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Approach to pelvic venous disorders

Author/s: 
Andrew D Brown

Objective: To provide a practical guide to help family physicians recognize, diagnose, and manage patients with pelvic venous disorders (PeVDs), often overlooked as causes of chronic pelvic pain and varicose veins.

Sources of information: This review is based on guidelines from the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, the Society of Interventional Radiology, and the European Society for Vascular Surgery.

Main message: PeVDs are common, though frequently misdiagnosed, causes of chronic pelvic pain and varicose veins predominantly in female patients. These conditions arise from venous reflux or obstruction, which can cause varicose veins and venous hypertension in the renal hilum, pelvis, perineum, and lower extremities. Family physicians should recognize the clinical signs of PeVDs and use appropriate imaging to confirm diagnoses. Interventional treatments, including embolization and stenting, are effective for symptom management and improving patient outcomes.

Conclusion: Early recognition of patients with PeVDs by family physicians is crucial for timely and effective treatment. By using appropriate diagnostic tools and making timely referrals, physicians can substantially improve patients' quality of life.

Keywords 
Perineum female quality of life physicians family Radiology Interventional Varicose Veins Vascular Surgical Procedures hypertension

Patent Foramen Ovale and Stroke A Review

Author/s: 
David M. Kent, Andy Y. Wang

Importance: A patent foramen ovale (PFO), an opening between the right and left atria during normal fetal development that fails to close after birth, is present in approximately 25% of all adults. Paradoxical embolism, a venous thromboembolism that travels to the systemic circulation typically through a PFO, accounts for about 5% of all strokes and 10% of strokes in younger patients.

Observations: Approximately 50% of patients 60 years or younger with an embolic stroke of undetermined source (cryptogenic stroke) have a PFO, compared with 25% of the general population. The Risk of Paradoxical Embolism (RoPE) score incorporates clinical characteristics (age, history of stroke or transient ischemic attack, diabetes, hypertension, smoking, cortical infarct on imaging) to predict the likelihood that embolic stroke of undetermined source was caused by a PFO. Among patients in the lowest RoPE score category (score <3), PFO prevalence was similar to that in the general population (23%), while PFO prevalence was 77% in patients with a RoPE score of 9 or 10. The PFO-Associated Stroke Causal Likelihood (PASCAL) classification system combines the RoPE score and anatomical criteria from echocardiography (large shunt, atrial septal aneurysm) to classify PFO as the “probable,” “possible,” or “unlikely” cause of otherwise cryptogenic stroke. PFO closure reduces recurrent ischemic stroke in patients 60 years or younger with cryptogenic stroke. In a pooled analysis of 6 trials (3740 patients), the annualized incidence of stroke over a median follow-up of 57 months was 0.47% (95% CI, 0.35%-0.65%) with PFO closure vs 1.09% (95% CI, 0.88%-1.36%) with medical therapy (adjusted hazard ratio, 0.41 [95% CI, 0.28-0.60]). However, the benefits and harms of closure were highly heterogeneous across the trial populations. In patients categorized as PASCAL “probable” (ie, younger patients without vascular risk factors and high-risk PFO anatomical features), there was a 90% decreased relative rate of recurrent ischemic stroke after PFO closure at 2 years (hazard ratio, 0.10 [95% CI, 0.03-0.35]; absolute risk reduction, 2.1% [95% CI, 0.9%-3.4%]). PASCAL “unlikely” patients (eg, older patients with vascular risk factors and no high-risk PFO anatomical features) did not have a lower recurrent stroke rate with PFO closure but had higher risk of procedure- and device-related adverse events, such as atrial fibrillation.

Conclusions and Relevance: Patent foramen ovale is present in approximately 25% of all adults and is a common cause of stroke in young and middle-aged patients. The PASCAL classification system can help guide patient selection for PFO closure. Percutaneous PFO closure substantially reduces the risk of stroke recurrence in well-selected patients younger than 60 years after cryptogenic stroke.

Keywords 
Congenital Defects pediatrics female

Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement

Author/s: 
US Preventive Services Task Force

Importance Osteoporotic fractures are associated with psychological distress, subsequent fractures, loss of independence, reduced ability to perform activities of daily living, and death.

Objective The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the evidence on the benefits and harms of screening for osteoporosis to prevent fractures in adults 40 years or older with no known diagnosis of osteoporosis or history of fragility fracture.

Population Adults 40 years or older without known osteoporosis or history of fragility fractures.

Evidence Assessment The USPSTF concludes with moderate certainty that screening for osteoporosis to prevent osteoporotic fractures in women 65 years or older has moderate net benefit. The USPSTF concludes with moderate certainty that screening for osteoporosis to prevent osteoporotic fractures in postmenopausal women younger than 65 years at increased risk has moderate net benefit. The USPSTF concludes that the evidence is insufficient and the balance of benefits and harms for screening for osteoporosis to prevent osteoporotic fractures in men cannot be determined.

Recommendation The USPSTF recommends screening for osteoporosis to prevent osteoporotic fractures in women 65 years or older. (B recommendation) The USPSTF recommends screening for osteoporosis to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk for an osteoporotic fracture as estimated by clinical risk assessment. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men. (I statement)

Keywords 
women osteoporosis female

Stress urinary incontinence and synthetic mesh midurethral slings in women

Author/s: 
Kanji, Sarah, Clancy, Aisling A.

Stress urinary incontinence has a prevalence of 10%–40% and is considered severe in 3%–17% of women worldwide.1 Diagnosis involves demonstrating involuntary urine leakage with increases in intra-abdominal pressure (e.g., exercising, coughing). On history, it is important to differentiate this leakage from symptoms like urgency, frequency and nocturia, as these may indicate mixed urinary incontinence or overactive bladder.

Keywords 
female Surgical treatment suburethral slings

Pelvic organ prolapse

Author/s: 
Lee, Patricia E., Mcleod, Laura

Prolapse is found in 41%–50% of adult females, with symptoms of pelvic pressure and vaginal bulge sensation reported by 3%–6% of adult females. Prolapse is diagnosed and staged with physical examination based on the maximum descent of vaginal tissue (anterior, posterior or apex) on Valsalva manoeuvre. Symptoms commonly begin when the bulge reaches within 0.5 cm of the vaginal opening. Imaging is not routinely needed. Risk factors include increasing age, parity, a history of vaginal delivery, obesity, constipation, postmenopausal status and connective tissue disorders.

Keywords 
pelvic organ female postmenopause

Diagnosis and management of endometriosis

Author/s: 
Allaire, Catherine, Bedaiwy, Mohamed, Yong, Paul

Endometriosis is a chronic condition defined by the presence of endometrial-like tissue outside of the uterus, which can lead to estrogen-driven inflammation. The extent of disease can be highly variable, ranging from minimal peritoneal deposits to deep disease that can invade into the bowel, bladder and ureter and, more rarely, spread to extrapelvic (e.g., cutaneous, thoracic) sites. Endometriosis is a complex disease that has considerable impact on the quality of life of those affected and that has no cure. It remains poorly understood. We review the epidemiology, pathophysiology, diagnosis and management of endometriosis, based on the best available evidence and clinical guidelines

Keywords 
female Endometriosis ureter Inflammation

A challenging diagnosis: hereditary angioedema presenting during pregnancy

Author/s: 
Chair, I., Lacuesta, G., Nash, C. M., Cook, V.

• Hereditary angioedema (HAE) is a rare autosomal dominant
disorder characterized by recurrent episodes of painful (and
usually asymmetric) swelling without urticaria that leads to
substantial morbidity and even mortality (in the case of
laryngeal involvement) if left untreated.
• Delayed diagnosis and misdiagnosis of HAE are common,
particularly during pregnancy and the postpartum period.
• Hereditary angioedema should be considered in the differential
diagnosis of any patient presenting with unexplained
abdominal pain and recurrent episodes of angioedema
(particularly if asymmetric in nature) without urticaria.
• Tests to confirm the diagnosis of HAE include measurement of
C4 and C1 inhibitor (INH) antigen and function.
• Successful pregnancy and delivery are possible in HAE with
proper medical management, which includes plasma-derived
C1-INH and collaboration with HAE specialists.

Keywords 
abdominal pain Morbidity diagnosis, differential Hereditary angioedema (HAE) female

Screening for Syphilis Infection in Nonpregnant Adolescents and Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement

Author/s: 
US Preventative Services task Force, Mangione, C. M., Barry, M. J., Nicholson, W. K., Cabana, M., Chelmow, D., Coker, T. R., Davis, E. M., Donahue, K. E., Jaén, C. R., Kubik, M., Li, L., Ogedegbe, G., Pbert, L., Ruiz, J. M., Stevermer, J., Wong, B. J.

Importance: Syphilis is a sexually transmitted infection that can progress through different stages (primary, secondary, latent, and tertiary) and cause serious health problems if left untreated. Reported cases of primary and secondary syphilis in the US increased from a record low of 2.1 cases per 100 000 population in 2000 and 2001 to 11.9 cases per 100 000 population in 2019. Men account for the majority of cases (83% of primary and secondary syphilis cases in 2019), and rates among women nearly tripled from 2015 to 2019.

Objective: To reaffirm its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence update focusing on targeted key questions evaluating the performance of risk assessment tools and the benefits and harms of screening for syphilis in nonpregnant adolescents and adults.

Population: Asymptomatic, nonpregnant adolescents and adults who have ever been sexually active and are at increased risk for syphilis infection.

Evidence assessment: Using a reaffirmation process, the USPSTF concludes with high certainty that there is a substantial net benefit of screening for syphilis infection in nonpregnant persons who are at increased risk for infection.

Recommendation: The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. (A recommendation).

Keywords 
Syphilis secondary STDs adolescent adult male female syphilis

Diagnosis and treatment of adenomyosis

Author/s: 
Dason, Ebernella Shirin, Chan, Crystal, Sobel, Mara

Adenomyosis is a benign gynecological disorder characterized by aberrant development of endometrial glands and stroma within the myometrium, causing inflammation and neuroangiogenesis. Adenomyosis often coexists with other gynecological conditions and may cloud the clinical presentation.

Keywords 
Adenomyosis Endometrium Genital Diseases female gynecology women menstruation
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