Pelvic Floor Physical Therapy and Women’s Health

Personalized approaches for the management and maintenance of women’s pelvic health are increasingly in demand. As pelvic floor dysfunction is multifactorial and origins vary, it is essential as a clinician, to be familiar with available interventions to address each of these dysfunctions and their causes. This chapter will discuss the role of physical therapy in the management of female patients presenting with pelvic floor dysfunction related to bowel, bladder and sexual health with focus on variations associated with age. Each section addresses a specific type of pelvic floor dysfunction, discusses the methodology for management, as well as the efficacy of the physical therapy intervention related to treatment of each diagnosis

Refractory Sexual Arousal Subsequent to Sacral Neuromodulation

Background. Sacral neuromodulation has become a widely used treatment for lower urinary tract symptom and dysfunction. It has been observed to benefit sexual function in the domains of arousal and desire. Studies have yet to report markedly increased arousal symptoms as an adverse effect. Case. We present the case of a 57-year-old woman who developed symptomatic persistent genital arousal following implantation of a neuromodulator. Despite device reprogramming, a trial of the device being shut off, and eventual device removal, she continued to have residual new-onset undesired genital hyper-arousal symptoms. Conclusion. Our patient demonstrated markedly increased and persistent arousal symptoms that may be the result of upregulated or alternative activation of sacral nerve pathways. While other case reports describe improvement in persistent genital arousal disorder symptoms through neuromodulation, no studies mention hyperarousal symptoms as an adverse side effect after sacral neuromodulator placement nor persistence despite removal of the implant

Corrigendum to “Symptomatic Clitoral Neuroma within an Epidermal Inclusion Cyst at the Site of Prior Female Genital Cutting”

Background. Clitoral neuromas occurring after female genital mutilation/cutting (FGM/C) can vary in presentation and may require surgical management. Case. A 39-year-old East African female with a history of FGM/C presented during pregnancy with a progressively enlarging mass and worsening periclitoral pain. Postpartum surgical excision restored cosmesis and resolved the discomfort with pathology confirming the presence of a neuroma within the epidermal inclusion cyst. Conclusion. We present the first published case of a symptomatic clitoral neuroma within an epidermal inclusion cyst. This unique pathology demonstrates that complications of female genital cutting can present in complex and varied ways. Considering the prevalence of FGM/C and increasing rates of emigration from countries in which FGM/C is performed, complex clitoral neuromas are an important long-term complication which providers in Africa or internationally must be aware of

Minimally Invasive Excision of a Giant Paratubal Cyst: Case Report and Management Review

Paratubal cysts are usually incidentally found due to being small and asymptomatic adnexal structures. Enlargement to more than 15 cm concurrent with late presentation in an adult is rare. We present the case of a 36 cm diameter cyst in a 31-year-old female whose symptoms involved overactive bladder, abdominal bloating, and pressure. Radiologic findings suggested that it extended from the xiphoid and pubic symphysis. Removal was through a minimally invasive technique

Maternal morbidity associated with skin incision type at cesarean delivery in obese patients: a systematic review

Aim: To describe the relationship between cesarean skin incision type and postoperative wound complications (WCs) in obese pregnant patients. Materials & methods: MEDLINE (PubMed and OVID), Embase, Scopus, Web of Science Core Collection, Cochrane Library and ClinicalTrials.gov databases were used for publication search. Selection criteria consisted of articles studying pregnant patients with BMI ≥30 kg/m2 undergoing cesarean delivery and assessing the effect of skin incision type on postoperative maternal outcomes. Results: Ten publications met criteria for a systematic review of a total of 2946 patients. The transverse skin incision was associated with a lower rate of WC compared with the vertical skin incision. The pooled risk ratio for WCs was 0.47 (95% CI: 0.37–0.58; p < 0.00001). Conclusion: Transverse skin incision may be preferable to vertical skin incision at cesarean delivery in pregnant patients with obesity as it may be associated with a lower rate of WCs. PROSPERO registration ID: CRD4202015110

Analysis of Surgical Outcomes and Determinants of Litigation Among Women With Transvaginal Mesh Complications

Objectives To identify litigation predictors among women with complications of transvaginal mesh. Methods Chart review and patient survey were conducted among women who had undergone a complication-related explant of a transvaginal prolapse or incontinence sling mesh. Trained study personnel administered a 57-question survey addressing subjective complaints related to bowel, bladder, sexual dysfunction, and development of pain or recurrent prolapse. These data were analyzed with respect to the subject\u27s reported pursuit of litigation related to the mesh complication. Categorical and continuous variables were analyzed using the χ2 test and the t test as indicated. Results Ninety-five (68%) of 139 women completed the surveys with 60% of the patients pursuing litigation at the time of the survey. Individual risk factors for pursuing litigation included development of vaginal pain after mesh placement (P = 0.01); dyspareunia after mesh placement (P = 0.01); persistence of dyspareunia, suprapubic pain, and groin pain after mesh excision (P = 0.04, P = 0.02, and P = 0.001, respectively); unsuccessful attempts at conservative management of pelvic pain using pelvic floor rehabilitation (P = 0.002). Conclusion There is an association between a higher likelihood of pursuing litigation and new-onset or persistent pain symptoms attributable to transvaginal mesh

Analysis of Surgical Outcomes and Determinants of Litigation Among Women With Transvaginal Mesh Complications

Objectives To identify litigation predictors among women with complications of transvaginal mesh. Methods Chart review and patient survey were conducted among women who had undergone a complication-related explant of a transvaginal prolapse or incontinence sling mesh. Trained study personnel administered a 57-question survey addressing subjective complaints related to bowel, bladder, sexual dysfunction, and development of pain or recurrent prolapse. These data were analyzed with respect to the subject\u27s reported pursuit of litigation related to the mesh complication. Categorical and continuous variables were analyzed using the χ2 test and the t test as indicated. Results Ninety-five (68%) of 139 women completed the surveys with 60% of the patients pursuing litigation at the time of the survey. Individual risk factors for pursuing litigation included development of vaginal pain after mesh placement (P = 0.01); dyspareunia after mesh placement (P = 0.01); persistence of dyspareunia, suprapubic pain, and groin pain after mesh excision (P = 0.04, P = 0.02, and P = 0.001, respectively); unsuccessful attempts at conservative management of pelvic pain using pelvic floor rehabilitation (P = 0.002). Conclusion There is an association between a higher likelihood of pursuing litigation and new-onset or persistent pain symptoms attributable to transvaginal mesh

Management of a Splenic Artery Aneurysm in the Third Trimester of Pregnancy

Background. Splenic artery aneurysm (SAA) is a rare but potentially fatal complication associated with high maternal and fetal mortality when occurring during pregnancy. Case. A 29-year-old G4P3003 at 34 4/7 weeks of gestation was admitted with left upper quadrant pain and newly diagnosed SAA in the hilum. She was scheduled for embolization of the SAA but the night before went into labor. A multidisciplinary team discussion was held, and the patient underwent successful primary low transverse c-section via Pfannenstiel skin incision followed by laparoscopic splenectomy under general anesthesia. She delivered a male newborn with birth weight of 2855 and Apgar score of 8/5. Summary and Conclusion. Early diagnosis and management of SAA are key for improved maternal and fetal outcomes. Our case demonstrates that through a multidisciplinary approach and anticipation of the possible clinical scenarios, good outcomes can be achieved

Unilateral Vulvar Pneumatocele (Pneumolabium) Diagnosed during Robotic Hysterectomy

Background. Persistent canal of Nuck may manifest in adulthood and be detected after increased abdominal pressure. Case. A 52-year -old female undergoing a robotic hysterectomy developed an acute left labial enlargement. The patient was discovered to have an 8 × 4 × 4 cm swelling in the left labium majus. Palpation revealed the mass to be air-filled and reducible by gentle compression with slow redevelopment upon release of the pressure while intra-abdominal insufflation was maintained. Conclusion. We present the first case of a labial pneumatocele during robotic hysterectomy. We theorize that the underlying cause to be a patent canal of Nuck that, once supplied with increasing abdominal peritoneal pressure, allowed air to travel into the labia majora through the inguinal canal. Simple reduction corrected the pneumatocele and no complications or recurrence was noted postop. This case suggests that pathologies of the canal of Nuck should be considered in the differential of an adult presenting with inguinal or genital swelling

Insight into resident burnout, mental wellness, and coping mechanisms early in the COVID-19 pandemic.

BackgroundAcute augmentation of stress and disruption of training, such as during the COVID-19 pandemic, may impact resident wellbeing.ObjectivesWe investigated how residents in various specialties in the United States were impacted by COVID-19 on mental wellbeing and resilience levels, and the methodology for coping with the stress incurred.MethodsIn April 2020, the authors electronically surveyed 200 residency programs of all specialties nationally. The survey utilized two validated questionnaires to assess wellbeing and resilience, while investigating demographics and coping mechanisms. The authors used student t-test and ANOVA to quantitatively analyze the data.ResultsThe sample consisted of 1115 respondents (with an 18% response rate). Male gender & Age >39 years were associated with more favorable average well-being indices (both pConclusionsFindings highlight the critical importance of resident mental status in cases of augmented stress situations. Institutional support may contribute to promotion of resident wellbeing