Interstitial Cystitis, feat. Dr. Edward Kim

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Here’s the RoshReview Question of the Week!

A 41-year-old woman presents to your office for dysuria. She states that she has been having persistent urinary urgency and frequency for the past six months. She reports discomfort with bladder filling, pain with urination, and relief after voiding. A review of her history reveals normal fluid intake. A workup for pelvic pain performed by her primary care provider and gastroenterologist was negative. On physical exam, you note suprapubic tenderness. Her urinalysis and culture are negative. Which of the following is the best therapeutic option?

Check out if you answered correctly at the links above!

Today we welcome Dr. Edward Kim to the podcast. He is a urogynecology fellow at the University of Pennsylvania, performing research on a challenging topic: interstitial cystitis. Dr. Kim is looking to recruit more patients into a study on quality of life and patient education in IC — if you have questions or someone to refer, let us know by emailing us or contacting us with the form on the website!

Overview

  • IC: kind of a misnomer!

    • There is no conclusive evidence that there is an inflammation nor distinct pathology in the bladder interstitium.

    • Contemporary thinking: chronic pain condition related to or perceived to be originating from the bladder.

      • Newer terminology has been proposed: bladder pain syndrome.

      • In clinical practice, some patients seem to prefer ‘interstitial cystitis’ because to them is sounds more like a more medical diagnosis and they don’t want to be labeled as having a pain syndrome. So IC/BPS are used interchangeably.

Epidemiology

  • Can affect men and women but more common in women.

    • High prevalence in age 40s.

    • Don’t know the precise prevalence given complexity of syndrome.

Clinical Presentation

  • Variable

  • Persistent urinary urgency, urinary frequency, and pain or discomfort related to voiding.

    • Note that we say pain or discomfort. Some patients describe what they’re feeling as discomfort and not pain.

    • Classic: patient with these symptoms who had been treated multiple times for urinary tract infections despite having negative urine cultures. They also may report going to the bathroom frequently or spending a lot of their day on the toilet to relieve their urgency and discomfort or pain.

      • Many of these patients may also have associated conditions like irritable bowel syndrome, fibromyalgia, and pelvic floor muscle dysfunction.

      • They also may have concurrent psychiatric comorbidities such as depression or anxiety.

Diagnosis

  • American Urological Association: “An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.”

    • In other words, IC is a clinical diagnosis and diagnosis of exclusion.

    • Differential diagnosis should include:

      • Infection

      • Overactive bladder

      • Bladder or urethral cancer, gynecologic cancer

      • Uterine fibroids with compression effect on the bladder

      • Bladder stone

      • Bladder diverticulum

      • Foreign material such as synthetic mesh or suture

      • Neurologic conditions that may cause urinary retention in particular

      • Other chronic pelvic pain conditions such as endometriosis.

    • This is why it’s important to perform a thorough history and physical and obtain a post void residual and urine tests as an initial evaluation to rule out these other etiologies.

  • Hunner lesions can be seen on cystoscopy.

    • They are specific for IC, but they only are seen in about 10% of patients with IC.

  • Potassium sensitivity test KCl is instilled into the bladder.

    • This is not performed anymore due to its low sensitivity and specificity and also it’s very painful!

  • Urodynamics is not typically used to diagnose IC but it can be done to rule out other etiologies.

Treatment

  • Management strategy is multi-faceted.

  • First-line treatments are patient education, behavior and diet modification, and general stress management.

    • There is good evidence behind teaching patients bladder retraining where they learn to increase the interval between each voids.

    • Avoidance of things like artificial sweetener, caffeine, alcohol, spicy food, citrusy or acidic foods can help with symptoms.

      • Doesn’t require elimination, but helps to make informed decisions about diet.

    • Applying heat or ice packs to the suprapubic or perineal regions can also be helpful.

    • Pelvic floor muscle tenderness or dysfunction on exam —> consider pelvic floor PT.

  • Second-line treatments include oral medications and bladder instillation.

    • PRN medication is usually pyridium or over the counter AZO.

      • Warn patients that their urine will turn orange and may stain clothing.

    • Daily medications, the most commonly used ones are: amitriptyline, hydroxyzine and pentosan polysulfate sodium (Elmiron).

      • Note that Elmiron is the only FDA approved medication for IC. However, use of Elmiron has been associated with macular eye disease. Thus, in 2020, the FDA inserted a warning label to reflect this and use of Elmiron has been declining.

      • Between amitriptyline and hydroxyzine, currently there is more data on amitriptyline. Some patients find amitriptyline helpful in controlling their symptoms but some cannot tolerate its sedative and anticholinergic side effects.

    • If there is inadequate response to medications, then bladder instillation can be considered. This involves instilling a mixture of local anesthetic, heparin, DMSO, etc. via a catheter. Usually this involves repeated treatments.

  • Third-line treatment is hydrodistention.

    • Hyper-distention of the bladder under anesthesia for about 10 minutes and emptying the bladder.

      • The thought is that sensory nerves in the bladder are disrupted due to the hyper distention.

      • For patients who see prolonged and significant benefit, repeat treatments are considered.

    • If on cystoscopy Hunner lesions are found, they can be addressed with cautery, resection or injection with steroids.

  • Fourth-line treatments include neuromodulation using Botulinum toxin A injection into the bladder and sacral neuromodulation.

    • These techniques have been used for overactive bladder and neurogenic bladder but recent clinical trials have reported efficacy for interstitial cystits. 

  • Fifth-line treatment is cyclosporine A. Use is limited due to its side effects and paucity of convincing data.

  • Sixth-line and last resort is surgical diversion of the bladder with or without cystectomy.

    • Fortunately, patients seldom have to go past fourth-line treatments. As with any chronic pain condition, it is a difficult journey for many of them and it is critical for providers to listen and empathize with them.

Choosing The Route of Hysterectomy

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Here’s the RoshReview Question of the Week!

​​A 49-year-old P3003 woman presents to the clinic with a complaint of heavy menses for several years and asks for definitive management. She has a history of type 4 fibroids, all < 3 cm, and hypercholesterolemia. Her obstetrical history is significant for two vaginal deliveries and one cesarean section. On physical examination, her BMI is 31 kg/m2. Her uterus is anteverted, and the fundus reaches 3 fingerbreadths below the umbilicus. What surgical intervention would be most cost- and clinically effective for this patient?

Check if you got the right answer at the links above!

Reading: Committee Opinion 701 - Choosing the Route of Hysterectomy for Benign Disease 

Why do we do a hysterectomy?  

  • Hysts are one of the most common surgeries in the United States (per the CDC, over 600,000 are performed annually) 

  • Many of them are elective - ie. patients are choosing surgical option over medical for example  

What exactly are the ways to do a hyst anyway and why does route matter?

Note: We won’t go into exact techniques here since we are a podcast. However, some great resources include the Atlas of Pelvic Surgery online: http://www.atlasofpelvicsurgery.com/home.html

Also the textbook by Baggish and Karam: Atlas of Pelvic Anatomy and Gynecologic Surgery 

Vaginal hysterectomy 

  • First type of minimally invasive hysterectomy 

  • Advantages 

    • Preferred type of hysterectomy when possible due to no incisions on the abdomen and minimally invasive route 

    • High safety and low cost

      • Meta-analysis of seven trials report similar rates of visceral injury and long-term complication among vaginal and laparoscopic procedures 

    • Minimally invasive approach associated with faster recovery compared to laparotomy 

  • Disadvantages

    • Unfortunately, despite advantages, there are fewer vaginal hysts performed compared to others due to limited training, fewer numbers of hysts overall being performed and greater diversity of operative approaches 

    • Must remove cervix with this type of procedure - no option for supracervical hyst 

    • Small chance of converting to laparotomy 

Laparoscopic hysterectomy 

  • Usually performed with laparoscopic instruments via 3-4 small ports in the abdomen. Uterus can be morcellated and removed through a bag (morcellate in bag) or via the vagina 

  • Increasing in popularity 

  • Advantages 

    • Better visualization with minimally invasive surgery 

    • Can perform supracervical hyst if needed 

    • Can also perform last part vaginally for ease if needed 

    • May be easier in some obese patients 

  • Disadvantages 

    • Requires surgeon skilled in use of laparoscopy 

    • Certain patient populations with certain medical illnesses may not tolerate Trendelenburg position or pneumoperitoneum 

    • Possibility of conversion to laparotomy 

    • Slightly higher rate of vaginal cuff dehiscence compared to other routes of hyst (still low, like 0.64-1.1%) 

Robotic hysterectomy 

  • Very similar overall in terms of advantages and disadvantages to laparoscopic hysterectomy due requiring Trendelenburg and pneumoperitoneum, as well as minimally invasive course 

  • Advantages 

    • Superior visualization compared to traditional laparoscopy due to ability to move camera and 3D vision 

    • Mechanical improvement - wrists with robots 

    • Better stabilization of instruments 

    • Improved ergonomics for surgeons - you can sit down (as someone who has definitely passed out during a long case) 

    • Even more options for minimally invasive routes (ie. single port hyst) 

  • Disadvantages 

    • Additional surgical training 

    • Does not necessarily decrease time (in fact can increase cost and operating room times) 

      • Cost of instruments overall + cost of robot 

    • Lack of haptics (no tactile feedback) 

Abdominal hysterectomy  

  • Only non minimally-invasive technique 

  • Advantages

    • Visualization 

    • Ability to remove large masses and large uteruses 

    • Tactile feedback  

    • Lowest risk of vaginal cuff dehiscence compared to other methods 

    • Studies like the VALUE study and the eVALuate trial showed decreased rates of complications of abdominal hyst compared to laparoscopic hyst, but these studies are also old (1990s) 

  • Disadvantages 

    • Increased postoperative pain and length of stay (average LOS is 3 days after abdominal hyst) 

    • Increased risk of bleeding and infection 

    • Increased risk of VTE (also may be due to increased stasis) 

    • Increased risk of colonic stasis 

How do we pick the route of hysterectomy? 

Consideration of minimally invasive routes 

  • MIS should be considered whenever possible because of well-documented advantages over abdominal hysterectomy 

  • Vaginal hyst is preferred over other types due to cost, effectiveness, and overall outcomes 

  • Even if opportunistic salpingectomy is desired, these can be performed with vaginal hysterectomy 

Anatomy 

  • Size and shape of vagina and uterus + descent of uterus 

  • More difficult to perform a vaginal hysterectomy if there is no descent, if there is large uterus (bulky fibroids) and small introitus 

    • However, nulliparity is not a contraindication to vaginal hysterectomy 

    • Study showed that 92% of vaginal hysterectomies planned for women with no prior vaginal deliveries could be successfully completed 

  • Accessibility of the uterus also important - is there likely to be a lot of pelvic adhesive disease? (endometriosis) 

    • Large uterine size - morcellation has come under scrutiny previously 

    • However, still can morcellate in a bag 

    • Even if large, bulky uterus, can refer to skilled MIS surgeon

  • Need of concurrent procedures (ie. will the patient need their appendix removed as well?) 

  • Work up: 

    • Physical exam with evaluation of mobility of uterus on bimanual 

    • Evaluation for adnexal masses on bimanual 

    • Feel for fundal height 

    • Pelvic ultrasound may be helpful 

Surgeon comfort/preference 

  • Surgeon preference for other operative routes - no longer considered an appropriate reason to avoid vaginal approach 

  • Surgeon experience 

    • Average case volume

    • Available hospital technology, devices, and support 

Patient preference 

  • If patient desires supracervical hysterectomy, will need laparoscopic or abdominal approach 

  • However, no clinically significant difference in complication and uncertain benefit in terms of patient outcomes (ie. sexual function, urinary function, bowel function)

ACOG CO 701

Endometrial Ablation

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Here’s your RoshReview Question of the Week!

A 41-year-old G3P2103 woman is scheduled to undergo nonresectoscopic endometrial ablation for a history of heavy menstrual bleeding. She previously tried combined oral contraceptives but was not satisfied with medical management. An endometrial biopsy was completed and benign. Which of the following do you inform her is the most common complication when counseling her about the risks of the procedure?

Check to see if your answer is correct at the links above!

Read along with ACOG PB 81

What is an Endometrial Ablation? 

  • History and Rationale 

    • Minimally invasive surgical procedure designed to treat heavy uterine bleeding in select women who DO NOT WANT FUTURE FERTILITY 

    • Developed originally in 1937 

      • 1967 - cryoendometrial ablation where you “supercooled” the endometrial lining

      • Becomes more prevalent in the 1980s when hysteroscopy became more widely available 

  • How is it done today? - many ways! 

    • Laser and resectoscopic endometrial ablation 

      • Done under hysteroscopic visualization 

      • Uses a resectoscope with 4 current techniques 

        • Endometrial desiccation with electrosurgical rollerball or rollerbarrel - basically heats the tissue up to 60-90 degrees and destroys the endometrium 

        • Resection with monopolar or bipolar loop electrode - will also resect endometrium to level of myometrium (basically same way that we take care of fibroids from within)  

        • Radiofrequency vaporization - high energy to rapidly heat the intracellular water to 100 degrees C → vaporization of tissue, but no tissue is removed 

        • Laser vaporization - same as above 

    • Nonresectoscopic techniques (in the US) - can be nice because these can sometimes be less uncomfortable and can be performed in the office 

      • Bipolar radiofrequency (Novasure) - 3-dimensional bipolar mesh probe that delivers radiofrequency current until specific tissue impedance is reached 

      • Cryotherapy (Her Option, Cerene) - probe inserted into the uterus and cooled via liquid nitrogen or differential gas exchange 

      • Circulating hot water (Hydro ThermAblator or HTA-ablation) - only one of the non-resectoscopic techniques that uses hysteroscopy.

        • Sheath is inserted into the uterus → heated saline is administered for 10 minutes, and fluid should be at 90 degrees C

      • Combined thermal and bipolar frequency (Minerva) 

        • Heat applied to endometrium via silicone membrane with circulating ionized argon gas (advertised as “plasma”) 

      • Vapor ablation (Mara) - no longer FDA approved 

    • After the endometrium is burned, it can scar down, leading to difficulty entering the uterine cavity again 

    • Anesthesia 

      • Most trials describing non-resectoscopic ablation devices have used local anesthesia and parenteral conscious sedation

      • Can use cervical and paracervical block if desired to do procedures in the office - however need to select if patient is a good candidate for in office procedure (ie. low risk for complications) 

Candidacy for Endometrial Ablation  

  • Who is the right candidate? 

    • Treatment is indicated for heavy bleeding in premenopausal women with no desire for future fertility 

      • An important caveat: this should be for those with heavy OVULATORY menstrual bleeding 

      • Should not be first line to treat for abnormal uterine bleeding due to anovulation 

        • This is because you should figure out the cause of that abnormal bleeding otherwise and treat the cause (ie. if due to PCOS, treat for PCOS) 

        • That is not to say that a patient with PCOS cannot have an ablation - however, you need to make sure that you are treating the causes of the PCOS.

    • Usually, these are patients who have tried other medical therapies and have failed or who should not have medical therapies

    • It is importance to counsel that patients should accept normalization of menstruation, not complete amenorrhea 

      • Not a treatment for those who do not want to have menstruation 

      • Variability across studies in amount of menstrual bleeding after ablation

      • In a meta-analysis, both non-resectoscopic and resectoscopic ablation resulted in similar rates of amenorrhea at 1 year (37% vs 38%) 

Preoperative Evaluation

  • Evaluate the structure and histology of the endometrial cavity 

  • Reasons:

    • Rule out cancer - either via hysteroscopy or endometrial biopsy in the office

      • Don’t want the reason for heavy bleeding to be cancer and complete endometrial ablation which can scar the endometrium and make later evaluation very difficult  

      • Those with hyperplasia (EIN) or cancer should not undergo ablation 

    •  Evaluate the shape of the uterine cavity 

      • Can be done either via sounding + transvaginal ultrasound, sonohysterogram, hysteroscopy, or combination 

      • Evaluate internal architecture (ie. is there a bicornuate uterus? Are there fibroids?)

      • Reason is that many of the devices have uterine cavity requirements.

        • For example, for Novasure, the cavity must sound between 6-10cm and have a cornua to cornua distance of at least 2.5cm. Also, those with polyps or fibroids > 2cm were excluded from the FDA approval studies 

  • Pretreatment 

    • Not required, but most surgeons will usually use hormonal agents to pre-treat to thin the endometrium 

    • GnRH agonist can be used 30-60 days prior to procedure 

  • Risk counseling

    • There are many adverse events that have been reported from ablation and can depend on the device used:

  • Some rare but possible complications: 

    • Distention media overload - just like in hysteroscopy.

      • Especially if you are doing resectoscope and you are using monopolar instruments, you have to use electrolyte-free fluid like 3% sorbitol or 5% mannitol - review our hysteroscopy episode with Dr. Dolinko to learn more! 

    • Uterine trauma - as with any procedure in the uterus, there is possibility of injury. Specifically, with ablation, injury is usually caused when there is hemorrhage or perforation.

      • Cervical lacerations and vaginal burns can also occur if hot fluid comes out through the cervix  

    • Postablation tubal ligation syndrome

      • Can occur in patients with history of tubal ligation 

      • Described as cyclic pelvic pain, likely due to residual and trapped endometrium in one or both cornua - tissue cannot exit through the cervix or through the cornua due to ablation causing scar tissue + tubal ligation causes scar tissue 

      • Incidence has been reported as high as 10%  

  • Complications that are more significant 

    • Pregnancy 

      • Ablation is not designed to be a form of birth control. Patients should be counseled extensively that they should not get pregnant and use a form of reliable birth control afterward 

      • Pregnancy can still occur after ablation 

        • Those that continue pregnancy have higher rates of malpresentation, prematurity, placenta accreta, and perinatal mortality 

    • Endometrial malignancy 

      • Endometrial ablation does not seem to delay the diagnosis of malignancy 

      • However, due to scarring of the endometrium, it can make it more difficult for usual assessment of the endometrial tissue such as biopsy or hysteroscopy 

      • In one study of 303 patients who needed endometrial sampling after ablation, the failure rate for obtaining bleeding assessment was 40% 

Contraindications to Endometrial Ablation

  • Uterine size/shape - as discussed before; all available non-resectoscopic endometrial ablation devices have limitations with respect to size of cavity and extent of anatomic distortion 

  • Do not perform if:

    • Pregnant or recently pregnant or desires future pregnancy 

    • Presence of active or recent uterine infection 

    • Endometrial malignancy or EIN 

  • Consider not performing if: 

    • Uterine anomalies - ie septum or unicornuate uterus 

    • Myometrial thinning after uterine surgery 

    • Postmenopausal women - very few studies on postmenopausal women, and those are usually small; the studies were done in those with persistent bleeding after using HRT 

Outcomes from endometrial ablation

  • Overall outcomes 

    • Non-resectoscopic and resectoscopic ablation result in comparable rates of amenorrhea and patient satisfaction 

    • However, resectoscopic ablation is associated with more OR time, more frequent use of GA, increased risk of surgical complication (ie. fluid overload) 

    • Resectoscopic procedures are less costly

      • Resectoscopic procedures: $125-$150 

      • Non-resectoscopic: $850-$1300  

  • Improvement in bleeding 

    • Patients may have irregular bleeding immediately following procedure 

    • Success rates should not be determined until 8-12 weeks after surgery 

    • Randomized trial of Her Option cryo vs. resectoscope (279 patients): comparable rates of menstrual reduction at 1 year (85 vs. 89%) 

    • Patient satisfaction overall is high for both types of ablation (91 vs 88%) at one year, and similarly at 2-5 years (93 vs 87%) 

  • Surgical outcomes 

    • Subsequent surgery rates range from 17-25% for both types 

    • Hysterectomy rates are 14 vs 19% 

    • Higher risk of treatment failure in younger patients (<45 years old): 

      • Risk of subsequent hysterectomy or repeat ablation was 2x in patients <45 years old compared to patients >45 years old 

Fecal Incontinence

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Here’s your RoshReview Question of the Week!

Which of the following physical exam findings would be present in a woman with fecal incontinence and disruption of the external anal sphincter?

Find out the right answer by clicking on what you think the answer is, and find out how to save 20% on a RoshReview QBank Subscription for CREOG studying!

What is Fecal Incontinence? 

  • Definition

    • Part of accidental bowel leakage - where there is loss of normal control of the bowels. The other aspect of ABL is leakage of stool and gas (anal incontinence) 

    • Fecal incontinence - specifically is leakage of stool 

    • National Health and Nutritional Examination Survey defined it as: loss of solid or liquid stool or mucus at least once in previous 30 days 

  • How common is it?

    •  NHANES survey; 8.3% prevalence (in 4308 community dwelling adults 

    • Prevalence increases with age (2.6% in 20s to 15.3% in adults 70 and older) 

    • Likely underestimated since 75-80% of individuals with fecal incontinence don’t seek help or report them to their health care provider 

  • Risk factors 

    • Loose or watery stool 

    • Increased frequency of stools (more than 21 a week) ← ok, who is pooping more than 3x a day, and how can I get to this level of regularity  

    • Having 2 or more chronic illnesses 

    • Urinary incontinence, obesity, smoking, increasing age, decreased physical activity, anal intercourse, history of OASIS, history of pelvic radiation

What are the causes of fecal incontinence? 

  • Neurologic - ie. spinal cord injuries, spina bifida, and CVAs 

  • Non-neurologic

    • Most common in women are non-neurologic, usually after OASIS, may occur even remote from delivery 

    • Medications can also cause

Why do we care? 

  • Effect on quality of life

    • Significant effect 

    • Can cause depression, social isolation, shame, embarrassment, etc 

    • Can also worsen sexual function 

How do we evaluate? 

  • Screen!

    • ACOG says women with risk factors should be screened because they are often reluctant to disclose  

    • Should ask in women with other pelvic floor disorders 

    • Other risk factors that can be considered: Age >50, residence in nursing home, prior OASIS, history of pelvic irradiation, engagement in anal intercourse, presence of urinary incontinence, chronic diarrhea, diabetes, obesity, rectal urgency 

  • History and physical 

    • Ask about underlying neurological disorders and also modifiable risk factors for fecal incontinence (ie. obesity, diabetes, smoking, anal sex, certain medications that cause loose stools) 

    • Symptoms: what type of leakage (solid, liquid, gas, mucus), timing, frequency, severity (volume of loss), if there is fecal urgency, and how this affects their life 

    • There are a few validated surveys 

      • FI Severity Index, FI Quality of Life Scale, Fecal incontinence and Constipation Assessment Questionnaire 

    • Physical exam should include vaginal exam, exam of perineal area, and rectal exam (prior anal sphincter surgery/trauma) 

      • “Dovetail” sign - loss of normal puckering around the anus anteriorly

      • Digital rectal exam - sensitivity and specificity is overall low for detection of complete anal sphincter disruption 

      • Can also consider endoanal ultrasonography 

  • Other tests

    • Anal sphincter imaging/defecography/anorectal manometry not recommended for routine evaluation 

    • However, if anatomic defect or dysfunction is suspected or if clinical exam findings are inconclusive, can refer for ancillary testing 

    • Can also consider referring to urogynecology/colorectal surgery for further evaluation if not sure in clinic 

How do we manage and treat FI? 

  • Medical

    • Should be multidisciplinary approach 

      • Consider pelvic floor PT and management with urogynecology 

      • Also can consider gastroenterology

    • Medications

      • While loose stool itself does not cause fecal incontinence, it can worsen it and be a risk factor

        • Try something to bulk up stool - ie. fiber supplementation, dietary manipulation, bowel scheduling, etc 

      • Lifestyle management - should be offered in conjunction with everything else 

        • Wearing pads, diapers, briefs, etc 

        • Anal plugs ← 51% of people reported some sort of adverse event, like urgency, irritation, pain, soreness.

    • How effective are non-surgical treatments? 

      • Associated with modest short-term efficacy and low risk of adverse events, so should be recommended for initial management unless there is a fistula or rectal prolapse on exam 

      • However, lacking evidence for effectiveness of treatment beyond 6 months 

  • Surgical

    • Anal Sphincter Bulking Agents - not really surgery, kind of in between? 

      • Include things like dextranomer in stabilized hyaluronic acid, silicon biomaterial, carbon-coated beads 

      • May be effective in decreasing FI episodes up to 6 months 

    • Who is eligible for surgeries?

      • Not first line except for the two indications mentioned above (fistula or prolapse)

      • Proven to only provide short term improvement and have more complications than medical treatments/lifestyle modifications 

      • If patients fail medical treatments → can have surgery 

      • Refer to urogynecologist or qualified specialist to do them  

    • Neuromodulation 

      • Sacral nerve stimulation is possible for ABL 

        • Implantation of wire electrode near third sacral nerve root 

        • Two step → if initial testing is beneficial, then permanent battery is attached to wire electrode 

        • 2013 systemic review: 63% success rate (50% or greater reduction of FI) in the short term (<1 year), 58% in medium term (17-36 months), 54% (44-118 months)

      • Peripheral tibial nerve stimulation is not approved for FI 

    • Anal Sphincter Repair 

      • Sphincteroplasty can be considered with anal sphincter disruption and fecal incontinence symptoms who have failed conservative treatment 

      • Can do it end to end or overlapping sphincteroplasty 

      • Most studies:

        • Found to have similar outcomes 

        • Some evidence has shown that there can be significant deterioration in fecal incontinence over time after either type of repair, with 50% of women reporting symptoms 5-10 years after their repair

      • Most common adverse effect is wound infection (6-35% of cases!!) 

    • Other surgeries can be considered:

      • Radiofrequency anal sphincter remodeling 

      • Gracilis muscle transposition 

      • Diverting colostomy  

Cesarean Scar Ectopic Pregnancy

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Here’s the RoshReview Question of the Week!

A 31-year-old G2P0102 woman at 6 weeks gestation by last menstrual period presents with vaginal spotting. Her history is significant for a previous twin pregnancy where the second twin was emergently delivered by cesarean. Her vital signs are normal, hCG level is 4,440 mIU/mL, and ultrasound findings are shown above. After reviewing the treatment options, the patient indicates she prefers medical management. You further counsel her that compared to medical therapy, most interventional options have a lower risk of which of the following?

Check out the answer at the links above and get 20% off the Rosh Review question bank!

More reading: SMFM Consult Series #49

What is a Cesarean Scar Ectopic? 

  • The implantation of an early gestation in the hysterotomy incision from a previous cesarean birth. Two main types:

    • Endogenic - implantation in the scar itself  

    • Exogenic - implantation in the defect or “niche” left behind by incomplete healing of the scar 

  • Why do we care?

    • Overall very rare → 1 in 2000 pregnancies and 6% of ectopic pregnancies in total among patient with history of cesarean delivery.

    • Doesn’t seem to be related to number of prior cesareans

    • Risk factors: 

      • Not very well studied, since it is so rare 

      • There may be some increased risk associated with smoking, higher parity

    • Unrecognized C-section scar ectopics can rupture and cause hemorrhage and death! 

How do we diagnose a cesarean scar ectopic? 

  • We may suspect ectopics when there is not an appropriate rise in beta HCG (if following)

  • Signs and symptoms:

    • Early on can be asymptomatic 

    • Later on, can result in vaginal bleeding 

    • If ruptured, will lead to hemoperitoneum and hypovolemic shock 

    • Usually patients present early in first trimester 

  • Diagnosis is usually with ultrasound

    • Can be suspected if hx of C-section 

    • Gestational sac center is low (<5cm from cervical os) and anterior on ultrasound 

    • Appears to be an enlarged hysterotomy scar with embedded mass which may bulge beyond anterior contour of the uterus and toward adjacent pelvic structures 

    • Other findings that support:

      • Empty uterine cavity and endocervix  

      • Triangular gestational sac and < 8 weeks or rounded or oval sac > 8 weeks that fills the scar area 

      • Thin or absent myometrial layer between GS and bladder (1-3 mm) 

      • Prominent vascular pattern on Doppler suggestive of blood flow at the area 

  • Can also be diagnosed with surgery, where it is directly visualized 

Radiopaedia

Treatment and Management 

  • Termination of pregnancy due to risk of maternal morbidity and mortality 

  • If hemodynamically unstable

    • To OR 

    • Wedge resection or gravid hysterectomy 

      • If profusely bleeding, usually will require hysterectomy  

  • If hemodynamically stable 

    • Can consider medical or surgical treatment 

    • Medical 

      • Usually methotrexate injection 

      • Options include intrasac injection of MTX or systemic injection of MTX 1mg/kg of maternal weight up to 50 mg

        • One lit review showed that 74% of the time, no other treatment is needed.

        • Also, an additional IM or intrasac injection of MTX led to resolution up to 89% of cases 

        • However, numbers vary widely. Another review said the intrasac injection was effective 65% of the time, and UAE made it 69% effective  

    • Other surgical options 

      • Can consider UAE in addition to MTX, which seems to increase efficacy 

    • Expectant management 

      • Not recommended due to likelihood of maternal morbidity/mortality without fetal benefit 

      • May be reasonable if there is already embryonic/fetal demise and lowering bHCGs 

Follow up

  • Should have weekly HCGs drawn (like after MTX injection after other ectopics 

  • Periodic ultrasound evaluation 

  • More likely to have favorable outcome with ectopics that are diagnosed earlier vs later 

  • There have been reports of pregnancy after treatment of C-section scar ectopic, but risks include recurrence (reported at rate of 5-40%), rupture, and PAS