Chronic Pelvic Pain: ACOG Practice Bulletin Summary, Number 218

Association of Uterine Tissue Innervation and Peripheral Nerve Density with Adenomyosis Related Pain. A Systematic Review

Adenomyosis is associated with dysmenorrhea and chronic pelvic pain; however, the triggering mechanisms of painful stimuli and the role of uterine nerve fibers in the manifestation of pain remain poorly understood. The objective of this study was to systematically review the role of uterine nerve fibers' presence and density in the occurrence of pain in patients with adenomyosis. An electronic search was performed using the Embase, PubMed/Medline, and Cochrane databases. We included all studies from inception to November 2023. A total of ten studies that compared uterine biopsies samples of women with and without adenomyosis were included. The biomarker antiprotein gene product 9.5 was decreased or absent in the endometrium of most included women with adenomyosis. None of the included studies observed a difference in neurofilament (NF) staining between the adenomyosis and non-adenomyosis groups. Studies that assessed nerve growth factor (NGF) staining were heterogeneous in design. One study reported no difference in immunohistochemistry staining in any endometrial layer between the adenomyosis and non-adenomyosis groups, while another reported increased staining in the adenomyosis functional endometrial layer, and a third study reported overexpression of NGF, synaptophysin (SYN), and microtubule-associated protein 2 mRNA in focal adenomyosis alone. Preliminary data from poor-quality studies suggest an increase in the uterine density of nerve fibers in patients with adenomyosis. Well-designed studies are essential to assess the cause-and-effect relationship between uterine nerve fibers and pain in patients with adenomyosis.

Efficacy of embolotherapy for the treatment of pelvic congestion syndrome: A systematic review

Pelvic congestion syndrome (PCS) poses a significant health, diagnostic, and economic challenges. Transcatheter embolisation has emerged as a promising treatment for PCS. A systematic review was performed in order to assess the safety and efficacy of transcatheter embolisation in the treatment of PCS. A systematic search of electronic databases was performed using 'PubMed', 'Embase', 'Medline (OVID)', and 'Web of Science', for articles pertaining to efficacy of embolotherapy for the treatment of pelvic congestion syndrome. A total of 25 studies were included in this systematic review with a combined total of 2038 patients. All patients included were female with a mean average age of 37.65 (31-51). Of the 25 studies, 18/25 studies reported pre- and post-procedural pelvic pain outcomes using a visual analogue scale (VAS). All studies showed a reduction in VAS post-procedure. Transcatheter embolisation had a high technical success rate (94%) and an overall complication rate of 9.0%, of which 10.4% were major and 89.6% were minor. Fifteen out of 19 (78.9%) major complications required a subsequent intervention. Transcatheter embolisation using various techniques is effective and safe in treating PCS. A low quality of evidence limits the currently available literature; however, embolisation has shown to improve symptoms in the majority of patients with low complication rates and recurrence rates.

Efficacy and factors of myofascial release therapy combined with electrical and magnetic stimulation in the treatment of chronic pelvic pain syndrome

The objective of this study was to evaluate the efficacy and factors of myofascial release therapy combined with electrical and magnetic stimulation in the treatment of chronic pelvic pain syndrome (CPPS). A total of 79 female patients diagnosed with CPPS from January 2021 to December 2022 were prospectively analyzed. Every patient received 3 weeks of treatment which included myofascial release therapy combined with electrical and magnetic stimulation. The visual analog score (VAS) of pelvic floor muscle (PFM) trigger points (TrPs) and the changes in pelvic floor surface electromyography before and after treatment were compared. Multiple linear regression was used to analyze the influencing factors of each outcome index. There were significant differences in VASs of muscle TrPs before and after treatment (P < 0.05). For the surface electromyography of PFMs, the differences in pre-baseline rest, post-baseline rest, isometric contractions for muscle endurance evaluation, and coefficient of variation were statistically significant (P < 0.05). Linear regression analysis showed that disease course (X 1), dyspareunia (X 5), and urinary incontinence (X 6) were influencing factors for the decline of pre-baseline rest (r5 = 1.067, R 2 = 0.089), post-baseline rest (r1 = 0.055, r5 = 0.99, R 2 = 0.119), VASs of ischial spine (r5 = 0.916, R 2 = 0.102), obturator internus (r5 = 0.796, r6 = -0.703, R 2 = 0.245), and pubococcygeus (r5 = 0.885, R 2 = 0.149) after treatment in the CPPS group. This study confirmed that individualized myofascial release therapy combined with electrical and magnetic stimulation has significant efficacy for patients with CPPS. At the same time, it is more effective for CPPS patients with longer course of disease, dyspareunia, and without urinary incontinence.

Acupuncture for chronic pelvic pain in patients with SPID: A protocol for systematic review and meta-analysis

BACKGROUND

Chronic pelvic pain (CPP) is one of the common sequela of pelvic inflammatory disease, the pathological factors are adhesions, scarring and pelvic congestion which caused by inflammation, often cause abdominal pain and lumbosacral soreness, and aggravated after fatigue, sexual intercourse and during menstruation. It is difficult to treat because special pathological changes. Although acupuncture has gained increased popularity for the management of CPP, evidence regarding its efficacy is lacking. Therefore, a systematic review of acupuncture for chronic pelvic pain in patients with SPID is required to provide available evidence for further study.

METHODS AND ANALYSIS

We will conduct a systematic review of randomized controlled trials (RCTs) that investigate the effect and safety of acupuncture for the treatment of chronic pelvic pain patients with SPID. We will electronically search the literature in the databases of PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, the Web of Science, China National Knowledge Infrastructure (CNKI), Wan-fang Digital Periodicals, Chinese Biomedical Literature Database (CBM), Chinese Scientific Journal Database (VIP) and select eligible articles. Data extraction will be conducted by 2 researchers independently, and risk of bias of the meta-analysis will be evaluated based on the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcomes will be total effective rate and VAS pain score, and the secondary outcomes include the recurrence rate and adverse reaction. All data analysis will be conducted by software Review Manager V.5.3.

RESULTS

This study will provide the latest analysis of the currently available evidence for the efficacy of acupuncture for chronic pelvic pain in patients with SPID.

PROSPERO REGISTRATION NUMBER

CRD42020193826.

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.