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Knapman BL, Li FG, Deans R, Nesbitt-Hawes E, Maheux-Lacroix S, Abbott J. Botulinum Toxin for the Management of Pelvic Floor Tension Myalgia and Persistent Pelvic Pain: A Systematic Review and Meta-analysis. Obstet Gynecol 2024; 143:e7-e17. [PMID: 37797336 DOI: 10.1097/aog.0000000000005388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 06/29/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To systematically review the literature on use of botulinum toxin to treat pelvic floor tension myalgia and persistent pelvic pain. DATA SOURCES The ClinicalTrials.gov , PubMed, EMBASE, and Scopus databases were searched from inception to November 2022 by two independent assessors (B.L.K. and F.G.L.). Identified studies were screened by title and abstract and included after full-text review. Data extraction was subsequently performed and recorded in Microsoft Excel. METHODS This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines after registration in PROSPERO (CRD42022289132). All randomized studies, prospective studies with more than five participants, and retrospective studies with more than 10 participants published in English or French and assessing the use of botulinum toxin for the treatment of pelvic floor tension myalgia and persistent pelvic pain in women were included. Meta-analyses were performed on randomized data. TABULATION, INTEGRATION, AND RESULTS Of 4,722 articles identified, 24 satisfied inclusion criteria. A meta-analysis of five randomized controlled trials totaling 329 participants demonstrated no differences in patient- and clinician-reported outcome measures, including pain, dyspareunia, sexual function, and vaginal manometry. Mean duration of follow-up was 6 months. A qualitative analysis of 14 prospective and four retrospective studies including 804 participants is supportive of botulinum toxin; however, the quality of data is low, and there is marked heterogeneity between studies. CONCLUSION Meta-analyses of randomized data do not support the use of botulinum toxin to treat pelvic floor tension myalgia and persistent pelvic pain. Failure of these data to confirm the findings of nonrandomized prospective studies that suggest a treatment benefit may be attributable to the absence of placebo control and confounding outcomes obtained from an active comparator group. Further randomized controlled trials with true placebo are strongly recommended. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022289132.
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Affiliation(s)
- Blake Lawson Knapman
- University of New South Wales, Sydney, New South Wales, Australia; and Université Laval, Québec City, Québec, Canada
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Parenti M, Degliuomini RS, Cosmi E, Vitagliano A, Fasola E, Origoni M, Salvatore S, Buzzaccarini G. Botulinum toxin injection in vulva and vagina. Evidence from a literature systematic review. Eur J Obstet Gynecol Reprod Biol 2023; 291:178-189. [PMID: 38353087 DOI: 10.1016/j.ejogrb.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 08/20/2023] [Accepted: 10/18/2023] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Botulinum toxin (BoNT) administration has been proposed in the gynecologic field for pelvic, vulvar and vaginal disorders. On this regard, we aimed assessing the therapeutic effectiveness and safety of BoNT usage in the treatment of vaginal, vulvar and pelvic pain disorders. METHODS We searched for all the original articles without date restriction until 31.12.2021. We included all the original articles which administered botulinum toxin in the vulva or vagina of women suffering from vaginismus, dyspareunia, and chronic pelvic pain. Only English language studies and those performed in humans were eligible. We excluded all case reports and pilot study from the qualitative analysis, although we accurately evaluated them. 22 original studies were finally included in the systematic review. RESULTS Botulinum toxin injection was found to be effective in improving vulvar and vaginal dyspareunia, vaginismus, and chronic pelvic pain. No irreversible side effects were detected. Major side effects reported were transient urinary or fecal incontinence, constipation and rectal pain. The risk of bias assessment proved original articles to be of medium quality. No metanalysis could have been performed since lack of congruency in the definition of pathology and methods of botulinum toxin administration. CONCLUSION Data extraction pointed out different endpoints and different methods of analysis. Studies focus on different types of participants and use various techniques and timing. According to the best evidence available, different techniques provide evidence about positive outcomes, with the need for a standardized protocol.
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Affiliation(s)
- Michele Parenti
- Gynaecologic and Obstetrics Clinic, Department of Women's and Children's Health, University of Padua, 35128, Padua, Italy
| | - Rebecca Susanna Degliuomini
- Department of Obstetrics and Gynaecology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy; Italian Association of Functional and Esthetic Gynecology (AIGEF), Milan, Italy
| | - Erich Cosmi
- Gynaecologic and Obstetrics Clinic, Department of Women's and Children's Health, University of Padua, 35128, Padua, Italy
| | - Amerigo Vitagliano
- Gynaecologic and Obstetrics Clinic, Department of Women's and Children's Health, University of Padua, 35128, Padua, Italy
| | - Elena Fasola
- Italian Association of Functional and Esthetic Gynecology (AIGEF), Milan, Italy
| | - Massimo Origoni
- Department of Obstetrics and Gynaecology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - Stefano Salvatore
- Department of Obstetrics and Gynaecology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy; Italian Association of Functional and Esthetic Gynecology (AIGEF), Milan, Italy
| | - Giovanni Buzzaccarini
- Department of Obstetrics and Gynaecology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
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Bhuiyan J, Habeshian KA, Booser AC, Gomez-Lobo V, Dowlut-McElroy T. Botulinum Toxin Injections as a Treatment of Refractory Vulvodynia in Adolescents: A Case Series. J Pediatr Adolesc Gynecol 2023; 36:497-500. [PMID: 37301425 PMCID: PMC10527077 DOI: 10.1016/j.jpag.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/09/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Vulvodynia involves vulvar discomfort that occurs in the absence of an identifiable cause. Because vulvodynia is often accompanied by myofascial pain and pelvic floor tension, transvaginal botulinum toxin (BT) injection into the pelvic floor has been proposed as a possible treatment. METHODS Retrospective case series RESULTS: Three adolescents with vulvodynia had a suboptimal response to treatment with several interventions, including neuromodulators (oral and topical), tricyclic antidepressants (oral and topical), and pelvic floor physical therapy. Subsequently, these patients underwent BT injections to the pelvic floor as treatment with varying responses. CONCLUSION In select adolescent patients with vulvodynia, transvaginal BT injection into the pelvic floor can be an effective treatment. Further studies are needed to assess the optimal dosing, frequency, and sites of BT injections in the treatment of vulvodynia in pediatric and adolescent patients.
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Affiliation(s)
- Julia Bhuiyan
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | | | - Adam C Booser
- Department of Anesthesiology, Children's Mercy Hospital, Kansas City, Missouri
| | - Veronica Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; Pediatric and Adolescent Gynecology, Department of Surgery, Children's National Hospital, Washington, D.C
| | - Tazim Dowlut-McElroy
- Pediatric and Adolescent Gynecology, Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri.
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Villa-Muñoz P, Albaladejo-Belmonte M, Nohales-Alfonso FJ, Alberola-Rubio J, Garcia-Casado J. Treatment of Vestibulodynia with Submucosal Injections of IncobotulinumtoxinA into Targeted Painful Points: An Open-Label Exploratory Study. Toxins (Basel) 2023; 15:476. [PMID: 37624233 PMCID: PMC10467121 DOI: 10.3390/toxins15080476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/26/2023] Open
Abstract
The studies carried out to date on vulvodynia treatment with botulinum neurotoxin type A (BoNT/A) have followed generic injection protocols and reported contradictory outcomes on its effects. The aim of the present study was thus to propose a protocol for injecting BoNT/A into targeted painful points, to comprehensively assess the clinical effect of BoNT/A treatment and identify the risk/protective factors for successful treatment. Thirty-five vestibulodynia patients were treated with submucosal injections of incobotulinumtoxinA and assessed 8, 12 and 24 weeks after their treatment. Their clinical and pelvic statuses were assessed from self-reported questionnaires (Visual Analogue Scale (VAS), Female Sexual Function Index (FSFI), Marinoff's Dyspareunia Scale (MDS), Hospital Anxiety and Depression Scale (HADS), Catastrophizing Scale (CS)), physical examinations and surface electromyography (sEMG). The patients reported a reduction in provoked vestibulodynia ( FSFI, p < 0.01;
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Affiliation(s)
- Paula Villa-Muñoz
- Servicio De Ginecología Y Obstetricia, Hospital Universitari I Politècnic La Fe, 46026 Valencia, Spain; (P.V.-M.); (F.J.N.-A.)
| | - Monica Albaladejo-Belmonte
- Centro De Investigación E Innovación En Bioingeniería (CI2B), Universitat Politècnica De València, 46022 Valencia, Spain;
| | - Francisco J. Nohales-Alfonso
- Servicio De Ginecología Y Obstetricia, Hospital Universitari I Politècnic La Fe, 46026 Valencia, Spain; (P.V.-M.); (F.J.N.-A.)
| | | | - Javier Garcia-Casado
- Centro De Investigación E Innovación En Bioingeniería (CI2B), Universitat Politècnica De València, 46022 Valencia, Spain;
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Bajzak K, Rains A, Bishop L, Swab M, Miller ME, Logan GS, Jackman V, Jackman L, Gustafson DL. Pharmacological Treatments for Localized Provoked Vulvodynia: A Scoping Review. INTERNATIONAL JOURNAL OF SEXUAL HEALTH : OFFICIAL JOURNAL OF THE WORLD ASSOCIATION FOR SEXUAL HEALTH 2023; 35:427-443. [PMID: 38601726 PMCID: PMC10903690 DOI: 10.1080/19317611.2023.2222114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/28/2023] [Accepted: 06/01/2023] [Indexed: 04/12/2024]
Abstract
Introduction Localized provoked vulvodynia (LPV) is a chronic pain condition without an identifiable cause that is localized to a portion of the vulva and provoked by pressure or touch. LPV is a commonly occurring but poorly understood condition lacking consensus on management. Method This scoping review used Arksey and O'Malley's approach to identify and evaluate literature published between 2010 and 2023 that addressed the question: What is the current evidence on the efficacy or effectiveness of pharmacological treatments in the management of LPV? Results This review evaluated 18 papers reporting on the efficacy or effectiveness of oral, topical, and injectable medications. Seven of the studies were randomized controlled trials. Oral gabapentin and oral desipramine showed some improvement in sexual function compared to placebo. Small sample sizes and methodological issues limited confidence in interpreting findings. Pain was reduced in descriptive studies of tricyclic antidepressants, milnacipran, injectable anesthetics, and botulinum toxin. Where pain did not improve with treatment, some oral medications improved participants' mood and sexual function. Some topical agents may be effective in reducing peripherally mediated neuropathic pain. Botulinum toxin was the most well-studied injectable but yielded mixed outcomes related to pain, quality of life, and sexual function. Conclusion There is a lack of convincing evidence to draw conclusions about the efficacy or effectiveness of pharmacological therapies for LPV. The breadth of therapies for treating LPV warrants the development of evidence-based, consensus guidelines for measuring treatment outcomes and improving comparisons across studies. Recommendations for research include addressing methodological shortcomings and diversifying the participant pool to increase the generalizability of findings.
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Affiliation(s)
- Krisztina Bajzak
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
| | - Alex Rains
- Department of Medicine, University of Chicago, Chicago, IL
| | - Lisa Bishop
- School of Pharmacy, Memorial University, St. John’s, NL, Canada
| | - Michelle Swab
- Health Sciences Library, Memorial University, St. John’s, NL, Canada
| | - Michelle E. Miller
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gabrielle S. Logan
- Department of Anesthesiology, Perioperative, and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Victoria Jackman
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
| | - Liam Jackman
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Jindal A, Mysore V, Mysore JV. Cosmetic gynecology-An emerging field for the dermatologist. J Cosmet Dermatol 2023; 22:111-118. [PMID: 36335587 DOI: 10.1111/jocd.15484] [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: 03/31/2022] [Revised: 09/28/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Cosmetic gynecology is an expanding field with a steep rise in awareness and demand for procedures to enhance the aesthetic appearance of female genitalia. AIM This article aims to provide an overview of aesthetic gynecology for a practicing dermatologist. METHODS A study conducted in India showed a rising trend in the demand of aesthetic vaginal procedures from 3.9% in 2012 to 28.97% in 2015. CONCLUSION Several aesthetic modalities such as peels, platelet rich plasma, and energy-based devices and surgical modalities have been in use, though serious evidence for efficacy of many of these procedures is lacking.
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Affiliation(s)
- Anuradha Jindal
- Venkat Institute of Skin and plastic surgery, Karnataka, Bangalore, India
| | - Venkataram Mysore
- Venkat Institute of Skin and plastic surgery, Karnataka, Bangalore, India
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Khalife T, Hagen AM, Alm JEC. Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management. Sex Med Rev 2022; 10:529-542. [PMID: 37051972 DOI: 10.1016/j.sxmr.2022.06.009] [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: 03/14/2022] [Revised: 06/13/2022] [Accepted: 06/24/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Women with pelvic pain commonly report pain in their ovaries, vagina, uterus, or bladder. These symptoms may be caused by visceral genitourinary pain syndromes but also may be caused by musculoskeletal disorders of the abdomen and pelvis. Understanding neuroanatomical and musculoskeletal factors that may contribute to genitourinary pain is important for evaluation and management. OBJECTIVES This review aims to (i) highlight the importance of clinical knowledge of pelvic neuroanatomy and sensory dermatomal distribution of the lower abdomen, pelvis, and lower extremities, exemplified in a clinical case; (ii) review common neuropathic and musculoskeletal causes of acute and chronic pelvic pain that may be challenging to diagnose and manage; and (iii) discuss female genitourinary pain syndromes with a focus on retroperitoneal causes and treatment options. METHODS A comprehensive review of the literature was performed by searching the PubMed, Ovid Embase, MEDLINE, and Scopus databases using the keywords "chronic pelvic pain," "neuropathy," "neuropathic pain," "retroperitoneal schwannoma," "pudendal neuralgia," and "entrapment syndromes." RESULTS Retroperitoneal causes of genitourinary pain syndromes have substantial overlap with common conditions treated in a primary care setting. Thus, a comprehensive and systematic history and physical examination, with focused attention to the pelvic neuroanatomy, is key to establishing the correct diagnosis. In the clinical case, such a comprehensive approach led to the unexpected finding of a large retroperitoneal schwannoma. This case highlights the intricacy of pelvic pain syndromes and the complex nature of their possible overlapping causes, which ultimately affects treatment planning. CONCLUSION Knowledge of the neuroanatomy and neurodermatomes of the abdomen and pelvis, in addition to understanding pain pathophysiology, is critical when evaluating patients with pelvic pain. Failure to apply proper evaluation and implement proper multidisciplinary management strategies contributes to unnecessary patient distress, decreased quality of life, and increased use of health care services. Khalife T, Hagen AM, Alm JEC. Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management. Sex Med Rev 2022;XX:XXX-XXX.
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Affiliation(s)
- Tarek Khalife
- Obstetrics and Gynecology, Mayo Clinic Health System - Southwest Minnesota region, Mankato, MN, USA.
| | - Amy M Hagen
- Obstetrics and Gynecology, Mayo Clinic Health System - Southwest Minnesota region, Mankato, MN, USA
| | - Jessica E C Alm
- Physical Medicine and Rehabilitation, Mayo Clinic Health System - Southwest Minnesota region, Mankato, MN, USA
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Botulinum Toxin A: A Review of Potential Uses in Treatment of Female Urogenital and Pelvic Floor Disorders. Ochsner J 2020; 20:400-409. [PMID: 33408578 PMCID: PMC7755545 DOI: 10.31486/toj.19.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Botulinum toxin is an injectable neuromodulator that inhibits transmission between peripheral nerve endings and muscle fibers, resulting in muscle paralysis. Botulinum toxin type A is the most common form of botulinum toxin used in clinical practice. Methods: In this review, we examine the mechanism of action, formulations, common clinical use in the genital-urinary tract, and potential clinical use in pelvic floor disorders of botulinum toxin type A. Results: Several aspects of botulinum toxin A make it a favorable therapeutic tool, including its accessibility, its longevity, and its impermanence and reversibility of resultant chemodenervation in a relatively short and safe manner. Although botulinum toxin A has well-established efficacy in treating refractory overactive bladder and neurogenic detrusor overactivity, its use in pelvic floor disorders is still in its infancy. Conclusion: The efficacy of botulinum toxin A for treating pelvic pain, voiding dysfunction, muscle pain and dysfunction, and certain colorectal-related pain issues shows promise but requires additional rigorous evaluation.
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Abstract
Botulinum toxin type A (BoNTA) is a powerful neurotoxin that inhibits acetylcholine release from presynaptic vesicles. The potency and safety profile of BoNTA grant the toxin vast therapeutic potential. It has been used off-label for a variety of dermatologic conditions. This review aims to analyze published literature regarding the benefits and risks of the off-label use of BoNTA beyond facial lines, including eccrine hidrocystomas, enlarged pores, keloids and hypertrophic scars, hidradenitis suppurativa, hyperhidrosis, masseter muscle hypertrophy, and salivary gland hypertrophy, among others. A MEDLINE search from January 2000 to December 2019 was conducted on the off-label uses of botulinum toxin in dermatology.
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Affiliation(s)
- Tina S Alster
- Washington Institute of Dermatologic Laser Surgery, 1430 K St NW, Suite 200, Washington, DC, 20005, USA.
| | - Iris S Harrison
- Washington Institute of Dermatologic Laser Surgery, 1430 K St NW, Suite 200, Washington, DC, 20005, USA
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Dick B, Natale C, Reddy A, Akula KP, Yousif A, Hellstrom WJG. Application of Botulinum Neurotoxin in Female Sexual and Genitourinary Dysfunction: A Review of Current Practices. Sex Med Rev 2020; 9:57-63. [PMID: 32238326 DOI: 10.1016/j.sxmr.2020.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The past 2 decades have witnessed an increased amount of research into botulinum neurotoxin (BoNT) as a treatment for various forms of sexual dysfunction and pain syndromes refractory to other medical therapy. BoNT is postulated to reduce pain sensation by inhibiting neuropeptide release in the presynaptic neuron. Dyspareunia, vaginismus, vestibulodynia, and persistent genital arousal disorder are female sexual dysfunctions with cryptic pathophysiology and limited treatment options. BoNT has emerged as a potential treatment for many of these afflictions in women. OBJECTIVES To review the literature regarding BoNT as a treatment for female sexual and genitourinary dysfunction. METHODS A PubMed search for English-language articles was performed using the following terms: "Botox," "botulinum toxin," "botulinum toxin A," "Onabotulinum A," "Abobutlinum A," "BoNT," and "BoNT-A." The main outcomes measured by each study were resolution of dysfunction. This entailed reduction of pain with intercourse for dyspareunia, reduction of pain for vestibulodynia, decreased arousal for persistent genital arousal disorder, and ability to tolerate penetration for vaginismus. RESULTS A total of 12 human studies that evaluated BoNT as a treatment for female sexual disorders were included. Study types included prospective, retrospective, cohort, pilot, and open-label. CONCLUSION There is growing evidence suggesting that BoNT is a safe and efficacious treatment option for female patients suffering from various sexual and genitourinary disorders. However, more research is needed to develop a better understanding of the mechanisms through which BoNT treats these disorders. Dick B, Natale C, Reddy A, et al. Application of Botulinum Neurotoxin in Female Sexual and Genitourinary Dysfunction: A Review of Current Practices. Sex Med 2021;9:57-63.
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Affiliation(s)
- Brian Dick
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Caleb Natale
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Amit Reddy
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Kole Prasad Akula
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Ayad Yousif
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Wayne J G Hellstrom
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA.
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Chen CL, Meng E. Can Botulinum Toxin A Play A Role In Treatment Of Chronic Pelvic Pain Syndrome In Female Patients?-Clinical and Animal Evidence. Toxins (Basel) 2020; 12:toxins12020110. [PMID: 32050685 PMCID: PMC7076794 DOI: 10.3390/toxins12020110] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/05/2020] [Accepted: 02/07/2020] [Indexed: 11/16/2022] Open
Abstract
Chronic pelvic pain (CPP) is defined as chronic pain and inflammation in the pelvic organs for more than six months. There are wide ranges of clinical presentations, including pelvic pain, painful intercourse, irritable bowel syndrome, and pain during urinating. Chronic pelvic pain syndrome (CPPS) is a subdivision of CPP, and the pain syndrome may be focused within a single organ or more than one pelvic organ. As there is uncertain pathogenesis, no standard treatment is currently available for CPPS. Botulinum toxin A (BoNT-A) is a potent neurotoxin that blocks acetylcholine release to paralyze muscles. Intravesical BoNT-A injection can reduce bladder pain in patients with interstitial cystitis/bladder pain syndrome. BoNT-A injected into the pelvic floor muscles of women has also been reported to improve chronic pain syndrome. Due to the reversible effect of BoNT-A, repeated injection appears to be necessary and effective in reducing symptoms. Adverse effects of BoNT-A may worsen the preexisting conditions, including constipation, stress urinary incontinence, and fecal incontinence. This review summarizes the evidence of BoNT-A treatment for CPPS in animal studies and clinical studies regarding the therapeutic effects of BoNT-A for CPPS in female patients.
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Affiliation(s)
| | - En Meng
- Correspondence: ; Tel.: +886-2-87927169
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Abstract
Vulvodynia is a common, recurrent, vulvar pain condition with debilitating consequences for affected women's health and quality of life. The heterogeneity of women suffering from vulvodynia as well as its uncertain and likely multifactorial etiology pose a significant challenge to identifying any kind of "gold standard" treatment. Thus, treatment providers must be well versed in the various options and the evidence for each. In this review, we begin with pharmacological treatments, followed by non-pharmacological treatments, surgery, and finally multimodal treatments. For each approach, we briefly discuss the method, mechanism of action, and empirical support for the treatment. In sum, pharmacological treatments that may be beneficial but require further research include antinociceptive agents (lidocaine, capsaicin), anti-inflammatory agents (corticosteroids, interferon), neuromodulating medications (anticonvulsants and antidepressants), hormonal agents, and muscle relaxants (e.g., botulinum toxin). There is strong evidence to support and recommend non-pharmacological interventions including psychological therapy, pelvic floor physical therapy, as well as surgery (i.e., vestibulectomy for provoked vestibulodynia) for the treatment of vulvodynia. We conclude this review with a discussion of issues that may have hindered progress of treatment efficacy and effectiveness, and recommendations for moving the field forward.
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Hedebo Hansen T, Guldberg R, Meinert M. Botulinum toxin-treatment of localized provoked vulvodynia refractory to conventional treatment. Eur J Obstet Gynecol Reprod Biol 2019; 234:6-9. [DOI: 10.1016/j.ejogrb.2018.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 12/02/2018] [Accepted: 12/09/2018] [Indexed: 11/17/2022]
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Subcutaneous botulinum toxin type A injections for provoked vestibulodynia: a randomized placebo-controlled trial and exploratory subanalysis. Arch Gynecol Obstet 2019; 299:993-1000. [DOI: 10.1007/s00404-019-05043-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
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Methodological approaches to botulinum toxin for the treatment of chronic pelvic pain, vaginismus, and vulvar pain disorders. Int Urogynecol J 2019; 30:1071-1081. [DOI: 10.1007/s00192-018-3831-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/16/2018] [Indexed: 12/15/2022]
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Moga MA, Dimienescu OG, Bălan A, Scârneciu I, Barabaș B, Pleș L. Therapeutic Approaches of Botulinum Toxin in Gynecology. Toxins (Basel) 2018; 10:toxins10040169. [PMID: 29690530 PMCID: PMC5923335 DOI: 10.3390/toxins10040169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 12/15/2022] Open
Abstract
Botulinum toxins (BoNTs) are produced by several anaerobic species of the genus Clostridium and, although they were originally considered lethal toxins, today they find their usefulness in the treatment of a wide range of pathologies in various medical specialties. Botulinum neurotoxin has been identified in seven different isoforms (BoNT-A, BoNT-B, BoNT-C, BoNT-D, BoNT-E, BoNT-F, and BoNT-G). Neurotoxigenic Clostridia can produce more than 40 different BoNT subtypes and, recently, a new BoNT serotype (BoNT-X) has been reported in some studies. BoNT-X has not been shown to actually be an active neurotoxin despite its catalytically active LC, so it should be described as a putative eighth serotype. The mechanism of action of the serotypes is similar: they inhibit the release of acetylcholine from the nerve endings but their therapeutically potency varies. Botulinum toxin type A (BoNT-A) is the most studied serotype for therapeutic purposes. Regarding the gynecological pathology, a series of studies based on the efficiency of its use in the treatment of refractory myofascial pelvic pain, vaginism, dyspareunia, vulvodynia and overactive bladder or urinary incontinence have been reported. The current study is a review of the literature regarding the efficiency of BoNT-A in the gynecological pathology and on the long and short-term effects of its administration.
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Affiliation(s)
- Marius Alexandru Moga
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Oana Gabriela Dimienescu
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Andreea Bălan
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Ioan Scârneciu
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Barna Barabaș
- Department of Fundamental Disciplines and Clinical Prevention, Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Liana Pleș
- Clinical Department of Obstetrics and Gynecology, The Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania.
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Miranda Varella Pereira G, Soriano Marcolino M, Silveira Nogueira Reis Z, Vale de Castro Monteiro M. A systematic review of drug treatment of vulvodynia: evidence of a strong placebo effect. BJOG 2018; 125:1216-1224. [PMID: 29569822 DOI: 10.1111/1471-0528.15223] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vulvodynia is the most common type of chronic pelvic pain and dyspareunia in premenopausal women. The effect of drugs for the treatment of vulvodynia remains poorly discussed. OBJECTIVES To conduct a systematic review of randomised controlled studies which assess medications used to treat vulvar pain in vulvodynia. SEARCH STRATEGY Web of Science, Cochrane Library, EBSCO Academic, LILACS and MEDLINE were searched from 1985 to September 2016. SELECTION CRITERIA Randomised controlled trials comparing any kind of medication for vulvodynia treatment with placebo or with another medication in adult patients were included. DATA COLLECTION AND ANALYSIS The two investigators independently conducted data extraction. The synthesis was provided by the pain reduction index. Study quality assessment was performed using the Cochrane Handbook for Systematic Reviews of Intervention and analysis of publication bias was conducted. MAIN RESULTS Five studies were included in qualitative synthesis. Number of participants varied from 30 to 133 participants among the eligible studies, resulting in a total of 297 patients. The pain reduction rates of patients with vulvodynia assessed by Q-tipped cotton test and visual analogue scale varied between studies. Placebo was shown to be as effective as any medication. CONCLUSIONS There is a need for further studies evaluating topical monotherapy for the treatment of vulvodynia, as they are the main drugs used in clinical practice. TWEETABLE ABSTRACT No medication has shown impact on vulvar pain in vulvodynia. There is evidence of a placebo effect.
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Affiliation(s)
- G Miranda Varella Pereira
- Department of Obstetrics and Gynaecology, Federal University de Minas Gerais, Belo Horizonte, Brazil
| | - M Soriano Marcolino
- Department of Internal Medicine, Federal University de Minas Gerais, Belo Horizonte, Brazil
| | - Z Silveira Nogueira Reis
- Department of Obstetrics and Gynaecology, Federal University de Minas Gerais, Belo Horizonte, Brazil
| | - M Vale de Castro Monteiro
- Department of Obstetrics and Gynaecology, Federal University de Minas Gerais, Belo Horizonte, Brazil
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Antipruritic Effects of Botulinum Neurotoxins. Toxins (Basel) 2018; 10:toxins10040143. [PMID: 29596343 PMCID: PMC5923309 DOI: 10.3390/toxins10040143] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 12/20/2022] Open
Abstract
This review explores current evidence to demonstrate that botulinum neurotoxins (BoNTs) exert antipruritic effects. Both experimental and clinical conditions in which botulinum neurotoxins have been applied for pruritus relief will be presented and significant findings will be highlighted. Potential mechanisms underlying antipruritic effects will also be discussed and ongoing challenges and unmet needs will be addressed.
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Lamont J. Directive clinique de consensus sur la santé sexuelle de la femme. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:S79-S142. [DOI: 10.1016/j.jogc.2016.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Affected women report negative impacts in terms of sexual functioning, relationship adjustment, psychological well-being and overall quality of life. Although the etiology of vulvodynia is not well understood, it appears as if different levels of pathophysiology are implicated. Accordingly, therapeutic options are targeted at a variety of mechanisms. Unfortunately, few randomized, controlled trials exist, and few combination therapies have been examined; however, the quality and breadth of the treatment literature is improving. Further studies are needed to more fully investigate the mechanisms involved in the development and maintenance of vulvodynia, and more research in the area of treatment outcome is needed.
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Affiliation(s)
- Caroline F Pukall
- Queen's University, Humphrey Hall, 62 Arch Street, Kingston, ON, K7L 3N6, Canada, Tel: +1 613 533 3200; Fax: +1 613 533 2499
| | - Kelly B Smith
- Queen's University, Department of Psychology, Humphrey Hall, 62 Arch Street, Kingston, ON, K7L 3N6, Canada, Tel: +1 613 533 3276; Fax: +1 613 533 2499
| | - Susan M Chamberlain
- Kingston General Hospital, Department of Obstetrics and Gynecology, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada, Tel: +7 613 548 6069; Fax: +7 613 548 1330
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Forbat E, Ali F, Al-Niaimi F. Non-cosmetic dermatological uses of botulinum neurotoxin. J Eur Acad Dermatol Venereol 2016; 30:2023-2029. [DOI: 10.1111/jdv.13772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/19/2016] [Indexed: 12/29/2022]
Affiliation(s)
| | - F.R. Ali
- Dermatological Surgery & Laser Unit; St John's Institute of Dermatology; St Thomas' Hospital; London UK
| | - F. Al-Niaimi
- Dermatological Surgery & Laser Unit; St John's Institute of Dermatology; St Thomas' Hospital; London UK
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Collier F, Staumont-Salle D, Delesalle F, Vinatier D, Bregegere S, Martin C. Nouveau regard sur les vulvodynies spontanées. SEXOLOGIES 2016. [DOI: 10.1016/j.sexol.2016.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Houman J, Feng T, Eilber KS, Anger JT. Female Sexual Dysfunction: Is It a Treatable Disease? Curr Urol Rep 2016; 17:28. [DOI: 10.1007/s11934-016-0583-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Al-Abbadey M, Liossi C, Curran N, Schoth DE, Graham CA. Treatment of Female Sexual Pain Disorders: A Systematic Review. JOURNAL OF SEX & MARITAL THERAPY 2015; 42:99-142. [PMID: 26036302 DOI: 10.1080/0092623x.2015.1053023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Sexual pain disorders affect women's sexual and reproductive health and are poorly understood. Although many treatments have been evaluated, there is no one "gold standard" treatment. The aim of this systematic review was to investigate what treatments for female sexual pain have been evaluated in clinical studies and their effectiveness. The search strategy resulted in 65 papers included in this review. The articles were divided into the following categories: medical treatments; surgical treatments; physical therapies; psychological therapies; comparative treatment studies; and miscellaneous and combined treatments. Topical and systemic medical treatments have generally been found to lead to improvements in, but not complete relief of, pain, and side effects are quite common. Surgical procedures have demonstrated very high success rates, although there has been variability in complete relief of pain after surgery, which suggests less invasive treatments should be considered first. Physical therapies and psychological therapies have been shown to be promising treatments, supporting a biopsychosocial approach to sexual pain disorders. Although most of the interventions described have been reported as effective, many women still experience pain. A multidisciplinary team with active patient involvement may be needed to optimize treatment outcome.
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Affiliation(s)
- Miznah Al-Abbadey
- a Department of Psychology , University of Southampton , Southampton , United Kingdom
| | - Christina Liossi
- a Department of Psychology , University of Southampton , Southampton , United Kingdom
| | - Natasha Curran
- b Pain Management Centre, University College London Hospitals , London , United Kingdom
| | - Daniel E Schoth
- c Department of Psychology , University of Southampton , Southampton , United Kingdom
| | - Cynthia A Graham
- c Department of Psychology , University of Southampton , Southampton , United Kingdom
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De Andres J, Sanchis-Lopez N, Asensio-Samper JM, Fabregat-Cid G, Villanueva-Perez VL, Monsalve Dolz V, Minguez A. Vulvodynia-An Evidence-Based Literature Review and Proposed Treatment Algorithm. Pain Pract 2015; 16:204-36. [DOI: 10.1111/papr.12274] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 11/05/2014] [Indexed: 01/23/2023]
Affiliation(s)
- Jose De Andres
- Valencia University Medical School; Valencia Spain
- Department of Anesthesiology Critical Care and Pain Management; General University Hospital; Valencia Spain
- Multidisciplinary Pain Management Department; General University Hospital; Valencia Spain
| | - Nerea Sanchis-Lopez
- Department of Anesthesiology Critical Care and Pain Management; General University Hospital; Valencia Spain
- Multidisciplinary Pain Management Department; General University Hospital; Valencia Spain
| | - Juan Marcos Asensio-Samper
- Department of Anesthesiology Critical Care and Pain Management; General University Hospital; Valencia Spain
- Multidisciplinary Pain Management Department; General University Hospital; Valencia Spain
| | - Gustavo Fabregat-Cid
- Department of Anesthesiology Critical Care and Pain Management; General University Hospital; Valencia Spain
- Multidisciplinary Pain Management Department; General University Hospital; Valencia Spain
| | - Vicente L. Villanueva-Perez
- Department of Anesthesiology Critical Care and Pain Management; General University Hospital; Valencia Spain
- Multidisciplinary Pain Management Department; General University Hospital; Valencia Spain
| | - Vicente Monsalve Dolz
- Department of Anesthesiology Critical Care and Pain Management; General University Hospital; Valencia Spain
- Multidisciplinary Pain Management Department; General University Hospital; Valencia Spain
| | - Ana Minguez
- Department of Anesthesiology Critical Care and Pain Management; General University Hospital; Valencia Spain
- Multidisciplinary Pain Management Department; General University Hospital; Valencia Spain
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Jeon Y, Kim Y, Shim B, Yoon H, Park Y, Shim B, Jeong W, Lee D. A retrospective study of the management of vulvodynia. Korean J Urol 2013; 54:48-52. [PMID: 23362448 PMCID: PMC3556554 DOI: 10.4111/kju.2013.54.1.48] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 09/10/2012] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Vulvodynia is characterized by chronic vulvar pain caused by sexual intercourse and often results in female sexual dysfunction. Because the causes of vulvodynia are not clear, many patients do not receive optimal treatment. Recently, gabapentin and botulinum toxin A have both been shown to be effective treatments for vulvodynia. In this study, we retrospectively analyzed the clinical outcomes of botulinum toxin A and gabapentin treatment for chronic pain in women with this condition. MATERIALS AND METHODS Seventy-three women with vulvar pain were administered either gabapentin (n=62) or botulinum toxin A (n=11) injections. Effectiveness was measured by use of a visual analogue scale (VAS). We analyzed the treatment method, treatment duration, success of treatment, and side effects or adverse reactions. RESULTS Pain levels in both groups significantly decreased after treatment. In the gabapentin group, the VAS score decreased from 8.6 before treatment to 3.2 after treatment (p<0.001). The VAS score in the botulinum toxin A group was reduced from 8.1 to 2.5 (p<0.001). Side effects for both therapies were few and subsided with treatment with general antibiotics and nonsteroidal antiinflammatory drugs. CONCLUSIONS Gabapentin and botulinum toxin A are safe and effective treatments for vulvodynia. This condition can cause sexual dysfunction and affect quality of life. However, with proper management, satisfactory outcomes for women with vulvodynia can be achieved.
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Affiliation(s)
- Yongseok Jeon
- Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea
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28
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Ferreira JR, Souza RP. Botulinum toxin for vaginismus treatment. Pharmacology 2012; 89:256-9. [PMID: 22507920 DOI: 10.1159/000337383] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 02/08/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND/AIMS Vaginismus is characterized by recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when penile, finger, tampon, or speculum penetration is attempted. Recent results have suggested the use of botulinum toxin for the treatment of vaginismus. Here, we assessed previously published data to evaluate the therapeutic effectiveness of botulinum toxin for vaginismus. METHODS We have carried out a systematic review followed by a meta-analysis. RESULTS Our results indicate that botulinum toxin is an effective therapeutic option for patients with vaginismus (pooled odds ratio of 8.723 with 95% confidence interval limits of 1.942 and 39.162, p = 0.005). This may hold particularly true in treatment-refractory patients because most of the studies included in this meta-analysis have enrolled these subjects in their primary analysis. CONCLUSION Botulinum toxin appears to bea reasonable intervention for vaginismus. However, this conclusion should be read carefully because of the deficiency of placebo-controlled randomized clinical trials and the quality issues presented in the existing ones.
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Affiliation(s)
- Juliana Rocha Ferreira
- Graduate Program in Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense, Criciuma, SC, Brazil
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29
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Urogynecological Causes of Pain and the Effect of Pain on Sexual Function in Women. Female Pelvic Med Reconstr Surg 2012; 18:259-67. [DOI: 10.1097/spv.0b013e3182686631] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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30
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Coital Pain. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012. [DOI: 10.1016/s1701-2163(16)35358-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Vaginismus: review of current concepts and treatment using botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia. Aesthetic Plast Surg 2011; 35:1160-4. [PMID: 21556985 DOI: 10.1007/s00266-011-9737-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
Abstract
Vaginismus is a poorly understood condition affecting approximately 1-7% of females worldwide. This article aims to bring attention to this disorder and to review the use of Botox injections to treat these patients. Vaginismus, also known as vaginal penetration disorder, is an aversion to any form of vaginal penetration as a result of painful attempts and a fear of anticipated pain. It is involuntary and uncontrolled and functions much the same as any reflex to avoid injury. It is the most common reason for unconsummated marriages. The etiology is thought to be unknown. Numerous papers note a history of religious or strict sexual upbringing or aversion to penetration because of perceived pain and bleeding with first-time intercourse. Sexual molestation may be more prevalent in this group of patients. The Lamont classification is very helpful in stratifying these patients for treatment. Lamont grade 5 vaginismus is introduced. Vaginal Botox injections for the treatment of vaginismus has received increasing attention since the technique was first described in a 1997 case report. Plastic surgeons worldwide with their experience using Botox are well positioned to learn more about this relatively unknown entity and render treatment.
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Bornstein J, Tuma R, Farajun Y, Azran A, Zarfati D. Topical Nifedipine for the Treatment of Localized Provoked Vulvodynia: A Placebo-Controlled Study. THE JOURNAL OF PAIN 2010; 11:1403-9. [DOI: 10.1016/j.jpain.2010.03.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Revised: 03/06/2010] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
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Gottsch HP, Miller JL, Yang CC, Berger RE. A pilot study of botulinum toxin for interstitial cystitis/painful bladder syndrome. Neurourol Urodyn 2010; 30:93-6. [PMID: 20589903 DOI: 10.1002/nau.20946] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 04/27/2010] [Indexed: 12/30/2022]
Affiliation(s)
- Henry P Gottsch
- Department of Urology, University of Washington, Seattle, Washington 98195-6510, USA
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Peptide-mediated transdermal delivery of botulinum neurotoxin type A reduces neurogenic inflammation in the skin. Pain 2010; 149:316-324. [PMID: 20223589 DOI: 10.1016/j.pain.2010.02.024] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 01/20/2010] [Accepted: 02/16/2010] [Indexed: 11/23/2022]
Abstract
Release of inflammatory pain mediators from peripheral sensory afferent endings contributes to the development of a positive feedback cycle resulting in chronic inflammation and pain. Botulinum neurotoxin type A (BoNT-A) blocks exocytosis of neurotransmitters and may therefore block the release of pain modulators in the periphery. Subcutaneous administration of BoNT-A (2.5, 5 and 10U) reduced plasma extravasation (PE) caused by electrical stimulation of the saphenous nerve or capsaicin in the rat hindpaw skin (ANOVA, Post hoc Tukey, p<0.05, n=6). Subcutaneous BoNT-A also reduced blood flow changes evoked by saphenous nerve stimulation (ANOVA, Post hoc Tukey, p<0.05, n=6). Subcutaneous BoNT-A had no effect on PE induced by local injection of substance P (SP) or vasodilation induced by local CGRP injection. Although BoNT-A is an effective treatment for a wide range of painful conditions, the toxin's large size necessitates that it be injected at numerous sites. We found that a short synthetic peptide (TD-1) can facilitate effective transdermal delivery of BoNT-A through intact skin. Coadministration of TD-1 and BoNT-A to the hindpaw skin resulted in a significant reduction in PE evoked by electrical stimulation. The findings show that BoNT-A can be administered subcutaneously or topically with a novel transdermal delivery peptide to reduce inflammation produced by activating nociceptors in the skin. Peptide-mediated delivery of BoNT-A is an easy and non-invasive way of administering the toxin that may prove to be useful in clinical practice.
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Mandal D, Nunns D, Byrne M, McLelland J, Rani R, Cullimore J, Bansal D, Brackenbury F, Kirtschig G, Wier M. Guidelines for the management of vulvodynia. Br J Dermatol 2010; 162:1180-5. [DOI: 10.1111/j.1365-2133.2010.09684.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Botulinum neurotoxin type A injections for vaginismus secondary to vulvar vestibulitis syndrome. Obstet Gynecol 2010; 114:1008-1016. [PMID: 20168100 DOI: 10.1097/aog.0b013e3181bb0dbb] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate whether botulinum neurotoxin type A improves vaginismus and study its efficacy with repeated treatments. METHODS Outpatients were referred because standard cognitive-behavioral and medical treatment for vaginismus and vulvar vestibular syndrome failed. From this group, we prospectively recruited consecutive women (n=39) whose diagnostic electromyogram (EMG) recordings from the levator ani muscle showed hyperactivity at rest and reduced inhibition during straining. These women were followed for a mean (+/-standard deviation) of 105 (+/-50) weeks. Recruited patients underwent repeated cycles of botulinum neurotoxin type A injected into the levator ani under EMG guidance and EMG monitoring thereafter. At enrollment and 4 weeks after each cycle, women were asked about sexual intercourse; underwent EMG evaluation and examinations to grade vaginal resistance according to Lamont; and completed a visual analog scale (VAS) for pain, the Female Sexual Function Index Scale, a quality-of-life questionnaire (Short-Form 12 Health Survey), and bowel and bladder symptom assessment. RESULTS At 4 weeks after the first botulinum neurotoxin type A cycle, the primary outcome measures (the possibility of having sexual intercourse, and levator ani EMG hyperactivity) both improved, as did the secondary outcomes, Lamont scores, VAS, Female Sexual Function Index Scales, Short-Form 12 Health Survey, and bowel-bladder symptoms. These benefits persisted through later cycles. When follow-up ended, 63.2% of the patients completely recovered from vaginismus and vulvar vestibular syndrome, 15.4% still needed reinjections (censored), and 15.4% had dropped out. CONCLUSION Botulinum neurotoxin type A is an effective treatment option for vaginismus secondary to vulvar vestibular syndrome refractory to standard cognitive-behavioral and medical management. After patients received botulinum neurotoxin type A, their sexual activity improved and reinjections provided sustained benefits. LEVEL OF EVIDENCE III.
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Gynecological indications for the use of botulinum toxin in women with chronic pelvic pain. Toxicon 2009; 54:647-53. [PMID: 19264089 DOI: 10.1016/j.toxicon.2009.01.036] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 01/04/2009] [Accepted: 01/06/2009] [Indexed: 11/23/2022]
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Damsted-Petersen C, Boyer SC, Pukall CF. Current perspectives in vulvodynia. ACTA ACUST UNITED AC 2009; 5:423-36. [PMID: 19586434 DOI: 10.2217/whe.09.30] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Although its etiology is not well understood, it appears to be multifactorial. As such, treatment options are targeted to reduce singular symptoms in a piecemeal fashion. A number of randomized, controlled trials have been conducted and at least one paper on combination therapy has been published; however, further systematic research is needed in order to more fully inform clinical practice.
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Petersen CD, Giraldi A, Lundvall L, Kristensen E. Botulinum Toxin Type A—A Novel Treatment for Provoked Vestibulodynia? Results from a Randomized, Placebo Controlled, Double Blinded Study. J Sex Med 2009; 6:2523-37. [DOI: 10.1111/j.1743-6109.2009.01378.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- Archana Rao
- Department of Endo-Gynaecology, Royal Hospital for Women, Randwick, New South Wales, Australia.
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Kennedy CM, Turcea AM, Bradley CS. Prevalence of vulvar and vaginal symptoms during pregnancy and the puerperium. Int J Gynaecol Obstet 2009; 105:236-9. [PMID: 19275950 DOI: 10.1016/j.ijgo.2009.01.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 01/12/2009] [Accepted: 01/23/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To identify the prevalence of vulvar and vaginal symptoms during pregnancy and at 3 months post partum. METHODS A prospective, longitudinal, descriptive study of 103 pregnant women was undertaken in which a self-administered questionnaire was completed at each trimester and 3 months post partum. Retrospective data was collected from 122 women, queried using similar tools, who comprised a nonpregnant control group. Descriptive and comparative statistics were employed. RESULTS The prevalence of vulvar burning, itching, pain, and vaginal discharge generally increased during pregnancy, and improved postpartum. Dyspareunia increased during pregnancy, but remained elevated post partum. Compared with the historical nonpregnant group (adjusted for age, marital status, education, and smoking), dyspareunia was reported less often in the first trimester (P=0.03) and more often post partum (P<0.01). Furthermore, reports of vulvar pain and vaginal discharge were significantly greater during the second and third trimesters. CONCLUSIONS Vulvar and vaginal symptoms are common during pregnancy, and the prevalence of some, but not all, increase during gestation and decrease post partum.
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Affiliation(s)
- Colleen M Kennedy
- Department of Obstetrics and Gynecology, University of Iowa, Iowa City, IA 52242, USA.
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Abbott J. The Use of Botulinum Toxin in the Pelvic Floor for Women with Chronic Pelvic Pain–A New Answer to Old Problems? J Minim Invasive Gynecol 2009; 16:130-5. [DOI: 10.1016/j.jmig.2008.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 10/21/2008] [Accepted: 11/06/2008] [Indexed: 10/21/2022]
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Sinha D, Thomson AJ. Botulinum toxin for pelvic pain in women. WOMEN'S HEALTH (LONDON, ENGLAND) 2008; 4:173-81. [PMID: 19072519 DOI: 10.2217/17455057.4.2.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pelvic pain is a common disorder in women, causing significant morbidity. Often the etiology is not clear as it results from a complex interaction between neurologic, musculoskeletal and endocrine systems that is further influenced by behavioral and psychological factors. A comprehensive approach to the problem requires recognition of the multiple organ systems that may be involved. A thorough history and physical examination, followed by selected laboratory and imaging studies, is essential in evaluation of these patients. Medical and surgical management improves or controls the symptoms in the majority of cases, but there remains a group of women who are difficult to treat. Botulinum toxin is a presynaptic neuromuscular blocking agent inducing selective and reversible muscle weakness that lasts several months when injected intramuscularly. It has been shown to be effective in treating pain caused by muscular spasm in conditions other than pelvic pain caused by muscular hypertonicity. Evidence or literature related to treatment of pelvic pain with botulinum toxin is discussed in this review.
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Affiliation(s)
- Deepali Sinha
- Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR51DD, UK.
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Jeynes LC, Gauci CA. Evidence for the use of botulinum toxin in the chronic pain setting--a review of the literature. Pain Pract 2008; 8:269-76. [PMID: 18503628 DOI: 10.1111/j.1533-2500.2008.00202.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A significant proportion of chronic pain is of musculoskeletal origin. Botulinum toxin (BTX) has been successfully used in the treatment of spasmodic torticollis, limb dystonia, and spasticity. Investigators have, thus, become interested in its potential use in treating many chronic pain conditions. Practitioners have used BTX, outside the product license, in the treatment of refractory myofascial pain syndrome and neck and low back pain (LBP). This article reviews the current evidence relating to chronic pain practice. There is evidence supporting the use of both BTX type A and type B in the treatment of cervical dystonias. The weight of evidence is in favor of BTX type A as a treatment in: pelvic pain, plantar fasciitis, temporomandibular joint dysfunction associated facial pain, chronic LBP, carpal tunnel syndrome, joint pain, and in complex regional pain syndrome and selected neuropathic pain syndromes. The weight of evidence is also in favor of BTX type A and type B in piriformis syndrome. There is conflicting evidence relating to the use of BTX in the treatment whiplash, myofascial pain, and myogenous jaw pain. It does appear that BTX is useful in selected patients, and its duration of action may exceed that of conventional treatments. This seems a promising treatment that must be further evaluated.
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Affiliation(s)
- Louise C Jeynes
- The Boyle Department of Anesthesia, St. Bartholomew's Hospital, London, UK
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Abstract
INTRODUCTION Vulvodynia is increasingly recognized as a cause of sexual pain. Aim. The goal of this Continuing Medical Education article was to provide a comprehensive review of vulvodynia including terminology, possible etiologies, and offer treatment options. METHODS A Medline search was conducted using several terms related to and including the terms vulvodynia, vulvar vestibulitis, vestibulodynia, and pudendal neuralgia. RESULTS A thorough review of vulvodynia. CONCLUSION Vulvodynia most likely represents several disorders without an identifiable cause in many cases. The management of these patients requires a sensitive provider who can coordinate a multidisciplinary approach to their care. Despite the lack of large-scale, placebo-controlled trials, several new treatment options exist.
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