Pelvic Origin Research Articles

Anatomical, Pathophysiological, and Clinical Aspects of Extra-Pelvic Varicose Veins of Pelvic Origin

Venous hypertension in the pelvic veins can result in the development of varicosities in the perineum, and sometimes also in the lower extremities. These varicose veins are anatomically and functionally different from typical varicosities associated with an incompetence of the saphenous veins. Since the pelvic cavity is anatomically separated from the lower extremity and perineum by muscles and skeleton, there are only a few routes through which pelvic veins can communicate with extra-pelvic veins. These routes should primarily be examined during diagnostic workout. In this review article, clinical anatomy concerning varicose veins of pelvic origin is presented, and the anatomically-driven diagnostics for these atypical varicose veins are discussed. Focus on ultrasonographic detection of the escape points, which are located at the sites where the incompetent intra-pelvic and extra-pelvic veins are connected—such as the perineal veins, veins running alongside the round ligament of the uterus, the obturator vein, as well as the inferior and superior gluteal veins—is emphasized.

An integrative taxonomic study on needlefishes (Belonidae) unveils two new species within the genus Ablennes from the Indian Ocean

The needlefish genus Ablennes remains monotypic, characterized by the globally distributed flat needlefish known as Ablennes hians. Their taxonomy has been mired with ambiguities due to the greater-than-average morphological variations observed in samples from different regions. Utilizing integrated taxonomic methods relying on mitochondrial molecular markers, it was revealed that the species initially perceived as a single entity is, in fact, a complex comprising at least three different species. In this context, we introduce two new species: Ablennes joseberchmansis sp. nov. and Ablennes gracalii sp. nov., They are morphologically distinct: in view of the morphometry and meristic characteristics. A. joseberchmansis sp. nov. and A. gracalii sp. nov. display distinct differentiation characteristics from A. hians in terms of dorsal fin, nostril position, dorsal fin origin, vertebrae count, scale counts, head length, eye diameter, interorbital width, maxilla length, dorsal ray height, depth at pelvic origin, lower lobe of the caudal fin, and caudal peduncle depthcaudal peduncle depth. These variations highlight their unique morphological traits and aid in their differentiation within the genus Ablennes. We assessed genetic relationships using a Maximum likelihood (ML) phylogenetic tree, revealing three distinct clades of morphological differences in Ablennes specimens from different morphological groups. The genetic variation, as represented by Kimura 2 parameter (K2P) distances, within the three Ablennes species spans from 6.5% to 9.4%. More specifically, we observed a 7.5% genetic difference between A. hians and A. joseberchmansis sp. nov., and a 6.5% distinction between A. hians and A. gracalii sp. nov. The interspecies divergence between the two newly identified species measured at 9.4%. These findings, which showcase the genetic distinctions among the three morphologically distinct Ablennes specimens, provide strong confirmation for the existence of three separate species within the Ablennes genus of needlefish in the Indian Ocean.

A comprehensive ultrasound approach to lower limb varicose veins and abdominal-pelvic connections

ObjectivePelvic venous reflux may be responsible for pelvic venous disorders and/or lower-limb (LL) varicose veins. Ultrasound investigation with Doppler allows a complete study of the entire infra-diaphragmatic venous reservoir. The aim of this study was to guide and standardize the investigation of the pelvic origin of venous reflux in female patients with LL varicose veins. MethodsIn this case-control study, we applied a comprehensive ultrasound investigation protocol, which involved four steps: (1) venous mapping of the lower limbs; (2) transperineal and vulvar approach; (3) transabdominal approach; and (4) transvaginal approach. ResultsForty-four patients in group 1 (patients with LL varicose veins and pelvic escape points [PEPs]) and 35 patients in group 2 (patients with LL varicose veins without PEPs [control group]) were studied, matched by age. The median age was 43 years in both groups. The calculated body mass index was lower in group 1 (23.4 kg/m2) compared with the control group (25.4 kg/m2), and this difference reached statistical significance (P < .001). The presence of pelvic varicose veins (PVs) by transvaginal ultrasound was 86% in group 1 and 31% in group 2. Perineal PEPs were the most prevalent, being found in 35 patients (79.5%), more frequent on the right (57.14%) than on the left (42.85%) and associated with bilateral PVs 65.7% of the time. In group 1, 23 patients (52%) reported recurrent varicose veins vs eight patients (23%) in the control group (P = .008). Regarding the complaint of dyspareunia, a significant difference was identified between the groups (P = .019), being reported in 10 (23%) patients in group 1 vs one patient (2.9%) in the control group. The median diameters in the transabdominal approach of the left gonadal veins were 6.70 mm for group 1 and 4.60 mm for group 2 (P < .001). In patients with PVs in group 1, the median diameter of PEPs at the trans-perineal window was 4.05 mm. In the transvaginal examination, the mean diameter of the veins in the peri uterine region was 8.71 mm on the left and 7.04 mm on the right. ConclusionsThe identification of PEPs by venous mapping demonstrates the pelvic origin of the reflux and its connections with the LL varicose veins. For a more adequate treatment plan, we suggest a complete investigation protocol based on the transabdominal and transvaginal study to rule out venous obstructions, thrombotic or not, and confirm the presence of varicose veins in the pelvic adnexal region.

Pelvic escape points: Bottom- up is the way to go!

Varicose veins (VVs) of pelvic origin are one of the clinical presentations of pelvic venous disorders (PeVD) and are increasingly being diagnosed in patients in phlebological offices these days. To investigate VVs potentially resulting from pelvic vein incompetence (PVI), a usual full duplex ultrasonography (DUS) of lower extremity veins in the upright position is recommended as well as DUS for evaluation of pelvic escape points (PELVs). Seven PELVs have been described, connecting the pelvic veins to the veins of the genital region and/or legs. There are two possible treatment options for pelvic origin VVs, top-down treatment such as pelvic vein embolization or treatment of iliac/renal vein compression if it is the cause of PVI and bottom-up treatment of PELVs and related VVs. The idea of the latter approach is to treat the causes of the external pelvic VVs in the genital region and VVs in the legs without having to treat asymptomatic pelvic veins within the pelvis. The most common methods of bottom- up treatment are sclerotherapy, surgical ligation and miniphlebectomy. The efficacy of such treatment approach for VVs of pelvic origin has been reported in the literature, whereas studies have failed to demonstrate good results of top- down treatment in the context of eliminating VVs of pelvic origin as well as minimizing the risk of VVs recurrence. Bottom-up treatment is a useful option to avoid unnecessary and more expensive pelvic vein embolization and should be considered as an initial therapeutic approach. Only if bottom-up treatment fails, if the VVs recur rapidly, or if the patient develops pelvic symptoms due to PVI, pelvic veins embolization can be considered.

Apples and oranges in pelvic venous disorders: Heterogeneity and best practice

Pelvic venous disorder represents an as common as challenging clinical scenario because of the blurred borders between pelvic region and lower limb treatment target, because of the subtle and aspecific signs and symptoms, because of the lack of large randomized comparative trials providing clarity on the best practice and strong recommendations. Herein we present pathophysiology and clinical considerations on the lower limb varicosities of pelvic origin, suggesting possible management strategies based on clinical manifestation, ultrasound detection and targeted sclerotherapy. Large studies are needed to identify the best diagnostic parameters guiding the best strategy and highlighting the most reliable reported outcomes from such heterogeneous patients.

Acute Abdominal Case Report: Ruptured Ovarian Endometriotic Cyst Concurrent with Acute Appendicitis

Acute pain of pelvic origin is a common symptom necessitating emergent medical evaluation. Acute pelvic pain in young women can present as a unique diagnostic dilemma. Differential diagnosis in acute pelvis pain can vary according to risk. Possible causes span a gamut from functional ovarian cysts that require routine follow-up to adnexal torsion and ectopic pregnancy requiring urgent surgical management. This case report illustrates how concomitant gynecologic disorders can occur in patients with acute appendicitis. The laparoscopic operation revealed a ruptured ovarian endometriotic cyst concurrent with acute appendicitis and was proven by histopathology. This serves as a reminder that even though a rare case is contemporary, two different entities can occur.

Routine use of concurrent fluoroscopic imaging during superficial endovenous interventions: A position statement of the International Union of Phlebology, the Australasian College of Phlebology, the Australia and New Zealand Society for Vascular Surgery, the American Venous Forum, the American Vein and Lymphatic Society, the European College of Phlebology and the Interventional Radiology Society of Australasia.

International evidence-based guidelines recommend preoperative duplex ultrasound mapping in the assessment of chronic venous disease, and concurrent ultrasound imaging to guide superficial endovenous interventions such as endovenous laser ablation, radiofrequency ablation, cyanoacrylate adhesive closure, and sclerotherapy (ultrasound-guided sclerotherapy). Other imaging modalities such as venography, alone or in combination with computed tomography scan or magnetic resonance imaging, may be included in the preoperative assessment of a small and select group of patients to exclude central venous obstruction, certain deep venous pathologies, pelvic origin extrapelvic varices, and complex vascular malformations. The signatory scientific and medical societies recommend against the routine use of fluoroscopy and other radiation-based imaging in the investigation and treatment of superficial venous disease.

Routine use of concurrent fluoroscopic imaging during superficial endovenous interventions: A position statement of the International Union of Phlebology (UIP), the Australasian College of Phlebology (ACP), the Australia and New Zealand Society for Vascular Surgery (ANZSVS), the American Venous Forum (AVF), the American Vein and Lymphatic Society (AVLS), the European College of Phlebology (ECoP) and the Interventional Radiology Society of

International evidence-based guidelines recommend preoperative duplex ultrasound mapping in the assessment of chronic venous disease, and concurrent ultrasound imaging to guide superficial endovenous interventions such as endovenous laser ablation, radiofrequency ablation, cyanoacrylate adhesive closure, and sclerotherapy (ultrasound-guided sclerotherapy). Other imaging modalities such as venography, alone or in combination with computed tomography scan or magnetic resonance imaging, may be included in the preoperative assessment of a small and select group of patients to exclude central venous obstruction, certain deep venous pathologies, pelvic origin extrapelvic varices, and complex vascular malformations. The signatory scientific and medical societies recommend against the routine use of fluoroscopy and other radiation-based imaging in the investigation and treatment of superficial venous disease.

Percutaneous Nephrostomy Verses Ureteral Stenting for the Analysis and Management of Urinary Track Obstruction

Introduction: Ureteral obstruction is a heterogeneous clinical entity, and it is often challenging for the clinician to determine the optimal method of decompression. Objectives of the study: The main objective of the study is to find the percutaneous nephrostomy verses ureteral stenting for the analysis and management of urinary track obstruction. Methodology of the study: This cross sectional study was conducted at Department of Urology, DHQ Teaching Hospital Gujranwala during January 2021 till October 2021. The data was collected from 55 patients. The data was collected with the permission of ethical committee of hospital. In all patients, the procedures were conducted by urologists. Results: There were 55 patients in this study. The mean age was 57.65 ± 2.54 years. There were 33 patients with ureteral stents and 22 (40%) with PCN tubes. The mean length of redirection was 17.8 ± 4.6 months in the stent bunch versus 13.1 ± 4.89 months in the PCN bunch (p = 0.059) (table 01). Conclusion: It is concluded that PCN is proved to be a suitable modality for drainage of pyonephrosis and ureteric obstruction especially due to malignant disease of pelvic origin which can otherwise be highly fatal.

Redescription of the Guiana Shield Darter Species Characidium crandellii and C. declivirostre (Crenuchidae) with Descriptions of Two New Species

Based on collections made in the western Guiana Shield over the last 21 years, Characidium crandellii and C. declivirostre are redescribed and two similar species are described from Guyana. These species all have enlarged paired fins with three to four rays thickened ventrally on the pectoral fin and two rays thickened on the pelvic fin. The species can be separated from all other Characidium and Melanocharacidium by having the venter unscaled from the isthmus to the pelvic origin. Characidium crandellii is found in the Essequibo and Takutu River systems and in an isolated population above Tencua Falls in the Ventuari River and the upper Paragua River (Orinoco River basin). Characidium declivirostre is found throughout the right-bank, shield tributaries of the Orinoco River system and in the upper Negro River. Characidium duplicatum, new species, appears to be rare but widely distributed in the Essequibo River system. Characidium wangyapoik, new species, is only known from the upper Ireng River, Branco River basin, along the border between Brazil and Guyana.

Clinical Presentation and Evaluation of Pelvic Venous Disorders in Women

The term pelvic venous disorders (PeVD) describes a group of related clinical entities with overlapping clinical presentations that were previously characterized by separate imprecise syndromic terminology. The clinical manifestations of PeVD may variously include chronic pelvic pain; pelvic origin extrapelvic lower extremity and genital varices; lower extremity pain and swelling; and left flank pain and hematuria. This manuscript focuses on the primary manifestations of PeVD in women - chronic pelvic pain and pelvic origin lower extremity and vulvar varices - and will review the underlying pathophysiology and related complicating factors (such as maladaptive pain responses) to explain the variety of clinical presentations.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology (“SVP”) classification for PeVD, includes three domains—Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVPA,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Effect of auriculotherapy on pain and sexual function of primary dysmenorrhea female patients

ABSTRACT BACKGROUND AND OBJECTIVES: Dysmenorrhea is characterized by pain in the abdominal and pelvic region, of chronic and cyclic origin, associated with menstruation, more prevalent in childbearing age women, and occurs in adolescence after the onset of the ovulatory cycles. The objective of this study was to analyze the effects of auriculotherapy on pain levels and sexual function in women with primary dysmenorrhea. METHODS: This is a longitudinal, prospective, randomized controlled, blinded clinical trial with a quantitative approach, with 168 students of a higher education institution. RESULTS: The controlled groups in the intragroup analysis did not present significant results on pain, while one of the experimental groups presented significant values, In the intergroup data, only the controlled and one experimental showed significant values. Regarding the female sexual function analysis, none of the groups presented significant data. CONCLUSION: Auriculotherapy proved to be beneficial in reducing the level of pain.

Antimicrobial Stewardship Opportunities in Patients with Bacteremia Not Identified by BioFire FilmArray.

A subset of bacteremia cases are caused by organisms not detected by a rapid-diagnostics platform, BioFire blood culture identification (BCID), with unknown clinical characteristics and outcomes. Patients with ≥1 positive blood culture over a 15-month period were grouped by negative (NB-PC) versus positive (PB-PC) BioFire BCID results and compared with respect to demographics, infection characteristics, antibiotic therapy, and outcomes (length of hospital stay [LOS] and in-hospital mortality). Six percent of 1,044 positive blood cultures were NB-PC. The overall mean age was 65 ± 22 years, 54% of the patients were male, and most were admitted from home; fewer NB-PC had diabetes (19% versus 31%, P = 0.0469), although the intensive care unit admission data were similar. Anaerobes were identified in 57% of the bacteremia cases from the NB-PC group by conventional methods: Bacteroides spp. (30%), Clostridium (11%), and Fusobacterium spp. (8%). Final identification of the NB-PC pathogen was delayed by 2 days (P < 0.01) versus the PB-PC group. The sources of bacteremia were more frequently unknown for the NB-PC group (32% versus 11%, P < 0.01) and of pelvic origin (5% versus 0.1%, P < 0.01) compared to urine (31% versus 9%, P < 0.01) for the PB-PC patients. Fewer NB-PC patients received effective treatment before (68% versus 84%, P = 0.017) and after BCID results (82% versus 96%, P = 0.0048). The median LOS was similar (7 days), but more NB-PC patients died from infection (26% versus 8%, P < 0.01). Our findings affirm the need for the inclusion of anaerobes in BioFire BCID or other rapid diagnostic platforms to facilitate the prompt initiation of effective therapy for bacteremia.

The efficacy of the ganglion impar block in perineal and pelvic cancer pain.

Visceral pain conducted by sympathetic fibers with pelvic and perineal origin can be treated using ganglion impar (GIB) or Walters' block in a simple and effective manner. This article aims to evaluate the effectiveness, security, and performance difficulty of GIB in patients with pelvic and perineal oncological pain. A retrospective study between January 2016 and August 2017. Patients with poorly controlled pelvic oncological pain and patients experimenting opioid side effects in which GIB was performed ambulatory were included. Prognostic GIB was performed, under echographic and fluoroscopic control, with local anesthetic and corticoid. The neurolytic block was performed under fluoroscopic guidance. The technique was performed by the same anesthetist with pain management competence. For statistical analysis, Microsoft Excel 2013® and IBM SPSS Statistics version 22.0 were used. Fifteen patients were included. One patient was excluded. A statistical significant basal pain score reduction was observed ((median of the verbal numerical scale (VNS) 7 (p25 = 7; p75 = 8)) compared with 72h median VNS 4 ((p25 = 3; p75 = 5.3) p= 0.001, and 3months (median VNS 4 (p25 = 3, p75 = 7)) p= 0.003 after the procedure. Regarding morphine consumption, a statistically significant reduction was observed 3months after GIB performance (p = 0.012). GIB is a safe and easy-to-perform technique achieving satisfactory and statistically significant results, regarding pain control improvement and opioid consumption reduction in patients which meet selection criteria. Prospective, randomized studies with more patients are needed for further conclusions.

The Effectiveness of Surgeon Decision on Pain Syndrome of Pelvic Origin Treatment in Women Estimated with the Model of Decision Tree

The Effectiveness of Surgeon Decision on Pain Syndrome of Pelvic Origin Treatment in Women Estimated with the Model of Decision Tree

Careproctus surugaensis sp. nov. (Liparidae), a new snailfish from Suruga Trough, Japan

A new species of liparid fish Careproctus surugaensis is described from a single specimen collected between 1,450 and 1,570 m depth on the northern part of Suruga Trough, Suruga Bay, Japan. It can be distinguished from all currently recognized congeners by the following combination of characters: 50 total vertebrae, 47 dorsal-fin rays, 39 anal-fin rays, 32 pectoral-fin rays, 10 principal caudal-fin rays, pectoral proximal radials 4 (first to third with notches); trilobate teeth on both jaws, gill slit 7.1 % SL, extending in front of 7th pectoral fin ray base; maximum body depth 19.1 % SL, disk length 7.9 % SL, anus midway between posterior margin of pelvic disk and anal-fin origin; body and fins light orange except blackish peritoneum.

Intractable Rectal Pain Secondary to Colonic Stent Placement in Patient With Advanced Pelvic Cancer Successfully Treated With Hypogastric Nerve Plexus Neurolysis

Introduction: Symptomatic treatment of advanced rectal cancer can prove sometimes difficult to manage. Untreated pain from cancerous origin can lead to decreased quality of life and increase in morbidity. Colonic stent placement is a tool to relieve bowel obstruction and improve quality of life. Complications with the hypogastric nerve with colonic stent placement is sometimes an unfortunate result. The technique of superior hypogastric nerve plexus neurolysis is a procedure that can be used to relieve pain from stent insertion in individuals suffering from cancers of pelvic origin. Case Report: A 59 year old Caucasian female presented to the pain clinic diagnosed with ovarian cancer stage IV status post debulking surgery, chemotherapy and radiotherapy. She was found to have recurrent cancer involving the rectum, liver and peritoneum. Uncovered self-expandable metallic colonic stent (25 mm x 120 mm) was placed at the rectosigmoid junction with distal end of the stent positional at 5 cm proximal to the anorectal junction to relieve bowel obstruction for better quality of life. The patient subsequently developed intractable rectal pain despite use of opioids. Diagnostic block of the superior hypogastric plexus followed by neurolysis was performed by pain management service under fluoroscopy to relieve this patient's pain. The pain relief was achieved after neuolysis. Conclusion: Significant rectal pain is a potential complication of post endoluminal colonic stent placement. The condition could be alleviated by hypogastric nerve plexus neurolysis when medical therapy failed.Figure 1Figure 2

Embolization is not essential in the treatment of leg varices due to pelvic venous insufficiency.

To consider if it is essential to perform embolization in the treatment of leg varices due to pelvic venous insufficiency. Review of the current literature concerning treatment options of leg varicose veins of pelvic origin. Pelvic venous insufficiency, vulvar and pudendal varicose veins as well as pelvic congestive syndrome are under diagnosed entities. Embolization of ovarian and pelvic veins is well established in patients with pelvic congestive syndrome. In varicose veins of pelvic origin but without pelvic congestive syndrome, comparative studies comparing the outcome of embolization or treatment of varicose veins by sclerotherapy or phlebectomy alone are missing. Foam sclerotherapy or phlebectomy shows good results in patients with varicose veins of pelvic origin. Embolization is not essential in the treatment of leg varices of pelvic origin without pelvic congestive syndrome. Foam sclerotherapy or phlebectomy shows good results in patients with vulvar or pudendal varicose veins. Randomized comparative studies using embolization of incompetent pelvic veins or sclerotherapy of varicose veins with pelvic origin should be performed.

Prevention of pelvic radiation disease.

Pelvic cancers are among the most frequently diagnosed cancers worldwide. Treatment of patients requires a multidisciplinary approach that frequently includes radiotherapy. Gastrointestinal (GI) radiation-induced toxicity is a major complication and the transient or long-term problems, ranging from mild to very severe, arising in non-cancerous tissues resulting from radiation treatment to a tumor of pelvic origin, are actually called as pelvic radiation disease. The incidence of pelvic radiation disease changes according to the radiation technique, the length of follow up, the assessment method, the type and stage of cancer and several other variables. Notably, even with the most recent radiation techniques, i.e., intensity-modulated radiotherapy, the incidence of radiation-induced GI side effects is overall reduced but still not negligible. In addition, radiation-induced GI side effects can develop even after several decades; therefore, the improvement of patient life expectancy will unavoidably increase the risk of developing radiation-induced complications. Once developed, the management of pelvic radiation disease may be challenging. Therefore, the prevention of radiation-induced toxicity represents a reasonable way to avoid a dramatic drop of the quality of life of these patients. In the current manuscript we provide an updated and practical review on the best available evidences in the field of the prevention of pelvic radiation disease.