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Pain syndromes in gynecology: Vulvodynia
MONDAY,
SEPTEMBER
7
4
and gynaecologists search for physiologically-based reasons for disease, offering physical remedies and treatments. In turn, this reinforces the idea that the body is entirely and solely responsible. From the psychosomatic viewpoint, only a global approach including attention to patient’s memories, psychological structures, body attitudes, words and expressions and social relationships can offer a therapeutic approach. Only when patients assume a subject position in the recovery process and move from the objectified position to a leading questionning role it’s possible for them to find new solutions. Results of our study conducted on 100 outpatient women, by semi-structured interviews and bodyschema testing, suggest that any illness is accompanied by a modification of the body-schema, perception of the external world and perception of the distances existing between the self and the others.
ss1.03.05 PAIN SYNDROMES IN GYNECOLOGY: VULVODYNIA Ph.Weiienborg, Dept Psychosom Gyn & Sexuology Leiden University Medical Center, Leiden, The Netherlands. By the International Society for the Study of Vulvar Disease (1) vulvodynia is defined as chronic vulvar discomfort, characterized by the patient’s complaint of a burning and sometimes stinging sensation in the vulvar area. Five subsets of vulvodynia have been identified (2), all of which result in chronic vulvar pain: vulvar dermatosis, cyclic candidiasis, vulvar vestibulitis, squamous papillomatosis and essential vulvodynia. Proper diagnosis is a prerequisite for adequate patient management. Recently, attention has been directed to the essential or dysesthetic vulvodynia (3-5). Research (5) has supported the idea that essential vulvodynia represents a unique syndrome, rather than a subset of vulvar vestibilitis. The etiology is unknown. Some reports suggest a relation with cysts of the sacral nerve roots (6). An association with psychological distress is found (4). Optimal management should include multispecialistic medical care as well as attention to the consequences of the pain syndrome on the psychological and sexual life of the patient. 1. BumingVulvar Syndrome: Report of the ISSVD. .I Reprod Med 1984;29:457. 2. McKay M. Subsets of vulvodynia. .I Reprod Med 1988;33:695-8. 3. McKay M. Dysesthetic (“essential”) vulvodynia: treatment with amitriptyline. .I Reprod Med 1993;38:9-13. 4. Stewart DE, Reicher AE, Gerulath AH, Boydell KM. Vulvodynia and psychological distress. Obstet Gynecol 1994;84:587-90 5. Bomstein .I, Zarfati D, Goldshmid N, Stolar Z, Lahat N, Abramovici H. Vestibulodynia-a subset of vulvar vestibulitis or a novel syndrome? Am J Obstet Gynecol1997;177:1439-43. 6. Van de Kleft E, Van Vyve M. Chronic perineal pain related to sacral meningeal cysts. Neurosurgery 1991;29:223-6.
EN1.02.02 ARTERIAL EMBOLIZATION OF UTERINE FIBROIDS J. A. Aymard, N. Ciraru-Vigneron, 0. Ledreff, J. Clerissi, D. Herbreteau, J. J. Merland, Clinique Spontini, Paris, France Since uterine artery embolization (UAE) for fibroids disease was first reported (1995) his procedure is being increasingly adopted at the end of 1999 more 6000 embolizations are realised in the world. The technique consists of selectively catheterising both uterine arteries under free flow conditions. UAE is performed with polyvinyl alcohol particles until interruption of arterial blood flow. Population: All patients before embolization were symptomatic and justified surgical treatment in every case the average age was 42143 and 80% were older than 40. Results: All the large series have the same results six months after UAE, 92 to 94% of patients are symptomatic free. Hemorrhage are stopped in more 90% and cycle became normal quickly. Average reduction in fibroid volume was 60165% at 6 months and 70 to 75% at one year. The shrinkage is so more large in very young women. At this time any relapse was observed. The recurrent complication is the frost embolization pain and required powerful1 analgesy (intraveinous narcotics PCA). Major complications are rare the most serious were infection with one fatal case, few cases of ovarian failure and transient amenerrhea were observed, but normal pregnancies can result after UAE. Large
pedonculated subserous or submucous fibroids are a contraindication to embolization. The results of published series confirm that embolization is an effective treatment for symptomatic uterine myomata.
EN1.02.03 ULTRASONICALLY ACTIVATE SCALPEL FOR MYOMECTOMY Roner Ferland, Laurie Telfer-Whelan, Barrington, RI, USA The ultrasonically activated scalpel is a surgical energy source capable of incising tissue with minimal lateral thermal injury while achieving hemostasis of capillaries and small blood vessels. By delivering mechanical energy generated in a piezo-electric generator, the UAS causes three tissue effects: 1. Disruption of hydrogen bonds in tissue proteins 2. Cavitation of intracellular water 3. Secondary thermal effects. The disruption of chemical bonds at the molecular level produces a proteinaceous coagulum that effectively seals blood vessels. This effect is variable depending on the size of the vessel, energy setting applied, and length of activation. Vessels up to 3 mm in diameter can be reliably managed with the UAS. Cavitation of intracellular water created by an area of low atmospheric pressure adjacent to the vibrating blade causes intracellular water to change from the liquid phase to vapor phase at body temperature. (Boyle’s Law). This facilitates incision of tissue by causing cell membranes to rupture. With increasing time of activation, some of the mechanical energy is transformed to thermal energy. This produces some hemostatic effect similar to resistance thermal units, but at much lower operating temperatures (80 deg. C) and with much less lateral thermal injury (lmm vs. 3-7 mm). Effective transfer of mechanical energy is dependant on coupling of blade motion with the target tissue. Thin filmy tissue such as peritoneum can be incised only if adequate tension is created between the blade and tissue. Otherwise the tissue will not absorb energy and there will be no tissue effect. In the case of myomectomy, the solid firm tissue of myometrium and fibroid readily absorbs mechanical energy. This maximizes tissue effect and allows to rapid cutting without generation of excessive heat. Additionally, since the energy transfer is not dependant on electrical current, blood does not reduce the power density as it may with use of monopolar electrosurgical units. Although I have no second look data in the human, experimental porcine models demonstrate fewer adhesions to uterine horn transection sites performed with UAS vs. electrosurgery. This presumably results from less thermal injury and ischemia at incision sites with better preservation of TPA activity to prevent adhesions. For these reasons, the UAS seems a superior energy modality for myomectomy.
FM1.03.01 IMPLANTATION AND MOLECULAR BIOLOGY S. D. Rocha, A. Sharkey, Department of Obstetrics and Gynaecology, University of Cambridge, The Rosie Hospital, Cambridge, United Kingdom Implantation remains the principal cause of failure in patients seeking to achieve a healthy pregnancy. New evidence suggests that the oocyte and embryo are an important feature in this failure but it is still thought that interactions between the embryo and endometrium are the principal factors involved in the failure of implantation. The development of a cyclical endometrium under the influence of steroids essentially involves the coordinated response of a variety of cells to promote the development of receptive endometrium. The process of implantation begins with attachment of the embryo to the epithelium surface and the subsequent apoptosis of epithelial cells and the interstitial migration of trophoblast into the endometrial surface. Individual genes have yet to be identified in humans that are differently regulated to induce their implantation. However, genetic manipulation in mice has begun to identify a range of molecules whose ablation or over-expression results in abnormal implantation. The first of these was the LIF gene and that has been followed by evidence of abnormalities of the interleukin-11 receptor, a gene that shares with the LIF ligand signal accessory transduction molecule GP130. Further evidence suggests that LIFgene expression is regulated by hox genes and deletion of these genes also
SEPTEMBER
7
4
and gynaecologists search for physiologically-based reasons for disease, offering physical remedies and treatments. In turn, this reinforces the idea that the body is entirely and solely responsible. From the psychosomatic viewpoint, only a global approach including attention to patient’s memories, psychological structures, body attitudes, words and expressions and social relationships can offer a therapeutic approach. Only when patients assume a subject position in the recovery process and move from the objectified position to a leading questionning role it’s possible for them to find new solutions. Results of our study conducted on 100 outpatient women, by semi-structured interviews and bodyschema testing, suggest that any illness is accompanied by a modification of the body-schema, perception of the external world and perception of the distances existing between the self and the others.
ss1.03.05 PAIN SYNDROMES IN GYNECOLOGY: VULVODYNIA Ph.Weiienborg, Dept Psychosom Gyn & Sexuology Leiden University Medical Center, Leiden, The Netherlands. By the International Society for the Study of Vulvar Disease (1) vulvodynia is defined as chronic vulvar discomfort, characterized by the patient’s complaint of a burning and sometimes stinging sensation in the vulvar area. Five subsets of vulvodynia have been identified (2), all of which result in chronic vulvar pain: vulvar dermatosis, cyclic candidiasis, vulvar vestibulitis, squamous papillomatosis and essential vulvodynia. Proper diagnosis is a prerequisite for adequate patient management. Recently, attention has been directed to the essential or dysesthetic vulvodynia (3-5). Research (5) has supported the idea that essential vulvodynia represents a unique syndrome, rather than a subset of vulvar vestibilitis. The etiology is unknown. Some reports suggest a relation with cysts of the sacral nerve roots (6). An association with psychological distress is found (4). Optimal management should include multispecialistic medical care as well as attention to the consequences of the pain syndrome on the psychological and sexual life of the patient. 1. BumingVulvar Syndrome: Report of the ISSVD. .I Reprod Med 1984;29:457. 2. McKay M. Subsets of vulvodynia. .I Reprod Med 1988;33:695-8. 3. McKay M. Dysesthetic (“essential”) vulvodynia: treatment with amitriptyline. .I Reprod Med 1993;38:9-13. 4. Stewart DE, Reicher AE, Gerulath AH, Boydell KM. Vulvodynia and psychological distress. Obstet Gynecol 1994;84:587-90 5. Bomstein .I, Zarfati D, Goldshmid N, Stolar Z, Lahat N, Abramovici H. Vestibulodynia-a subset of vulvar vestibulitis or a novel syndrome? Am J Obstet Gynecol1997;177:1439-43. 6. Van de Kleft E, Van Vyve M. Chronic perineal pain related to sacral meningeal cysts. Neurosurgery 1991;29:223-6.
EN1.02.02 ARTERIAL EMBOLIZATION OF UTERINE FIBROIDS J. A. Aymard, N. Ciraru-Vigneron, 0. Ledreff, J. Clerissi, D. Herbreteau, J. J. Merland, Clinique Spontini, Paris, France Since uterine artery embolization (UAE) for fibroids disease was first reported (1995) his procedure is being increasingly adopted at the end of 1999 more 6000 embolizations are realised in the world. The technique consists of selectively catheterising both uterine arteries under free flow conditions. UAE is performed with polyvinyl alcohol particles until interruption of arterial blood flow. Population: All patients before embolization were symptomatic and justified surgical treatment in every case the average age was 42143 and 80% were older than 40. Results: All the large series have the same results six months after UAE, 92 to 94% of patients are symptomatic free. Hemorrhage are stopped in more 90% and cycle became normal quickly. Average reduction in fibroid volume was 60165% at 6 months and 70 to 75% at one year. The shrinkage is so more large in very young women. At this time any relapse was observed. The recurrent complication is the frost embolization pain and required powerful1 analgesy (intraveinous narcotics PCA). Major complications are rare the most serious were infection with one fatal case, few cases of ovarian failure and transient amenerrhea were observed, but normal pregnancies can result after UAE. Large
pedonculated subserous or submucous fibroids are a contraindication to embolization. The results of published series confirm that embolization is an effective treatment for symptomatic uterine myomata.
EN1.02.03 ULTRASONICALLY ACTIVATE SCALPEL FOR MYOMECTOMY Roner Ferland, Laurie Telfer-Whelan, Barrington, RI, USA The ultrasonically activated scalpel is a surgical energy source capable of incising tissue with minimal lateral thermal injury while achieving hemostasis of capillaries and small blood vessels. By delivering mechanical energy generated in a piezo-electric generator, the UAS causes three tissue effects: 1. Disruption of hydrogen bonds in tissue proteins 2. Cavitation of intracellular water 3. Secondary thermal effects. The disruption of chemical bonds at the molecular level produces a proteinaceous coagulum that effectively seals blood vessels. This effect is variable depending on the size of the vessel, energy setting applied, and length of activation. Vessels up to 3 mm in diameter can be reliably managed with the UAS. Cavitation of intracellular water created by an area of low atmospheric pressure adjacent to the vibrating blade causes intracellular water to change from the liquid phase to vapor phase at body temperature. (Boyle’s Law). This facilitates incision of tissue by causing cell membranes to rupture. With increasing time of activation, some of the mechanical energy is transformed to thermal energy. This produces some hemostatic effect similar to resistance thermal units, but at much lower operating temperatures (80 deg. C) and with much less lateral thermal injury (lmm vs. 3-7 mm). Effective transfer of mechanical energy is dependant on coupling of blade motion with the target tissue. Thin filmy tissue such as peritoneum can be incised only if adequate tension is created between the blade and tissue. Otherwise the tissue will not absorb energy and there will be no tissue effect. In the case of myomectomy, the solid firm tissue of myometrium and fibroid readily absorbs mechanical energy. This maximizes tissue effect and allows to rapid cutting without generation of excessive heat. Additionally, since the energy transfer is not dependant on electrical current, blood does not reduce the power density as it may with use of monopolar electrosurgical units. Although I have no second look data in the human, experimental porcine models demonstrate fewer adhesions to uterine horn transection sites performed with UAS vs. electrosurgery. This presumably results from less thermal injury and ischemia at incision sites with better preservation of TPA activity to prevent adhesions. For these reasons, the UAS seems a superior energy modality for myomectomy.
FM1.03.01 IMPLANTATION AND MOLECULAR BIOLOGY S. D. Rocha, A. Sharkey, Department of Obstetrics and Gynaecology, University of Cambridge, The Rosie Hospital, Cambridge, United Kingdom Implantation remains the principal cause of failure in patients seeking to achieve a healthy pregnancy. New evidence suggests that the oocyte and embryo are an important feature in this failure but it is still thought that interactions between the embryo and endometrium are the principal factors involved in the failure of implantation. The development of a cyclical endometrium under the influence of steroids essentially involves the coordinated response of a variety of cells to promote the development of receptive endometrium. The process of implantation begins with attachment of the embryo to the epithelium surface and the subsequent apoptosis of epithelial cells and the interstitial migration of trophoblast into the endometrial surface. Individual genes have yet to be identified in humans that are differently regulated to induce their implantation. However, genetic manipulation in mice has begun to identify a range of molecules whose ablation or over-expression results in abnormal implantation. The first of these was the LIF gene and that has been followed by evidence of abnormalities of the interleukin-11 receptor, a gene that shares with the LIF ligand signal accessory transduction molecule GP130. Further evidence suggests that LIFgene expression is regulated by hox genes and deletion of these genes also