Vulvodynia and Concomitant Femoro-Acetabular Impingement: Long-Term Follow-up After Hip Arthroscopy
OBJECTIVE: We hypothesized that in patients with vulvodynia and femoro-acetabular impingement (FAI), vulvar pain may be generated by the effect of FAI on pelvic floor structures, and treatment with arthroscopy may improve vulvodynia. We also sought to identify characteristics of patients whose vulvodynia improved after arthroscopy. MATERIALS AND METHODS: A case series of patients with vulvodynia and FAI underwent physical therapy, and, if hip symptoms did not improve, arthroscopy. Three to 5 years postoperatively, follow-up of outcomes after arthroscopy on vulvodynia was performed using chart review and patient questionnaire. Clinical characteristics and pain scores describing patients with and without vulvodynia improvement were assessed. RESULTS: Twenty-six patients with generalized unprovoked vulvodynia (GUV) or clitorodynia underwent arthroscopy for FAI. Six patients, all younger than 30 years, experienced lasting improvement in vulvodynia. Twenty patients, with an older mean age, longer mean vulvodynia duration, and mainly severe pain scores, did not experience vulvar pain improvement after arthroscopy. CONCLUSION: This case series describes improved vulvodynia outcomes after arthroscopy for FAI in women younger than 30 years. Patients with vulvar pain and coexisting FAI had GUV and clitorodynia.
Pelvic pain of pudendal nerve origin: surgical outcomes and learning curve lessons
Purpose When pudendal nerve dysfunction fails to improve after medical and pelvic floor therapy, a surgical approach may be indicated. "Traditional," "posterior," transgluteal nerve decompression fails in an unacceptably high percentage of patients. Insights into pudendal neuroanatomy and pathophysiology offer improved microsurgical outcomes. Methods To evaluate results of a peripheral nerve approach to the pudendal nerve, 55 patients were prospectively evaluated. This cohort included 25 men and 30 women. Surgical approach was posterior, transgluteal if symptoms included rectal pain; or "anterior," inferior pubic ramus approach if symptoms excluded rectal pain. Surgical approach was "resection," if trauma created a neuroma, and "decompression," if there were no neuroma. Effect of comorbidities was analyzed. Results At 14.3 months postoperatively, untreated anxiety/depression correlated with outcome failure, regardless of surgical approach, p < 0.002. There was no difference in results, men versus women, "anterior" versus "posterior" approach, or neuroma resection versus neurolysis. Success correlated with the "learning curve" of the surgeon. Self-rated success was significantly better (p < 0.0001) for patients operated on during the second year of the study than the first year of the study, and improved again in the final year of the study (p < 0.04), with 86% of the patients in final year achieving an excellent result and 14% achieving a good result. Conclusion There is hope for surgical relief from pudendal nerve problems by distinguishing neuroma from compression in the diagnosis, and then choosing a site-specific surgical approach related to which pudendal nerve branches are involved.
AUTONOMIC TESTING FOR SMALL FIBER NEUROPATHIES IN VULVODYNIA PATIENTS [Meeting Abstract]
The genome of the simian and human malaria parasite Plasmodium knowlesi
Plasmodium knowlesi is an intracellular malaria parasite whose natural vertebrate host is Macaca fascicularis (the 'kra' monkey); however, it is now increasingly recognized as a significant cause of human malaria, particularly in southeast Asia. Plasmodium knowlesi was the first malaria parasite species in which antigenic variation was demonstrated, and it has a close phylogenetic relationship to Plasmodium vivax, the second most important species of human malaria parasite (reviewed in ref. 4). Despite their relatedness, there are important phenotypic differences between them, such as host blood cell preference, absence of a dormant liver stage or 'hypnozoite' in P. knowlesi, and length of the asexual cycle (reviewed in ref. 4). Here we present an analysis of the P. knowlesi (H strain, Pk1(A+) clone) nuclear genome sequence. This is the first monkey malaria parasite genome to be described, and it provides an opportunity for comparison with the recently completed P. vivax genome and other sequenced Plasmodium genomes. In contrast to other Plasmodium genomes, putative variant antigen families are dispersed throughout the genome and are associated with intrachromosomal telomere repeats. One of these families, the KIRs, contains sequences that collectively match over one-half of the host CD99 extracellular domain, which may represent an unusual form of molecular mimicry.