Treatment of Dyspareunia with Botulinum Neurotoxin Type A: Clinical Improvement and Influence of Patients' Characteristics

Botulinum Toxin for the Management of Pelvic Floor Tension Myalgia and Persistent Pelvic Pain: A Systematic Review and Meta-analysis

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.

Botulinum toxin injection in vulva and vagina. Evidence from a literature systematic review

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.

Treatment of Vestibulodynia with Submucosal Injections of IncobotulinumtoxinA into Targeted Painful Points: An Open-Label Exploratory Study

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; Collapse

Key Words

• algometer
• botulinum toxin A
• sexual function
• surface electromyography
• vestibulodynia
• vulvodynia

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MESH Headings

• Humans
• Female
• Vulvodynia/drug therapy
• Botulinum Toxins, Type A/therapeutic use
• Pain
• Pain Threshold

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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.)
Jose Alberola-Rubio Sonda Devices S.L., 46004 Valencia, Spain;
Javier Garcia-Casado Centro De Investigación E Innovación En Bioingeniería (CI2B), Universitat Politècnica De València, 46022 Valencia, Spain;

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Changes in pelvic floor electrical activity and vulvar pain after botulinum toxin treatment of vestibulodynia: are clinical and electrophysiological outcomes related?. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023;2023:1-4. [PMID: 38082636 DOI: 10.1109/embc40787.2023.10340830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Vestibulodynia is a gynecological condition with different treatment options available, including botulinum neurotoxin type A (BoNT/A) injections into the vulvar vestibule. Unlike other treatments, no studies have assessed changes in the myoelectrical activity of the pelvic floor muscles (PFM) after BoNT/A treatment. The aim of this study was thus to evaluate these changes and to correlate them with changes in vulvar pain sensitivity. To do this, 35 patients with vestibulodynia were recruited, the myoelectrical activity of their left and right PFM was recorded with surface electromyography (sEMG), and their vulvar pain sensitivity was monitored according to Visual Analogue Scale (VAS) and an algometer, both before and after BoNT/A treatment. According to our results, patients' signals during PFM relaxation showed a significantly higher power than those of healthy women at baseline, as shown by their root mean square values (RMS), but became similar at follow-up. Patients' mean vulvar pain VAS scores significantly decreased after treatment. Furthermore, baseline-to-follow-up differences of RMS at PFM rest vs. mean VAS were significantly correlated (CC=0.48, p<0.01) so that higher reductions in the PFM activity power were associated with higher decreases in vulvar pain.Clinical Relevance- Altered PFM electrophysiological condition of patients with vestibulodynia becomes similar to healthy women's after BoNT/A treatment. This study also points to a relationship between the evolution of clinical and PFM electrophysiological conditions.

Trigger point injections followed by immediate myofascial release in the treatment of pelvic floor tension myalgia

PURPOSE

Pelvic floor physical therapy (PFPT) is first-line therapy for treatment of pelvic floor tension myalgia (PFTM). Pelvic floor trigger point injections (PFTPI) are added if symptoms are refractive to conservative therapy or if patients experience a flare. The primary objective was to determine if a session of physical therapy with myofascial release immediately following PFTPI provides improved pain relief compared to trigger point injection alone.

METHODS

This was a retrospective cohort analysis of 87 female patients with PFTM who underwent PFTPI alone or PFTPI immediately followed by PFPT. Visual analog scale (VAS) pain scores were recorded pre-treatment and 2 weeks post-treatment. The primary outcome was the change in VAS between patients who received PFTPI alone and those who received PFTPI followed by myofascial release.

RESULTS

Of the 87 patients in this study, 22 received PFTPI alone and 65 patients received PFTPI followed by PFPT. The median pre-treatment VAS score was 8 for both groups. The median post-treatment score was 6 for the PFTPI only group and 4 for the PFTPI followed by PFPT group, showing a median change in VAS score of 2 and 4, respectively (p = 0.042). Seventy-seven percent of patients in the PFTPI followed by PFPT group had a VAS score improvement of 3 or more, while 45% of patients in the PFTPI only group had a VAS score improvement greater than 3 (p = 0.008).

CONCLUSION

PFTPI immediately followed by PFPT offered more improvement in pain for patients with PFTM. This may be due to greater tolerance of myofascial release immediately following injections.

Pain Specialist Management of Sexual Pain-II: Interventional

INTRODUCTION

Treatment of female sexual pain often requires the use of diverse modalities crossing multiple medical disciplines. Interventional procedures are important in the diagnosis and treatment of female sexual pain. Pain specialists and other medical specialties can provide these capabilities.

OBJECTIVES

To provide a current summary of the procedures used in the diagnosis and treatment of female sexual pain.

METHODS

The internet, PubMed, and the Cochrane Library were searched for relevant articles on female sexual pain within the clinical purview and scope of the practice of pain management.

RESULTS

A thorough review of the literature was conducted to include basic science studies, clinical trials, systematic reviews, consensus statements, and case reports. An effort was made to also include a sampling of information on real-world patient self-directed therapies. Descriptions of interventional procedures for the diagnosis and treatment of sexual pain were made and clinical studies reviewed. The evidence for the use of various interventional treatment strategies for sexual pain was assessed.

CONCLUSIONS

The process of care for female sexual pain employs an interdisciplinary biopsychosocial model that includes a role for interventional procedures commonly performed by pain management specialists. These specialists are a resource of knowledge, skills, and abilities that can be used to improve the care of women with chronic sexual pain.