Non-surgical interventions for the management of chronic pelvic pain

A Multisite Randomized Feasibility Trial of a Remotely Delivered Pelvic Yoga Program for Women with Chronic Pelvic Pain Syndrome

Objective: Yoga has been recommended as a complementary management strategy for women with chronic pelvic pain (CPP), but many women lack access to specialized yoga instruction for this indication, and few data are available to evaluate changes in CPP with yoga. This feasibility trial evaluated the acceptability and tolerability of a remotely delivered yoga program for CPP in women and examined data quality and interpretability for measures of pelvic pain intensity and impact with yoga instruction. Methods: Ambulatory women with CPP were recruited from northern California in 2020-2022 and randomly assigned to a 2-month program involving twice weekly group classes delivered by videoconference supplemented by individual practice of pelvic yoga techniques versus a control program involving equivalent-time instruction and practice of nonspecific skeletal muscle stretching-strengthening exercises. Diaries, questionnaires, and in-class observations assessed intervention adherence and self-efficacy as well as CPP intensity and impact. Results: Among the 36 participants randomized (aged 27-77 years), the average (±standard deviation) baseline pelvic pain intensity was 4.2 (±2.0) (0-10 scale). Thirty-one (86%) completed the 2-month intervention programs, and 27 (75%) attended more than 85% of intervention classes. Among participants completing the yoga program (N = 16), 14 (87%) reported being at least moderately confident about performing all yoga postures after 2 months. Thirty (83%) provided pain intensity data at 2 months. Average pelvic pain intensity "at its worst" and "on average" were 1.9 (±1.6) and 1.1 (±1.4) points lower, respectively, after 2 months in this yoga group. Yoga participants also reported improvements in scores in the emotional, occupational, and psychological domains of the Impact of Female Chronic Pelvic Pain Questionnaire. Conclusions: Findings demonstrate the feasibility and acceptability of a videoconference-based yoga program and collection of pain-related data among women with CPP, paving the way for future research to rigorously evaluate its specific efficacy in representative samples of women. Clinicaltrials.gov identifier: NCT04615247.

Endovascular management of pelvic congestion syndrome: An expert consensus statement from the French Society of Cardiovascular Imaging (SFICV), Interventional Radiology Federation (FRI), College of French Radiology Teachers (CERF), and French Society of Women's Imaging (SIFEM)

PURPOSE

Pelvic congestion syndrome (PCS) is a major cause of chronic pelvic pain in women of reproductive age. It is often associated with pelvic venous insufficiency and venous dilatation of the ovarian and uterine veins, resulting in a variety of symptoms exacerbated by venous hypertension. Despite its prevalence, PCS lacks standardized diagnostic and management protocols, making effective treatment challenging. The purpose of this expert consensus statement was to summarize the opinions of French radiologists and gynecologists regarding the diagnosis, imaging, treatment, and management of PCS.

MATERIALS AND METHODS

A working group of 14 expert radiologists and gynecologists from various French medical centers used a Delphi panel approach with several rounds of remote and face-to-face meetings to formulate and refine expert opinions based on the current literature and clinical expertise. These opinions were categorized according to diagnostic criteria, imaging techniques, therapeutic options, and follow-up protocols.

RESULTS

The group formulated 72 initial opinions, and 65 were retained after rigorous evaluation for consensus. Key diagnostic tools include Doppler ultrasound for detection of venous reflux and magnetic resonance imaging for detailed assessment of venous anatomy. Endovascular embolization was highlighted as the primary treatment approach and recommended after thorough imaging evaluation. Noninvasive treatments and multidisciplinary care were also emphasized for comprehensive management. The expert opinion also included post-treatment follow-up to assess quality of life and symptom resolution.

CONCLUSION

This structured consensus approach helped develop standardized expert opinions on management of, providing clear guidelines for diagnosis, treatment, and follow-up. These guidelines should improve clinical practice and patient care in the management of PCS.

Analysis of the Clinical Efficacy of Interlock Detachable Coil Interventional Embolization on Pelvic Congestion Syndrome and Ovarian Reserve Function: A Retrospective Study

Objective

This study aimed to examine the effects and the efficacy of a combination of interventional embolization and endocrine hormone therapy for Pelvic congestion syndrome (PCS).

Methods

We retrospectively analyzed 132 patients diagnosed with PCS, and divided them into three groups based on their therapeutic schedule. The visual analog scale (VAS), pelvic venous blood flow parameters, and serum hormone levels of the three groups were compared before and after treatment. Moreover, the clinical efficacy and long-term changes in ovarian reserve functions were analyzed. For the comparison of measurement data before and after treatment within the group, paired - sample t - test was used for analysis. For the comparison between groups, one - way analysis of variance was applied. A P - value less than 0.05 indicated a statistically significant difference.

Results

Patients in the study group had significantly lower pain degrees than in the control group I and the control group II at 24 h and the first month after the operation (p < 0.05). The degree of pain in patients in the study group was significantly lower than that in the control group I at the third and 6 months following the treatment (p < 0.05). The parameters of venous blood flow and ovarian reserve in patients treated with the combined endocrine hormone therapy were significantly better than those in patients not treated with endocrine hormone therapy (p < 0.05). The total effective rate of the study group was significantly higher than that of the control groups (p < 0.05).

Conclusion

A combination of precise interventional embolization and endocrine hormone therapy can rapidly and effectively relieve pain in patients with PCS. Compared with free coil embolization, this combination can effectively increase vascular tension, reduce congestion, inhibit ovarian function, reduce pelvic congestion, and relieve symptoms.

Pelvic Varicose Veins in Women. Russian Experts Consensus

Pelvic Varicose Veins in Women. Russian Experts Consensus.

Clinical outcomes of a digital musculoskeletal women's pelvic health program: an observational, longitudinal study with comparison group

BACKGROUND

Chronic pelvic pain is a common yet undertreated condition that significantly impacts quality of life for women worldwide. Digital exercise therapy designed to target pelvic pain can improve symptomology while reducing time and cost-related barriers to in-person clinical care.

METHODS

This longitudinal, observational study of a digital women's pelvic health program examined pelvic pain, anxiety, and depression at 4 and 12 weeks in female adults experiencing chronic pelvic pain. Intervention participants received a digital pelvic health program including personalized exercise therapy sessions, health education articles, and health coaching. A comparison group of nonparticipants received a series of education articles related to pelvic health. Data were collected at baseline, 4 and 12 weeks. Unadjusted and adjusted linear mixed effects models were conducted to model changes in clinical outcomes over time.

RESULTS

A total of 797 participants (intervention: 495, nonparticipants: 302) were included in the sample. Baseline mean (SD) age was 41.5 (11.7) years and mean pain was 45.7 (18.5) out of 100. Compared to baseline, the intervention group showed significantly more pain improvement at 4 and 12 weeks versus nonparticipants after adjusting for baseline factors. The intervention group's pain scores decreased by 44.5% at 4 weeks and 53.6% at 12 weeks. The intervention group's adjusted pain scores decreased from 42.0 (95% CI: [39.4, 44.7]) at baseline to 23.3 (95% CI: [20.5, 26.2]) at 4 weeks to 19.5 (95% CI: [16.7, 22.4]) at 12 weeks. In contrast, nonparticipants' pain scores decreased by 21.6% at 4 weeks and 32.7% at 12 weeks. Nonparticipants' adjusted pain scores decreased from 42.1 (95% CI: [38.4, 45.9]) at baseline to 33.0 (95% CI: [29.2, 36.8]) at 4 weeks to 28.3 (95% CI: [24.5, 32.2]) at 12 weeks. After adjustments, the probability of the intervention group screening for moderate or severe depression was significantly lower by 11.0% at 12 weeks versus nonparticipants. There were no significant differences in anxiety outcomes between groups at baseline, week 4, or week 12.  CONCLUSIONS: A digital women's pelvic health program may help reduce short-term pelvic pain and depression symptoms.

TRIAL REGISTRATION

The WIRB-Copernicus Group Institutional Review Board (registration number IRB20234932) approved this study on November 6, 2023.

Effect of different electric stimulation modalities on pain and functionality of patients with pelvic pain: Systematic review with META-analysis

INTRODUCTION

Pelvic pain is located in the anterior abdominal wall, below the umbilical scar. Its treatment includes pharmacological therapy, which can cause adverse effects and is not always sufficient to control symptoms. Thus, the use of adjunct therapies such as electric stimulation has been suggested. Therefore, this review intends to appraise the literature on the effectiveness of electrostimulation in the treatment of pelvic pain.

METHODS

The search for studies was conducted until April 2024 in PubMed, Cochrane Library, ScienceDirect, SciELO, PEDro, CINAHL, BVS, Web of Science, Scopus, and Google Scholar databases using a combination of Mesh terms "Electric Stimulation" and "Pelvic Pain." Risk of bias assessment and meta-analysis were performed with The Cochrane Collaboration tool (RevMan 5.4). Quality of the evidence was assessed with GRADE tool.

RESULTS

From the 3247 studies found, 19 were included. In the qualitative analysis, seven studies showed TENS, electroacupuncture, PTNS, and tDCS reduced pain intensity, one study on PTNS showed increased quality of life, and one on tDCS showed improved functional performance. However, in the meta-analysis, only TENS showed efficacy for the reduction of acute pelvic pain and primary dysmenorrhea.

CONCLUSION

Our results indicate that there is moderate-quality evidence for TENS to reduce pain intensity in primary dysmenorrhea and low-quality evidence for the same outcome in acute pelvic pain. Randomized controlled clinical trials with larger sample size and with better methodological quality are needed to establish the effectiveness of other forms of electrical stimulation in pelvic pain.

Endometriosis and physical activity: A narrative review

Endometriosis is a painful gynecological disorder that affects many women. Constant treatments and contraception changes affect women looking for solutions to treat and limit the problems caused by endometriosis. The current narrative review discusses the effects of physical activity on the management, pain, and quality of life in patients with endometriosis. Findings suggest that body awareness practices such as Hatha yoga, the Jacobson method, and progressive muscle relaxation reduce pain and stress and improve the quality of life associated with endometriosis. It also highlights the current knowledge gap on available evidence and future research. Moreover, care must be taken when considering patients' physical abilities and goals and avoiding intense physical activities. The forms of endometriosis and its symptoms vary from one woman to another, so it is important to perform studies with various nonmedicinal or surgical techniques. It is important to continue randomized controlled trials to obtain more data on the benefits of physical activity in women with endometriosis and also to identify what types of activities could be beneficial to combat pain symptoms and improve the daily lives of women with endometriosis.

Pelvic floor hypertension: possible factors for pelvic floor tenderness in endometriosis patients-a pilot study

PURPOSE

Chronic pelvic pain (CPP) is one of the main problems of endometriosis, leading to a significant impairment of quality of life. Understanding the pain mechanisms and the pelvic floor muscles (PFM) changes in these patients is essential to integrate additional therapeutic strategies. We hypothesize that endometriosis patients have changes in PFM and that targeted vaginal electrostimulation can be a treatment option for CPP in this disease.

METHODS

Fifteen patients with endometriosis and chronic acyclical pelvic pain were included. PFM electromyography with the Multiple Array Probe Leiden (MAPLe) was performed. Mapping of PFM was utilized and targeted electrostimulation of the hypertensive muscles was conducted. Control electromyography was performed afterward to evaluate the electrostimulation therapeutic effect.

RESULTS

In 12/15 (80%) patients, the myofascial trigger point could be localized by digital examination. The most frequently affected muscle was the puborectalis (10/15-66.7%). Most of the patients showed serious changes in the average resting tone (aRT) of PFM. aRT was significantly increased in all patients and decreased after stimulation, whereby the difference prior to and after stimulation was not significant (p = 0.064). The detailed separated analysis of the hypertensive muscles showed a significant (p = 0.026) reduction in their resting tone (hRT), after targeted stimulation.

CONCLUSION

Vaginal electrostimulation is a promising and feasible complementary treatment option for CPP in endometriosis patients. Targeted treatment of pelvic floor dysfunction should be included in clinical trials.

Dorsal root ganglion stimulation for the treatment of chronic pelvic pain: A systematic review

BACKGROUND

Chronic pelvic pain (CPP) is a difficult condition to treat. Due to complex pelvic innervation, dorsal column spinal cord stimulation (SCS) has not been shown to produce the same effect as dorsal root ganglion stimulation (DRGS) given emerging evidence suggesting that applying DRGS may result in favorable outcomes for individuals with CPP. The aim of this systematic review is to investigate the clinical use and effectiveness of DRGS for patients with CPP.

MATERIALS AND METHODS

A systematic review of clinical studies demonstrating the use of DRGS for CPP. Searches were conducted using four electronic databases (PubMed, EMBASE, CINAHL, and Web of Science) across August and September 2022.

RESULTS

A total of nine studies comprising 65 total patients with variable pelvic pain etiologies met the inclusion criteria. The majority of subjects implanted with DRGS reported >50% mean pain reduction at variable times of follow-up. Secondary outcomes reported throughout studies including quality of life (QOL) and pain medication consumption were reported to be significantly improved.

CONCLUSIONS

Dorsal root ganglion stimulation for CPP continues to lack supportive evidence from well-designed, high-quality studies and recommendations from consensus committee experts. However, we present consistent evidence from level IV studies showing success with the use of DRGS for CPP in reducing pain symptoms along with reports of improved QOL through periods as short as 2 months to as long as 3 years. Because the available studies at this time are of low quality with a high risk of bias, we strongly recommend the facilitation of high-quality studies with larger sample sizes in order to better ascertain the utility of DRGS for this specific patient population. At the same time, from a clinical perspective, it may be reasonable and appropriate to evaluate patients for DRGS candidacy on a case-by-case basis, especially those patients who report CPP symptoms that are refractory to noninterventional measures and who may not be ideal candidates for other forms of neuromodulation.

Associations and gastrointestinal symptoms in women with endometriosis in comparison to women with irritable bowel syndrome: a study based on a population cohort

BACKGROUND

Endometriosis and irritable bowel syndrome (IBS) have similar symptoms, pathogenesis, and risk factors. These diagnoses often coexist and are frequently misdiagnosed leading to diagnostic delays. This study of a population-based cohort aimed to investigate associations relating to endometriosis and IBS and to compare gastrointestinal symptoms between endometriosis and IBS.

METHOD

The study cohort included women from the Malmö Offspring Study with information about endometriosis and IBS diagnoses from the National Board of Health and Welfare. The participants answered a questionnaire about lifestyle habits, medical and drug history, and self-reported IBS. The visual analog scale for IBS was used to estimate gastrointestinal symptoms the past 2 weeks. Endometriosis diagnosis and self-reported IBS were used as dependent variables to study associations with age, body mass index (BMI), education, occupation, marital status, smoking, alcohol habits, and physical activity using logistic regression. Mann-Whitney U Test or Kruskal-Wallis tests were used to calculate the differences in symptoms between groups.

RESULTS

Of the 2,200 women with information from medical records, 72 participants had endometriosis; 21 (29.2%) of these had self-reported IBS. Of the 1,915 participants who had answered the questionnaire, 436 (22.8%) had self-reported IBS. Endometriosis was associated with IBS (OR:1.86; 95%CI:1.06-3.26; p = 0.029), as well as with age 50-59 years (OR:6.92; 95%CI:1.97-24.32; p = 0.003), age ≥ 60 years (OR:6.27; 95%CI:1.56-25.17; p = 0.010), sick leave (OR:2.43; 95%CI:1.08-5.48; p = 0.033), and former smoking (OR:3.02; 95%CI:1.19-7.68; p = 0.020). There was an inverse association with BMI (OR:0.36; 95%CI:0.14-4.91; p = 0.031). IBS was associated with endometriosis (OR:1.77; 95%CI:1.02-3.07; p = 0.041) and sick leave (OR:1.77; 95%CI:1.14-2.73; p = 0.010), with a tendency to association with smoking (OR:1.30; 95%CI:0.98-1.72; p = 0.071). When excluding participants using drugs associated with IBS, the condition was associated with current smoking (OR:1.39; 95%CI:1.03-1.89; p = 0.033) and inversely with age 50-59 years (OR:0.58; 95%CI:0.38-0.90; p = 0.015). There were differences in the gastrointestinal symptoms between IBS and healthy participants, but not between endometriosis and IBS or healthy participants.

CONCLUSION

There were associations between endometriosis and IBS, without differences in gastrointestinal symptoms. Both IBS and endometriosis were associated with smoking and sick leave. Whether the associations reflect causality or depend on common risk factors and pathogenesis remains to be determined.

Uterine botulinum toxin injections in severe dysmenorrhea, dyspareunia and chronic pelvic pain: Results on quality of life, pain level and medical consumption

OBJECTIVE

To evaluate quality of life (Qol), pain level and medical consumption before and after uterine botulinum toxin (BT) injections in severe dysmenorrhea, dyspareunia and chronic pelvic pain.

METHODS

This was a before and after study using the database of a pilot study (Open-label non comparative study, on 30 patients, with severe dysmenorrhoea in therapeutic failure) assessing efficacy and cost of uterine injection of BT in women with chronic pelvic pain after failure of conventional treatment (hormonal and analgesics) (CT). Main clinical outcome: Patient Global Impression of Improvement (PGI-I), EuroQol health-related QoL (EQ-5D-5L), EuroQol-visual analogue scale (EQ-VAS), Female Sexual Function Index (FSFI), utility measure of health-related quality of life (also called health state preference values), cost and of health care consumption were collected prospectively and analysed in the two phases (before and after). The two timepoints were 12 months before uterine BT injection, when the patient had been receiving CT, and 12 months after uterine BT injection.

RESULTS

Median visual analogue scale scores were significantly improved by BT regarding the patients' main source of pain (31.6 vs 80.55; p < 0.00001). We also noted a significant reduction in the proportion of patients who reported dyspareunia [15 (75%) vs 3 (15%) patients, p = 0.001] and pain during menstruation (p < 0.0001). The PGI-I scale showed a significant increase in the proportion of patients who were satisfied with their treatment after receiving the BT injection. The injection of BT was frequently associated with increase in QoL and a reduction in health care consumption, and cost: 714.82 €+/- €336.43 (BT) versus 1104.16 €+/- €227.37 (CT), which could result in substantial savings approximately (389,34€) per patient.

CONCLUSION

This study revealed the clinical effectiveness of BT injections on dysmenorrhea, chronic pelvic pain as well as reduction of cost and health care consumption, in our population, which is innovative since no standard of treatment exists in this domain.

High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews

BACKGROUND

This overview was originally published in 2017, and is being updated in 2022.  Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue, for which opioids are prescribed by some physicians for pain management. There are concerns that the use of high doses of opioids for CNCP lacks evidence of effectiveness, and may increase the risk of adverse events.

OBJECTIVES

To describe the evidence from Cochrane Reviews and overviews regarding the efficacy and safety of high-dose opioids (defined as 200 mg morphine equivalent or more per day) for CNCP.

METHODS

We identified Cochrane Reviews and overviews by searching the Cochrane Database of Systematic Reviews in The Cochrane Library. The date of the last search was 21 July 2022. Two overview authors independently assessed the search results. We planned to analyse data on any opioid agent used at a high dose for two weeks or more for the treatment of CNCP in adults.

MAIN RESULTS

We did not identify any reviews or overviews that met the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses, where all doses were analysed as a single group; we were unable to extract any data for high-dose use only.

AUTHORS' CONCLUSIONS

There is a critical lack of high-quality evidence, in the form of Cochrane Reviews, about how well high-dose opioids work for the management of CNCP in adults, and regarding the presence and severity of adverse events.  No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Considering that high-dose opioids have been, and are still being used in clinical practice to treat CNCP, knowing about the efficacy and safety of these higher doses is imperative.

Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews

OBJECTIVE

To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition.

DESIGN

Overview of systematic reviews.

DATA SOURCES

PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews comparing any antidepressant with placebo for any pain condition in adults.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework.

RESULTS

26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference -5.3, 95% confidence interval -7.3 to -3.3), postoperative pain (-7.3, -12.9 to -1.7), neuropathic pain (-6.8, -8.7 to -4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons).

CONCLUSIONS

Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews-seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022311073.

Current Challenges in the Management of Chronic Pelvic Pain in Women: From Bench to Bedside

Chronic pelvic pain (CPP) affects a significant proportion of women worldwide And has a negative impact on several aspects of these women’s lives including mental health, work, relationships and sexual function, among others. This set of factors ultimately reflects negatively on quality Of life. The physiopathology of CPP is complex and remains to be fully clarified; however, recent advances have increased understanding of the mechanisms involved in chronic pain in general, and more specifically, CPP. Nonetheless, even when a detailed clinical history is obtained, meticulous physical examination is performed and imaging resources are appropriately used, the organic cause of the pain may still fail to be identified in a substantial number of women with CPP. Management of CPP may therefore be challenging. This narrative review was aimed at adding to the available literature on the subject, presenting and discussing the principal characteristics of CPP in women. The paper highlights gaps in the literature while providing the most up-to-date evidence associated with the physiopathology and classification of pain, its diagnosis and treatment. In addition, current challenges in the management of women with CPP are discussed.

The effect of biofeedback interventions on pain, overall symptoms, quality of life and physiological parameters in patients with pelvic pain : A systematic review

BACKGROUND

Biofeedback is recognized as an effective additive method for treating certain phenotypes of chronic pelvic pain syndrome and is a therapeutic option in other pelvic pain conditions. This review aims to evaluate evidence from the literature with a focus on the effect of biofeedback on pain reduction, overall symptom relief, physiological parameters and quality of life.

METHODS

A systematic literature search was conducted using the databases PubMed, MEDLINE, Embase, Cochrane Library and PEDro from inception to July 2020. Data were tabulated and a narrative synthesis was carried out, since data heterogeneity did not allow a meta-analysis. The PEDro scale and the McMaster Critical Review Form-Quantitative Studies were applied to assess risk of bias.

RESULTS

Out of 651 studies, 37 quantitative studies of primary research evaluating pelvic pain conditions in male and female adults and children were included. They covered biofeedback interventions on anorectal disorders, chronic prostatitis, female chronic pelvic pain conditions, urologic phenotypes in children and adults and a single study on low back pain. For anorectal disorders, several landmark studies demonstrate the efficacy of biofeedback. For other subtypes of chronic pelvic pain conditions there is tentative evidence that biofeedback-assisted training has a positive effect on pain reduction, overall symptoms relief and quality of life. Certain factors have been identified that might be relevant in improving treatment success.

CONCLUSIONS

For certain indications, biofeedback has been confirmed to be an effective treatment. For other phenotypes, promising findings should be further investigated in robust and well-designed randomized controlled trials.

Gabapentin has Longer-Term Efficacy for the Treatment of Chronic Pelvic Pain in Women: A Systematic Review and Pilot Meta-analysis

INTRODUCTION

Gabapentin has potential analgesic benefits in patients with neuropathic pain, such as post-herpetic neuralgia and diabetic peripheral neuropathy neuropathic pain. However, its efficacy in women with chronic pelvic pain (CPP) remains contradictory. In the present study, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to ascertain the efficacy of this treatment.

METHODS

We systematically reviewed RCTs published in PubMed, Embase, the Cochrane Library, Web of Science, and Google Scholar databases, up to July 2021. These articles compared gabapentin with placebo or any other active treatment for CPP in women, with 'the change in pain scores from the baseline during the first 3 and 6 months of treatment' taken as the primary outcome. We considered reductions equivalent to 1.0 cm for primary outcomes to be clinically important.

RESULTS

Four studies, comprising 469 participants, were included in our meta-analysis. Results revealed that the gabapentin group had significantly higher change in pain intensity scores from baseline to 3 months [weighted mean difference (WMD) - 0.61 cm; 95% confidence interval (CI) - 0.97 to - 0.25; I² = 0%; p = 0.0009] and 6 months (WMD - 1.38 cm; 95% CI - 1.89 to - 0.88; I² = 0%; p < 0.00001), relative to the control group. The difference of 6-month pooled result was more clinically important. Results from analysis of secondary outcomes showed that gabapentin had no beneficial efficacy during the first 3 months of treatment. Although gabapentin treatment was associated with a higher risk of dizziness and somnolence, no statistically significant differences were observed with regards to the total incidence of adverse events.

CONCLUSIONS

Overall, gabapentin could be a potential treatment option for CPP in women. However, as a pilot study, further studies are needed to explore the longer-term benefits and definite safety of this therapy in the future.

REGISTRATION NUMBER

PROSPERO registration number CRD42021249421.

Clinical Efficacy of Conservative Treatment with Micronized Purified Flavonoid Fraction in Female Patients with Pelvic Congestion Syndrome

INTRODUCTION

Pelvic congestion syndrome (PCS) may be effectively managed with conservative treatment in certain patients. Treatment with venoactive drugs is common, but supportive data are limited. This study evaluated the clinical efficacy of micronized purified flavonoid fraction (MPFF) in women with PCS.

METHODS

In a single-blind, placebo-controlled study, women with duplex ultrasound diagnosis of pelvic varicose veins (PVV) and PCS were randomized to MPFF 1000 mg once daily or placebo for 2 months. Clinical manifestations of PCS were evaluated at baseline and end of treatment (M2) using three assessment tools: disease-specific quality of life (QoL) Pelvic Varicose Vein Questionnaire (PVVQ), Pelvic Venous Clinical Severity Score (PVCSS), and the Visual Analog Scale (VAS) for the main symptoms of the disease.

RESULTS

A total of 83 women were included, 42 received MPFF and 41 received placebo. In the MPFF group, the mean global PVVQ QoL index decreased significantly from 45.1 ± 14.7 at baseline to 36.6 ± 10.6 at M2 (mean change: 8.2 ± 10.4); no significant change was observed in the control group (mean change: - 0.3 ± 4.0). The between-group difference was statistically significant (P < 0.001). Compared with control, significant improvements were observed in all four QoL parameters (pain, physical, social, psychological, all P < 0.001). The mean PVCSS summary score decreased significantly by 3.4 ± 3.4 in the MPFF group (P < 0.001) compared with a non-significant change of - 0.2 ± 1.6 in the control group (between-group difference P < 0.001). In the MPFF group, improvements were statistically significant for 6 out of 10 clinical manifestations of PCS measured using the PVCSS, including pain (mean change from baseline: 0.5 ± 0.7) heaviness (0.4 ± 0.7), discomfort (0.6 ± 0.7) and tenderness (0.3 ± 0.5). No significant improvements were observed in the control group. When measured by VAS, between-group differences were statistically significant for the overall summary score (P < 0.001) and for 8 out of 10 PCS symptoms, including: pain (mean MPFF change from baseline: 2.0 ± 2.2), heaviness (1.3 ± 2.1), discomfort (1.5 ± 2.0), tenderness (0.9 ± 1.9), and edema (1.3 ± 2.1).

CONCLUSION

In women with PCS, conservative treatment with MPFF was associated with improved QoL and reduced symptom severity. MPFF may be considered an effective and safe treatment option for PCS in routine clinical practice.

Effect of physical activity and exercise on endometriosis-associated symptoms: a systematic review

Background

Endometriosis is a common benign gynecological disease that has the potential to debilitate due to pain and reduced quality of life. Treatment modalities such as hormones and surgery have limitations and do not treat all dimensions of the problems caused by endometriosis, and physical activity (PA) and exercise have been suggested as alternative treatments. Aim of this study was to perform a systematic review and meta-analysis to assess the effect of PA and exercise on endometriosis-associated symptoms.

Methods

Eleven databases were searched systematically. Study selection, quality assessment, and data extraction were carried out by two independent researchers in accordance with PRISMA guidelines. Eligibility criteria were women with diagnosed endometriosis receiving an intervention (PA and/or exercise). The primary outcome was pain intensity, but all outcomes were accepted.

Results

This study screened 1045 citations for eligibility. Four interventional studies were identified, of which one showed fatal design flaws and so was excluded. Three studies, two randomized controlled trials (RCT) and one pre-post study with no control group, involving 109 patients were included in a descriptive synthesis. The interventions included flexibility and strength training, cardiovascular fitness, and yoga, and were performed from one to four times per week for a total duration of 8–24 weeks, with or without supervision. Only one study found improvements in pain intensity. One study showed decreases in stress levels. Due to the heterogeneity of the study outcomes and measures, as well as confounding factors, a quantitative meta-analysis could not be performed.

Conclusion

The effect of PA and exercise as treatments for endometrioses-associated symptoms could not be determined due to significant limitations of the included studies. Future research should be based on RCTs of high methodological quality, measuring and reporting relevant core outcomes such as pain, improvements in symptoms and quality of life, and acceptability and satisfaction from the perspectives of patients. Furthermore, these outcomes need to be measured using reliable and validated tools.

Trial registration number

CRD42021233138.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01500-4.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Advances of Laparoscopy for the Diagnosis of Pelvic Congestion Syndrome

The objective of this review is to describe the effectiveness of laparoscopy in the diagnosis and treatment of pelvic congestion syndrome (PCS). PCS is a cause of chronic pelvic pain (CPP) and is associated with dysfunction of the pelvic venous system. PCS is more common in women of reproductive age, and hormonal changes are associated with its development along with other reasons (e.g., working and living habits). There is an urgent need to establish an effective algorithm for the diagnosis and treatment of CPP, which could have a dramatic effect in patients' everyday life. This algorithm should be able to overcome known issues that lead to the underdiagnosis of PCS, such as the overlap of its symptoms with other diseases. Here, we present our findings from literature articles about the methods used in practice today for the diagnosis of this syndrome. We also compare the methods to propose the most promising technique for providing a diagnosis with high accuracy. In our understanding, laparoscopy is superior when compared to other methods. It can provide a diagnosis of PCS while excluding or identifying other comorbidities and can also lead toward the next steps for the treatment of PCS.

Treatment of Dyspareunia with Botulinum Neurotoxin Type A: Clinical Improvement and Influence of Patients' Characteristics

The treatment of chronic pelvic pain (CPP) with botulinum neurotoxin type A (BoNT/A) has increased lately, but more studies assessing its effect are needed. This study aimed to evaluate the evolution of patients after BoNT/A infiltration and identify potential responders to treatment. Twenty-four women with CPP associated with dyspareunia were treated with 90 units of BoNT/A injected into their pelvic floor muscle (PFM). Clinical status and PFM activity were monitored in a previous visit (PV) and 12 and 24 weeks after the infiltration (W12, W24) by validated clinical questionnaires and surface electromyography (sEMG). The influence of patients' characteristics on the reduction in pain at W12 and W24 was also assessed. After treatment, pain scores and the impact of symptoms on quality of life dropped significantly, sexual function improved and sEMG signal amplitude decreased on both sides of the PFM with no adverse events. Headaches and bilateral pelvic pain were risk factors for a smaller pain improvement at W24, while lower back pain was a protective factor. Apart from reporting a significant clinical improvement of patients with CPP associated with dyspareunia after BoNT/A infiltration, this study shows that clinical characteristics should be analyzed in detail to identify potential responders to treatment.

Effect of BoNT/A in the Surface Electromyographic Characteristics of the Pelvic Floor Muscles for the Treatment of Chronic Pelvic Pain

Chronic pelvic pain (CPP) is a complex condition with a high economic and social burden. Although it is usually treated with botulinum neurotoxin type A (BoNT/A) injected into the pelvic floor muscles (PFM), its effect on their electrophysiological condition is unknown. In this study, 24 CPP patients were treated with BoNT/A. Surface electromyographic signals (sEMG) were recorded at Weeks 0 (infiltration), 8, 12 and 24 from the infiltrated, non-infiltrated, upper and lower PFM. The sEMG of 24 healthy women was also recorded for comparison. Four parameters were computed: root mean square (RMS), median frequency (MDF), Dimitrov’s index (DI) and sample entropy (SampEn). An index of pelvic electrophysiological impairment (IPEI) was also defined with respect to the healthy condition. Before treatment, the CPP and healthy parameters of almost all PFM sides were significantly different. Post-treatment, there was a significant reduction in power (<RMS), a shift towards higher frequencies (>MDF), lower fatigue index (<DI) and increased information complexity (>SampEn) in all sites in patients, mainly during PFM contractions, which brought their electrophysiological condition closer to that of healthy women (<IPEI). sEMG can be used to assess the PFM electrophysiological condition of CPP patients and the effects of therapies such as BoNT/A infiltration.

Choosing the Most Appropriate Treatment Option for Pelvic Venous Disease: Stenting versus Embolization

Pelvic venous disease (PeVD) in women encompasses a wide variety of entities all resulting in pelvic pain and varices. Successful treatment with percutaneous interventions is dependent on identifying underlying factors contributing to the disease and addressing them with either embolization of incompetent veins or stenting for venous stenoses. There are a multitude of embolization methods with marked practice heterogeneity. Moreover, with the ongoing development of dedicated venous stents in the treatment of chronic venous disease, there are more opportunities to consider this modality for the treatment of PeVD, as many patients present with combined vein reflux and central venous stenosis. The necessity to address both and the order of interventions in these patients is still to be elucidated. Here, we describe when to choose stenting or embolization for PeVD, their limitations, and our practice and identify further areas of research in this field.

Efficacy of capacitive resistive monopolar radiofrequency in the physiotherapeutic treatment of chronic pelvic pain syndrome: study protocol for a randomized controlled trial

BACKGROUND

Chronic pelvic pain syndrome (CPPS) is a multifactorial disorder that affects 5.7% to 26.6% of women and 2.2% to 9.7% of men, characterized by hypersensitivity of the central and peripheral nervous system affecting bladder and genital function. People with CPPS have much higher rates of psychological disorders (anxiety, depression, and catastrophizing) that increase the severity of chronic pain and worsen quality of life. Myofascial therapy, manual therapy, and treatment of trigger points are proven therapeutic options for this syndrome. This study aims to evaluate the efficacy of capacitive resistive monopolar radiofrequency (CRMRF) at 448 kHz as an adjunct treatment to other physiotherapeutic techniques for reducing pain and improving the quality of life of patients with CPPS.

METHODS

This triple-blind (1:1) randomized controlled trial will include 80 women and men with CPPS. Participants will be randomized into a CRMRF activated group or a CRMRF deactivated group and receive physiotherapeutic techniques and pain education. The groups will undergo treatment for 10 consecutive weeks. At the beginning of the trial there will be an evaluation of pain intensity (using VAS), quality of life (using the SF-12), kinesiophobia (using the TSK-11), and catastrophism (using the PCS), as well as at the sixth and tenth sessions.

DISCUSSION

The results of this study will show that CRMRF benefits the treatment of patients with CPPS, together with physiotherapeutic techniques and pain education. These results could offer an alternative conservative treatment option for these patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03797911 . Registered on 8 January 2019.

Expression and Significance of Matrix Metalloproteinase-2 and Matrix Metalloproteinas-9 in Endometriosis

Endometriosis is a chronic benign hormone-dependent condition when the endometrial tissue, identical with the endometrium by its morphological and functional properties, grows outside the borders of the uterine mucous membrane. Recent studies have pointed to the possible role of matrix metalloproteinases (MMPs) in the pathogenesis of endometriosis. We suggested a hypothesis that increased expression of MMPs activity in eutopic and ectopic endometrium of patients with endometriosis might correlate with the presence of endometriotic lesions.

The aim of the study was to evaluate the level of MMP-2 and MMP-9 expression in the ectopic endometrium of women with visible endometriotic lesions and eutopic endometrium in patients with no signs of endometriosis.

The study was conducted on 43 patients. They were divided into two groups. Group 1 included 31 patients with peritoneal/ovarian endometriosis who had undergone laparoscopy and hysteroscopy. Group 2 consisted of 12 patients with leiomyoma, endometrial polyps or relatively healthy patients who had undergone hysterectomy or polypectomy and endometrial curettage.

This study showed statistically higher expression of MMP-2 (1.7783 ± 0.22 immunohistochemistry (IHC) optical density score compared to the control group – 1.41± 0.34, p = 0.0017) and MMP-9 (1.352 ± 0.067 versus 1.85 ± 0.26 in the control group, p = 0.001) in ectopic and eutopic endometrium samples from patients with endometriosis compared to samples taken from patients without endometriosis. A strong correlation between expression of the above-mentioned MMPs (r=0.74 for MMP-2 and r=0.88 for MMP-9) in ectopic and eutopic endometrium might be of promising diagnostic value.

Baseline pain characteristics predict pain reduction after physical therapy in women with chronic pelvic pain. Secondary analysis of data from a randomized controlled trial

Background and aims Women with chronic pelvic pain represent a heterogeneous group, and it is suggested that the existence of sub-groups can explain varying results and inconclusiveness in clinical trials. Some predictors of treatment outcome are suggested, but the evidence is limited. The primary aim of this study was to explore if selected pre-treatment characteristics of the participants in a recently conducted randomized controlled trial were associated with treatment outcome. Methods In this study secondary analysis of data collected in a randomized trial were conducted. The participants were women with chronic pelvic pain randomized to two different physical therapy treatments. Analyses in this study were performed for the whole group as a cohort. The primary outcome measure was change in pain intensity from baseline to 12 months, measured with the numeric rating scale (0-10). The women were asked to rate their mean pelvic pain intensity during the last 7 days. Based on previous research and on available variables from the randomized controlled trial four potential predictive factors were derived from the baseline data and assessed one by one in a linear regression model, adjusted for age and treatment group. The variables with strongest association (p < 0.10) with the primary outcome were further included in a multivariable linear regression model with backward selection, adjusted for age and treatment group. Results Fifty women (mean age 38.1, SD = 12.2) were included in the analysis. For these women the mean change in pain intensity was -1.2 points (95% CI -1.8 to -0.7) from baseline to 12 months. The multivariable regression model showed that pelvic pain duration of 6 years or more was associated with less decrease in pain intensity with a regression coefficient of 1.3 (95% CI 0.3-2.4). Baseline pain intensity was associated with higher pain reduction after PT treatment with a regression coefficient per SD increase in baseline pain of -0.6 (95% CI -1.1 to -0.1). None of the women with main pain site other places than in the pelvis reported any pain reduction after physical therapy treatment, but due to the small numbers the predictor was not included in the regression analysis. Conclusions We identified that pelvic pain duration of 6 years or more was associated with less pain reduction, and that higher baseline pain intensity was associated with higher pain reduction after physical therapy treatment in this sample of women with chronic pelvic pain. For the variable main pain site other places than the pelvis the results are unsure due to small numbers. Implications Based on our finding of long pain duration as a negative predictor for pain reduction, we emphasize that early intervention is important. Many of the participants in our RCT reported pelvic surgeries or other treatments prior to referral for PT, and we suggest that referral to a non-invasive intervention such as PT should be considered at an earlier stage. In order to tailor interventions to the individual women's needs, thorough baseline assessments, preferably in a multidisciplinary setting, should be performed.

The Link Between Stress and Endometriosis: from Animal Models to the Clinical Scenario

There is strong evidence from humans and animal models showing that abnormal functioning of the hypothalamic-pituitary-adrenal (HPA) axis and/or the inflammatory response system disrupts feedback regulation of both neuroendocrine and immune systems, contributing to disease. Stress is known to affect the physiology of pelvic organs and to disturb the HPA axis leading to chronic, painful, inflammatory disorders. A link between stress and disease has already been documented for many chronic conditions. Endometriosis is a complex chronic gynecological disease associated with severe pelvic pain and infertility that affects 10% of reproductive-aged women. Patients report the negative impact of endometriosis symptoms on quality of life, work/study productivity, and personal relationships, which in turn cause high levels of psychological and emotional distress. The relationship between stress and endometriosis is not clear. Still, we have recently demonstrated that stress increases the size and severity of the lesions as well as inflammatory parameters in an animal model. Furthermore, the "controllability" of stress influences the pathophysiology in this model, offering the possibility of using stress management techniques in patients. The crosstalk between stress-inflammation-pain through HPA axis activity indicates that stress relief should alleviate inflammation and, in turn, decrease painful responses. This opens up the opportunity of altering brain-body-brain pathways as potential new therapeutic option for endometriosis. The goal of this review is to gather the research evidence regarding the interaction between stress (psychological and physiological) and the development and progression of endometriosis on the exacerbation of its symptoms with the purpose of proposing new lines of emerging research and possible treatment modalities for this still incurable disease.

Predictors of Depression, Anxiety and Stress Indicators in a Cohort of Women with Chronic Pelvic Pain

OBJECTIVE

Establishing predictors of mental health outcomes is a crucial precursor to the development and assessment of psychological interventions for women with chronic pelvic pain (CPP). The objective of this study was to identify predictors of depression, anxiety and stress in a cohort of women with CPP.

DESIGN

Cross-sectional analytic study.

METHODS

Pre-treatment questionnaires were collected from 212 women with CPP, who had attended a private specialist pelvic pain clinic over a period of 18 months. Multivariate linear regression with backwards elimination was used to determine the best joint predictors of depression, anxiety and stress scores on the Depression, Anxiety and Stress Scale-21 item (DASS 21).

RESULTS

Of 19 potential predictor variables, seven key predictors of depression, anxiety and stress indicators were identified. Higher depression scores were associated with higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, having experienced pain as a child, and never having been pregnant before. Higher anxiety scores were associated with higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, younger age of menarche, and younger age. Predictors of high-stress scores were higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, and being younger.

CONCLUSION

We have identified several important predictors of mental health in women with CPP. Using this information, psychological assessment and treatment for these women may be better tailored to client needs.

Can Botulinum Toxin A Play A Role In Treatment Of Chronic Pelvic Pain Syndrome In Female Patients?-Clinical and Animal Evidence

Chronic pelvic pain (CPP) is defined as chronic pain and inflammation in the pelvic organs for more than six months. There are wide ranges of clinical presentations, including pelvic pain, painful intercourse, irritable bowel syndrome, and pain during urinating. Chronic pelvic pain syndrome (CPPS) is a subdivision of CPP, and the pain syndrome may be focused within a single organ or more than one pelvic organ. As there is uncertain pathogenesis, no standard treatment is currently available for CPPS. Botulinum toxin A (BoNT-A) is a potent neurotoxin that blocks acetylcholine release to paralyze muscles. Intravesical BoNT-A injection can reduce bladder pain in patients with interstitial cystitis/bladder pain syndrome. BoNT-A injected into the pelvic floor muscles of women has also been reported to improve chronic pain syndrome. Due to the reversible effect of BoNT-A, repeated injection appears to be necessary and effective in reducing symptoms. Adverse effects of BoNT-A may worsen the preexisting conditions, including constipation, stress urinary incontinence, and fecal incontinence. This review summarizes the evidence of BoNT-A treatment for CPPS in animal studies and clinical studies regarding the therapeutic effects of BoNT-A for CPPS in female patients.

Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis

Chronic pelvic pain (CPP) in women is defined variably, but for clinical use it is cyclical or non-cyclical pain of at least 3-6 months' duration. It has major impacts on individuals and society. There are both structural and idiopathic causes. Whereas CPP is not curable in many cases, it is treatable. The most promising approach is multidisciplinary patient-centered care including cause-directed therapy, lifestyle changes, talking therapies, meditation, acupuncture, and physiotherapy (this is not a complete list). One of the most common structural causes for CPP is endometriosis. This review investigates current scientific concepts and recent innovations in this field as well as for CPP in general.

[Neurobiological aspects of venous pelvic pain]

Mechanisms of the development of pain in chronic venous diseases (CVD), including pelvic congestion syndrome (PCS), are understudied. The existing hypotheses of the occurrence of venous pelvic pain (VVP) do not allow to answer the question why some patients have no pain syndrome while others have very pronounced pain despite the same morphofunctional changes in the pelvic veins. This review presents current hypotheses of the VPP development, data on some vasoactive neuropeptides (endothelin, calcitonin gene-related peptide, and substance P), their role in the modulation of vascular tone and sensation of pain, possible association between neurogenic inflammation and VPP and provides a rationale for studying the activity of these neurotransmitters in the treatment of PCS and pelvic pain.

Pelvic pain rehabilitation

Chronic pelvic pain is defined as persistent painful condition which lasts for at least six months under umbilicus. Numerous factors are blamed for etiopathogenesis, and quality of life of individuals is adversely affected. Chronic pain as well as functional disorders are accompanied to chronic pelvic pain. The treatment and rehabilitation program should be tailored for specific causes, targeting general pain treatment. Consequently, chronic pelvic pain management can be used to propose personalized treatment options and include patient education, behavioral therapy, and a biopsychosocial approach. Interdisciplinary teamwork and collaboration are essential for facilitating patient-centered rehabilitation.

Neuromodulation for Pelvic and Urogenital Pain

Chronic pain affecting the pelvic and urogenital area is a major clinical problem with heterogeneous etiology, affecting both male and female patients and severely compromising quality of life. In cases where pharmacotherapy is ineffective, neuromodulation is proving to be a potential avenue to enhance analgesic outcomes. However, clinicians who frequently see patients with pelvic pain are not traditionally trained in a range of neuromodulation techniques. The aim of this overview is to describe major types of pelvic and urogenital pain syndromes and the neuromodulation approaches that have been trialed, including peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and brain stimulation techniques. Our conclusion is that neuromodulation, particularly of the peripheral nerves, may provide benefits for patients with pelvic pain. However, larger prospective randomized studies with carefully selected patient groups are required to establish efficacy and determine which patients are likely to achieve the best outcomes.

Acupuncture Treatment for Chronic Pelvic Pain in Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Aim of the Study

This systematic review and meta-analysis aims to evaluate the current evidence from randomized controlled trials (RCTs) related to the effectiveness and safety of acupuncture treatment (AT), including electroacupuncture or thread-embedding therapy in combination with modern technology, for chronic pelvic pain (CPP) in women.

Materials and Methods

We searched 12 electronic databases up to December 2017. All randomized controlled trials evaluating the effect of AT for CPP were considered.

Results

Four RCTs with 474 participants were included. The methodological quality of included studies was generally low. The results of meta-analysis of two studies showed that AT combined with conventional treatment (CT) was associated with significantly reduced CPP, based on the total effectiveness rate (n=277, mean difference = 1.29, confidence interval = 1.13 to 1.47, P=0.0001, I² = 0%).

Conclusions

This review suggests the potential of AT combined with CT compared to CT alone for treating female CPP. However, there is insufficient evidence to conclude that AT can be recommended as a complementary and alternative (CAM) treatment for women with CPP. To draw a firm conclusion, future studies should require not only lager, more rigorously designed RCTs but also research on different AT types.

Protocol Registration Number

This study is registered with PROSPERO 2018 (CRD42018088627).

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

Pelvic Congestion Syndrome: Systematic Review of Treatment Success

Pelvic venous insufficiency is now a well-characterized etiology of pelvic congestion syndrome (PCS). The prevalence of CPP is 15% in females aged 18 to 50 years in the United States and up to 43.4% worldwide. In addition to individual physical, emotional, and quality-of-life implications of CPP, there are profound healthcare and socioeconomic expenses with estimated annual direct and indirect costs in the United States in excess of 39 billion dollars. PCS consists of clinical symptoms with concomitant anatomic and physiologic abnormalities originating in venous insufficiency. The etiology of PCS is diverse involving both mechanical and hormonal factors contributing to venous dilatation (>5 mm) and insufficiency. Factors affecting the diagnosis of PCS include variance of causes and clinical presentations of pelvic pain and relatively low sensitivity of noninvasive diagnostic imaging and laparoscopy to identify insufficiency compared with catheter venogram. A systematic review of the literature evaluating patient outcomes following percutaneous treatment of PCS is presented.

Are pelvic adhesions associated with pain, physical, emotional and functional characteristics of women presenting with chronic pelvic pain? A cluster analysis

Background

Chronic pelvic pain is a debilitating condition. It is unknown if there is a clinical phenotype for adhesive disorders. This study aimed to determine if the presence or absence, nature, severity and extent of adhesions correlated with demographic and patient reported clinical characteristics of women presenting with CPP.

Methods

Women undergoing a laparoscopy for the investigation of chronic pelvic pain were recruited prospectively; their pain and phenotypic characteristics were entered into a hierarchical cluster analysis. The groups with differing baseline clinical and operative characteristics in terms of adhesions involvement were analyzed.

Results

Sixty two women were recruited where 37 had adhesions. A low correlation was found between women’s reported current pain scores and that of most severe (r = 0.34) or average pain experienced (r = 0.44) in the last 6 months. Three main groups of women with CPP were identified: Cluster 1 (n = 35) had moderate severity of pain, with poor average and present pain intensity; Cluster 2 (n = 14) had a long duration of symptoms/diagnosis, the worst current pain and worst physical, emotional and social functions; Cluster 3 (n = 11) had the shortest duration of pain and showed the best evidence of coping with low (good) physical, social and emotional scores. This cluster also had the highest proportion of women with adhesions (82%) compared to 51% in Cluster 1 and 71% in Cluster 2.

Conclusions

In this study, we found that there is little or no correlation between patient-reported pain, physical, emotional and functional characteristics scores with the presence or absence of intra-abdominal/pelvic adhesions found during investigative laparoscopy. Most women who had adhesions had the lowest reported current pain scores.

Chronic Pelvic Pain: Assessment, Evaluation, and Objectivation

Chronic Pelvic Pain (CPP) and Chronic Pelvic Pain Syndrome (CPPS) have a significant impact on men and women of reproductive and nonreproductive age, with a considerable burden on overall quality of life (QoL) and on psychological, functional, and behavioural status. Moreover, diagnostic and therapeutic difficulties are remarkable features in many patients. Therefore evaluation, assessment and objectivation tools are often necessary to properly address each patient and consequently his/her clinical needs. Here we review the different tools for pain assessment, evaluation, and objectivation; specific features regarding CPP/CPPS will be highlighted. Also, recent findings disclosed with neuroimaging investigations will be reviewed as they provide new insights into CPP/CPPS pathophysiology and may serve as a tool for CPP assessment and objectivation.

High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue where opioids are routinely used for pain management. There are concerns that the use of high doses of opioids for chronic non-cancer pain lacks evidence of effectiveness and may increase the risk of adverse events.

OBJECTIVES

To describe the evidence from Cochrane Reviews and Overviews regarding the efficacy and safety of high-dose opioids (here defined as 200 mg morphine equivalent or more per day) for chronic non-cancer pain.

METHODS

We identified Cochrane Reviews and Overviews through a search of the Cochrane Database of Systematic Reviews (The Cochrane Library). The date of the last search was 18 April 2017. Two review authors independently assessed the search results. We planned to analyse data on any opioid agent used at high dose for two weeks or more for the treatment of chronic non-cancer pain in adults.

MAIN RESULTS

We did not identify any reviews or overviews meeting the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses where all doses were analysed as a single group; no data for high dose only could be extracted.

AUTHORS' CONCLUSIONS

There is a critical lack of high-quality evidence regarding how well high-dose opioids work for the management of chronic non-cancer pain in adults, and regarding the presence and severity of adverse events. No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Trials typically used doses below our cut-off; we need to know the efficacy and harm of higher doses, which are often used in clinical practice.

Health technology assessment of magnet therapy for relieving pain

Background: Magnet therapy has been used increasingly as a new method to alleviate pain. Magnetic products are marketed with claims of effectiveness for reducing pain of various origins. However, there are inconsistent results from a limited number of randomized controlled trials (RCTs) testing the analgesic efficacy of magnet therapy. This study aimed to evaluate the safety and effectiveness of magnet therapy on reliving various types of pain. Methods: A systematic search of two main medical databases (Cochrane Library and Ovid Medline) was conducted from 1946 to May 2014. Only English systematic reviews that compared magnet therapy with other conventional treatments in patients with local pain in terms of pain relieving measures were included. The results of the included studies were thematically synthesized. Results: Eight studies were included. Magnet therapy could be used to alleviate pain of various origins including pain in various organs, arthritis, myofascial muscle pain, lower limb muscle cramps, carpal tunnel syndrome and pelvic pain. Results showed that the effectiveness of magnetic therapy was only approved in muscle pains, but its effectiveness in other indications and its application as a complementary treatment have not been established. Conclusion: According to the results, it seems that magnet therapy could not be an effective treatment for relieving different types of pain. Our results highlighted the need for further investigations to be done in order to support any recommendations about this technology.

Androgens Upregulate Endometrial Epithelial Progesterone Receptor Expression: Potential Implications for Endometriosis

BACKGROUND

Androgenic compounds have been implicated in induction of endometrial atrophy yet the mechanisms of androgen effects on human endometrium have not been well studied. We hypothesized that androgens may promote their endometrial effects via modulation of progesterone receptor (PR) expression.

METHODS

Proliferative phase endometrial samples were collected at the time of hysterectomy. We evaluated the effect of the potent androgen 5α-dihydrotestosterone (DHT) on endometrial PR expression by treating human endometrial explants, endometrial stromal cells, and Ishikawa cells with DHT. Ishikawa cells were also treated with DHT ± the androgen receptor (AR) blocker flutamide. The PR-B, total PR messenger RNA (mRNA), and PR protein expression were assessed. Expression of cyclin D1 and D2 was checked as markers of cell proliferation.

RESULTS

As expected, estradiol induced PR expression in isolated stromal cells, endometrial epithelial cells, and tissue explants. The DHT treatment also resulted in increased PR expression in endometrial explants and Ishikawa cells but not in stromal cells. Further, protein levels of both nuclear PR isoforms (PR-A and PR-B) were induced with the DHT treatment. Although flutamide treatment alone did not affect PR expression, flutamide diminished androgen-induced upregulation of PR in both endometrial explants and Ishikawa cells. Although estradiol induced both cyclin D1 and cyclin D2 mRNA, DHT did not induce these markers of cell proliferation.

CONCLUSION

Androgens may mediate endometrial effects through upregulation of PR gene and protein expression. Endometrial PR upregulation by androgens is mediated, at least in part, through AR.

New developments in the pharmacotherapy of neuropathic chronic pelvic pain

Advancements in further understanding the pathophysiology of chronic pelvic pain syndromes continue to direct therapy. The mechanisms of chronic pelvic pain are often multifactorial and therefore require a multidisciplinary approach. The final treatment plan is often an accumulation of organ-specific treatment and chronic pain medications directed to the CNS and PNS. This article is a review of commonly used medications for chronic pelvic neuropathic pain disorders as well as an introduction to recent innovative developments in pain medicine.

The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness

BACKGROUND

Pelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence (PVI) and CPP is not established. Non-invasive screening methods such as Doppler ultrasound and magnetic resonance venography are used before confirmation by venography. Percutaneous embolisation has become the principal treatment for PCS, with high success rates often cited.

OBJECTIVES

Our proposal aimed to systematically and critically review the definitions and diagnostic criteria of PCS, the association between PVI and CPP, the accuracy of various non-invasive imaging techniques and the effectiveness of embolisation for PVI; and to identify factors associated with successful outcome. We also wished to survey clinicians and patients to assess awareness and management of PCS and gauge the enthusiasm for further research.

DATA SOURCES

A comprehensive search strategy encompassing various terms for pelvic congestion, pain, imaging techniques and embolisation was deployed in 17 bibliographic databases, including MEDLINE, EMBASE and Web of Science. There was no restriction on study design.

METHODS

Methodological quality was assessed using appropriate tools. Online surveys were sent to clinicians and patients. The quality and heterogeneity generally precluded meta-analysis and so results were tabulated and described narratively.

RESULTS

We identified six association studies, 10 studies involving ultrasound, two studies involving magnetic resonance venography, 21 case series and one poor-quality randomised trial of embolisation. There were no consistent diagnostic criteria for PCS. We found that the associations between CPP and PVI were generally fairly similar, with three of five studies with sufficient data showing statistically significant associations (odds ratios of between 31 and 117). The prevalence of PVI ranged widely, although the majority of women with PVI had CPP. Transvaginal ultrasound with Doppler and magnetic resonance venography are both useful screening methods, although the data on accuracy are limited. Early substantial relief from pain symptoms was observed in approximately 75% of women undergoing embolisation, a figure which generally increased over time and was sustained. Reintervention rates were generally low. Transient pain was a common occurrence following foam embolisation, while there was a < 2% risk of coil migration. Confidence in the embolisation technique is reasonably high, although there is a desire to strengthen the evidence base. Even among women with CPP, fewer than half had any knowledge about PCS.

CONCLUSIONS

The data supporting the diagnosis and treatment of PCS are limited and of variable methodological quality. There is some evidence to tentatively support a causative association, but it cannot be categorically stated that PVI is the cause of CPP in women with no other pathology, as the six most pertinent drew on clinically disparate populations and defined PVI inconsistently. Embolisation appears to provide symptomatic relief in the majority of women and is safe. However, the majority of included studies of embolism were relatively small case series and only the randomised controlled trial was considered at risk of potential biases. There is scope and demand for considerable further research. The question of the association of PVI and CPP requires a well-designed and well-powered case-control study, which will also provide data to derive a diagnostic standard. An adequately powered randomised trial is essential to provide evidence on the effectiveness of embolisation, but this faces methodological challenges.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002237 and CRD42012002238.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Vocal Music Therapy for Chronic Pain Management in Inner-City African Americans: A Mixed Methods Feasibility Study

BACKGROUND

To date, research on music for pain management has focused primarily on listening to prerecorded music for acute pain. Research is needed on the impact of active music therapy interventions on chronic pain management.

OBJECTIVE

The aim of this mixed methods research study was to determine feasibility and estimates of effect of vocal music therapy for chronic pain management.

METHODS

Fifty-five inner-city adults, predominantly African Americans, with chronic pain were randomized to an 8-week vocal music therapy treatment group or waitlist control group. Consent and attrition rates, treatment compliance, and instrument appropriateness/burden were tracked. Physical functioning (pain interference and general activities), self-efficacy, emotional functioning, pain intensity, pain coping, and participant perception of change were measured at baseline, 4, 8, and 12 weeks. Focus groups were conducted at the 12-week follow-up.

RESULTS

The consent rate was 77%. The attrition rate was 27% at follow-up. We established acceptability of the intervention. Large effect sizes were obtained for self-efficacy at weeks 8 and 12; a moderate effect size was found for pain interference at week 8; no improvements were found for general activities and emotional functioning. Moderate effect sizes were obtained for pain intensity and small effect sizes for coping, albeit not statistically significant. Qualitative findings suggested that the treatment resulted in enhanced self-management, motivation, empowerment, a sense of belonging, and reduced isolation.

CONCLUSIONS

This study suggests that vocal music therapy may be effective in building essential stepping-stones for effective chronic pain management, namely enhanced self-efficacy, motivation, empowerment, and social engagement.

Hysterectomy and Bilateral Salpingo-Oophorectomy: Variations by History of Military Service and Birth Cohort

INTRODUCTION

Little is known about hysterectomy and bilateral salpingo-oophorectomy (BSO), which are associated with both health risks and benefits, among women Veterans.

PURPOSE OF THE STUDY

To compare the prevalence of hysterectomy with or without BSO, and early hysterectomy, between postmenopausal Veterans and non-Veterans.

DESIGN AND METHODS

We used baseline data from the Women's Health Initiative Clinical Trial and Observational Study. Multinomial logistic regression models examined differences in the prevalence of hysterectomy (neither hysterectomy nor BSO, hysterectomy without BSO, and hysterectomy with BSO) between Veterans and non-Veterans. Generalized linear models were used to determine whether early hysterectomy (before age 40) differed between Veterans and non-Veterans. Analyses were stratified by birth cohort (<65, ≥65 years at enrollment).

RESULTS

The unadjusted prevalence of hysterectomy without BSO was similar among Veterans and non-Veterans in both birth cohorts (<65: 22% vs 21%; ≥65: 22% vs 21%). The unadjusted prevalence of hysterectomy with BSO was equivalent among Veterans and non-Veterans in the >65 cohort (21%), but higher among Veterans in the <65 cohort (22% vs 19%). In adjusted analyses, although no differences were observed in the >65 cohort, Veterans in the <65 cohort had higher odds of hysterectomy without BSO (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03, 1.36) and with BSO (OR 1.26, 95% CI 1.10, 1.45), as well as elevated risk of early hysterectomy (relative risk 1.32, 95% CI 1.19, 1.47), compared with non-Veterans.

IMPLICATIONS

Aging women Veterans may have higher prevalence of hysterectomy and BSO than non-Veterans. This information contributes to understanding the health needs and risks of women Veterans and can inform clinical practice and policy for this population.

Pain and Urinary Symptoms Should Not be Combined into a Single Score: Psychometric Findings from the MAPP Research Network

PURPOSE

The purpose of this study was to create symptom indexes, that is scores derived from questionnaires to accurately and efficiently measure symptoms of interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome, collectively referred to as urological chronic pelvic pain syndromes. We created these indexes empirically by investigating the structure of symptoms using exploratory factor analysis.

MATERIALS AND METHODS

As part of the MAPP (Multi-Disciplinary Approach to the Study of Chronic Pelvic Pain) Research Network 424 participants completed questionnaires, including GUPI (Genitourinary Pain Index), ICSI (Interstitial Cystitis Symptom Index) and ICPI (Interstitial Cystitis Problem Index). Individual items from questionnaires about bladder and pain symptoms were evaluated by principal component and exploratory factor analyses to identify indexes with fewer questions to comprehensively quantify symptom severity. Additional analyses included correlating symptom indexes with symptoms of depression, which is a known comorbidity of patients with pelvic pain.

RESULTS AND CONCLUSIONS

Exploratory factor analyses suggested that the 2 factors pain severity and urinary severity provided the best psychometric description of items in GUPI, ICSI and ICPI. These factors were used to create 2 symptom indexes for pain and urinary symptoms. Pain, but not urinary symptoms, was associated with symptoms of depression on multiple regression analysis, suggesting that these symptoms may impact patients with urological chronic pelvic pain syndromes differently (B ± SE for pain severity = 0.24 ± 0.04, 95% CI 0.16-0.32, β = 0.32, p <0.001). Our results suggest that pain and urinary symptoms should be assessed separately rather than combined into 1 total score. Total scores that combine the separate factors of pain and urinary symptoms into 1 score may be limited for clinical and research purposes.

The development and delivery of a female chronic pelvic pain management programme: a specialised interdisciplinary approach

CONTEXT/BACKGROUND

Chronic pelvic pain (CPP) is a physically and psychologically debilitating condition. European Association of Urology (EAU) Guidelines (2013) and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (2012) place strong emphasis upon multi-speciality assessment and liaison, as well as interdisciplinary assessment and intervention in reference to the management of CPP.

OBJECTIVES

The aim was to introduce and describe the development and delivery of an interdisciplinary pain management programme (PMP), at a Specialised Pain Management Centre in Liverpool, United Kingdom, for women diagnosed with CPP.

METHOD

The format and content of the CPP PMP at The Walton Centre, Liverpool, is described and the preliminary results from the CPP PMP are presented.

RESULTS

Preliminary data suggest that outcomes on the specialised CPP PMP indicate that patients are able to make clinically important change across a range of outcome measures. Moreover, these results compare favourably to the established PMP for generalised chronic pain when comparing clinically significant outcomes with the Walton Centre's (a tertiary-level pain management centre) 2013 PMP Audit document. Patients attending the CPP PMP positively appraised the PMP and felt it was useful and supportive to be in a group dedicated to CPP.

CONCLUSIONS

This article presents some preliminary results that suggest there is value in delivering a specialised multidisciplinary PMP for this group. There is a clear need for further clinical research into the effectiveness of similar interventions for CPP, including the early identification of those CPP patients who may benefit from both multi-specialty and interdisciplinary management.