Pelvic Pain Symptoms Research Articles

Diagnostic accuracy of Cancer Antigen 125 (CA125) for endometriosis in symptomatic women: A multi-center study

Study objectiveTo assess the diagnostic accuracy of serum Cancer Antigen 125 (CA 125)≥30units/milliliter (u/ml) for diagnosing endometriosis in symptomatic women. Study designProspective observational cohort study including patients with symptoms of pelvic pain or subfertility undergoing elective diagnostic laparoscopy at two tertiary referral hospitals. We excluded patients suspected to have other gynecological pathology. We evaluated the accuracy of serum CA 125 (index test) with histologically confirmed endometriosis (reference standard). Main resultsFifty-eight consecutive women recruited between October 2013 to March 2015. Women with endometriosis had a higher CA 125 level than those without endometriosis (mean 54.7+/−71.6 vs 16.2+/− 8.0). The specificity of CA 125≥30u/ml was 96% (95% CI 81.7–99.9%) and sensitivity was 57% (95% CI 37.4–74.5%). The positive likelihood ratio for the histological presence of endometriosis with a CA 125≥30u/ml was 15.8 (95% CI 2.3-112) providing a post-test probability of 94% (95% CI 71%–99%) in women with pelvic pain or subfertility. The area under the curve, 0.85 (95% CI 0.74–0.96) indicates high test accuracy. ConclusionsCA 125≥30u/ml is highly predictive of endometriosis in women with symptoms of pain and/or subfertility. CA 125 should be considered as a rule-in test for expediting the diagnosis and management of endometriosis, CA 125 <30u/ml is, however, unable to rule out endometriosis.

Interstitial Cystitis/Bladder Pain Syndrome: a Review and an Update

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition characterized by pelvic pain and lower urinary tract symptoms. The evolution of nomenclature of IC/BPS has experienced a long history. The disease etiology is not yet fully understood; potential pathophysiologic causes proposed include defect of layer of glycosaminoglycan (GAG) on the apical surface of bladder floor; autoimmune, inflammatory, and neurogenic mechanisms; infection; and so on. There are a lot of strategies to cure IC/BPS, mainly including behavioral therapy, oral medicines, intravesical treatments, and intradetrusor botulinum toxin A (BTXA) injection. But none of them is curative. Most treatments are aimed at controlling symptom and improving the quality of life of patients. In this article, we will talk about the new progress of definition, etiology, and treatment on IC/BPS.

Psychotherapy With Somatosensory Stimulation for Endometriosis-Associated Pain: A Randomized Controlled Trial.

To evaluate whether psychotherapy with somatosensory stimulation is effective for the treatment of pain and quality of life in patients with endometriosis-related pain. Patients with a history of endometriosis and chronic pelvic pain were randomized to either psychotherapy with somatosensory stimulation (ie, different techniques of acupuncture point stimulation) or wait-list control for 3 months, after which all patients were treated. The primary outcome was brain connectivity assessed by functional magnetic resonance imaging. Prespecified secondary outcomes included pain on 11-point numeric rating scales (maximal and average global pain, pelvic pain, dyschezia, and dyspareunia) and physical and mental quality of life. A sample size of 30 per group was planned to compare outcomes in the treatment group and the wait-list control group. From March 2010 through March 2012, 67 women (mean age 35.6 years) were randomly allocated to intervention (n=35) or wait-list control (n=32). In comparison with wait-list controls, treated patients showed improvements after 3 months in maximal global pain (mean group difference -2.1, 95% confidence interval [CI] -3.4 to -0.8; P=.002), average global pain (-2.5, 95% CI -3.5 to -1.4; P<.001), pelvic pain (-1.4, 95% CI -2.7 to -0.1; P=.036), dyschezia (-3.5, 95% CI -5.8 to -1.3; P=.003), physical quality of life (3.8, 95% CI 0.5-7.1, P=.026), and mental quality of life (5.9, 95% CI 0.6-11.3; P=.031); dyspareunia improved nonsignificantly (-1.8, 95% CI -4.4 to 0.7; P=.150). Improvements in the intervention group remained stable at 6 and 24 months, and control patients showed comparable symptom relief after delayed intervention. Psychotherapy with somatosensory stimulation reduced global pain, pelvic pain, and dyschezia and improved quality of life in patients with endometriosis. After 6 and 24 months, when all patients were treated, both groups showed stable improvements. ClinicalTrials.gov, https://clinicaltrials.gov, NCT01321840.

Laparoscopic Essure Removal

Essure contraceptive device is an FDA approved tubal occlusive sterilization method that has been available for over a decade. There has been a steady increase in the number of patients requesting Essure removal due to perceived relationship to pelvic pain and other symptoms. Patients presenting for consultation request complete removal of the device. They are counseled that their symptoms may persist despite Essure removal. This video presents three techniques of laparoscopic Essure removal. In the first technique, the fallopian tubes and the uterine cornua are removed. In the second technique, the distal fallopian tube is incised and the Essure device is extracted, followed by a salpingectomy while preserving the cornua. Some patients elect to undergo a total laparoscopic hysterectomy with bilateral salpingectomy. In 11 patients surveyed, 73% reported improvement in pelvic pain and quality of life.

Clinical Commentary: Pelvic Organ Prolapse and Incontinence

Background and Purpose: Pelvic organ prolapse (POP) and urinary incontinence (UI) are more prevalent with increasing life expectancy. Up to 75% of women age 45 to 85 years have some degree of prolapse. Typical symptoms related to POP include pelvic pressure, pelvic and low back pain, urinary and bowel symptoms, and sexual dysfunction. The purpose of this report is to describe the theoretical basis of a novel conservative intervention for the treatment of symptoms related to POP and incontinence in older women through the use of a case description. Methods: The conservative management program combines deep pelvic and hip muscle exercises with pelvic postural inversion. The case description exemplifies the treatment protocol that has the potential to reduce the severity or degree of prolapse and improve symptoms and quality of life in women with POP and associated UI. Conclusion: The basis for the novel conservative approach to treatment of POP and UI revolves around the perspective that POP is the functional failure of the pelvic organ support system and associated lumbopelvic hip musculoskeletal system. The combined organ and musculoskeletal system, the “pelvic core” system, includes all structures within the lower pelvis. As one organ's descent occurs, it leads to alterations in the position of adjacent organs, fascia, and muscles. Postural or positional inversion of the pelvis simultaneous with deep pelvic muscle and pelvic core exercises theoretically realigns the pelvic organs within the pelvic cavity and reduces strain on fascia and ligaments. Without the strain of the organs descending in the pelvis, the pelvic core muscles can theoretically work more efficiently for muscle strengthening and motor control retraining. Organ realignment and deep pelvic core muscle activation theoretically recreates the support system for optimal organ function and symptom-free daily activities.

Transgenic Mice Expressing MCP-1 by the Urothelium Demonstrate Bladder Hypersensitivity, Pelvic Pain and Voiding Dysfunction: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Animal Model Study.

Monocyte chemoattractant protein-1 (MCP-1) is one of the key chemokines that play important roles in diverse inflammatory and chronic pain conditions. Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic and debilitating inflammatory condition of the urinary bladder characterized by the hallmark symptoms of pelvic pain and voiding dysfunction. To facilitate IC/BPS research, we used transgenic technology to develop a novel urothelial MCP-1 secretion mouse model (URO-MCP-1). A transgene consisting of the uroplakin II gene promoter and the mouse MCP-1 coding sequence with a secretory element was constructed and microinjected. URO-MCP-1 mice were found to express MCP-1 mRNA in the bladder epithelium and MCP-1 protein in the urine, and developed bladder inflammation 24 hours after intravesical administration of a single sub-noxious dose of lipopolysaccharide (LPS). The inflamed bladders of URO-MCP-1 mice exhibited elevated mRNAs for interleukin (IL)-1ß, IL-6, substance P precursor, and nerve growth factor as well as increased macrophage infiltration. In parallel with these phenotypic changes, URO-MCP-1 mice manifested significant functional changes at days 1 and 3 after cystitis induction. These functional changes included pelvic pain as measured by von Frey filament stimulation and voiding dysfunction (increased urinary frequency, reduced average volume voided per micturition, and reduced maximum volume voided per micturition) as measured by micturition cages. Micturition changes remained evident at day 7 after cystitis induction, although these changes were not statistically significant. Control wild-type C57BL/6 mice manifested no clear changes in histological, biochemical and behavioral features after similar cystitis induction with LPS. Taken together, our results indicate that URO-MCP-1 mice are hypersensitive to bladder irritants such as LPS and develop pelvic pain and voiding dysfunction upon cystitis induction, providing a novel model for IC/BPS research.

Dyspareunia and depressive symptoms are associated with impaired sexual functioning in women with endometriosis, whereas sexual functioning in their male partners is not affected.

To what extent are endometriosis and its related physical and mental symptoms associated with the perceived level of sexual functioning in women and their male partners? Dyspareunia and depressive symptoms are associated with impaired sexual functioning in women with endometriosis, whereas sexual functioning in their male partners is not affected. Women with endometriosis suffer from more dyspareunia, lower sexual functioning, and lower quality of life. In qualitative studies, partners of women with endometriosis report that endometriosis affected their quality of life and produced relational distress. In this cross-sectional study, sexual functioning in women with endometriosis (n=83) and their partners (n=74) was compared with sexual functioning in a control group of women attending the outpatient department for issues related to contraception (n=40), and their partners (n=26). Women and partners were recruited in the Maastricht University Medical Centre (MUMC) and the VieCuri Medical Centre Venlo between June 2011 and December 2012. All participants were asked to complete a set of online questionnaires. Response rates were 59.3% (83/140) for women with endometriosis and 52.3% (74/140) for their partners. Response rates in the control group were respectively 43.2% and 27.4% (41/95 and 27/95), of whom 40 women and 26 partners could be included in the study. Women with endometriosis as compared with the control group, reported significantly more frequent pain during intercourse (53% versus 15%, P<0.001); higher levels of chronic pain (median VAS 2.0 cm versus 0.0 cm, P<0.001); more impairment of sexual functioning (median Female Sexual Function Index 25.4 versus 30.6, P<0.001); more impairment of quality of life (median Short Form-12 66.3 versus 87.2, P<0.001); more pain catastrophizing (mean Pain Catastrophizing Scale 17.8 versus 8.5, P<0.001), more depression and anxiety symptoms (median Hospital Anxiety and Depression Scale for depression 7 versus 4, P<0.001 and for anxiety 4 versus 1, P<0.001). Sexual functioning was comparable between male partners of women with endometriosis and male partners of the control group based on the International Index of Erectile Function. Logistic regression analyses showed that dyspareunia (OR 0.54; 95% CI 0.39-0.75) and depressive symptoms (OR 0.761; 95% CI 0.58-0.99) were independent and significant negative predictors for sexual functioning. Chronic pelvic pain (OR 0.53; 95% CI 0.35-0.81) and depressive symptoms (OR 0.65; 95% CI 0.44-0.96) were independent and significant negative predictors for quality of life. Patient recruitment was performed in one tertiary care centre and to a lesser extent one general hospital, possibly leading to an over-representation of patients with more severe endometriosis. All participating women had a partner and are therefore 'survivors' in relationship terms. This may have led to an underestimation of the impact of endometriosis on sexual functioning. It would be worthwhile to further explore the role of depressive symptoms in women with symptomatic endometriosis and to assess the effect of treatment of depressive symptoms on sexual functioning and quality of life. The fact that the partners did not report impaired sexual functioning could be a reassuring thought to women that might be discussed in the consulting room. The study was funded by the MUMC. An unconditional research grant was given by the Dutch Society of Psychosomatic Obstetrics and Gynaecology (21 June 2011). Not applicable.

Psychologie et sexologie : une approche essentielle, du diagnostic à la prise en charge globale de l’endométriose

Endometriosis, defined by the presence of endometrial tissue outside the uterine cavity, is a common but often under diagnosed pathology. The clinical manifestations are varied (chronic pelvic pain, urinary or gastrointestinal symptoms) and can sometimes be very frustrated, delaying the diagnosis. This delay in diagnosis can be a high source of stress responsible for an important psychological impact in these patients, having a sense of misunderstanding and neglect of the medical profession. This climate of stress and anxiety can cause alteration of behavior including sexual disorders. In addition, endometriosis can be revealed as part of an infertility evaluation, and the patient and the couple can already be affected by this situation. The clinical and psychological impact of endometriosis inevitably leads to an impairment of patient's quality of life and sexuality. The objective of this article is to show the psychological consequences of endometriosis and its impact on sexuality, in order to highlight this essential aspect for a comprehensive care of patients.

AB271. Sexual dysfunction in chronic prostatitis

Chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS), or NIH category III prostatitis, is a clinical syndrome characterized by genital/ pelvic pain and lower urinary tract symptoms in the absence of urinary tract infection. CPPS is the most common prostatic disease in men younger than 50 years of age and the third most common in men older than 50 years of age. CP/CPPS is a complex entity with unclear etiology. Many articles reported that the high percentage of patients with CP/CPPS had sexual dysfunction. The most common symptoms of sexual dysfunction in chronic prostatitis patients are erectile dysfunction (ED), painful ejaculation and premature ejaculation. So we will discuss about ED and ejaculation problems in CP/CPPS patients.

8: Use of suprapubic carter-thomason needle to assist in cystoscopic excision of intravesical foreign object

We present a video of a minimally-invasive technique using the Carter-Thomason Needle Suture Passer for suprapubic assistance in the cystoscopic removal of the intravesical eroded suture. Suture injury to the bladder occurs in 0.6% of cases of retropubic bladder neck suspension procedures (1). These injuries can occur from inadvertent placement of the sutures through the bladder at the time of surgery or postoperative erosion or migration of the sutures into the bladder, and can lead to chronic inflammatory reaction in the wall of the bladder and stone formation. Common symptoms are of urinary frequency, urgency, urinary tract infection, voiding difficulty and pelvic pain. Intraoperative cystoscopy detects some, but not all, suture bladder injuries. It is therefore important to exclude intravesical foreign body in patients with lower urinary tract symptoms and a history of bladder neck suspension. We describe a case of a 63 year old woman with symptoms of recurrent urinary tract infections, urinary frequency, urgency, hesitancy, dysuria, microscopic hematuria and pelvic pain. She underwent a ‘bladder suspension’ 23 years prior for stress urinary incontinence, which she reported as being uncomplicated. Pelvic ultrasound demonstrated a 2cm bladder calculus. Office cystoscopy revealed a 3cm stone-encrusted suture erosion of the bladder. The use of a Carter-Thomason Needle Suture Passer for suprapubic assistance in the cystoscopic removal of intravesical suture is a minimally invasive surgical technique that can be applied to removal of other foreign objects, such as mesh. Compared to suprapubic trocars, prolonged catheterization and follow-up cystogram are not necessary.

Do Fibromyalgia Flares Have a Neurobiological Substrate?

Fibromyalgia (FM) is a chronic central pain sensitivity syndrome manifesting as widespread pain and tenderness with no evidence of soft tissue inflammation [1]. It affects around 2% to 8% of the general population, with a prevalence that increases with age, and marked female predominance [2]. The main clinical manifestations are chronic widespread pain (CWP) with multiple tender points on physical examination, fatigue [3], headaches [4], sleep difficulties, and cognitive disturbances referred to as “fibro fog” [5]. Individuals with FM may also present with nonspecific symptoms of chest, abdominal, or pelvic pain, paresthesias, and lower urinary tract symptoms [6–9]. The 2010 ACR preliminary diagnostic criteria for FM offer nonspecialists a new diagnostic approach that does not require tender point examination and counting, as was the case with the 1990 criteria, and provide a symptom severity scale and a recognition of the importance of cognitive and somatic symptoms in this disorder [10]. Moreover, several functional somatic syndromes (e.g., chronic fatigue syndrome and irritable bowel syndrome), rheumatic diseases (e.g., rheumatoid arthritis, systemic lupus erythematosus, Sjogren’s syndrome, and ankylosing spondylitis), and psychiatric disorders occur with FM with a frequency that is significantly higher than that of the general population [6,11–15]. Major depressive disorder (MDD) and/or anxiety disorders are found in one-third to one-half of patients at the time of diagnosis [6]. Furthermore, depressed women with FM presented with more severe symptoms, worse overall physical condition, and lower quality of life compared with controls [16]. While the serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine and the anticonvulsant pregabalin are both FDA approved as first-line therapies [17,18], nonpharmacological therapies (i.e., aerobic exercises, physical therapy, cognitive behavioral therapy [CBT], and patient education) remain …

Abdominal Wall Pain in Women With Chronic Pelvic Pain.

To investigate the role of abdominal wall pain (AWP) in women with pelvic pain. We conducted a retrospective review of consecutive patients with pelvic pain seen in a tertiary referral centre between January and December 2012. AWP was defined as abdominal wall tenderness with a positive Carnett test (i.e., tenderness that worsened or remained the same with abdominal wall contraction). Pairwise comparisons were carried out between clinical variables (e.g., chronic pelvic pain) and AWP. This was followed by multiple logistic regression to identify the clinical variables with an independent association with AWP. The prevalence of AWP in women with pelvic pain was 67% (127/190). On multiple logistic regression, AWP was independently associated with chronic pelvic pain (OR 13.8; 95% CI 3.71 to 51.2, P< 0.001), but not with other symptoms including dysmenorrhea, deep and superficial dyspareunia, or bowel and bladder symptomology. In a corollary analysis, women with AWP were more likely to require opioids or pain adjuvants than women without AWP (P= 0.015 and P < 0.001). AWP is common in women with pelvic pain and may contribute specifically to the symptom of chronic pelvic pain.

Uterine Leukocyte Function and Dysfunction: A Hypothesis on the Impact of Endometriosis.

Endometriosis is a chronic inflammatory disease characterized by the growth of endometrial glands and stroma outside of the uterus. The disease affects approximately 10-15% of women of reproductive age and presents with clinical symptoms of pelvic pain and infertility. Changes in the leukocyte populations within the ectopic tissue and eutopic endometrium have been reported, and data suggest these alterations contribute to the pathology and symptoms of the disease. In this review, we discussed differences when comparing uterine NK cells and regulatory T cells within the eutopic endometrium between patients with endometriosis and healthy patients, and how these differences relate to implantation failure and/or decreased clearance of menstrual tissue in patients with the disease. The data demonstrate a critical need to examine endometrium and menstrual tissue in patients with endometriosis excluded from studies examining unknown causes of infertility and heavy menstrual bleeding. The information gathered from excluded patients will further enhance our understanding of how the immune system contributes to the pathophysiology of endometriosis and help to identify biomarkers for patients at higher risk for developing endometriosis-associated infertility.

Female sexual dysfunction in female genital mutilation.

Female genital mutilation (FGM), otherwise known as female genital cutting (FGC), is currently very topical and has become a significant global political issue. The impact of FGM on the lives of women and girls is enormous, as it often affects both their psychology and physical being. Among the complications that are often under-reported and not always acknowledged is female sexual dysfunction (FSD). FSD presents with a complex of symptoms including lack of libido, arousability and orgasm. This often occurs in tandem with chronic urogenital pain and anatomical disruption due to perineal scarring.To treat FSD in FGM each woman needs specifically directed holistic care, geared to her individual case. This may include psychological support, physiotherapy and, on occasion, reconstructive surgery. In many cases the situation is complicated by symptoms of chronic pelvic pain, which can make treatment increasingly difficult as this issue needs a defined multidisciplinary approach for its effective management in its own right. The problems suffered by women with FGM are wholly preventable, as the practice need not happen. The current global momentum to address the social, cultural, economic and medical issues of FGM is being supported by communities, governments, non-governmental agencies (NGOs) and healthcare providers. It is only by working together that the practice can be abolished and women and girls may be free from this practice and its associated consequences.

Herlyn-Werner-Wunderlich Syndrome /OHVIRA Syndrome; A Rare Urogenital Anomaly with Unusual Presentation in Two Cases with Review of Literature

The OHVIRA syndrome classically occurs in the setting of uterine didelphys or more rarely, a septate uterus with incidence in various case series is 0.1-3.8%. Renal agenesis is the most commonly reported urologic anomaly. The typical patient with this rare condition usually presents after menarche with nonspecific symptoms of recurrent pelvic pain or dysmenorrhea but both of our patients had atypical presentation. Sonography is frequently the initial imaging modality for evaluation of suspected Mullerian duct anomalies, MR imaging is an excellent modality for evaluating the frequently complex Mullerian duct anomalies. Treatment invariably requires surgical intervention in the form of excision of vaginal septum to relieve obstruction. In addition to relief of pain due to obstruction, surgery also reduces chances of pelvic endometriosis due to retrograde menstrual seeding. We are reporting these cases being their atypical presentation in adulthood life.

Is pelvic vein incompetence associated with symptoms of chronic pelvic pain in women? A pilot study

ObjectivePelvic vein incompetence (PVI) affects 15–20% of all women, yet we know little about how it affects sufferers. The aim of this prospective pilot study was to explore symptoms experienced by women with PVI, and determine its impact on quality of life and NHS costs. Study designCase-control study at a UK University teaching hospital conducted over an eight-month period. Cases were 40 premenopausal women aged 18–49 years with PVI and varicose veins (VV). There were two age-matched controls groups: (i) 40 healthy women with no PVI but with VV, and (ii) 40 healthy women with no PVI and no VV. Subjects were asked to complete a structured questionnaire on disease specific outcomes, health status and use of healthcare resources. ResultsMean age (range) was 39.8 (24–47) years for cases, 39.1 (24–49) for VV controls and 38 (25–49) for healthy controls. Pelvic pain was reported by 38 of 40 (95%) PVI cases, compared with 25 of 40 (62%) VV controls, and 26 of 40 (65%) healthy controls (p=0.001). The median (range) EQ-5D utility score for PVI cases was 0.80 (0.29–1.0) compared with 0.80 (0.09–1.0) for VV controls and 1.0 (0.62–1.0) for healthy controls (p=0.002). Of the 40 PVI cases, 35 (88%) visited a consultant in the previous 12 months compared with 12 of 40 (30%) VV controls, and 14 of 40 (35%) healthy controls (p<0.001). ConclusionsWomen with PVI report a greater frequency of pelvic pain with reduced health status and increased use of healthcare resources compared with matched controls.

Tanezumab Reduces Pain in Women with Interstitial Cystitis/Bladder Pain Syndrome and Patients with Nonurological Associated Somatic Syndromes

We performed pooled analyses from 3 small, clinical trials of tanezumab in patients with urological chronic pelvic pain, including chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis/bladder pain syndrome, to identify patient subpopulations more likely to benefit from tanezumab treatment. Pooled analyses included data from 208 patients with interstitial cystitis/bladder pain syndrome or chronic prostatitis/chronic pelvic pain syndrome randomized to placebo (104, 65 [62.5%] female) or tanezumab (104, 63 [60.6%] female) who received 1 dose or more of study medication. Data on tanezumab were from study A4091010 (interstitial cystitis/bladder pain syndrome) on 200 μg/kg intravenous, study A4091019 (chronic prostatitis/chronic pelvic pain syndrome) on 20 mg intravenous and study A4091035 (interstitial cystitis/bladder pain syndrome) on 20 mg subcutaneous. Primary study end points were evaluated using analysis of covariance with gender, study and baseline pain as covariates. For pooled analyses least squares mean (SE) change from baseline in 24-hour pain intensity vs placebo was -0.60 (0.24, 90% CI -0.99, -0.20) overall and -0.99 (0.32, p=0.002) and -0.17 (0.36, p=0.650) for females and males, respectively. The improvement in pain intensity was significant (p=0.011) for patients with symptoms suggesting the concomitant presence of nonurological associated somatic syndromes but not for those with pelvic pain symptoms only (p=0.507). Women with interstitial cystitis/bladder pain syndrome and patients with symptoms suggesting the concomitant presence of nonurological associated somatic syndromes were more likely to experience significant pain reduction with tanezumab than with placebo therapy. In contrast, no difference was reported in response between tanezumab and placebo therapy for men with chronic prostatitis/chronic pelvic pain syndrome symptoms only.

Recommendations to the primary care practitioners and the patients for managing pelvic pain, especially in painful bladder syndrome for early and better prognosis.

Painful bladder syndrome (PBS) is a common disease presenting with chronic pelvic pain and discomfort with at least one urinary symptom with no identifiable cause. The etiology is still unknown, and the medication has limited effects on pelvic pain or other urinary symptoms. This article presents advanced insight regarding the approach to PBS, particularly pelvic pain for primary care practitioners and patients. We suggest six tips for medical staff and suspected patients for easy diagnosis and proper treatment of pelvic pain. These six tips cover: Self-awareness of the disease; immediate urine culture test; specifying the location of pain urinary incontinence; frequency, or urgency without functional disorder of an overactive bladder helpful dietary control; complementary, and alternative medicine, and finding an expert. These tips might be helpful in advancing the schematic approach and in achieving better prognosis of PBS. Further study should be conducted to achieve better treatment for this disease, including development of a definitive test and diagnosis.

Ovarian Torsion in Postmenopausal Women and risk of malignancy

Background: Ovarian torsion is one of the most common causes of emergency surgery in gynecology, with a tendency to occur in postmenopausal women. The aim of this study was to provide information concerning the clinical presentations, surgical management, pathological findings and risk of malignancy in postmenopausal women with ovarian torsion. Methods:In this cross-sectional study, the risk of malignancy was assessed in postmenopausal women with ovarian torsion, who admitted to the Tumor Clinic of Ghaem Hospital, Mashhad, Iran in 2013. Frozen section technique was applied in patients undergoing laparotomy. The recorded data included patients’ age and symptoms, tumor markers, type of surgery, radiological findings and pathological results. Results: Among 44 menopausal patients with pelvic masses, 10 women were selected. The most common symptom was acute abdominopelvic pain (100%). In ultrasonic evaluation, complex ovarian mass was the most frequent finding. Free fluid in the pelvis was reported in 30% of cases. Moreover, serous tumor was the most common pathological finding. Malignancy was reported in 20% of cases; therefore, surgical staging was carried out for these patients. Conclusion: Ovarian torsion is a differential diagnosis in postmenopausal women with acute symptoms of lower abdominal or pelvic pain. Risk of malignancy due to adnexal masses should be considered in these patients.

Introduction: Management of endometriosis: moving toward a problem-oriented and patient-centered approach

Endometriosis is a protean disease, and its manifestations, associated clinical problems, and possible treatments are numerous. Deep endometriosis that infiltrates multiple pelvic organs should be considered the most severe endometriotic form that poses the most difficult therapeutic uncertainties in both infertility and pelvic pain symptoms limiting quality of life. The available evidence demonstrates that endometriosis is not only a gynecologic disorder but, contrary to previous belief, its impact extends into pregnancy, delivery, and the post-partum period. The old clinical tenet that pregnancy is a cure for endometriosis may be revealed as fallacious. Safe and effective modalities to reduce the risk of the recurrence of symptoms and lesions after conservative surgery for endometriosis are now available. These treatment options should be offered post-operatively to women not immediately seeking conception. Endometriosis is associated with a moderate increase in ovarian cancer risk. However, as there are no definitive demonstrations that endometriosis constitutes per se a pre-neoplastic condition, it seems currently unwise to set-up a screening program to detect undiagnosed endometriosis in asymptomatic women. Endometriosis is not a cancer; therefore a paradigm shift from treatment of lesions to treatment of symptoms is warranted. Management should be shaped on the main clinical problem, taking into consideration a woman's preferences and priorities. Quantitative information should be provided to describe the potential benefits, potential harms, and costs of each treatment alternative. Counseling should be complete and transparent, and the duty of the caring gynecologist is to inform the woman on the pros and cons of each option and support her in the shared decision-making process. The physician should be able to explain in detail all the available treatments, and not only those that the physician prefers or is able to offer.