Uterine Suspension for Pelvic Pain
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: Pain from symptomatic uterine retroversion may be relieved with laparoscopic uterine suspension.
Source: Perry CP, et al. Laparoscopic uterine suspension for pain relief: a multicenter study. J Reprod Med. 2005;50:567-570.
Patients with pain, retroversion, dysmenorrheal and/or dyspareunia were recruited from 5 private practices. Pain was rated from 0 to 10 pre-operatively, and at 1, 3, 6, and 12 months post-operatively. Each patient underwent a specific standardized laparoscopic procedure known as UPLIFT (uterine positioning by ligament investment, fixation, and truncation). Out of the 62 patients who underwent the procedure, the average pain score was reduced from 7.3 to 3.7 at 12 months (46 patients). The average dysmenorrhea score changed from 7.8 to 4.4 (n = 39), dyspareunia scores decreased from 8.0 to 3.3 (n = 41). The average follow-up was 10.2 months.
Since there were no postoperative complications, and since there was statistically significant reduction in pain, Perry and associates conclude that the technique is an effective method of repositioning a symptomatic retroverted uterus.
Commentary
To the seasoned clinician, this may sound like a new verse of an old song. Uterine suspension for symptomatic retroversion has been around for a long time with multiple open as well as laparoscopic techniques described. To the younger gynecologic surgeon, the conversation may even seem a bit unusual because surgery for this type of pain has not been taught in residency in recent years. Because a retroverted uterus is anatomically normal in up to a third of women, contemporary wisdom questions whether or not a truly normal variant should be corrected. The paper raises important clinical questions that remain unanswered even after reading the study.
Perry et al did a very nice job of ruling out other etiologies of pain such as vulvar vestibulitis and pelvic floor myalgia. They also specifically tried to enroll patients whose pain on deep thrusting with sex was recreated with their pelvic examination. In fact, this is one of the best attempts to rule out other sources of pain that I have read in surgical studies on pain management. This is teaching point #1: before even considering operating for symptomatic retroversion, make sure other causes have been ruled out.
Perry et al faithfully made this a prospective study with documentation by the patient of various aspects of pain before and after surgery. Again, this is very well done and important, particularly since this is a multi-site study. Making sure that preoperative baseline data are obtained is critical. This reduces the obvious weakness of any study that tries to rely on a patient's recall of her pain prior to surgery. This is teaching point #2: when evaluating studies on surgical outcomes, make sure that there is preoperative assessment, which needs to be standardized relative to postoperative measurements.
The outcomes are promising because there is statistically less pain reported after the operation than before. Unfortunately, Perry et al report that approximately 85% of the patients also had adhesions and/or endometriosis at the time of laparoscopy. Since surgery to correct these abnormalities was also undertaken, the outcome of the uterine surgery itself becomes obscured. Is the patient better because of the uterine suspension or because of the other surgical management? There is no way to know. Because there was no control group (patients who underwent laparoscopy without suspension), we have no way to determine what the effects of only laparoscopy were. Teaching point #3 says: what you can conclude about a study without a control group is limited at best, and particularly when there is no control for adjunctive surgery. It would have been much better if there had been a control group of either no suspension or at least no treatment of adhesions and endometriosis.
Are my criticisms insurmountable? Not really. In the past, when there were studies on laparoscopic uterosacral nerve ablations, one study did not tell the patients whether ablation had been done or not. Even the postoperative evaluators did not know, thus creating a truly double-blind study. It’s certainly a harder study to do, but it can be done.
How should this affect our practice? First, at least consider symptomatic retroversion. Second, see if the pelvic examination or uterine repositioning using knee-chest position or pessary might help. Third, rule out other sources of pain. Fourth, if you do a surgical procedure to suspend the uterus, make sure that the patient gets full consent as to the potential risks and benefits. Fifth, don’t feel obligated to use this technique since there are more than 100 others in the literature. I even contributed to the list when we used silastic bands used for sterilization to shorten the round ligaments and pull the uterus forward. As always, however, keep the patient’s welfare as the first priority.
Patients with pain, retroversion, dysmenorrheal and/or dyspareunia were recruited from 5 private practices. Pain was rated from 0 to 10 pre-operatively, and at 1, 3, 6, and 12 months post-operatively.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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