PhD, Rockefeller N, MD, Nieto R, BS, BA, Marcu I, MD, Miller C, MSW, Yeung P, MD, Holloran‐Schwartz MB, MD, Steele A, MD, Leong FC, MD, McLennan MT, MD and Campian EC, MD, PhD
Dept of Obstetrics, Gynecology and Women's Health
St. Louis University
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Laparoscopic Ovarian Vein Ligation for treatment of Pelvic Congestion Syndrome
Presenter: Smitha Vilasagar, MD Carolinas HealthCare System, Charlotte, North Carolina
Objective: To demonstrate pelvic congestion syndrome using transcervical pelvic venography followed
by laparoscopic ovarian vein ligation for surgical treatment.
Design: Stepwise demonstration of the techniques with narrated video footage.
Setting: Pelvic congestion syndrome is characterized by cyclic chronic pelvic discomfort exacerbated by
prolonged standing and intercourse. Pelvic venography is the diagnostic study of choice; it provides
dynamic images of the utero-ovarian venous varicosities. This video illustrates a patient who was
diagnosed with right sided pelvic congestion syndrome with persistent aching discomfort that started
during pregnancy. After confirmation on venography, she underwent laparoscopic right ovarian vein
ligation.
Interventions: Transcervical pelvic venography followed by laparoscopic ovarian vein ligation for surgical
management of pelvic congestion syndrome, with consideration of the following key points:
1. Transcervical pelvic venography with fluoroscopy can be performed in the operating room, and
diagnosis of pelvic congestion syndrome can be made using an objective scoring system.
2. Retroperitoneal dissection of the infundibulopelvic ligament to isolate the two ovarian
vasculature is carried out parallel to the course of the vessels to avoid injuries.
3. The external iliac vessels and ureter are identified and kept in view during exposure of the
ovarian vessels.
Conclusion: With careful surgical technique, laparoscopic ovarian vein ligation is a safe fertility-sparing
treatment with reports of pain improvement in up to 75% of women following surgery.
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Presacral Neurectomy: Relevant Anatomy and Strategies for Success
Presenter: Mallory A. Stuparich, MD
Magee-Womens Hospital of UPMC, Pittsburgh, PA
Objective: To highlight important anatomic landmarks in the performance of presacral neurectomy,
review patient selection criteria that will increase the procedure’s chance for success, and provide
evidence of the procedure’s effectiveness in improving endometriosis-related pain.
Design: Stepwise demonstration of the technique with narrated video footage.
Setting: Presacral neurectomy is a surgical procedure that transects the nerve fibers carrying afferent
pain sensation from the upper vagina, cervix, uterus, broad ligament, and proximal 1/3 of the fallopian
tube. Candidates for the procedure should have midline pelvic pain, failed medical therapy, and desire
conservative surgery. Presacral neurectomy has an excellent published success rate when performed
concomitantly with laparoscopic excision of endometriosis.
Interventions: Laparoscopic presacral neurectomy with particular attention directed to:
1. Identification of key anatomic structures overlying the sacral promontory, most importantly the
left common iliac vein and the middle sacral artery.
2. Delineation of the borders of dissection for presacral neurectomy, including the aortic
bifurcation, inferior mesenteric artery, right common iliac artery, and sacral promontory.
3. Meticulous surgical technique to minimize the risk of injury to surrounding anatomic and
vascular structures.
4. Maintenance of hemostasis to preserve a clean operative field.
Conclusion: Presacral neurectomy is a conservative surgical procedure for endometriosis-related pelvic
pain that has an excellent published success rate. In our video, we demonstrate important concepts for
safe performance of the procedure, appropriate patient selection, and effectiveness of the procedure.
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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsian
Indo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
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