[Symptomatic approach to chronic neuropathic somatic pelvic and perineal pain]

Assessment of women's sexual quality of life after benign adnexal surgery using vNOTES approach in comparison to conventional laparoscopy: protocol for a randomised controlled trial

INTRODUCTION

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has already proven its non-inferiority to conventional abdominal laparoscopy (CAL) for hysterectomy without conversion. The results in terms of efficacy and safety are promising. However, we note a lack of medical literature and no specific randomised controlled trial assessing women's sexual function after vNOTES for benign adnexal surgery. The aim of this RCT is to confirm the non-inferiority of the vNOTES approach for benign adnexal pathology compared with CAL on women's sexual function. Secondary outcomes will evaluate vNOTES's efficiency, morbidity and postoperative complications compared with CAL for benign adnexal surgery. The relationship between adnexal mass morcellation and the quality of the histological analysis will also be evaluated as secondary outcome.

METHODS AND ANALYSIS

Women aged 18-70 years undergoing a benign adnexal surgery at the Geneva University Hospitals will be eligible and randomised with a 1:1 ratio to the CAL arm or the vNOTES arm, if inclusion criteria are met. Participants will complete the Female Sexual Function Index, the Couple Satisfaction Index-16 and a self-reported questionnaire on dyspareunia within 4 weeks prior to randomisation and at 3+6 months after surgery. General and clinical data will be collected when the patient is enrolled in the study, during hospitalisation and at 1 month postoperative to assess secondary outcomes.An absence of impairment on sexual function will be confirmed with a stability or an improvement of the evaluated scores in each group at 3 and 6 months postoperative compared with the preoperative scores. We expect to have no statistically significant difference in sexuality questionnaires scores between the two groups.

ETHICS AND DISSEMINATION

Protocol of this study was validated by the Cantonal Research Ethics Commission of Geneva, Switzerland, on 9 August 2022. We aim to publish the study's results in peer-reviewed journals within 3 years.

TRIAL REGISTRATION NUMBER

NCT05761275.

"Neuro-Fiber Mapping": An Original Concept of Spinal Cord Neural Network Spatial Targeting Using Live Electrostimulation Mapping to (Re-)Explore the Conus Medullaris Anatomy

Spinal cord (SC) anatomy is often assimilated to a morphologically encapsulated neural entity, but its functional anatomy remains only partially understood. We hypothesized that it could be possible to re-explore SC neural networks by performing live electrostimulation mapping, based on "super-selective" spinal cord stimulation (SCS), originally designed as a therapeutical tool to address chronic refractory pain. As a starting point, we initiated a systematic SCS lead programming approach using live electrostimulation mapping on a chronic refractory perineal pain patient, previously implanted with multicolumn SCS at the level of the conus medullaris (T12-L1). It appeared possible to (re-)explore the classical anatomy of the conus medullaris using statistical correlations of paresthesia coverage mappings, resulting from 165 different electrical configurations tested. We highlighted that sacral dermatomes were not only located more medially but also deeper than lumbar dermatomes at the level of the conus medullaris, in contrast with classical anatomical descriptions of SC somatotopical organization. As we were finally able to find a morphofunctional description of "Philippe-Gombault's triangle" in 19th-century historical textbooks of neuroanatomy, remarkably matching these conclusions, the concept of "neuro-fiber mapping" was introduced.

Therapy With Local Anesthetics to Treat Vulvodynia. A Pilot Study

Introduction

Vulvodynia (chronic vulvar pain) is a sexually debilitating disorder with a prevalence of ∼10%.

Aim

To investigate the effectiveness of therapy with local anesthetics (TLA) in women with severe vulvodynia, we conducted a prospective, non-controlled observational study.

Methods

45 patients with severe chronic vulvodynia (primary and secondary vulvodynia, 0–10 numeric analogue scale (NAS) ≥6, median 7.9, duration ≥6 months, median 65.2 months) in an outpatient practice in Germany were treated with TLA in 3–12 sessions using procaine 1% as local anesthetic. Effectiveness was analyzed with Wilcoxon signed rank tests and Wilcoxon rank sum tests.

Outcomes

Therapeutic success as a reduction of pain to ≤4 NAS lasting for ≥6 months after end of therapy.

Results

TLA successfully reduced vulvodynia in 36 of 45 patients (80 %, responders). The NAS reduction was from 7.9 to 2.4 (P < .001). Even patients denominated as non-responders experienced a significant reduction in NAS (P = .03). In responders, long-term success was observed for 6.8–125 months (median 24.1 months). No adverse events occurred.

Clinical Translation

A promising new treatment for a hard-to-treat chronic female pain disorder.

Strengths and Limitations

Limitation: Monocentric, non-controlled observational design; Strength: the high number of patients treated.

Conclusion

The high success rate of TLA in this investigation offers new perspectives on the etiology of vulvodynia as a complex pain syndrome affecting several nerves of the pelvic floor, and also provides early insight into the effectiveness of TLA in women with vulvodynia.

Weinschenk S, Benrath J, Kessler E, et al. Therapy With Local Anesthetics to Treat Vulvodynia. A Pilot Study. Sex Med 2022;10:100482.

Description and classification of postpartum chronic pain: A multicentric prospective study

INTRODUCTION

To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain.

MATERIAL AND METHOD

Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain.

RESULTS

40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant's sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria.

DISCUSSION

The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.

Skin, fascias, and scars: symptoms and systemic connections

Every element or cell in the human body produces substances that communicate and respond in an autocrine or paracrine mode, consequently affecting organs and structures that are seemingly far from each other. The same also applies to the skin. In fact, when the integrity of the skin has been altered, or when its healing process is disturbed, it becomes a source of symptoms that are not merely cutaneous. The skin is an organ, and similar to any other structure, it has different functions in addition to connections with the central and peripheral nervous system. This article examines pathological responses produced by scars, analyzing definitions and differences. At the same time, it considers the subcutaneous fascias, as this connective structure is altered when there is a discontinuous cutaneous surface. The consequence is an ample symptomatology, which is not limited to the body area where the scar is located, such as a postural or trigeminal disorder.

Successful treatment of pudendal neuralgia with tricolumn spinal cord stimulation: case report

BACKGROUND AND IMPORTANCE

There is large variation in the success of decompressive surgery for pudendal neuralgia (PN), the most chronic, disabling form of perineal pain. We attempt to determine whether spinal cord stimulation using new-generation multicolumn leads could form part of the treatment algorithm for refractory PN.

CLINICAL PRESENTATION

A man with PN that was unresponsive to conventional treatment demonstrated a neuropathic component and had a negative response to nerve infiltrations (so he was not indicated for decompressive surgery) and a positive response to perianal transcutaneous electrical nerve stimulation and was implanted with a 16-contact surgical lead at the level of conus medullaris, allowing multicolumn stimulation. Using transverse combinations, it was possible to obtain 100% paresthesia over the perineal area without unwanted dorsal root stimulation. Perineal and radicular pain was successfully relieved for up to 12 months (80% and 60% reduction in the visual analogue scale scores, respectively), with an improvement in all quality of life domains and a reduction in drug consumption.

CONCLUSION

Spinal cord stimulation using a 16-contact lead may be a viable therapeutic option for patients with refractory PN for whom decompressive surgery is contraindicated.