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A systematic approach to diagnosis and management of chronic pelvic pain
August 1998, Vol. 5, No. 3 Supplement The Journal of the American Association of Gynecologic Laparoscopists
112. Laparoscopic-Assisted Vault Suspension and Enterocele Repair with Site-Specific Fascial Defect Repair
as follows: deep-fibrotic endometriosis 14 (35%), extrapelvic endometriosis 1 (2.5%), allergies 21 (52.5%), gallbladder disease 3 (7.5%), inguinal hernias 27 (67.5%), interstitial cystitis 5 (12.5%), abdominal wall neuropathy 12 (30%), pelvic congestion 7 (17.5%), symptomatic uterine retroversion 3 (7.5%), and ovarian remnant 6 (54.5%). Four patients (10%) had no additional diagnoses other than endometriosis. Conclusion. Women with chronic pelvic pain and endometriosis who fail to obtain relief with traditional medical and surgical approaches should be evaluated for additional explanations for pain.
~JR Miklos, 2N Kohli, 3V Lucente, 4WB Saye. 1Northside Hospital, Alpharetta, Georgia; 2Good Samaritan Hospital, Cincinnati, Ohio; SLehigh Valley Medical Center, Allentown, Pennsylvania; %dvanced Laparoscopy Training Center, Marietta, Georgia.
Objective. To assess surgical feasibility and clinical outcomes of laparoscopic-assisted enterocele repair and vaginal vault suspension based on the theory of sitespecific defects in the vaginal fascia. Measurements and Main Results. Seventeen women with enterocele and vaginal vault prolapse with or without coexisting rectocele underwent surgical correction by site-specific enterocele repair and laparoscopic suspension of vaginal vault. Identification and site-specific fascial defect repair of enterocele were successful in all patients. No intraoperative complications occurred. Patients were examined 4 weeks postoperatively and at 6-month intervals for recurrent prolapse (mean follow-up 6.3 mo, range 1-17 mo). Two women (12%) had asymptomatic mild vaginal vault descensus, but none had evidence of recurrent enterocele. Conclusion. Correcting enterocele and vaginal vault prolapse with fascial defect repair and laparoscopic uterosacral ligament suspension is associated with minimal morbidity and excellent surgical outcomes at short-term follow-up.
111. A Systematic Approach to Diagnosis and
Management of Chronic Pelvic Pain I'2DA Metzger, 21 Daoud, 2p Bosco, 2N Epstein, ~J Peters-Gee. ~Yale New Haven Hospital, Hartford, Connecticut; 2St. Francis Hospital and Medical Center, Hartford, Connecticut.
Objective. To establish an efficient paradigm for diagnosis and management of chronic pelvic pain (CPP). Measurements and Main Results. Two-hundred one consecutive patients (age range 16-53 yrs) with recurrent or unresolved CPP were assessed between January 1996 and February 1998. All women were initially evaluated by questionnaire to elicit details of history, quality of life, and pain location and characteristics. Physical examination identified and reproduced the location of pain by way of patient feedback. Women were diagnosed and treated based on patterns of symptoms, physical findings, and additional testing. Fifteen women with urinary frequency, nocturia, and negative urine culture underwent cystoscopy. Of these, 10 (67%) met NIH criteria for the diagnosis of interstitial cystitis and 3 (20%) had transmural endometriosis. Of 152 patients with inguinal ring tenderness and/or internal inguinal tenderness, 100% had hernias (indirect, direct, femoral, obturator). Those with ovarian point tenderness and adnexal tenderness underwent transcervical venography, with 21 (81%) of 26 having evidence of pelvic congestion. Conclusion. This systematic approach to diagnosis and management identifies a large proportion of women with remediable sources of CPP that are often missed. Additional study is required to determine if these criteria are generally applicable.
113. /aparoscopic Myomectomy with Uterine Reconstruction Is a Safe Surgical Procedure CE Miller, S Davies. Center for Human Reproduction, Chicago, Illinois.
Objective. To evaluate the complication rate associated with laparoscopic m y o m e c t o m y and uterine reconstruction. Measurements and Main Results'. Study subjects were 274 consecutive patients who underwent laparoscopic myomectom Z and uterine reconstruction. Only one woman underwent laparotomy; she also required bowel resection. Fibroid size varied from 3 to 15 cm. Fibroids w6re generalL]r !located intramurally. When they had dual compondnts (intramural, submucosal), a laparoscopic approach was used. Laparosonic coagulating shears (LCS) was used to excise fibroids from myometrium. Excision occurred after dilute vasopressin was infiltrated into the fibroid bed. Until the
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112. Laparoscopic-Assisted Vault Suspension and Enterocele Repair with Site-Specific Fascial Defect Repair
as follows: deep-fibrotic endometriosis 14 (35%), extrapelvic endometriosis 1 (2.5%), allergies 21 (52.5%), gallbladder disease 3 (7.5%), inguinal hernias 27 (67.5%), interstitial cystitis 5 (12.5%), abdominal wall neuropathy 12 (30%), pelvic congestion 7 (17.5%), symptomatic uterine retroversion 3 (7.5%), and ovarian remnant 6 (54.5%). Four patients (10%) had no additional diagnoses other than endometriosis. Conclusion. Women with chronic pelvic pain and endometriosis who fail to obtain relief with traditional medical and surgical approaches should be evaluated for additional explanations for pain.
~JR Miklos, 2N Kohli, 3V Lucente, 4WB Saye. 1Northside Hospital, Alpharetta, Georgia; 2Good Samaritan Hospital, Cincinnati, Ohio; SLehigh Valley Medical Center, Allentown, Pennsylvania; %dvanced Laparoscopy Training Center, Marietta, Georgia.
Objective. To assess surgical feasibility and clinical outcomes of laparoscopic-assisted enterocele repair and vaginal vault suspension based on the theory of sitespecific defects in the vaginal fascia. Measurements and Main Results. Seventeen women with enterocele and vaginal vault prolapse with or without coexisting rectocele underwent surgical correction by site-specific enterocele repair and laparoscopic suspension of vaginal vault. Identification and site-specific fascial defect repair of enterocele were successful in all patients. No intraoperative complications occurred. Patients were examined 4 weeks postoperatively and at 6-month intervals for recurrent prolapse (mean follow-up 6.3 mo, range 1-17 mo). Two women (12%) had asymptomatic mild vaginal vault descensus, but none had evidence of recurrent enterocele. Conclusion. Correcting enterocele and vaginal vault prolapse with fascial defect repair and laparoscopic uterosacral ligament suspension is associated with minimal morbidity and excellent surgical outcomes at short-term follow-up.
111. A Systematic Approach to Diagnosis and
Management of Chronic Pelvic Pain I'2DA Metzger, 21 Daoud, 2p Bosco, 2N Epstein, ~J Peters-Gee. ~Yale New Haven Hospital, Hartford, Connecticut; 2St. Francis Hospital and Medical Center, Hartford, Connecticut.
Objective. To establish an efficient paradigm for diagnosis and management of chronic pelvic pain (CPP). Measurements and Main Results. Two-hundred one consecutive patients (age range 16-53 yrs) with recurrent or unresolved CPP were assessed between January 1996 and February 1998. All women were initially evaluated by questionnaire to elicit details of history, quality of life, and pain location and characteristics. Physical examination identified and reproduced the location of pain by way of patient feedback. Women were diagnosed and treated based on patterns of symptoms, physical findings, and additional testing. Fifteen women with urinary frequency, nocturia, and negative urine culture underwent cystoscopy. Of these, 10 (67%) met NIH criteria for the diagnosis of interstitial cystitis and 3 (20%) had transmural endometriosis. Of 152 patients with inguinal ring tenderness and/or internal inguinal tenderness, 100% had hernias (indirect, direct, femoral, obturator). Those with ovarian point tenderness and adnexal tenderness underwent transcervical venography, with 21 (81%) of 26 having evidence of pelvic congestion. Conclusion. This systematic approach to diagnosis and management identifies a large proportion of women with remediable sources of CPP that are often missed. Additional study is required to determine if these criteria are generally applicable.
113. /aparoscopic Myomectomy with Uterine Reconstruction Is a Safe Surgical Procedure CE Miller, S Davies. Center for Human Reproduction, Chicago, Illinois.
Objective. To evaluate the complication rate associated with laparoscopic m y o m e c t o m y and uterine reconstruction. Measurements and Main Results'. Study subjects were 274 consecutive patients who underwent laparoscopic myomectom Z and uterine reconstruction. Only one woman underwent laparotomy; she also required bowel resection. Fibroid size varied from 3 to 15 cm. Fibroids w6re generalL]r !located intramurally. When they had dual compondnts (intramural, submucosal), a laparoscopic approach was used. Laparosonic coagulating shears (LCS) was used to excise fibroids from myometrium. Excision occurred after dilute vasopressin was infiltrated into the fibroid bed. Until the
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