Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section

Incidence, Severity, and Interference of Chronic Postsurgical Pain After Cesarean Delivery: A Systematic Review and Meta-analysis

BACKGROUND

Chronic postsurgical pain (CPSP) is a common complication following surgery. Cesarean delivery (CD) is the most performed inpatient surgery, however, the true incidence of CPSP after CD in contemporary practice is unknown. This systematic review and meta-analysis aimed to determine the incidence and severity of CPSP after CD and assess interference with maternal health-related quality of life (HR-QoL).

METHODS

A 7-database literature search was used to identify observational and randomized controlled studies (RCTs) reporting the incidence of CPSP following CD (published January 2015 to August 2023). Included studies were added to the 29 studies identified from a prior review published in 2016. The primary outcome was incidence of CPSP (wound, scar or abdomen) between ≥3 to <6 months, ≥6 to <12, and ≥ 12 months. Secondary outcomes were incidence of chronic pain (back, pelvis or other residual); pain intensity at rest and movement-evoked, and chronic pain interference with maternal HR-QoL at each time interval.

RESULTS

50 studies involving 13,149 patients were included. Meta-analysis with random-effects model (n = 9228; 9 RCTs and 20 observational) revealed an incidence of scar-specific CPSP of 16.7 % (C·I. 13.1 to 20.4 %; I2 = 97.0 %; p < 0.001) at ≥3 to <6 months, 11.4 % (95 % CI 8.7 to 14.0 %; I2 = 94.1 %; P < 0.001) at ≥6 to <12 months, and 8.8 % (95 % CI 6.6 to 11.0 %; I2 = 97.3 %; P < 0.001) at ≥12 months. Meta-regression analysis using publication year as the co-variate revealed a stable CPSP incidence from 2002 onwards. Between ≥6 to <12 months, 51.2 % (95 % C·I: 18.7 to 83.8 %) and 13.5 % (95 % C·I: 0 to 27.1 %) of women had mild and severe pain at rest, respectively. CPSP interfered with HR-QoL in all 7 subdomains of the Brief Pain Inventory in the majority (>50 %) of patients. Walking ability was impacted in 67.6 % (95 % CI 57.6 to 77.6 %; I2 = 50 %) at ≥3 to <6 months. Normal work was impacted in 69.4 % (95 % CI 59.3 to 79.6 %; I2 = 18.6 %) and enjoyment of life in 79.5 % (67.1 to 91.9 %; I2 = 59.3 %) at ≥6 to <12 months. Therefore an estimated 10 % of patients experience CPSP after CD that interferes with daily life, work, social life and personal care. The GRADE quality of evidence was rated as very low for all outcomes.

CONCLUSIONS

CPSP after CD occurs in 16.7 % of patients at ≥3 to <6 months postpartum and widely interferes with maternal HR-QoL domains in the majority of those affected. Further studies are required to explore potential mitigating factors and optimal treatment strategies.

Association Between Cesarean Scar and Pelvic Floor Muscle Tone at 6-8 Weeks Postpartum

INTRODUCTION AND HYPOTHESIS

The relationship between cesarean section scars and active pelvic floor muscle tone lacks sufficient evidence. This study is aimed at investigating the relationship between the severity of cesarean section scars and active pelvic floor muscle tone in postpartum women.

METHODS

We conducted a prospective cross-sectional study of 604 women at 6-8 weeks postpartum. Active pelvic floor muscle tone was assessed using the Glazer protocol, and scar severity was categorized as no scar, normal scar, and hypertrophic scar. We collected data on demographic and clinical variables, including age, body mass index (BMI), and comorbidities. Linear regression analysis was employed to assess the association between scar severity and active pelvic floor muscle tone, adjusting for potential confounders.

RESULTS

Compared with the no scar group, the normal scar group exhibited higher levels of active pelvic floor muscle tone (β = 1.68 and 1.47), and the hypertrophic scar group had the highest levels of active pelvic floor muscle tone (β = 5.09 and 5.03). Active pelvic floor muscle tone was significantly higher in women with scars than in those without scars. The association remained significant after adjusting for age, BMI, and comorbidities. Moreover, women with hypertrophic scars exhibited higher active pelvic floor muscle tone than those with normal scars.

CONCLUSIONS

Cesarean section scar severity is positively associated with increased active pelvic floor muscle tone in postpartum women. This finding highlights the importance of scar management and targeted pelvic floor rehabilitation to optimize postpartum recovery.

MR imaging for preoperative characterization of pelvic adhesions: role in diagnosis and surgical planning

Pelvic adhesions are nonanatomic connections between organs and normal peritoneal surfaces that develop secondary to a maladaptive inflammatory response to tissue insults. Comprised of fibrous tissue, adhesions can result in the distortion of operative dissection planes, which can complicate the establishment of abdominal access in patients undergoing surgery, prolong the length of surgery, and increase the risk of injury to bowel and other structures if involved by extensive adhesive disease. This can adversely impact patient outcomes by increasing the risk of surgical complications including bleeding, infection, and prolonging postoperative length of stay. Literature on the characterization of adhesions with imaging is limited and a systematic framework for evaluating adhesive disease on cross-sectional imaging of the pelvis does not currently exist. In this review, we discuss the MR imaging features of pelvic adhesions, highlighting unique teaching cases in which surgical exploration was significantly complicated by the presence of adhesive disease. We will also review the correlation between MR imaging and intraoperative findings in these cases. A proposed standardized framework for the detection and characterization of adhesions on pelvic MRI will be reviewed with multiple imaging examples. Identification and characterization of pelvic adhesive disease on preoperative imaging provides radiologists with an opportunity to inform the referring clinician of their presence, potentially improving outcomes and the quality of patient care.

Prediction of vesicouterine adhesions by transvaginal sonographic sliding sign technique: validation study

OBJECTIVE

Adhesions between the uterus, bladder and anterior abdominal wall are associated with clinical sequelae, including chronic pelvic pain and dyspareunia, and can also yield complications during surgery. The transvaginal sonographic (TVS) sliding bladder sign is a minimally invasive diagnostic tool to evaluate the presence of vesicouterine adhesions. This study aimed to determine the predictive value and intra- and interobserver variation of the TVS sliding bladder sign in the assessment of vesicouterine adhesions.

METHODS

This was a prospective observational double-blind diagnostic accuracy study conducted at the Amsterdam University Medical Center. Patients scheduled for gynecological laparoscopic surgery for a benign disorder between January 2020 and December 2022 were included consecutively. All patients underwent preoperative TVS, including a dynamic sliding bladder sign examination in our outpatient clinic. Videoclips of the TVS scans were stored for offline assessment and used as an index test. The recordings of both TVS and laparoscopy were evaluated for diagnostic characteristics of vesicouterine adhesions by independent assessors, who were blinded to the clinical situation in addition to the laparoscopic findings when assessing recordings of TVS and vice versa. The presence of adhesions on laparoscopy was used as the reference standard. The positive predictive value (PPV), negative predictive value (NPV), specificity and sensitivity of the sliding bladder sign were calculated. In addition, inter- and intraobserver variability of the sliding bladder sign on TVS were assessed.

RESULTS

Of 116 included women, 57 had a negative sliding bladder sign on TVS, while on laparoscopy, 51 women had mild and 28 had severe vesicouterine adhesions. A negative sliding bladder sign had a PPV of 94.7% (95% CI, 88.9-100%) for the presence of any vesicouterine adhesions, and a positive sliding bladder sign had a specificity of 91.9% (95% CI, 83.1-100%). For severe adhesions, the negative sliding bladder sign had a sensitivity of 89.3% (95% CI, 77.8-100%) and a positive sliding bladder sign had a NPV of 94.9% (95% CI, 89.3-100%). When using Cohen's kappa coefficient, inter- and intraobserver agreement between assessors was good.

CONCLUSIONS

Sliding bladder sign evaluation using TVS is a reliable diagnostic tool for the prediction of vesicouterine adhesions on laparoscopy. A negative sliding bladder sign indicates the presence of vesicouterine adhesions, while a positive sliding bladder sign makes the presence of severe adhesions unlikely. Establishing vesicouterine adhesions by TVS may optimize preoperative planning, and can be used for future studies to evaluate the relationship between symptomatology and vesicouterine adhesions and, subsequently, the effect of adhesion-prevention interventions. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Transabdominal sonographic sliding signs for preoperative prediction of dense intra-abdominal adhesions in women undergoing repeat Cesarean delivery

OBJECTIVES

To assess the accuracy and utility of transabdominal sonographic paraumbilical and suprapubic sliding signs in predicting intra-abdominal adhesions in women undergoing repeat Cesarean section (CS), and to investigate the association of repeat CS with short-term maternal and neonatal outcomes.

METHODS

This was a prospective observational study of pregnant women with a history of CS who were scheduled for third-trimester elective or emergency CS at a tertiary referral and teaching hospital between July 2021 and June 2022. In order to evaluate the role of transabdominal sonographic paraumbilical and suprapubic sliding signs in the prediction of intra-abdominal adhesions, participants underwent a high-resolution transabdominal ultrasound scan prior to repeat CS. Free cephalad and caudad gliding of the uterus under the abdominal wall during deep inhalation and exhalation in each area was considered a positive sliding sign, suggesting a low risk of intra-abdominal adhesions. The absence of such movement was considered a negative sliding sign, suggesting a high risk of intra-abdominal adhesions. The presence or absence of intra-abdominal adhesions was then confirmed during surgery by physicians who were blinded to the sonographic sliding-sign findings. The type of adhesion, structures involved, method of adhesiolysis, incision-to-delivery time, 1-min and 5-min Apgar scores, maternal and neonatal injury and other short-term complications were also reported.

RESULTS

Of 419 women with a history of at least one previous CS who underwent repeat CS, the preoperative sonographic paraumbilical and suprapubic sliding signs were negative in 173 (41.3%) and 178 (42.5%) women, respectively. On repeat CS, 224 (53.5%) women had intra-abdominal adhesions, of which 165 (39.4%) had dense adhesions and 59 (14.1%) had only filmy adhesions. The sensitivity and specificity of a negative preoperative paraumbilical sliding sign in predicting the presence of dense intra-abdominal adhesions in women undergoing repeat CS were 94.6% (95% CI, 92.4-96.7%) and 93.3% (95% CI, 90.9-95.7%), respectively. A negative suprapubic sliding sign also showed high sensitivity (95.2% (95% CI, 93.1-97.2%)) and specificity (91.7% (95% CI, 89.1-94.4%)). Additionally, a negative sliding sign at both locations in the same patient had robust sensitivity (90.2% (95% CI, 87.3-93.0%)) and specificity (96.3% (95% CI, 94.5-98.1%)). We found that the risk of dense intra-abdominal adhesions increased with parity and the number of previous CS. Dense intra-abdominal adhesions were associated with increased incision-to-delivery time, higher risk of maternal bladder injury, intraoperative bleeding and postpartum hemorrhage.

CONCLUSIONS

Dense intra-abdominal adhesions are common in women with a history of CS and are associated with delayed delivery of the neonate and increased risk of adverse maternal outcomes. The transabdominal sonographic paraumbilical and suprapubic sliding signs are robust methods for the accurate preoperative prediction of dense intra-abdominal adhesions in patients with a history of CS. As the techniques are easy to learn and perform, the sliding sign should be used more widely for triaging patients at high risk of dense intra-abdominal adhesions for appropriate preoperative planning. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Can we predict peritoneal adhesions formation after cesarean delivery?

OBJECTIVE

To examine demographic and obstetrical factors that are associated with adhesion formation following cesarean delivery.

METHODS

We conducted a population-based study that included all women over 18 years og age who underwent two cesarean deliveries between the years 1988 and 2016 in a large tertiary medical center. We excluded women with adhesions already diagnosed during the first cesarean delivery, history of other abdominal or pelvic surgery, history of pelvic infection or pelvic inflammatory disease, history of endometriosis and history of uterine Müllerian anomalies. In addition, women with a classical or T-shaped uterine incision, non-singleton pregnancies, and fetal chromosomal or structural abnormalities were excluded.

RESULTS

During the study period, 32.6% (n = 2283) of women were diagnosed with peritoneal adhesions during the second cesarean delivery. Factors found to be significantly associated with peritoneal adhesions were maternal age 35 years or older at the first cesarean delivery, Bedouin Arab ethnicity, composite of intrapartum and postpartum infectious morbidity, and cesarean deliveries that were performed after the onset of labor. In contrast, having a previous vaginal birth was found to be protective.

CONCLUSIONS

Our results suggest that a woman's characteristics at her first cesarean delivery and her obstetrical history may be predictive of the likelihood of adhesion formation.

A novel machine learning model for predicting clinical pregnancy after laparoscopic tubal anastomosis

BACKGROUND

Laparoscopic tubal anastomosis (LTA) is a treatment for women who require reproduction after ligation, and there are no reliable prediction models or clinically useful tools for predicting clinical pregnancy in women who receive this procedure. The prediction model we developed aims to predict the individual probability of clinical pregnancy in women after receiving LTA.

METHODS

Retrospective analysis of clinical data of patients undergoing LAT in the Second Hospital of Lanzhou University from July 2017 to December 2021. Least absolute shrinkage and selection operator (LASSO) regression was used for data dimension reduction and feature selection. We incorporated the patients' basic characteristics, preoperative laboratory tests and laparoscopic tubal anastomosis procedure signature and obtained a nomogram. The model performance was evaluated in terms of its calibration, discrimination, and clinical applicability. The prediction model was further internally validated using 200 bootstrap resamplings.

RESULTS

A total of 95 patients were selected to build the predictive model for clinical pregnancy after LTA. The LASSO method identified age, intrauterine polyps, pelvic adhesion and thyroid stimulating hormone(TSH) as independent predictors of the clinical pregnancy rate. The prediction nomogram included the abovementioned four predictive parameters. The model showed good discrimination with an area under the curve (AUC) value of 0.752. The Hosmer‒Lemeshow test of calibration showed that χ2 was 4.955 and the p value was 0.838, which indicates a satisfactory goodness-of-fit. Decision curve analysis demonstrated that the nomogram was clinically useful. Internal validation shows that the predictive model performs well.

CONCLUSION

This study presents a nomogram incorporating age, intrauterine polyps, pelvic adhesion and TSH based on the LASSO regression model, which can be conveniently used to facilitate the individualized prediction of clinical pregnancy in women after LTA.

Prevalence and risk factor of postoperative adhesions following repeated cesarean section: A prospective cohort study

OBJECTIVE

To evaluate the prevalence of intraperitoneal adhesions after repeated cesarean delivery and its associated personal and surgical risk factors.

METHODS

This prospective cohort study was conducted at the delivery ward at Fayoum University Hospital from October 2020 to December 2021. Women were recruited according to predetermined inclusion and exclusion criteria. Eligible women were interviewed, and data were obtained for personal history, past surgical and obstetrical history, and data about the current delivery. Nair's scoring system was used to evaluate intraperitoneal adhesions. Postoperative data and complications were reported.

RESULTS

Three hundred women were recruited. Moderate to severe adhesions occurred in 186 patients (62%). These patients had a significantly prolonged hospital stay and were delivered by expert surgeons (P < 0.001 and P = 0.008, respectively). The adhesion score correlated positively with patients' age (P < 0.001), parity (P < 0.001), interpregnancy interval (P = 0.033), duration of hospital admission either previously or in the current delivery (P = 0.001 and P < 0.001), time to ambulation (P < 0.001), time to intestinal movement (P < 0.001), operative time (P < 0.001), and surgeons' age and experience (both P = 0.015).

CONCLUSION

Adhesions led to increased maternal morbidity. Multiple contributing factors were significantly related to adhesions with multiple cesarean deliveries.

Intra-abdominal Adhesions among Patients Undergoing Repeat Caesarean Section in Department of Obstetrics and Gynaecology of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Adhesions are one of the common complications encountered after caesarean section whose risk increases with the number of caesarean deliveries. This study aimed to find out the prevalence of intra-abdominal adhesions among patients undergoing repeat caesarean section in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted on 74 pregnant women undergoing repeat caesarean section in the Department of Obstetrics and Gynaecology of a tertiary care centre from July, 2021 to December, 2021 after receiving the ethical approval from the Institutional Review Committee (Reference number: 2107202103). Pregnant women who met the eligibility criteria were included in the study. Convenience sampling was done. The severity of the adhesions was classified using the Tulandi and Lyell classification. Data were analysed using the Statistical Package for the Social Sciences version 26.0 software. Point estimate at 90% Confidence Interval was calculated along with frequency and percentage for binary data along with mean and standard deviation for continuous data.

Results

Out of 74 women undergoing repeat caesarean section, 55 (74.32%) (65.99-82.65 at 90% Confidence Interval) had developed intra-abdominal adhesions.

Conclusions

Our study showed that the prevalence of intra-abdominal adhesions among patients undergoing repeat caesarean section was higher when compared to similar studies conducted in similar settings.

Keywords

postoperative complications; repeat caesarean section; surgical adhesions.

Effect of visceral manipulation on menstrual complaints in women with polycystic ovarian syndrome

CONTEXT

Research is lacking regarding osteopathic approaches in treating polycystic ovary syndrome (PCOS), one of the prevailing endocrine abnormalities in reproductive-aged women. Limited movement of pelvic organs can result in functional and structural deficits, which can be resolved by applying visceral manipulation (VM).

OBJECTIVES

This study aims to analyze the effect of VM on dysmenorrhea, irregular, delayed, and/or absent menses, and premenstrual symptoms in PCOS patients.

METHODS

Thirty Egyptian women with PCOS, with menstruation-related complaints and free from systematic diseases and/or adrenal gland abnormalities, prospectively participated in a single-blinded, randomized controlled trial. They were recruited from the women's health outpatient clinic in the faculty of physical therapy at Cairo University, with an age of 20-34 years, and a body mass index (BMI) ≥25, <30 kg/m². Patients were randomly allocated into two equal groups (15 patients); the control group received a low-calorie diet for 3 months, and the study group that received the same hypocaloric diet added to VM to the pelvic organs and their related structures, according to assessment findings, for eight sessions over 3 months. Evaluations for body weight, BMI, and menstrual problems were done by weight-height scale, and menstruation-domain of Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire (PCOSQ), respectively, at baseline and after 3 months from interventions. Data were described as mean, standard deviation, range, and percentage whenever applicable.

RESULTS

Of 60 Egyptian women with PCOS, 30 patients were included, with baseline mean age, weight, BMI, and menstruation domain score of 27.5 ± 2.2 years, 77.7 ± 4.3 kg, 28.6 ± 0.7 kg/m², and 3.4 ± 1.0, respectively, for the control group, and 26.2 ± 4.7 years, 74.6 ± 3.5 kg, 28.2 ± 1.1 kg/m², and 2.9 ± 1.0, respectively, for the study group. Out of the 15 patients in the study group, uterine adhesions were found in 14 patients (93.3%), followed by restricted uterine mobility in 13 patients (86.7%), restricted ovarian/broad ligament mobility (9, 60%), and restricted motility (6, 40%). At baseline, there was no significant difference (p>0.05) in any of demographics (age, height), or dependent variables (weight, BMI, menstruation domain score) among both groups. Poststudy, there was a statistically significant reduction (p=0.000) in weight, and BMI mean values for the diet group (71.2 ± 4.2 kg, and 26.4 ± 0.8 kg/m², respectively) and the diet + VM group (69.2 ± 3.7 kg; 26.1 ± 0.9 kg/m², respectively). For the improvement in the menstrual complaints, a significant increase (p<0.05) in the menstruation domain mean score was shown in diet group (3.9 ± 1.0), and the diet + VM group (4.6 ± 0.5). On comparing both groups poststudy, there was a statistically significant improvement (p=0.024) in the severity of menstruation-related problems in favor of the diet + VM group.

CONCLUSIONS

VM yielded greater improvement in menstrual pain, irregularities, and premenstrual symptoms in PCOS patients when added to caloric restriction than utilizing the low-calorie diet alone in treating that condition.

A consensus-based core feature set for surgical complexity at laparoscopic hysterectomy

BACKGROUND

There are no current standardized and accepted methods to characterize the surgical complexity of a laparoscopic hysterectomy. This leads to challenges when trying to understand the relationship between the patient and the surgical features and outcomes. The development of core feature sets for laparoscopic hysterectomy studies would enable future trials to measure the similar meaningful variables that can contribute to surgical complexity and outcomes.

OBJECTIVE

The purpose of this study was to develop a core feature set for the surgical complexity of a laparoscopic hysterectomy.

STUDY DESIGN

This was an international Delphi consensus study. A comprehensive literature review was conducted to identify the features that were reported in studies on laparoscopic hysterectomy complexity. All the features were presented for evaluation and prioritization to key experts in 3 rounds of online surveys. A priori consensus criteria were used to reach agreement on the final outcomes for inclusion in the core feature set.

RESULTS

Experts represented North America, South America, Europe, Africa, Asia, and Oceania. Most of them had fellowship training in minimally invasive gynecologic surgery. Sixty-four potential features were entered into round 1. Experts reached a consensus on 7 features to be included in the core feature set. These features were grouped under the following domains: 1) patient features, 2) uterine features, and 3) nonuterine pelvic features. The patient features include obesity and other nonobesity comorbidities that alter or limit the ability of a surgeon to perform the basic or routine steps in a laparoscopic hysterectomy. The uterine features include the size and presence of fibroids. The nonuterine pelvic features include endometriosis, ovarian cysts, and adhesions (bladder-to-uterus, rectouterine pouch, and other adhesions).

CONCLUSION

Using robust consensus science methods, an international consortium of experts has developed a core feature set that should be assessed and reported in all future studies that aim to assess the relationship between the patient features and surgical outcomes of laparoscopic hysterectomy.

Retained Placenta Percreta with Acquired Uterine Arteriovenous Malformation—Case Report and Short Review of the Literature

Placenta accreta spectrum disorder (PAS) has an increased frequency due to the high number of cesarean sections. The abnormal placentation associated with a retained placenta can cause persistent uterine bleeding, with ultrasound Doppler examination being the main choice to assess the uterine hemorrhage. An acquired uterine arteriovenous malformation (AVM) may occur because of uterine trauma, spontaneous abortion, dilation and curettage, endometrial carcinoma or gestational trophoblastic disease. The treatment for abnormal placentation associated with AVM can be conservative, represented by methotrexate therapy, arterial embolization, uterine curettage, hysteroscopic loop resection or radical, which takes into consideration total hysterectomy. Therapeutic management always considers the degree of placental invasion, the patient hemodynamic state and fertility preservation. Considering the aspects described, we present a case of retained placenta percreta associated with acquired uterine AVM, with imagistic and clinical features suggestive of a gestational trophoblastic disease, successfully treated by hysterectomy, along with a small review of the literature, as only a few publications have reported a similar association of diagnostics and therapy.

Laparotomy for Abdominal Adhesion and Removal of Intrauterine Device from Anatomically Distorted Uterus due to Adhesion in a 43-Year-Old Woman with 3 Previous Cesarean Sections

Patient: Female, 43-year-old

Final Diagnosis: Uterine adhesion to abdominal wall

Symptoms: Chronic pelvic pain

Medication: —

Clinical Procedure: Laparotomy

Specialty: Obstetrics and Gynecology

Personalising the risk of conversion from laparoscopic to open hysterectomy in benign conditions: Development and external validation of risk prediction models

OBJECTIVE

To develop and validate novel prediction models to personalise the risk of conversion from laparoscopic to open hysterectomy in benign conditions.

DESIGN

Retrospective cohort study.

SETTINGS

English NHS Hospitals between 2011 and 2018.

POPULATION

68 752 women undergoing laparoscopic hysterectomy for benign conditions.

METHODS

We developed two multivariable logistic models using readily available clinical information, one for the pre-operative setting and another for operative decision-making using additional surgical information, using 2011-2016 data in five regions (24 806 women). We validated them (a) temporally in the same regions using 2017-2018 data (12 438 women); (b) geographically in the same time-period using data from three different regions (22 024 women); and (c) temporally and geographically using 2017-2018 data in three different regions (9484 women).

MAIN OUTCOME MEASURES

Conversion from laparoscopic to open hysterectomy.

RESULTS

Conversions occurred in 6.8% (1687/24 806) of hysterectomies in the development group, and in 5.5% (681/12 438) in the temporal, 5.9% (1297/22 204) in the geographical and 5.2% (488/9484) in the temporal and geographical validation groups. In the development cohort, the area under the receiver operating characteristic curve values for the pre-operative and operative models were 0.65 and 0.67, respectively. In the validation cohorts the corresponding values were 0.65 and 0.66 (temporal), 0.66 and 0.68 (geographical) and 0.65 and 0.68 (temporal and geographical), respectively. Factors predictive of conversion included age, Asian ethnicity, obesity, fibroids, adenomyosis, endometriosis and adhesions. Adhesions were the most predictive (odds ratio 2.54, 95% confidence interval 2.22-2.90).

CONCLUSION

The models for predicting conversions showed acceptable performance and transferability.

TWEETABLE ABSTRACT

Novel tool to personalise the risk of conversion from laparoscopic to open hysterectomy in benign conditions.

Structured report for dynamic ultrasonography in patients with suspected or known endometriosis: Recommendations of the International Society for Gynecologic Endoscopy (ISGE)

OBJECTIVE

The International Society for Gynecologic Endoscopy (ISGE) developed this project to establish the recommendations for structured reporting of dynamic ultrasound findings, promoting on this manner the practice of standardized, comprehensive and systematic evaluation and reporting of endometriosis in pelvic structures, in correlation with the #Enzian classification.

STUDY DESIGN

A non-systematic review was done through a search on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database and Web of Science, using the medical subject heading (MeSH) term "endometriosis" (MeSH Unique ID: D004715) in combination with "diagnostic imaging" (MeSH Unique ID Q000000981) and "consensus" (MeSH Unique ID D032921). The information extracted from the articles of interest, written in English and published from inception of the above-mentioned databases until May 2021, was graded by the level of evidence using the American College of Chest Physicians (ACCP) classification system. The recommendations for a structured reporting of ultrasound findings were developed through multiple cycles of literature analysis and expert discussion following the Delphi method.

RESULTS

The ISGE recommends the adoption of the terms, definitions and methods proposed by the International Deep Endometriosis Analysis (IDEA) Group for ultrasound assessment of patients with suspected or known endometriosis (grade 1C), since this is the most comprehensive and systematic concept currently available. This paper provides the ISGE structured reporting template for presenting quantitative and qualitative information upon the IDEA consensus-based sonographic assessment of the uterus, adnexa, anterior and posterior compartment. The #Enzian classification is recommended to summarize the findings in a standard fashion (grade 1B).

CONCLUSION

Mapping of pelvic endometriosis by ultrasound is accurate when trained sonographers perform the technique. Structured reporting of the lesions may improve patient counseling and treatment planning, including the organization of multidisciplinary teams and the selection of the most appropriate medical or surgical therapeutic strategy.

Association between deficient cesarean delivery scar and cesarean scar syndrome

INTRODUCTION

The aim of our study was to compare long-term morbidity after elective and emergency cesarean delivery (CD).

METHODS

A prospective cohort study was conducted in 200 women delivered by CD. Ultrasound examinations were performed transvaginally at 6 weeks and 18 months after CD. Clinical data were collected at the time of CD and after 18 months.

RESULTS

In the group of 200 women, 29% underwent emergency and 71% elective CD. Then, 6 weeks and 18 months after CD, a severe scar defect was present in 7% and 5%, respectively (P = .4). After 18 months of CD, 17% (34/200) of women had evidence of adhesions of the vesicouterine pouch. Severe CD scar defects were significant predictors for adhesion formation in vesicouterine pouch (OR 3.14, 95% CI, 1.54-4.74), pelvic pain (OR 1.68, 95% CI, 0.22-3.14), dysmenorrhea (OR 2.12, 95% CI, 0.74-3.50), and dyspareunia (OR 1.38, 95% CI, 0.09-2.67). Uterine scar defects detected at 6 weeks after elective CD were detectable at 18 months in only 40% of cases, whereas uterine scar defects after emergency CD were still detectable in 87% of cases.

CONCLUSION

Uterine scar defects are more frequent at 18 weeks after emergency CD, than after elective CD (40% vs 87%). Women with severe scar defects have higher risk of adhesion formation, dysmenorrhea, dyspareunia, and chronic pelvic pain.

Maternal obesity and intra-abdominal adhesion formation at cesarean delivery

Objective: The aim of the study was to evaluate whether maternal obesity increases the risk of intra-abdominal adhesion formation at cesarean delivery.Methods: Two hundred and two pregnant women of at least 37 weeks' gestation and who had undergone only one prior cesarean delivery were included in this prospective observational study. The study population was divided into two groups according to body mass index (BMI) upon cesarean delivery (<30 kg/m² and ≥30 kg/m²). The intra-abdominal adhesion incidence and the scar characteristics of the groups were compared.Results: Intra-abdominal adhesions were more common in women ≥30 kg/m² than in those <30 kg/m² (OR 2.0, 95% CI 1.1-3.6). BMI upon cesarean delivery (32.6 ± 6.2 kg/m² vs. 30.5 ± 4.8 kg/m², p = .018) and pre-pregnancy BMI (27.9 ± 6.8 kg/m² vs. 25.7 ± 5.2 kg/m², p = .026) were higher in women with dense adhesions than in those with either filmy or no adhesions. The omentum was the most adherent tissue, and the omental adhesion rate was also higher in women ≥30 kg/m² than in those <30 kg/m² (39.6% vs. 23.7%, p = .016). When the scar characteristics were compared, it was observed that the hyperpigmented scar rate was significantly lower (17.8% vs. 39.6%, p = .001) in women ≥30 kg/m² with intra-abdominal adhesions (16.7% vs. 35.4%, p = .005).Conclusion: Intra-abdominal adhesion formation following cesarean delivery is more common in obese women.

Transvaginal US of Endometriosis: Looking Beyond the Endometrioma with a Dedicated Protocol

Transvaginal sonography (TVS) is a valuable primary imaging tool for the initial evaluation and management of endometriosis, a complex multifocal disease process with a varied spectrum of clinical and morphologic features that can substantially affect quality of life. The high accuracy of TVS for the detailed mapping of disease extent, an essential process for guiding treatment strategies, is well documented. The dynamic nature of US provides added value, revealing information that is not easily addressed with other imaging modalities. As recognized by the International Deep Endometriosis Analysis Consensus Group, a dedicated standardized protocol that is used by experienced and knowledgeable operators is necessary for a complete evaluation. The four components of a dedicated TVS protocol for evaluation of pelvic endometriosis are (a) evaluation of the uterus and adnexa, (b) dedicated search for deep infiltrating endometriosis, (c) assessment of the sliding sign, and (d) detection of sonographic soft markers. These components are described, and the multiple locations and US findings of endometriosis within the pelvis are reviewed, with emphasis on the unique features of US as an extension of the physical examination. In addition to enabling evaluation of the static findings of adenomyosis, endometrioma, hydrosalpinx, hematosalpinx, and hypoechoic nodules of deep infiltrating endometriosis, dynamic TVS enables assessment of pouch of Douglas obliteration, organ mobility, and site-specific tenderness, as well as tenderness-guided imaging. The benefits of implementing a dedicated TVS protocol in terms of improved patient care are also discussed. Online supplemental material is available for this article. ^©RSNA, 2019.

Captive uterus syndrome: An unrecognized complication of cesarean sections?

Cesarean sections are a common surgical procedure at risk of complications including adhesions and chronic pelvic pain. This case series presents 10 cases of patients presenting with chronic pelvic pain following a cesarean section which were found upon surgical exploration to have developed adhesions between the abdominal wall and the uterus. When they first consulted, patients were evaluated clinically with a questionnaire and physical exam, and with ultrasonography to evaluate pelvic anatomy when necessary. The evaluation was completed with diagnostic laparoscopy which revealed atypical post-cesarean adhesions which were treated by adhesion lysis or hysterectomy. Surgical protocols of the cesarean sections were retrieved and analysed for potential adhesion risk factors. Patients presented with chronic pelvic pain that appeared in the early post-operative period. Physical exam revealed a subinvoluted uterus with a high fixed cervix. Ultrasound examination revealed clues of adhesions manifested by points of traction and an irregular uterine border. No other diagnosis such as endometriosis, pelvic inflammatory disease, ovarian or bowel anomalies were identified during surgery. After laparoscopic adhesion lysis or hysterectomy, all patients who were treated noted a complete resolution of the pain that lasted during a follow-up of at least 5 years. These findings suggest that adhesions that create traction and fix the uterus to the abdominal wall following caesarian section can be the cause of severe chronic pelvic pain. In the presence of such pain, clinicians should suspect the presence of adhesions and investigate and treat patients accordingly.

Imaging techniques in endometriosis

Endometriosis is a common gynecological condition affecting up to 15% of the general female population. Here, we present a systematic review of imaging techniques of endometriosis. The aim of this review is to determine the most accurate site-specific preoperative diagnostic tools in order to map, locate, evaluate the extension, and stage the disease. There are important reasons to stage endometriosis: to create a common language, to enable specificity of diagnosis, standardize comparisons, and to facilitate research applications. The requirements of an ideal endometriosis classification system are that it be empirically and scientifically based, be of general consensus, have unambiguous definition of terms, be comprehensive in all cases, have a simple translation from anatomic features to verbal description, reflect disease, predict fertility, predict pain relief, be useful to guide treatment, indicate risk of recurrence, identify clinical situations in which it does not apply, be simple to calculate, and be easy to communicate to women. An extensive search of papers regarding imaging techniques in endometriosis was performed in Pubmed from January 1992 to February 2018, including original peer-reviewed papers, reviews, and international guidelines.

Transabdominal ultrasound: Can it be used to detect and quantify adhesions/reported pain, following Caesarean section?

BACKGROUND

Caesarean section is common in the UK with post-procedural adhesions causing life-long clinical symptoms and impacting future pregnancies. This study's aim was to explore associations between these surgical adhesions, via transabdominal ultrasound findings, and perceived symptoms.

METHOD

Females demonstrating 1-3 transverse, lower-segment Caesareans were included. Visceral slide transabdominal ultrasound elicited positive adhesions (<1 cm movement) and negative adhesions (>1 cm movement). Scar tissue quality was assessed by the Patient and Observer Scar Assessment Scale (POSAS) and Numerical rating scales (NRS) described pain symptoms. The relationship between adhesions was explored using Fisher's exact test and multiple regression analysis.

RESULTS

Twenty-two subjects (mean-age 35) were recruited; twenty participants (91%) had undergone 1 Caesarean, one each of the remainder had undergone 2 and 3 Caesareans respectively. Increased Visceral slide (>1 cm) was seen as predictive of increased scar pain (R² = 0.76 (95% CI 0.12-0.28), P < 0.001).

CONCLUSION

Caesarean adhesion scans showed significant associations with pain symptomology. Comprehensive adhesion assessment needs to be developed to improve long term outcomes of adhesions. Transabdominal Ultrasound can be considered a useful, quick and non-deleterious alternative diagnostic tool to Laparoscopy, therefore preventing further adhesion formation.

Accuracy of preoperative real-time dynamic transvaginal ultrasound sliding sign in prediction of pelvic adhesions in women with previous abdominopelvic surgery: prospective, multicenter, double-blind study

OBJECTIVE

To investigate the role of the transvaginal sonographic (TVS) sliding sign in predicting pelvic adhesions in women with previous abdominopelvic surgery.

METHODS

This was a multicenter, prospective, interventional, double-blind study of patients with a history of abdominopelvic surgery who were undergoing laparoscopy or laparotomy during the 6-month period from March to August 2016 in one of three academic obstetrics and gynecology departments. Prior to surgery, patients were examined by TVS to assess the vesicouterine pouch, uterus, ovaries and pouch of Douglas, using the TVS pelvic sliding sign. Ultrasound findings and medical and surgical data were recorded. We assessed the accuracy of the preoperative TVS sliding sign in the prediction of pelvic adhesions overall and in each compartment separately.

RESULTS

During the study period, complete TVS sliding sign and laparoscopic or laparotomic data were available for 107 women. Their mean age was 44.0 (95% CI, 41.6-46.4; range, 20-79) years. Their mean parity was 2.0 (95% CI, 1.7-2.3; range, 0-9) and the mean number of previous abdominal surgical procedures per patient was 1.3 (95% CI, 1.2-1.5; range, 1-4). Adhesions were noted in 27/107 (25.2%) patients. The TVS sliding sign had a sensitivity of 96.3% and specificity of 92.6% in predicting pelvic adhesions. There was a significant relationship between adhesions in each compartment and the TVS sliding sign (P < 0.05).

CONCLUSIONS

The TVS sliding sign is an effective means to detect preoperatively pelvic adhesions in patients with previous abdominopelvic surgery. Use of such a non-invasive and well-tolerated technique could help in the planning of laparoscopy or laparotomy and counseling of these patients. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Incidence and severity of chronic pain after caesarean section: A systematic review with meta-analysis

BACKGROUND

The frequency of caesarean section has increased dramatically in recent decades. Despite this, robust data regarding the consequences of caesarean section in terms of developing chronic postsurgical pain (CPSP) are still lacking.

OBJECTIVE

This systematic review analysed the incidence and severity of CPSP in women 3 to less than 6, 6 to less than 12, and at least 12 months after caesarean section.

DESIGN

Systematic review of prospective and retrospective observational studies and randomised controlled trials with meta-analysis.

DATA SOURCE

We searched MEDLINE to May 2015.

ELIGIBILITY CRITERIA

We included all studies investigating the incidence and/or severity of CPSP at least 3 months after caesarean section. The primary outcome was chronic postsurgical wound pain (CPSP 'wound'). Secondary outcomes were persistent pain in the back area, pelvic region or reported as residual pain, and severity of 'birth-related' chronic pain.

RESULTS

Meta-analysis using the random-effects model based on 15 studies (n = 4475) reporting CPSP 'wound' at 3 to less than 6 months after caesarean section revealed an incidence of 15.4% [95% confidence interval (CI): 9.9 to 20.9%]. For 6 to less than 12 and at least 12 months after caesarean section, the incidence of CPSP 'wound' was estimated at 11.5% (95% CI: 8.1 to 15.0%, n = 3345) and 11.2% (95% CI: 7.4 to 15.0%, n = 3451), respectively. Meta-regression analysis using the publication year as predictor revealed stable CPSP 'wound' incidences at each postoperative time slot from 2002 to the present. Of those patients who reported chronic pain, 9.6% (95% CI: 0.0 to 21.0%) had severe pain, 23.5% (95% CI: 10.0 to 37.0%) had moderate pain and 49.2% (95% CI: 18.9 to 79.4%) had mild pain at 6 months.

LIMITATIONS

Major limitations are high statistical heterogeneity of the meta-analyses and inconsistencies in reporting severity of chronic 'birth-related' pain.

CONCLUSION

This meta-analysis finds a clinically relevant incidence of CPSP 'wound' after caesarean section ranging from 15% at 3 months to 11% at 12 months or longer that has been largely stable in recent years.

Prevalence of adhesions and associated postoperative complications after cesarean section in Ghana: a prospective cohort study

BACKGROUND

The global increase in Cesarean section rate is associated with short- and long-term complications, including adhesions with potential serious maternal and fetal consequences. This study investigated the prevalence of adhesions and association between adhesions and postoperative complications in a tertiary referral hospital in Accra, Ghana.

METHODS

In this prospective cohort study, 335 women scheduled for cesarean section at Korle-Bu Teaching Hospital in Accra, Ghana were included from June to December 2015. Presence or absence of adhesions was recorded and the severity of the adhesions was scored using a classification system. Associations between presence and severity of adhesions, postoperative complications, and maternal and infant outcomes at discharge and 6 weeks postpartum were assessed using multivariate logistic and linear regression analysis.

RESULTS

Of the participating women, 128 (38%) had adhesions and 207 (62%) did not. Prevalence of adhesions increased with history of caesarean section; 2.8% with no CS but may have had an abdominal surgery, 51% with one previous CS, 62% with >1 CS). Adhesions significantly increased operation time (mean 39.2 (±15.1) minutes, absolute adjusted difference with presence of adhesions 9.6 min, 95%CI 6.4-12.8), infant delivery time (mean 5.4 (±4.8) minutes, adjusted difference 2.4 min, 95%CI 1.3-3.4), and blood loss for women with severe adhesions (mean blood loss 418.8 ml (±140.6), adjusted difference 57.6 ml (95%CI 12.1-103.0). No differences for other outcomes were observed.

CONCLUSION

With cesarean section rates rising globally, intra-abdominal adhesions occur more frequently. Risks of adhesions and associated complications should be considered in counseling patients for cesarean section.

Effect of remote cesarean delivery on complications during hysterectomy: a cohort study

BACKGROUND

Cesarean delivery is performed frequently worldwide, and follow-up studies that report complications at subsequent surgery are warranted.

OBJECTIVES

The aim of the study was to investigate the association between a previous abdominal delivery and complications during a subsequent hysterectomy and to estimate the fraction of complications that are driven by the presence of adhesions.

STUDY DESIGN

This was a longitudinal population-based register study of 25354 women who underwent a benign hysterectomy at 46 hospital units in Sweden 2000-2014.

RESULTS

Adhesions were found in 45% of the women with a history of cesarean delivery. Organ injury affected 2.2% of the women. The risk of organ injury (adjusted odds ratio, 1.74; 95% confidence interval, 1.41-2.15) and postoperative infection (adjusted odds ratio, 1.26; 95% confidence interval, 1.15-1.39) was increased with previous cesarean delivery, irrespective of whether adhesions were present or not. The direct effect on organ injury by a personal history of cesarean delivery was estimated to 73%, and only 27% was mediated by the presence of adhesions. Previous cesarean delivery was a predictor of bladder injury (adjusted odds ratio, 1.86; 95% confidence interval, 1.40-2.47) and bowel injury (adjusted odds ratio, 1.83; 95% confidence interval, 1.10-3.03), but not ureter injury. A personal history of other abdominal surgeries was associated with bowel injury (adjusted odds ratio, 2.27; 95% confidence interval, 1.37-3.78), and the presence of endometriosis increased the risk of ureter injury (adjusted odds ratio, 2.15; 95% confidence interval, 1.34-3.44).

CONCLUSION

Previous cesarean delivery is associated with an increased risk of complications during a subsequent hysterectomy, but the risk is only partly attributable to the presence of adhesions. Previous cesarean delivery and presence of endometriosis were major predisposing factors of organ injury at the time of the hysterectomy, whereas background and perioperative characteristics were of minor importance.

Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study

OBJECTIVE

The aim of the study was to evaluate the association between abdominal adhesions at the time of gynaecologic surgery and a history of caesarean delivery, and to investigate obstetric factors contributing to adhesion formation after caesarean section (CS).

DESIGN

Longitudinal population-based register study.

SETTING

Sweden.

POPULATION

Women undergoing benign hysterectomy and/or adnexal surgery in Sweden, 2000-2014, with a previous delivery during 1973-2013 (n = 15 479).

METHODS

Information about abdominal adhesions during gynaecological surgery, prior medical history, pregnancies and deliveries were retrieved from Swedish National Health and Quality registers.

MAIN OUTCOME MEASURES

Adhesions.

RESULTS

In women with previous CS, adhesions were present in 37%, compared with 10% of women with no previous CS [odds ratio (OR): 5.18, 95% confidence interval (CI): 4.70-5.71]. Adhesions increased with the number of caesarean sections: 32% after one CS; 42% after two CS and 59% after three or more CS (P < 0.001). Regardless of the number of CS, factors at CS such as age ≥35 years (aOR: 1.28, 95% CI: 1.05-1.55), body mass index (BMI) ≥30 [adjusted OR (aOR): 1.91, 95% CI: 1.49-2.45] and postpartum infection (aOR: 1.55, 95% CI: 1.05-2.30) increased the risk of adhesions.

CONCLUSIONS

Presence of adhesions in abdominal gynaecological surgery is associated with women's personal history of caesarean delivery. The number of caesarean sections was the important predictor of adhesions; advanced age, obesity and postpartum infection further increased the incidence.

TWEETABLE ABSTRACT

Repeat caesarean, age, obesity and infection increased the risk of pelvic adhesions after caesarean section.

Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group

The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Cesarean wound scar characteristics for the prediction of pelvic adhesions: a meta-analysis of observational studies

OBJECTIVE

The pathophysiologic processes that result in wound healing are the same regardless of the tissue involved. The purpose of the present meta-analysis is to evaluate whether cesarean scar characteristics may predict the presence of pelvic adhesions.

MATERIALS AND METHODS

We conducted a systematic review searching the Medline (1966-2016), Scopus (2004-2016), ClinicalTrials.gov (2008-2016), Cochrane Central Register of Controlled Trials CENTRAL (1999-2016) and Google Scholar (2004-2016) databases together with reference lists from included studies. All prospective and retrospective observational cohort studies were included. Statistical meta-analysis was performed using the RevMan 5.1 software.

RESULTS

Current evidence suggests that depressed scars are positively associated with intra-abdominal adhesions (ΟR 2.79, 95%CI 1.74-4.46). Elevated scars might also correlate with the presence of adhesions, however, this association did not reach statistical significance (OR 1.61, 95%CI 0.91-2.85, p = 0.10). The same was reported in the case of scar pigmentation (REM, OR 1.68, 95%CI 0.86-3.26, p = 0.13). Flat scars were predictive of the absence of adhesions (899 patients, REM, OR 0.33, 95%CI 0.23-0.54, p < 0.00001).

CONCLUSION

According to our meta-analysis, abdominal wound characteristics following cesarean section can predict the presence of adhesions. However, given the small number of published studies, further research is needed to corroborate our findings.

Clinical effects of integrated health care in patients undergoing cesarean section

AIM: To evaluate the clinical effects of integrated health care in patients undergoing cesarean section.

METHODS: Two hundred and forty-eight mothers who underwent cesarean section at our hospital from June 2013 to June 2014 were divided into two groups based on the time of admission: a control group (June 2013 to December 2013, n = 124) and an observation group (January 2014 to June 2014, n = 124). The control group was treated using the traditional care model, and the observation group was treated using the integrated health care model. The nursing care quality score, incidence of adhesions, gastrointestinal motility recovery and patient satisfaction were compared between the two groups.

RESULTS: The scores of disease cognition, implementation of doctors' orders, emergency drug use, condition observation, ward management, document management, and overall quality of care were significantly higher in the observation group than in the control group (P < 0.05). The incidence rates of adhesions, bloating, constipation, and intestinal obstruction were significantly lower in the observation group than in the control group (P < 0.05). The times to bloating disappearance, anal exhaust, recovery of bowel sounds, defecation, and first meal, as well as the average length of hospital stay were significantly shorter in the observation group than in the control group (P < 0.05), and patient satisfaction score in the observation group was significantly higher than that in the control group (P < 0.05).

CONCLUSION: Integrated health care can effectively improve health care quality, reduce the incidence of postoperative adhesions, and improve the recovery of gastrointestinal function in patients undergoing cesarean section.

Axotomy of tributaries of the pelvic and pudendal nerves induces changes in the neurochemistry of mouse dorsal root ganglion neurons and the spinal cord

Using immunohistochemical techniques, we characterized changes in the expression of several neurochemical markers in lumbar 4-sacral 2 (L4-S2) dorsal root ganglion (DRG) neuron profiles (NPs) and the spinal cord of BALB/c mice after axotomy of the L6 and S1 spinal nerves, major tributaries of the pelvic (targeting pelvic visceral organs) and pudendal (targeting perineum and genitalia) nerves. Sham animals were included. Expression of cyclic AMP-dependent transcription factor 3 (ATF3), calcitonin gene-related peptide (CGRP), transient receptor potential cation channel subfamily V, member 1 (TRPV1), tyrosine hydroxylase (TH) and vesicular glutamate transporters (VGLUT) types 1 and -2 was analysed seven days after injury. L6-S1 axotomy induced dramatic de novo expression of ATF3 in many L6-S1 DRG NPs, and parallel significant downregulations in the percentage of CGRP-, TRPV1-, TH- and VGLUT2-immunoreactive (IR) DRG NPs, as compared to their expression in uninjured DRGs (contralateral L6-S1-AXO; sham mice); VGLUT1 expression remained unaltered. Sham L6-S1 DRGs only showed a small ipsilateral increase in ATF3-IR NPs (other markers were unchanged). L6-S1-AXO induced de novo expression of ATF3 in several lumbosacral spinal cord motoneurons and parasympathetic preganglionic neurons; in sham mice the effect was limited to a few motoneurons. Finally, a moderate decrease in CGRP- and TRPV1-like-immunoreactivities was observed in the ipsilateral superficial dorsal horn neuropil. In conclusion, injury of a mixed visceral/non-visceral nerve leads to considerable neurochemical alterations in DRGs matched, to some extent, in the spinal cord. Changes in these and potentially other nociception-related molecules could contribute to pain due to injury of nerves in the abdominopelvic cavity.