Management of chronic pelvic pain

Botulinum toxin A (Botox) injection into muscles of pelvic floor as a treatment for persistent pelvic pain secondary to pelvic floor muscular spasm: A pilot study

BACKGROUND

Persistent pelvic pain (PPP) remains an important cause of morbidity. Pelvic floor muscle spasm is an important contributor to PPP.

AIMS

The study's primary aim was to assess if botulinum toxin (BoNT) injection to pelvic floor muscles altered pain scores or quality of life (QoL) at six, 12 and 26 weeks. Secondary aims included investigating the impact of BoNT on opiate usage, examining the role of pain catastrophising, and assessing for complications.

MATERIALS AND METHODS

A single-centre prospective cohort study enrolled 21 patients with PPP who had failed physiotherapy techniques. Each participant underwent BoNT injection to muscles of the pelvic floor and pudendal nerve block. Questionnaires and digital vaginal examinations were conducted at baseline, six, 12 and 26 weeks. Pain score quantification used visual analogue scales (VAS) and numerical rating scales (NRS). Other outcome assessments included The World Health Organization Quality of Life instrument (WHOQoL-BREF), Pain Catastrophising Scale (PCS), and modified Australian Pelvic Floor Questionnaire (APFQ). ACTRN12620000067976.

RESULTS

Following BoNT injection, median VAS scores decreased for all domains at six and 12 weeks, with VAS for dyspareunia significant at six weeks (P = 0.026). Scores returned to baseline by 26 weeks. Opiate usage was significantly less following BoNT injection, with a percentage reduction of 23.8% (95% CI -48.3 to 0.7, P = 0.06). Sexual function improved significantly (P < 0.01), and at six months, four previously apareunic participants reported successful penetrative vaginal intercourse. Health-related QoL and PCS demonstrated sustained improvement (P = 0.02-0.05). NRS for muscle tenderness decreased for all assessed muscle groups (P < 0.001).

CONCLUSIONS

BoNT requires further assessment as a treatment modality for select women with PPP.

Recreational Cannabis Use Before and After Legalization in Women With Pelvic Pain

OBJECTIVE

To evaluate the prevalence and characteristics of recreational cannabis use in women with pelvic pain, and to examine the influence of cannabis legalization on these parameters.

METHODS

We conducted a retrospective analysis of a prospective registry of women with self-reported moderate-to-severe pelvic pain referred to a tertiary care clinic in Vancouver, Canada, 2013-2019. We excluded patients aged 18 years or younger and those with unknown data on cannabis use. Demographic, clinical, and validated questionnaire data were extracted for two main analyses: 1) comparison of current cannabis users with current nonusers, and 2) comparison of current cannabis users who entered the registry before cannabis legalization (October 17, 2018) with those who entered the registry on or after legalization.

RESULTS

Overall, 14.9% (509/3,426) of patients were classified as current cannabis users. Compared with nonusers, cannabis users were younger (P<.001), had lower levels of education (P<.001) and lower household income (P<.001), were taking opioids (P<.001), antiinflammatories (P=.003), neuromodulators (P=.020), and herbal medications (P<.001) more frequently. They had worse questionnaire scores for depression, anxiety, pain catastrophizing, quality of life, and pelvic pain severity (P<.001 for all). After cannabis legalization, prevalence of current cannabis use increased from 13.3% (366/2,760) to 21.5% (143/666) (P<.001). Compared with prelegalization, postlegalization users were associated with higher levels of education (P<.001), worse anxiety (P=.036), and worse pain catastrophizing (P<.001) scores. They were taking fewer antiinflammatories (P<.001), neuroleptics (P=.027) and daily opioids or narcotics (P=.026), but more herbal medications (P=.010).

CONCLUSION

Recreational cannabis use increased among patients with pelvic pain after legalization in Canada. Cannabis users had worse pain-related morbidities. Postlegalization, cannabis users were less likely to require daily opioids compared with cannabis users before legalization. The role, perceived benefits, and possible risks of cannabis for pelvic pain require further investigation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02911090.

Surgical Decision Regret in Women Pursuing Surgery for Endometriosis or Chronic Pelvic Pain

STUDY OBJECTIVE

To identify incidence of decision regret associated with surgery for endometriosis or chronic pelvic pain (CPP).

DESIGN

Survey study.

SETTING

Academic medical center.

PATIENTS

All patients undergoing excisional surgery for endometriosis or CPP between January 2016 and June 2019.

INTERVENTIONS

The women were contacted to complete 2 validated questionnaires: the Decision Regret and Patient Global Impression of Improvement scales.

MEASUREMENTS AND MAIN RESULTS

A total of 253 patients were contacted, and 154 patients responded (60.8% response rate) to the survey. A total of 137 women (90%) agreed or strongly agreed that having excisional surgery was the right decision; 134 women (87%) indicated that they would choose to have surgery again. The survey responders did not differ from nonresponders in age (years, 33.9 vs 35; p = .25), robotic route of surgery (83.1% vs 78.8%; p = .66), or performance of hysterectomy (27.3% vs 26.3%; p = .85). The responders were more likely to have stage III/IV endometriosis (50.6% vs 29.3%; p <.01), more previous surgeries for endometriosis (median surgeries, 1 vs 0; p = .01), higher complication rate (8.4% vs 2.0%; p = .03), and pathology test results more frequently positive for endometriosis (87.7% vs 77.8%; p = .03). Overall, 25 patients (16.3%) reported some level of regret after excisional surgery for endometriosis or CPP. Regret was not associated with a lower Patient Global Impression of Improvement score (odds ratio [OR] 4.37; 95% confidence interval [CI], 0.81-23.7), age (OR 0.98; 95% CI, 0.93-1.04), time since surgery (OR 1; 95% CI, 0.97-1.04), number of previous surgeries (OR 1.08; 95% CI, 0.9-1.31), negative pathology test results (OR 2.82; 95% CI, 0.95-8.32), hysterectomy (OR 1.23; 95% CI, 0.45-3.32), or complications (OR 1.07; 95% CI, 0.22-5.16).

CONCLUSION

Most women who pursue excisional surgery for endometriosis or CPP are satisfied with their decision. Regret was not associated with patient-reported lack of improvement, negative pathology test results, hysterectomy, or complications. Gynecologic surgeons should engage in shared decision-making with patients and feel comfortable offering surgical evaluation and management to patients with endometriosis or CPP when clinically indicated.

A systematic review and meta-analysis of the associations between endometriosis and irritable bowel syndrome

Endometriosis and Irritable Bowel Syndrome (IBS) are common conditions among young women of reproductive age. The etiologies to the diseases are uncertain, but multifactorial pathophysiology has been proposed for each of them. Many studies have examined the two conditions separately, but the literature on the associations between endometriosis and IBS is sparse. However, there is an increasing amount of research on how endometriosis patients are likely to also have a diagnosis of IBS. Furthermore, endometriosis shares several features with IBS, such as low-grade inflammation and visceral hypersensitivity. This systematic review summarized published original articles in English that have compared associations between endometriosis and IBS. The inclusion criteria for articles in the review were: i) endometriosis was diagnosed by surgical methods, ii) gastrointestinal symptoms were examined in a structured manner and iii) IBS was diagnosed by Rome criteria. From the initial 254 publications identified on PubMed, Web of Science and EMBASE, 13 fulfilled the criteria and could finally be included in the summary. The findings from the review showed that women diagnosed with endometriosis seem to have a twofold or threefold risk to also fulfill the criteria for IBS. The summary risk estimate of the four studies included in the meta-analysis was 2.39 (95 % confidence interval: 1.83-3.11). In women initially diagnosed with IBS, some studies reported a threefold risk of having an endometriosis diagnosis. Despite the strong associations reported between the two conditions, this review also revealed a gap in adjusting for factors that may have affected the expression of gastrointestinal symptoms, e.g., phases of the menstrual cycle, medication and psychological aspects, which may have interpretation of the reviewed articles' results. The conclusion of this review is that there is a coexistence of gastrointestinal symptoms fulfilling the Rome criteria in patients with endometriosis, but it is uncertain whether there is a true comorbidity between endometriosis and IBS, or whether the gastrointestinal symptomatology in endometriosis depends on medication. Additionally, the adequacy of the Rome criteria to differentiate IBS from the shared symptomatology of other diseases with visceral hypersensitivity must be further evaluated.

Hair cortisol and the relationship with chronic pain and quality of life in endometriosis patients

Endometriosis is a chronic estrogen-dependent disease in which pelvic pain is the dominant symptom. The negative effects of endometriosis on the life of women with this disease can be a cause of stress. Stress levels can be measured in different ways, mostly reflecting acute stress responses. Hair cortisol measurements are a reflection of long-term systematic cortisol levels. In this study a first attempt is made to measure cortisol levels in hair of endometriosis patients in comparison with healthy controls. Moreover, it is explored whether chronic pain symptoms as well as different aspects of Health Related Quality of Life (HRQoL) are associated with hair cortisol levels in women with endometriosis. Results show that the mean hair cortisol level is significantly higher in women with endometriosis compared to healthy controls (p = 0.018). There is a positive correlation between hair cortisol level and HRQoL in patients but not in controls (Rho 0.426). The level of hair cortisol does not correlate with the reported pain intensity in patients (Rho -0.082). These results are indicative of an altered HPA-axis function in endometriosis patients, possibly caused by higher chronic stress level in these patients. Moreover, a potential explanation for the positive correlation of cortisol with the HRQoL in these patients is that patients with a high HRQoL have an adequate stress response by increasing their cortisol levels as a response to physical and emotional stress induced by the endometriosis.

Comparative, open-label prospective study on the quality of life and sexual function of women affected by endometriosis-associated pelvic pain on 2 mg dienogest/30 µg ethinyl estradiol continuous or 21/7 regimen oral contraceptive

PURPOSE

To evaluate the effects of a continuous regimen combined oral contraceptive (COC) containing 2 mg dienogest and 30 µg ethinyl estradiol (DNG/EE) compared to a 21/7 regimen on the quality of life (QoL) and sexual function in women affected by endometriosis-associated pelvic pain.

METHODS

Sixty-three women constituted the Study group treated with DNG/EE COC continuous regimen; 33 women were given DNG/EE COC in a 21/7 regimen. To define the endometriosis-associated pelvic pain, the Visual Analogic Scale was used. The Short Form-36, Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess QoL, sexual function and sexual distress, respectively. The study included two follow-ups.

RESULTS

At 3 and 6 months of treatment there was an improvement in pain of the Study group (p < 0.001). The Control group underwent pain improvement at the second follow-up (p < 0.05). At the first and the second follow-ups, the Study group reported QoL improvements in all categories (p < 0.001). The Control group reported QoL improvements in all categories at the second follow-up (p < 0.05). At the first and the second follow-ups of the Study group, the FSFI total score had risen (p < 0.001), and the FSDS score had dropped (p < 0.001). An improvement of the FSFI score and a reduction of the FSDS score of the Control group was observed at the second follow-up (p < 0.001), but not at the first follow-up (p = NS).

CONCLUSIONS

Women on DNG/EE COC continuous regimen reported a reduction of endometriosis-associated pelvic pain and there was an improvement of their sexual activity and their QoL that was better than the DNG/EE 21/7 conventional regimen.

Quality of life and sexual function of women affected by endometriosis-associated pelvic pain when treated with dienogest

PURPOSE

The aim of the study was to evaluate the effects of dienogest (DNG) on quality of life (QoL) and sexual function of women affected by endometriosis pain.

METHODS

Fifty-four women constituted the study group and were given 2 mg/daily DNG; 48 women were given non-steroidal anti-inflammatory drugs and constitut ed the control group. To define the endometriosis-associated pelvic pain, the Visual Analogic Scale (VAS) was used. The Short Form-36 (SF-36), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess the QoL, the sexual function and the sexual distress, respectively. The study included two follow-ups at 3 and 6 months.

RESULTS

Pain improvement was observed in the study group at 3 (p < 0.05) and 6 months (p < 0.001) of treatment. At the 1st follow-up, women reported QoL improvements in some functions (p < 0.05); at the 2nd follow-up, they reported improvement in all categories (p < 0.001). The FSFI score did not change at the 1st follow-up (p = NS). On the contrary, at the 2nd follow-up, it improved with respect to the baseline (p < 0.05). At the 2nd follow-up, the FSFI score had risen to 27.8 (p < 0.001) and the FSDS score had dropped to 11.3 (p < 0.001). No change was observed in the control group (p = NS).

CONCLUSIONS

The progressive reduction of the pain syndrome reported by women over the treatment period could contribute to improve the QoL and sexual life of women on DNG.

Evaluating CA125 and VAS Pain Modifications following Gnrh Analog to Exclude Superficial Endometriosis as Cause of Chronic Pelvic Pain

Background

The study aim was to assess the reliability in the diagnosis of superficial endometriosis of the combined evaluation of 2 parameters: modifications of serum CA125 and VAS pain score following 1 dose of GnRH analog (GnRH-a).

Methods

Women with chronic pelvic pain (CPP) were managed by GnRH-a administration and diagnostic laparoscopy. Serum CA125 and VAS pain score were assessed for each patient at the early follicular phase and 2 months after the administration of 11.25 mg GnRH-a. Following laparoscopy, subjects were grouped into groups A (72 women with endometriosis) and B (46 women without endometriosis). A multivariate model for CA125 and VAS reduction and for the combination of the 2 markers was calculated using logistic regression and diagnostic performance was evaluated as the AUC of ROC curve. Main outcome measure was the accuracy of the modifications of serum CA125 levels and VAS score following GnRH-a, in patients with histological diagnosis of superficial endometriosis.

Results

At baseline, both groups showed similar CA125 levels and VAS scores. Two months after GnRH-a, a significant reduction (delta [Δ]) in CA125 levels and VAS pain score was observed in group A only. AUCs for ΔCA125, ΔVAS score and for combination of these 2 deltas were 0.90, 0.83 and 0.97, respectively.

Conclusions

The assessment of serum CA125 and VAS pain score following GnRH-a demonstrates good reliability to exclude superficial endometriosis in patients with CPP. The response to GnRH-a administration in these women could therefore be employed as an ex juvantibus criterion for endometriosis diagnosis.

Nonspecific genitourinary pain improves after prostatectomy using holmium laser enucleation of prostate in patients with benign prostatic hyperplasia: a prospective study

OBJECTIVE

To investigate changes in nonspecific genitourinary discomfort or pain (GUDP) before and after holmium laser enucleation of prostate (HoLEP). GUDP associated with lower urinary tract symptoms (LUTS) is a common complaint among benign prostatic hyperplasia (BPH) patients, but very little is known about this clinical entity.

METHODS

From February 2010 to August 2011, 100 HoLEP patients with complete clinical data at a single institution were enrolled in the study to analyze the degree of GUDP with a visual analog scale (VAS) from 0 to 10 points at baseline and at 3 and 6 months postoperatively, and to investigate any relationships between GUDP and urodynamics, uroflowmetry, and scores from the International Prostate Symptom Score (IPSS) questionnaire.

RESULTS

Fifty-six patients had LUTS only, while the remaining 44 had both LUTS and GUDP. Pain was located in the suprapubic (42.0%), perineal/penile (33.0%), back (17.0%), and perianal (8.0%) regions. During the post-operative period, at six months, the VAS, IPSS, peak flow rate and post-void residual volume had improved significantly in 44 GUDP patients (p<0.010). GUDP had completely resolved in 40 (90.9%) patients and had decreased in four (9.1%) patients, while seven (12.5%) patients developed GUDP with voiding in the urethral and perineal areas by the third month postoperatively. When compared to patients with complete resolution, those with persistent GUDP were found to have a significantly higher preoperative presence of bladder outlet obstruction (BOO) as an independent risk factor (OR 6.173, 95% CI 1.132-1.323).

CONCLUSION

Both GUDP and LUTS improved significantly after HoLEP. Patients with significant preoperative BOO tended to have persistent GUDP after surgery.

Obstetrics-gynecology resident attitudes and perceptions about chronic pelvic pain: a targeted needs assessment to aid curriculum development

BACKGROUND

Chronic pelvic pain (CPP) accounts for 10% of gynecologic visits and is a common complaint in university-based and community resident clinics. Resident education about CPP has been inconsistent, and review of the limited literature shows predominantly negative perceptions of patients with CPP. Current literature lacks information regarding obstetrics-gynecology residents' attitudes and acquired knowledge regarding CPP.

OBJECTIVE

This targeted needs assessment aims to identify regional obstetrics-gynecology resident attitudes and self-perceived knowledge regarding chronic pelvic pain in order to better address potential educational barriers and look toward placing a greater emphasis on this area in resident training.

METHODS

We conducted a focus group of obstetrics-gynecology residents to identify major themes regarding attitudes about CPP. This informed the development of a survey administered to university-based and community-based obstetrics-gynecology residents (N  =  57) in the Colorado part of the Western Mountain Region. Cronbach α was calculated to determine reliability for each theme, and descriptive statistics were calculated for each theme. Independent samples t tests assessed differences between training levels and between university and community training sites.

RESULTS

Survey response rate was 72% (41 of 57). Residents consistently reported feeling overwhelmed by CPP patients, perceived a lack of time to see these patients, and indicated a desire to learn more in this area, but they varied in chosen learning methods. No significant differences were found between levels of training or training sites.

CONCLUSIONS

Most obstetrics-gynecology residents surveyed believe they are inadequately prepared to address the needs of women presenting with CPP.

Chronic pelvic pain

Chronic pelvic pain is pain lasting longer than 6 months and is estimated to occur in 15% of women. Causes of pelvic pain include disorders of gynecologic, urologic, gastroenterologic, and musculoskeletal systems. The multidisciplinary nature of chronic pelvic pain may complicate diagnosis and treatment. Treatments vary by cause but may include medicinal, neuroablative, and surgical treatments.

Complementary and Alternative Medicine in the Treatment of Chronic Pelvic Pain in Women: What Is the Evidence?

Chronic pelvic pain (CPP) is defined as pain of at least 6 months' duration that occurs in the lower abdomen or below the umbilicus and has resulted in functional or psychological disability or required intervention and treatment. Therapeutic interventions center around the treatment of CPP as a diagnosis in and of itself, and treatment of specific disorders that may be related to CPP. A multidisciplinary approach for diagnosis and treatment seems to be most effective for symptomatic relief. This paper reviews the evidence for such interventions as psychological treatments including the use of complementary and alternative medicine techniques for CPP in women. Unfortunately, finding the best evidence in this setting is difficult as only very few randomized controlled trials are available. A combination of treatments is usually required over time for the treatment of refractory CPP. The multifactorial nature of CPP needs to be discussed with the patient and a good rapport as well as a partnership needs to be developed to plan a management program with regular followup. Promotion of a multidisciplinary approach which includes complementary and alternative medicine techniques in managing CPP in women seems to yield the best results.

Evaluation of the frequency and the association of sexual pain and chronic headaches

BACKGROUND

Sexual pain and chronic headaches are both complex conditions with associated high disability. Little research has examined whether there is a relationship between the 2. The aim of this survey-based study was to explore the frequency of sexual pain in a population of women being treated for chronic headache. Peripheral aims included exploring the number of patients receiving treatment for sexual pain and the association between sexual pain and libido, and history of abuse.

METHODS

Patients presenting to an ambulatory chronic headache clinic were administered a short 10-item survey.

RESULTS

Forty-four percent of patients reported that they had pelvic region or genital pain brought on by sexual activity. Only half of these patients had ever discussed their pelvic pain with a health care provider, and 31% of these patients had not received treatment. Almost all patients would be interested in treatment if available. Seventy-five percent of patients indicated a change in libido.

CONCLUSION

Chronic headaches and sexual pain are both conditions that have a significant impact on patients and the health care system, and they do coexist. More research is needed to look at the relationship between these conditions in addition to epidemiology, symptomatology, evaluation, and treatments.

Attributes and barriers to care of pelvic pain in university women

STUDY OBJECTIVE

To describe rates of pelvic pain in university women ages 18 and older and to explore the barriers to adequate health care for pelvic pain in this population.

DESIGN

A cross-sectional study (Canadian Task Force classification II-2).

SETTING

University of Florida, Gainesville, FL.

PATIENTS

A total of 2000 female students at the University of Florida were randomly selected for participation.

INTERVENTIONS

The 2000 sample members were sent a questionnaire to be completed online.

MEASUREMENTS AND MAIN RESULTS

The online questionnaire was hosted through the REDCap electronic data capture tool hosted at the University of Florida. This questionnaire included demographic items, general health and health behavior questions, measures to assess different types of pelvic pain (e.g., dysmenorrheal; dyspareunia; urinary, bowel, and vulvar pain), items regarding barriers to care for pelvic pain problems, and quality of life measures. Data were exported to SAS software (SAS Institute Inc., Cary, NC) for analysis. Of the 2000 subjects who received the questionnaire invitation, 390 filled out the questionnaire, yielding a response rate of 19.5%. Respondents' ages ranged from 18 to 62 with a mean of 23 years. A total of 72.8% of respondents reported experiencing pelvic pain over the past 12 months. Dysmenorrhea was reported by nearly 80% of participants, over one third of participants noted deep dyspareunia, and a significant proportion of participants reported symptoms related to bowel movements. Vulvar symptoms, including superficial dyspareunia, were reported by 21.5% of participants. Most participants with pelvic pain (78.8%) have not received any diagnosis for their pain, whereas 73.6% reported not yet having visited a doctor. Significant barriers to receiving adequate medical care were reported, including difficulty with insurance coverage and physicians' lack of time and knowledge or interest in chronic pelvic pain conditions.

CONCLUSION

Pelvic pain in younger women is a critical public health issue experienced by a significant portion of the population. Significant awareness deficits and barriers to care exist. Careful study of the barriers to receiving adequate medical care reported by these women will allow researchers to describe how best to improve care for these syndromes.