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Merlino L, Ciminello E, Volpicelli AI, Tillier S, Pasquali MF, Dominoni M, Gardella B, Senatori R, Dionisi B, Piccioni MG. Evaluation of the Effectiveness of Combined Treatment with Intravaginal Diazepam and Pelvic Floor Rehabilitation in Patients with Vulvodynia by Ultrasound Monitoring of Biometric Parameters of Pelvic Muscles: A Pilot Study. Diseases 2024; 12:174. [PMID: 39195173 DOI: 10.3390/diseases12080174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/22/2024] [Accepted: 07/27/2024] [Indexed: 08/29/2024] Open
Abstract
(1) Background: Vulvodynia is characterized by vulvar pain for at least three months and may have related variables, one of these being pelvic floor hypertonus. The purpose of this study was to compare the therapeutic effectiveness of two weekly sessions of pelvic floor rehabilitation and 5 mg of vaginal diazepam daily vs. pelvic floor rehabilitation alone in individuals with vulvodynia. (2) Methods: A single-center, not-blind, randomized study enrolled 20 vulvodynic patients: A total of 10 were treated with dual therapy (intravaginal diazepam and pelvic floor rehabilitation), and 10 were treated with only pelvic floor rehabilitation. All of them underwent a pelvic floor ultrasound examination and VAS pain and Marinoff scale assessments before the beginning of therapy as well as three and six months later. (3) Results: The elevator plate angle ranged from 8.2 to 9.55 (p = 0.0005), hiatal area diameter ranged from 1.277 to 1.482 (p = 0.0002), levator symphysis distance ranged from 3.88 to 4.098 (p = 0.006), anorectal angle ranged from 121.9 to 125.49 (p = 0.006), Marinoff scale ranged from 2.3 to 1.4 (p = 0.009), and VAS scale ranged from 5.8 to 2.8 (p < 0.001). (4) Conclusions: This pilot study demonstrates that the suggested treatment improves the hypertonicity of the pelvic floor, as measured by ultrasound parameters, correlating with a reduction in symptomatology.
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Affiliation(s)
- Lucia Merlino
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 00161 Rome, Italy
| | | | | | - Stefano Tillier
- School of Gynecology and Obstetrics, University of Eastern Piedmont, 28100 Novara, Italy
| | - Marianna Francesca Pasquali
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | | | | | - Maria Grazia Piccioni
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 00161 Rome, Italy
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Torosis M, Carey E, Christensen K, Kaufman MR, Kenton K, Kotarinos R, Lai HH, Lee U, Lowder JL, Meister M, Spitznagle T, Wright K, Ackerman AL. A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction. Obstet Gynecol 2024; 143:595-602. [PMID: 38387036 PMCID: PMC10953682 DOI: 10.1097/aog.0000000000005536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/27/2023] [Accepted: 12/08/2023] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients. METHODS A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm. RESULTS A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits. CONCLUSION A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.
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Affiliation(s)
- Michele Torosis
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Erin Carey
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Kristin Christensen
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Melissa R. Kaufman
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Kimberly Kenton
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Rhonda Kotarinos
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - H. Henry Lai
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Una Lee
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Jerry L. Lowder
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Melanie Meister
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Theresa Spitznagle
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Kelly Wright
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - A. Lenore Ackerman
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
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Gaddam NG, Kingsberg SA, Iglesia CB. Sexual Dysfunction and Dyspareunia in the Setting of the Genitourinary Syndrome of Menopause. Clin Obstet Gynecol 2024; 67:43-57. [PMID: 38281169 DOI: 10.1097/grf.0000000000000846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Sexual dysfunction is a common consequence of the genitourinary syndrome of menopause (GSM). In this book chapter, we discuss the pathophysiology, prevalence, evaluation, and evidence-based management of sexual dysfunction in patients affected by GSM. Additionally, we present an algorithm to guide clinicians in the management and treatment of sexual dysfunction in this setting based on available evidence and best practices.
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Affiliation(s)
- Neha G Gaddam
- Section of Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center/Georgetown University, Washington, DC
| | - Sheryl A Kingsberg
- Department of OBGYN, University Hospitals Cleveland Medical Center
- Departments of Reproductive Biology, Psychiatry and Urology, Case Western Reserve University School of Medicine
| | - Cheryl B Iglesia
- Section of Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center
- Department of OB/GYN and Urology, Georgetown University School of Medicine, Cleveland, Ohio
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4
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Vogel JJ. Pain Specialist Management of Sexual Pain-II: Interventional. Sex Med Rev 2023; 11:81-88. [PMID: 36763948 DOI: 10.1093/sxmrev/qeac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Treatment of female sexual pain often requires the use of diverse modalities crossing multiple medical disciplines. Interventional procedures are important in the diagnosis and treatment of female sexual pain. Pain specialists and other medical specialties can provide these capabilities. OBJECTIVES To provide a current summary of the procedures used in the diagnosis and treatment of female sexual pain. METHODS The internet, PubMed, and the Cochrane Library were searched for relevant articles on female sexual pain within the clinical purview and scope of the practice of pain management. RESULTS A thorough review of the literature was conducted to include basic science studies, clinical trials, systematic reviews, consensus statements, and case reports. An effort was made to also include a sampling of information on real-world patient self-directed therapies. Descriptions of interventional procedures for the diagnosis and treatment of sexual pain were made and clinical studies reviewed. The evidence for the use of various interventional treatment strategies for sexual pain was assessed. CONCLUSIONS The process of care for female sexual pain employs an interdisciplinary biopsychosocial model that includes a role for interventional procedures commonly performed by pain management specialists. These specialists are a resource of knowledge, skills, and abilities that can be used to improve the care of women with chronic sexual pain.
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Affiliation(s)
- John J Vogel
- Innovative Pain Care, Marietta, GA 30062, United States
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5
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Schlaeger JM, Glayzer JE, Villegas‐Downs M, Li H, Glayzer EJ, He Y, Takayama M, Yajima H, Takakura N, Kobak WH, McFarlin BL. Evaluation and Treatment of Vulvodynia: State of the Science. J Midwifery Womens Health 2023; 68:9-34. [PMID: 36533637 PMCID: PMC10107324 DOI: 10.1111/jmwh.13456] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 09/03/2022] [Accepted: 09/07/2022] [Indexed: 12/23/2022]
Abstract
Vulvodynia affects 7% of American women, yet clinicians often lack awareness of its presentation. It is underdiagnosed and often misdiagnosed as vaginitis. The etiology of vulvodynia remains unknown, making it difficult to identify or develop effective treatment methods. The purpose of this article is to (1) review the presentation and evaluation of vulvodynia, (2) review the research on vulvodynia treatments, and (3) aid the clinician in the selection of vulvodynia treatment methods. The level of evidence to support vulvodynia treatment varies from case series to randomized controlled trials (RCTs). Oral desipramine with 5% lidocaine cream, intravaginal diazepam tablets with intravaginal transcutaneous electric nerve stimulation (TENS), botulinum toxin type A 50 units, enoxaparin sodium subcutaneous injections, intravaginal TENS (as a single therapy), multimodal physical therapy, overnight 5% lidocaine ointment, and acupuncture had the highest level of evidence with at least one RCT or comparative effectiveness trial. Pre to posttest reduction in vulvar pain and/or dyspareunia in non-RCT studies included studies of gabapentin cream, amitriptyline cream, amitriptyline with baclofen cream, up to 6 weeks' oral itraconazole therapy, multimodal physical therapy, vaginal dilators, electromyography biofeedback, hypnotherapy, cognitive behavioral therapy, cold knife vestibulectomy, and laser therapy. There is a lack of rigorous RCTs with large sample sizes for the treatment of vulvodynia, rendering it difficult to determine efficacy of most treatment methods. Clinicians will be guided in the selection of best treatments for vulvodynia that have the highest level of evidence and are least invasive.
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Affiliation(s)
- Judith M. Schlaeger
- Department of Human Development Nursing ScienceUniversity of Illinois Chicago College of NursingChicagoIllinoisUSA
| | - Jennifer E. Glayzer
- Department of Human Development Nursing ScienceUniversity of Illinois Chicago College of NursingChicagoIllinoisUSA
| | - Michelle Villegas‐Downs
- Department of Human Development Nursing ScienceUniversity of Illinois Chicago College of NursingChicagoIllinoisUSA
| | - Hongjin Li
- Department of Human Development Nursing ScienceUniversity of Illinois Chicago College of NursingChicagoIllinoisUSA
| | - Edward J. Glayzer
- Department of Sociology, Anthropology, and Social WorkUniversity of Dayton College of Arts and SciencesDaytonOhioUSA
| | - Ying He
- Department of Pharmaceutical SciencesOklahoma State UniversityStillwaterOklahomaUSA
| | - Miho Takayama
- Department of Acupuncture and MoxibustionTokyo Ariake University of Medical and Health SciencesTokyoJapan
| | - Hiroyoshi Yajima
- Department of Acupuncture and MoxibustionTokyo Ariake University of Medical and Health SciencesTokyoJapan
| | - Nobuari Takakura
- Department of Acupuncture and MoxibustionTokyo Ariake University of Medical and Health SciencesTokyoJapan
| | - William H. Kobak
- Department of Obstetrics and GynecologyUniversity of Illinois Chicago College of MedicineChicagoIllinoisUSA
| | - Barbara L. McFarlin
- Department of Human Development Nursing ScienceUniversity of Illinois Chicago College of NursingChicagoIllinoisUSA
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Aldrich ER, Tam TY, Saylor LM, Crisp CC, Yeung J, Pauls RN. Intrarectal diazepam following pelvic reconstructive surgery: a double-blind, randomized placebo-controlled trial. Am J Obstet Gynecol 2022; 227:302.e1-302.e9. [PMID: 35550374 DOI: 10.1016/j.ajog.2022.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/25/2022] [Accepted: 05/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients undergoing vaginal hysterectomy with native tissue pelvic reconstruction typically have low pain levels overall in the postoperative period. Notwithstanding, pain control immediately after surgery may be more challenging and a barrier to same-day discharge. Intrarectal diazepam has been used for acute and chronic pelvic pain and has a pharmacokinetic profile ideal for intermittent use. However, its use has not been investigated after the surgical intervention. OBJECTIVE This study aimed to evaluate the effect of diazepam rectal suppositories on early postoperative pain after hysterectomy and vaginal reconstruction for pelvic organ prolapse. STUDY DESIGN This was a double-blind, randomized, placebo-controlled trial comparing postoperative pain scores after vaginal hysterectomy with native tissue prolapse repairs. Patients were randomized to receive either an intrarectal 10-mg diazepam suppository or an identical placebo. Moreover, the participants completed the questionnaires at baseline, the morning of postoperative day 1, and 2 weeks after the operation. Surveys included visual analog scales for pain, a validated Surgical Satisfaction Questionnaire, and queries regarding medication side effects and postoperative recovery. The primary outcome was pain scores based on a visual analog scale approximately 3 hours after surgery. The secondary outcomes included total morphine equivalents after surgery, patient satisfaction with pain control, same-day discharge outcome, and overall satisfaction. The chi-square, Fisher exact, and Mann-Whitney tests were used. Based on a 10-mm difference in postoperative vaginal pain using the visual analog scale, sample size was calculated to be 55 patients in each arm to achieve 80% power with an alpha of.05. RESULTS From February 2020 to August 2021, 130 participants were randomized. Of those participants, 7 withdrew, and 123 were analyzed: 60 in the diazepam group and 63 in the placebo group. The median age was 65 years (interquartile range, 27-80), the median body mass index was 27.9 kg/m2 (interquartile range, 18.70-45.90), and 119 of 123 participants (96.7%) were White. There was no difference in the baseline characteristics, prolapse stage, or types of procedures performed between groups. Most participants had concurrent uterosacral ligament suspension with anterior and posterior repairs. Of note, 50 of 123 participants (41%) had midurethral slings. Moreover, 61 of 123 participants (50%) were discharged on the day of surgery. There was no difference in the primary outcome of vaginal pain 3.5 to 6.0 hours postoperatively (25 vs 21 mm; P=.285). In addition, the amount of rescue narcotics used in the immediate postoperative period (19.0 vs 17.0 MME; P=.202) did not differ between groups. At 2-weeks postoperatively, patients in the placebo group reported higher satisfaction with pain control in the hospital (31 vs 43 mm; P=.006) and pain control at home (31 vs 42 mm; P=.022). No difference was noted between same-day discharges and those who were admitted overnight. CONCLUSION The placement of a 10-mg diazepam rectal suppository immediately after pelvic reconstructive surgery did not improve pain or narcotic usage in the early postoperative period. Although the placebo group reported slightly higher satisfaction with pain control 2 weeks after surgery, overall pain levels were low. Therefore, we do not believe that the addition of diazepam to the postoperative regimen is warranted.
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Clinical Management of Chronic Pelvic Pain in Endometriosis Unresponsive to Conventional Therapy. J Pers Med 2022; 12:jpm12010101. [PMID: 35055416 PMCID: PMC8779548 DOI: 10.3390/jpm12010101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Although several treatments are currently available for chronic pelvic pain, 30–60% of patients do not respond to them. Therefore, these therapeutic options require a better understanding of the mechanisms underlying endometriosis-induced pain. This study focuses on pain management after failure of conventional therapy. Methods: We reviewed clinical data from 46 patients with endometriosis and chronic pelvic pain unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain from 2018 to 2021. Demographic data, clinical and exploratory findings, treatment received, and outcomes were collected. Results: Median age was 41.5 years, and median pain intensity was VAS: 7.8/10. Nociceptive pain and neuropathic pain were identified in 98% and 70% of patients, respectively. The most common symptom was abdominal pain (78.2%) followed by pain with sexual intercourse (65.2%), rectal pain (52.1%), and urologic pain (36.9%). A total of 43% of patients responded to treatment with neuromodulators. Combined therapies for myofascial pain syndrome, as well as treatment of visceral pain with inferior or superior hypogastric plexus blocks, proved to be very beneficial. S3 pulsed radiofrequency (PRF) plus inferior hypogastric plexus block or botulinum toxin enabled us to prolong response time by more than 3.5 months. Conclusion: Treatment of the unresponsive patient should be interdisciplinary. Depending on the history and exploratory findings, therapy should preferably be combined with neuromodulators, myofascial pain therapies, and S3 PRF plus inferior hypogastric plexus blockade.
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Frederice CP, Brito LGO, Pereira GMV, Lunardi ALB, Juliato CRT. Interventional treatment for myofascial pelvic floor pain in women: systematic review with meta-analysis. Int Urogynecol J 2021; 32:1087-1096. [PMID: 33640993 DOI: 10.1007/s00192-021-04725-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/04/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Female myofascial pain (MFP) of the pelvic floor muscles (PFM) is a subtype of chronic pelvic pain associated with urinary, anorectal, and sexual symptoms, such as dyspareunia. Treatment remains poorly discussed, and we hypothesized that different treatments could improve outcomes versus placebo or no treatment. METHODS A systematic review (CRD 42020201419) was performed in June 2020 using the following databases: PubMed, Cochrane Library, Web of Science, Embase, Scopus, BVSalud, Clinicaltrials.gov , and PEDro, including randomized clinical trials related to MPF of PFM. Primary outcome was pain after treatment, and secondary outcomes were quality of life and sexual function. Risk of bias and quality of evidence (GRADE criteria) were evaluated. Meta-analysis for continuous variables was performed (mean difference between baseline and treatment and post-treatment mean between groups). RESULTS Five studies were included (n = 218). Final mean VAS score (GRADE: very low) after 4 weeks of treatment (p = 0.14) and the mean difference from baseline and 4 weeks (p = 0.66) between groups were not different between the intervention and control groups. Quality of life according to the SF-12 questionnaire (GRADE: very low) followed the same pattern. However, sexual function (GRADE: low) according to the total FSFI score (MD = -5.07 [-8.31, -1.84], p < 0.01, i2 = 0%) and the arousal, orgasm, and pain domains improved in the intervention groups when the mean difference from baseline and 4 weeks was compared with controls. CONCLUSION Pain and quality of life after 4 weeks of heterogeneous intervention differed between the intervention and control groups in sexual function: FSFI in studies improved in almost all domains. VAS (in three studies) and SF-12 (in two studies) failed to demonstrate differences.
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Affiliation(s)
- Claudia Pignatti Frederice
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Rua Alexander Fleming, 101, Cidade Universitária, Campinas, SP, Brazil.,Department of Physiotherapy, Unimetrocamp University Center, Campinas, Brazil
| | - Luiz Gustavo Oliveira Brito
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Rua Alexander Fleming, 101, Cidade Universitária, Campinas, SP, Brazil
| | - Glaucia Miranda Varella Pereira
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Rua Alexander Fleming, 101, Cidade Universitária, Campinas, SP, Brazil
| | | | - Cássia Raquel Teatin Juliato
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Rua Alexander Fleming, 101, Cidade Universitária, Campinas, SP, Brazil.
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Compliance With Pelvic Floor Physical Therapy in Patients Diagnosed With High-Tone Pelvic Floor Disorders. Female Pelvic Med Reconstr Surg 2021; 27:94-97. [PMID: 31045618 DOI: 10.1097/spv.0000000000000732] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The primary objective of this study was to describe patient compliance with pelvic floor physical therapy (PFPT) for high-tone pelvic floor disorders (HTPFD) and to compare patients who are compliant with prescribed therapy to those who are not. The secondary objective is to describe second-line treatments offered for HTPFD for returning patients. METHODS This is a retrospective cohort study of women with a HTPFD who were prescribed PFPT at a tertiary care referral center. Patients were excluded if they had a primary diagnosis of urinary incontinence, had undergone prior PFPT, or if PFPT was part of preoperative planning. Noncompliance with PFPT was defined as not being formally discharged from therapy by the treating therapist. RESULTS Data on PFPT compliance were available for 662 patients (87.3%). A total of 128 patients (19.4%) were fully compliant. Noncompliant patients were more likely to smoke and to have mental health disease compared with compliant patients (18% vs 8.7%, P = 0.01, and 50.4% vs 37.5%, P = 0.009, respectively). A total of 285 patients (43.1%) returned to their prescribing provider. Noncompliant patients were less likely to return to their provider: 63.4% versus 29.7%, P = <0.0001. Of the patients who returned, 183 (64.2%) were offered second-line treatment. CONCLUSIONS Only 1 in 5 patients referred to PFPT for management of a high-tone pelvic floor disorder is compliant with the recommended therapy. Patients who are noncompliant are less likely to return to their prescribing provider, and less than half of referred patients return. Sixty percent of patients who return are offered second-line treatment.
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10
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Stone RH, Abousaud M, Abousaud A, Kobak W. A Systematic Review of Intravaginal Diazepam for the Treatment of Pelvic Floor Hypertonic Disorder. J Clin Pharmacol 2020; 60 Suppl 2:S110-S120. [PMID: 33274514 DOI: 10.1002/jcph.1775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022]
Abstract
This systematic review evaluates the efficacy of intravaginal diazepam in treating chronic pelvic pain and sexual dysfunction associated with high-tone pelvic floor dysfunction. A literature search was conducted in Medline and Web of Science, including articles from the database's inception to July 2019. The search identified 126 articles, and 5 articles met study inclusion criteria: 2 observational reviews and 3 small randomized, controlled trials (RCTs) evaluating intravaginal diazepam for high-tone pelvic floor dysfunction. The 2 observational studies identified subjective reports of improvement in sexual function for a majority of women, 96% and 71%, in each study. However, there were no statistical differences between Female Sexual Function Index (FSFI) and Visual Analog Scale (VAS) scores for pain identified. One RCT found no significant changes between groups in median FSFI or VAS scores, and a second RCT found no significant changes between groups in 100-mm VAS scores. The third RCT demonstrated that compared with placebo, treatment with transcutaneous electrical nerve stimulation and intravaginal diazepam for women with vestibulodynia and high-tone pelvic floor dysfunction yielded significant differences in reduction of dyspareunia (P ≤ .05), ability to relax pelvic floor muscles after contraction (P ≤.05), and current perception threshold values at a 5-Hz stimulation related to C fibers (P < .05), but no significant changes in 10-cm VAS scores. Intravaginal diazepam may be helpful in women with a specific diagnosis of high-tone pelvic floor dysfunction, but more and larger studies are needed to confirm these potential effects.
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Affiliation(s)
- Rebecca H Stone
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, Georgia, USA
| | - Marin Abousaud
- Department of Pharmacy, Emory Healthcare, Atlanta, Georgia, USA
| | - Aseala Abousaud
- Department of Pharmacy, Emory Healthcare, Atlanta, Georgia, USA
| | - William Kobak
- Department of Clinical Obstetrics and Gynecology, University of Illinois College of Medicine, Chicago, Illinois, USA
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11
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Grimes CL, Balk EM, Dieter AA, Singh R, Wieslander CK, Jeppson PC, Aschkenazi SO, Kim JH, Truong MD, Gupta AS, Keltz JG, Hobson DT, Sheyn D, Petruska SE, Adam G, Meriwether KV. Guidance for gynecologists utilizing telemedicine during COVID‐19 pandemic based on expert consensus and rapid literature reviews. Int J Gynaecol Obstet 2020. [PMCID: PMC9087699 DOI: 10.1002/ijgo.13276] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background COVID‐19 has impacted delivery of outpatient gynecology and shifted care toward use of telemedicine. Objective To rapidly review literature and society guidelines and create expert consensus to provide guidance regarding management of outpatient gynecology scenarios via telemedicine. Search strategy Searches were conducted in Medline and Cochrane databases from inception through April 15, 2020. Selection criteria Literature searches were conducted for articles on telemedicine and abnormal uterine bleeding, chronic pelvic pain, endometriosis, vaginitis, and postoperative care. Searches were restricted to available English language publications. Data collection and analysis Expedited literature review methodology was followed and 10 943 citations were single‐screened. Full‐text articles and relevant guidelines were reviewed and narrative summaries developed. Main results Fifty‐one studies on the use of telemedicine in gynecology were found. Findings were reported for these studies and combined with society guidelines and expert consensus on four topics (abnormal uterine bleeding, chronic pelvic pain and endometriosis, vaginal discharge, and postoperative care). Conclusions Guidance for treating gynecological conditions via telemedicine based on expedited literature review, review of society recommendations, and expert consensus is presented. Due to minimal evidence surrounding telemedicine and gynecology, a final consensus document is presented here that can be efficiently used in a clinical setting. Guidance for gynecologists using telemedicine during COVID‐19 based on rapid literature review, review of society recommendations, and expert consensus in accessible format.
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Affiliation(s)
- Cara L. Grimes
- Division of Female Pelvic Medicine and Reconstructive Surgery Departments of Obstetrics and Gynecology and Urology New York Medical College Valhalla NY USA
| | - Ethan M. Balk
- Center for Evidence Synthesis in Health Brown School of Public Health Brown University Providence RI USA
| | - Alexis A. Dieter
- Division of Urogynecology and Reconstructive Pelvic Surgery Department of Obstetrics and Gynecology University of North Carolina at Chapel Hill Chapel Hill NC USA
| | - Ruchira Singh
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology University of Florida Jacksonville FL USA
| | - Cecilia K. Wieslander
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA Los Angeles CA USA
| | - Peter C. Jeppson
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology University of New Mexico Albuquerque NM USA
| | - Sarit O. Aschkenazi
- Prohealth Women Services Division of Urogynecology Department of Obstetrics and Gynecology Waukesha Memorial Hospital Medical College of Wisconsin Waukesha WI USA
| | - Jin Hee Kim
- Division of Gynecologic Specialty Surgery Department of Obstetrics and Gynecology Columbia University Medical Center New York NY USA
| | - Mireille D. Truong
- Division of Minimally Invasive Gynecologic Surgery Department of Obstetrics and Gynecology Cedars‐Sinai Medical Center Los Angeles CA USA
| | - Ankita S. Gupta
- Department of Obstetrics & Gynecology University of Louisville Louisville KY USA
| | - Julia G. Keltz
- Department of Obstetrics and Gynecology New York Medical College Valhalla NY USA
| | - Deslyn T.G. Hobson
- Department of Obstetrics and Gynecology Wayne State University School of Medicine Detroit MI USA
| | - David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology MetroHealth Medical Center Cleveland OH USA
| | - Sara E. Petruska
- Department of Obstetrics & Gynecology University of Louisville Louisville KY USA
| | - Gaelen Adam
- Center for Evidence Synthesis in Health Brown School of Public Health Brown University Providence RI USA
| | - Kate V. Meriwether
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology University of New Mexico Albuquerque NM USA
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12
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Padoa A, McLean L, Morin M, Vandyken C. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med Rev 2020; 9:76-92. [PMID: 32631813 DOI: 10.1016/j.sxmr.2020.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The assessment of pelvic floor muscle (PFM) overactivity is part of a comprehensive evaluation including a detailed history (medical, gynecological history/antecedent), appraisal of the psychosocial contexts of the patient, as well as a musculoskeletal and a neurological examination. OBJECTIVES The aims of this article are to review (i) the assessment modalities evaluating pelvic floor function in women and men with disorders associated with an overactive pelvic floor (OPF), and (ii) therapeutic approaches to address OPF, with particular emphases on sexual pain and function. METHODS We outline assessment tools that evaluate psychological and cognitive states. We then review the assessment techniques to evaluate PFM involvement including digital palpation, electromyography, manometry, ultrasonography, and dynamometry, including an overview of the indications, efficacy, advantages, and limitations of each instrument. We consider each instrument's utility in research and in clinical settings. We next review the evidence for medical, physiotherapy, and psychological interventions for OPF-related conditions. RESULTS Research using these assessment techniques consistently points to findings of high PFM tone among women and men reporting disorders associated with OPF. While higher levels of evidence are needed, options for medical treatment include diazepam suppositories, botulinum toxin A, and other muscle relaxants. Effective psychological therapies include cognitive behavioral therapy, couple therapy, mindfulness, and educational interventions. Effective physiotherapy approaches include PFM exercise with biofeedback, electrotherapy, manual therapy, and the use of dilators. Multimodal approaches have demonstrated efficacy in reducing pain, normalizing PFM tone, and improving sexual function. Multidisciplinary interventions and an integrative approach to the assessment and management of OPF using a biopsychosocial framework are discussed. CONCLUSION Although the efficacy of various intervention approaches has been demonstrated, further studies are needed to personalize interventions according to a thorough assessment and determine the optimal combination of psychological, physical, and behavioral modalities. Padoa A, McLean, L, Morin M, et al. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med 2021;9:76-92.
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Affiliation(s)
- Anna Padoa
- Department of Obstetrics and Gynecology, Yitzhak Shamir (formerly Assaf Harofe) Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Linda McLean
- School of Rehabilitation Sciences, Chair in Women's Health Research, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Melanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke and Research Center of the Centre hospitalier de l'Université de Sherbrooke (CHUS), Sherbrooke, QC, Canada
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Wright SL. Limited Utility for Benzodiazepines in Chronic Pain Management: A Narrative Review. Adv Ther 2020; 37:2604-2619. [PMID: 32378069 PMCID: PMC7467435 DOI: 10.1007/s12325-020-01354-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Controversy and uncertainty exist about the use of benzodiazepine receptor agonists (BZRAs) in pain management. This article curates available research to determine the appropriate role of BZRAs in the course of pain management, and how prescribers might address these challenges. METHODS A narrative review was performed to determine the appropriate role of BZRAs in pain management and to develop practice recommendations. Publications were identified by a search of PubMed, references of retrieved reports, guidelines, and the author's personal files. RESULTS BZRAs were found to have analgesic benefit for two pain conditions: burning mouth syndrome and stiff person syndrome. Absence of research, heterogeneity of trials, and small sample sizes precluded drawing conclusions about efficacy of BZRAs for the other 109 pain conditions explored. Data supports the use of BZRAs to treat co-occurring insomnia and anxiety disorders but only when alternatives are inadequate and only for short periods of time (2-4 weeks). The utility of BZRAs is limited by loss of efficacy that may be seen with continued use and adverse reactions including physiologic dependence which develops in 20-100% of those who take these agents for more than a month. CONCLUSIONS BZRAs are often used inappropriately in pain management. Their initiation and duration of use should be limited to a narrow range of conditions. When prescribed for 4 weeks or more, patients should be encouraged to discontinue them through a supported, slow tapering process that may take 12-18 months or longer.
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Affiliation(s)
- Steven L Wright
- Alliance for Benzodiazepine Best Practices, Littleton, CO, USA.
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14
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Chronic Pelvic Pain and the Chronic Overlapping Pain Conditions in Women. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00267-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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15
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Female Sexual Dysfunction: ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists, Number 213. Obstet Gynecol 2020; 134:e1-e18. [PMID: 31241598 DOI: 10.1097/aog.0000000000003324] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Female sexual dysfunction encompasses various conditions that are characterized by reported personal distress in one or more of the following areas: desire, arousal, orgasm, or pain (). Although female sexual dysfunction is relatively prevalent, women are unlikely to discuss it with their health care providers unless asked (), and many health care providers are uncomfortable asking for a variety of reasons, including a lack of adequate knowledge and training in diagnosis and management, inadequate clinical time to address the issue, and an underestimation of the prevalence (). The purpose of this document is to provide an overview of female sexual dysfunction, to outline updated criteria for diagnosis, and to discuss currently recommended management strategies based on the best available evidence.
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16
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Jia X, Rana N, Crouss T, Whitmore KE. Gynecological associated disorders and management. Int J Urol 2019; 26 Suppl 1:46-51. [PMID: 31144734 DOI: 10.1111/iju.13974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic pelvic pain syndrome is complex and involves multiple organ systems. The gynecological aspects of chronic pelvic pain syndrome can be divided into four different areas: intra-abdominal, vaginal, pelvic floor muscles and sexual pain. This article provides an overview of gynecological evaluation in patients with chronic pelvic pain and reviews the most common gynecological diagnoses and their management. METHODS An extensive review of the literature including guidelines from the International Continence Society, the European Association of Urology, and the International Association for the Study of Pain was performed. RESULTS Gynecological evaluation of patients with chronic pelvic pain begins with a thorough history and physical examination. Laboratory tests, imaging studies and diagnostic procedures can be used as adjuncts to make a diagnosis. Treatment modalities include physical therapy, medications, trigger points injections, and surgery. CONCLUSION Common gynecological diagnoses of chronic pelvic pain include endometriosis, adenomyosis, vulvodynia, high tone pelvic floor dysfunction, and genitopelvic pain/penetration disorder. Gynecology is one of the many systems that can be associated with chronic pelvic pain. Managing patients with chronic pelvic pain requires a multimodal and multidisciplinary approach.
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Affiliation(s)
- Xibei Jia
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Neha Rana
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Tess Crouss
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Kristene E Whitmore
- Division of Female Pelvic Medicine and Reconstructive surgery and Urology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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Larish AM, Dickson RR, Kudgus RA, McGovern RM, Reid JM, Hooten WM, Nicholson WT, Vaughan LE, Burnett TL, Laughlin-Tommaso SK, Faubion SS, Green IC. Vaginal Diazepam for Nonrelaxing Pelvic Floor Dysfunction: The Pharmacokinetic Profile. J Sex Med 2019; 16:763-766. [PMID: 31010782 DOI: 10.1016/j.jsxm.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/13/2019] [Accepted: 03/02/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Vaginal diazepam is frequently used to treat pelvic floor tension myalgia and pelvic pain despite limited knowledge of systemic absorption. AIM To determine the pharmacokinetic and adverse event profile of diazepam vaginal suppositories. METHODS We used a prospective pharmacokinetic design with repeated assessments of diazepam levels. Eight healthy volunteers were administered a 10-mg compounded vaginal diazepam suppository in the outpatient gynecologic clinic. Serum samples were collected at 0, 45, 90, 120, and 180 minutes; 8, 24, and 72 hours; and 1 week following administration of a 10-mg vaginal suppository. The occurrence of adverse events was assessed using the alternate step and tandem walk tests, the Brief Confusion Assessment Method, and numerical ratings. Plasma concentrations of diazepam and active long-acting metabolites were measured. Pharmacokinetic parameters were calculated by standard noncompartmental methods. RESULTS The mean peak diazepam concentration (Cmax) of 31.0 ng/mL was detected at a mean time (Tmax) of 3.1 hours after suppository placement. The bioavailability was found to be 70.5%, and the mean terminal elimination half-life was 82 hours. The plasma levels of temazepam and nordiazepam peaked at 0.8 ng/mL at 29 hours and 6.4 ng/mL at 132 hours, respectively. Fatigue was reported by 3 of 8 participants. CLINICAL IMPLICATIONS Serum plasma concentrations of vaginally administered diazepam are low; however the half-life is prolonged. STRENGTHS & LIMITATIONS Strengths include use of inclusion and exclusion criteria aimed at mitigating clinical factors that could adversely impact diazepam absorption and metabolism, and the use of an ultrasensitive LC-MS/MS assay. Limitations included the lack of addressing the efficacy of vaginal diazepam in lieu of performing a pure pharmacokinetic study with healthy participants. CONCLUSION Vaginal administration of diazepam results in lower peak serum plasma concentration, longer time to peak concentration, and lower bioavailability than standard oral use. Providers should be aware that with diazepam's long half-life, accumulating levels would occur with chronic daily doses, and steady-state levels would not be reached for up to 1 week. This profile would favor intermittent use to allow participation in physical therapy and intimacy. Larish AM, Dickson RR, Kudgus RA, et al. Vaginal Diazepam for Nonrelaxing Pelvic Floor Dysfunction: The Pharmacokinetic Profile. J Sex Med 2019;16;763-766.
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Affiliation(s)
- Alyssa M Larish
- Department of Obstetrics and Gynecology. Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Rozalin R Dickson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Rachel A Kudgus
- Department of Pharmacology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Renee M McGovern
- Department of Pharmacology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Joel M Reid
- Department of Pharmacology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Wayne T Nicholson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Pharmacology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Lisa E Vaughan
- Department of Obstetrics and Gynecology. Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Tatnai L Burnett
- Department of Obstetrics and Gynecology. Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Stephanie S Faubion
- Women's Health, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Isabel C Green
- Department of Obstetrics and Gynecology. Mayo Clinic College of Medicine, Rochester, MN, USA.
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18
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Intravaginal Diazepam for the Treatment of Pelvic Floor Hypertonic Disorder. Female Pelvic Med Reconstr Surg 2019; 25:76-81. [DOI: 10.1097/spv.0000000000000514] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vaginal diazepam plus transcutaneous electrical nerve stimulation to treat vestibulodynia: A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2018; 228:148-153. [PMID: 29960200 DOI: 10.1016/j.ejogrb.2018.06.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/20/2018] [Accepted: 06/12/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the effectiveness of vaginal diazepam in addition to transcutaneous electrical nerve stimulation (TENS) in the treatment of vestibulodynia (VBD). STUDY DESIGN This study was a randomized, double-blind, placebo-controlled trial. Forty-two patients with VBD were randomized, 21 underwent diazepam and TENS (diazepam group) and 21 received placebo and TENS (placebo group). Vulvar pain was assessed on a on a 10-cm visual analogue scale (VAS) and dyspareunia according to the Marinoff dyspareunia scale. Vaginal surface electromyography (EMG) and vestibular current perception threshold (CPT) testing were performed at baseline and 60 days after treatment. The primary endpoints included the change in pain and dyspareunia from baseline to 60 days of pain and dyspareunia. The secondary endpoints was the variation in objectivity of pelvic floor muscle (PFM) function and vestibular nerve fiber current perception threshold (CPT). RESULTS The VAS scores for pain from basal values of 7.5 and 7.2 for the diazepam and placebo, respectively, showed significant (p 0.01) decreases from 4.7 to 4.3, but this difference was not statistically significant. The Marinoff dyspareunia scores in the diazepam group showed a significant difference (p 0.05) from values measured in the placebo group. The ability to relax the PFM after contraction (difference between maximal contraction and rest tone) was significantly greater for the diazepam group versus the placebo group (3.8 μv and 2.4 μv, respectively, p 0.01). The CPT values for all of the nerve fibers increased after the treatment, but this increase was significant in the diazepam group only for the values at a 5-Hz stimulation (C fibers) with a change of 47.8% vs 26.9% (p < 0.05). Only two patients reported a mild drowsiness in the diazepam group. CONCLUSIONS The present study provided indications that vaginal diazepam plus TENS is useful to improve pain and PFM instability in women with VBD.
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Comparative Perioperative Pain and Recovery in Women Undergoing Vaginal Reconstruction Versus Robotic Sacrocolpopexy. Female Pelvic Med Reconstr Surg 2017; 23:95-100. [PMID: 28067743 DOI: 10.1097/spv.0000000000000368] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In this study of patients undergoing vaginal hysterectomy with either robotic or vaginal prolapse repair, there was no difference in quality of life in the weeks following surgery; however, less narcotics were used, less pain was documented by nurses and Surgical Pain Scale (SPS), and better performance on voiding trials was noted in those undergoing robotic sacrocolpopexy. OBJECTIVES Minimally invasive surgery for pelvic organ prolapse is the preferred surgical route for optimal recovery. However, information regarding patient-centered outcomes among various techniques is lacking. We sought to describe pain and quality of life in patients undergoing vaginal hysterectomy with uterosacral ligament suspension (USLS) compared with robotic-assisted sacrocolpopexy (RSC). METHODS This institutional review board-approved prospective cohort study enrolled consecutive patients undergoing vaginal hysterectomy with USLS or with RSC. The primary outcome was pain on postoperative day 1 using the SPS. Nursing verbal pain scores, narcotic usage, surgical data, and Short-Form Health Survey 12 at baseline and 2 and 6 weeks after surgery were collected. A sample size calculation revealed 37 subjects per group would be required. RESULTS Seventy-eight women were enrolled (USLS, n = 39; RSC, n = 39). There were no significant differences in scores on the SPS between groups. Subjects undergoing RSC had lower nursing verbal pain scores (P = 0.04), less narcotic consumption (P = 0.02), and lower estimated blood loss (P = 0.01) and were less likely to fail voiding trials (P < 0.001); however, surgery duration was longer (P < 0.001). After controlling for age, regression analysis revealed SPS "worst pain" was lower in the robotic arm (P = 0.01), but not in other scales of the SPS. At 2 and 6 weeks postoperatively, Short-Form Health Survey 12 scores were not different between cohorts. CONCLUSIONS Both USLS and RSC are minimally invasive, with similar quality-of-life scores after surgery. However, the robotic approach may be associated with less pain, less narcotic use, and better performance in voiding trials. Surgeons should consider these findings when counseling patients regarding treatment options.
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An Interdisciplinary Approach to Endometriosis-associated Persistent Pelvic Pain. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2017. [DOI: 10.5301/jeppd.5000284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Endometriosis-associated pelvic pain is a common and often challenging problem. For certain patients, pain persists or recurs despite adequate medical or surgical therapy targeted to endometriosis. In this patient population, there is often the presence of coexisting pain conditions such as irritable bowel syndrome, painful bladder syndrome and myofascial pain as well central sensitisation. An interdisciplinary approach where both peripheral pain triggers and central sensitization are addressed is likely to lead to improved pain and quality of life. The approach to the evaluation and treatment of the patients with persistent/chronic pelvic pain and endometriosis is outlined in this article.
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Yong PJ. Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sex Med Rev 2017; 5:495-507. [DOI: 10.1016/j.sxmr.2017.06.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/19/2017] [Accepted: 06/24/2017] [Indexed: 12/30/2022]
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Botulinum Toxin A Injections Into Pelvic Floor Muscles Under Electromyographic Guidance for Women With Refractory High-Tone Pelvic Floor Dysfunction: A 6-Month Prospective Pilot Study. Female Pelvic Med Reconstr Surg 2016; 21:277-82. [PMID: 25900057 DOI: 10.1097/spv.0000000000000177] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES High-tone pelvic floor dysfunction (HTPFD) is a debilitating chronic pain disorder for many women with significant impact on their quality of life (QoL). Our objective was to determine the efficacy of electromyography-guided onabotulinumtoxinA (Botox; Allergan, Irvine, Calif) injections in treating patient's perception of pelvic pain and improving QoL measurement scores. METHODS This is a prospective pilot open-label study of women with chronic pelvic pain and HTPFD who have failed conventional therapy between January 2011 and August 2013. Botox injections (up to 300 U) were done using needle electromyography guidance, from a transperineal approach, to localize spastic pelvic floor muscles (PFMs). Data were collected at baseline, 4, 8, 12, and 24 weeks after injections. This included demographics; Visual Analog Scale (VAS) scores for pain and dyspareunia; validated questionnaires for symptoms, QoL, and sexual function; Global Response Assessment scale for pelvic pain; digital examination of PFM for tone and tenderness; and vaginal manometry. Side effects were also recorded. RESULTS Out of 28 women who enrolled in the study, 21 completed the 6-month follow-up and qualified for analysis. The mean (SD) age was 35.1 (9.4) years (range, 22-50 years), and the mean (SD) body mass index was 25 (4.4). Comorbidities included interstitial cystitis/bladder pain syndrome (42.9%) and vulvodynia (66.7%). Overall, 61.9% of subjects reported improvement on Global Response Assessment at 4 weeks and 80.9% at 8, 12, and 24 weeks post injection, compared with baseline. Of the subjects who were sexually active at baseline, 58.8% (10/17), 68.8% (11/16), 80% (12/15), and 83.3% (15/18) reported less dyspareunia at 4, 8, 12, and 24 weeks, respectively. Dyspareunia Visual Analog Scale score significantly improved at weeks 12 (5.6, P = 0.011) and 24 (5.4, P = 0.004) compared with baseline (7.8). Two of the 4 patients who avoided sexual activity at baseline secondary to dyspareunia resumed and tolerated intercourse after Botox. Sexual dysfunction as measured by the Female Sexual Distress Scale significantly improved at 8 weeks (27.6, P = 0.005), 12 weeks (27.9, P = 0.006), and 24 weeks (22.6, P < 0.001) compared with baseline (34.5). The Short-Form 12 Health Survey (SF-12) showed improved QoL in the physical composite score at all post injections visits (42.9, 44, 43.1, and 45.5 vs 40 at baseline; P < 0.05), and in the mental composite score at both 12 and 24 weeks (44.3 and 47.8 vs 38.5, P = 0.012). Vaginal manometry demonstrated significant decrease in resting pressures and in maximum contraction pressures at all follow-up visits (P < 0.05). Digital assessment of PFM (on a scale from 0 to 4) showed decreased tenderness on all visits (mean of 1.9, 1.7, 1.8, 1.9; P < 0.001) compared with baseline (2.8). Reported postinjection adverse effects included worsening of the following preexisting conditions: constipation (28.6%), stress urinary incontinence (4.8%), fecal incontinence (4.8%), and new onset stress urinary incontinence (4.8%). CONCLUSIONS Electromyography-guided Botox injection into PFM could be beneficial for women with refractory HTPFD who have failed conservative therapy.
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Cohn JA, Brown ET, Reynolds WS, Kaufman MR, Dmochowski RR. Pharmacologic management of non-neurogenic functional obstruction in women. Expert Opin Drug Metab Toxicol 2016; 12:657-67. [PMID: 27095013 DOI: 10.1080/17425255.2016.1178239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Impaired bladder emptying in women without neurologic disease may be related to urethral obstruction and/or impaired bladder contractility. Mechanical obstruction generally requires surgical management and options are limited for impaired bladder contractility. However, functional obstruction from voiding dysfunction or primary bladder neck obstruction may present an opportunity for pharmacologic intervention. AREAS COVERED In this review, the authors extensively reviewed available literature regarding the use of off-label medications for functional bladder outlet obstruction in women. In addition, side effect profiles and pharmacology of these medications determined from on-label indications are reviewed. Specific medications reviewed include vaginal diazepam, baclofen, urethral botulinum toxin injection, and alpha-adrenergic blockers. EXPERT OPINION Alpha-blockers in particular have demonstrated promise in women with demonstrable or suspected bladder outlet obstruction with side effect profiles similar to those observed in men. However, lack of quality data hinders informed decision making with alpha-blockers or any of the other agents studied in women with non-neurogenic functional outlet obstruction. In the absence of well-designed, placebo-controlled multi-institutional trials, those prescribing these medications must be aware of special considerations and side effects associated with relatively unfamiliar treatments in the context of uncertain benefit.
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Affiliation(s)
- Joshua A Cohn
- a Department of Urologic Surgery , University Medical Center , Nashville , TN , USA
| | - Elizabeth T Brown
- a Department of Urologic Surgery , University Medical Center , Nashville , TN , USA
| | - W Stuart Reynolds
- a Department of Urologic Surgery , University Medical Center , Nashville , TN , USA
| | - Melissa R Kaufman
- a Department of Urologic Surgery , University Medical Center , Nashville , TN , USA
| | - Roger R Dmochowski
- a Department of Urologic Surgery , University Medical Center , Nashville , TN , USA
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Shah N, Ginzburg N, Morrissey D, Whitmore K. Update in Diagnosis and Treatment of Chronic Pelvic Pain Syndromes. CURRENT BLADDER DYSFUNCTION REPORTS 2015. [DOI: 10.1007/s11884-015-0302-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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The Use of Specific Myofascial Release Techniques by a Physical Therapist to Treat Clitoral Phimosis and Dyspareunia. ACTA ACUST UNITED AC 2015. [DOI: 10.1097/jwh.0000000000000023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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A pilot randomized trial of levator injections versus physical therapy for treatment of pelvic floor myalgia and sexual pain. Int Urogynecol J 2014; 26:845-52. [PMID: 25527482 DOI: 10.1007/s00192-014-2606-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 12/02/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Our aim was to determine the effects of pelvic floor physical therapy (PT) and levator-directed trigger-point injections (LTPI) on sexual function and levator-related pelvic pain. STUDY DESIGN A randomized trial among women with pelvic floor myalgia (PFM) was performed wherein participants received either PT or LTPI. Pain was assessed and 1 month posttreatment completion. Levator-based pain was assessed using a numeric rating scale (NRS) and the Patient Global Impression of Improvement (PGI-I) scale. Sexual function was assessed using the Female Sexual Function Index (FSFI). RESULTS Twenty-nine women completed the study (17 had PT, 12 had LTPI). Both groups reported reduction in vaginal pain: mean NRS change from baseline of 4.47 [standard deviation (SD) 2.12) for PT and 4.67 (SD 1.72) for LTPI (p = 0.8)]. A >50 % improvement in NRS was documented among 59 % of women receiving PT and 58 % receiving LTPI (p = 1.0). Consistent with NRS scores, mean PGI-I score was 2.50 (SD 1.17) for PT and 2.17 (SD 1.01) for LTPI (p = 0.5). Mean change in FSFI favored PT [PT +8.87 (SD 5.60), LTPI +4.00 (SD 5.24), p = 0.04], reflecting improvement in the sexual pain domain favoring PT (p = 0.02). However, the time in weeks to effect improvement favored LTPI if controlling for the degree of change in NRS (p = 0.01) and FSFI (p = 0.01). CONCLUSIONS Vaginal myalgia and sex-related pain improved with pelvic floor PT and LTPI. Time-to-effect improvement and significance of therapy are dependent on treatment type.
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