Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus

BACKGROUND

Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE.

METHODS

The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid.

RESULTS

The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication.

CONCLUSION

These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care.

SIGNIFICANCE

Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.

A training program for fibromyalgia management: A 5-year pilot study

We studied the effects of a specific cardio training program lasting 5 years on pain and quality of life in fibromyalgia patients.

Impact of a specific training programme on the neuromodulation of pain in female patient with fibromyalgia (DouFiSport): a 24-month, controlled, randomised, double-blind protocol

INTRODUCTION

The main symptom of fibromyalgia (FM) is diffuse pain. There is currently no aetiological treatment for FM. However, all pain associations and best practice guidelines strongly advocate the practice of aerobic physical activity to improve the symptoms of FM subjects. The mechanisms of dysfunctional pain are mostly central and related to stress axis dysfunction (autonomic nervous system and corticotropic axis). Our main objective is to assess the efficacy of a specific training programme on endogenous pain control mechanisms in female patients with FM. Further aims include rebalancing the autonomic neurovegetative system, improving quality of life and sleep quality, and reintegrating patients into society and work.

METHODS AND ANALYSIS

110 female patients with FM diagnosed on American College of Rheumatology 2010 criteria, aged 18-65 years and meeting inclusion conditions will be recruited and randomised into two groups (active and semiactive). The training programme will consist of three 45 min sessions per week of supervised, individualised physical activity over 2 years. Only the intensity of the exercises will differ between the two groups (moderate intensity vs low intensity).All outcome measures will be conducted at baseline (T0), after 6-9 months of training (T6-9) and after 24 months of training (T24). The primary endpoint will be an improvement of pain modulation (activation of diffuse noxious inhibitory control) evaluated by the stimulation test. The secondary endpoint will be relief of pain, anxiety, depression, stress, sleep disorders, pain impact on life quality, and improved heart rate, blood pressure and salivary cortisol.

ETHICS AND DISSEMINATION

This study is approved by the Committee for the Protection of Persons West VI. The results will be published in specialised scientific journals and will be presented at scientific meetings on pain and/or physical activity.

TRIAL REGISTRATION NUMBER

NCT02486965; Pre-results.

Cervical cord compression due to delayed scarring around epidural electrodes used in spinal cord stimulation

The authors report on 2 cases of delayed compression of the cervical spinal cord by dense scar tissue forming around epidural electrodes implanted for spinal cord stimulation (SCS). This complication has not been previously reported.

Myelopathy developed in 2 patients 5 and 16 years after the surgical placement of a cervical epidural electrode. Prior to myelopathy, both patients experienced a tolerance phenomenon. Magnetic resonance imaging in both cases showed severe compression of the spinal cord by the electrode. At surgery, thick scar tissue surrounding the electrode and compressing the posterior aspect of the cord was discovered. Both patients experienced a full recovery following the removal of both scar tissue and the electrode.

Medical and paramedical staff dealing with SCS should be aware of this severe and delayed complication. In addition, the development of epidural fibrosis can explain the occurrence of tolerance.

Computed tomography images of entrapped epidural catheter

OBJECTIVE

Knotting and looping of catheters in the epidural space occur rarely. Visualization of a catheter by radiograph or fluoroscopy is not always possible and often inaccurate in locating the knot and/or the loop with precision. We report the case of an entrapped lumbar epidural catheter. Computed tomography (CT) clearly showed a knotted and looped catheter.

CASE REPORT

A 27-year-old woman underwent epidural analgesia during labor. The epidural catheter was inserted 7 cm into the epidural space. After unsuccessful attempts at removing the catheter, a CT scan was performed, and it showed a catheter knot in the epidural space as well as a loop within the interlaminar ligamentum flavum between L3 and L4. This explained why attempts to remove the catheter by manual traction failed. Surgical removal of the catheter was subsequently performed.

CONCLUSIONS

CT is useful in showing an entrapped epidural catheter and the mechanisms of entrapment. Surgery should be considered when gentle traction fails to retrieve the catheter. CT allows the clinician to localize the catheter with accuracy, thus facilitating surgical follow-up.

Selective decontamination of the digestive tract in multiple trauma patients. A prospective double-blind, randomized, placebo-controlled study

STUDY OBJECTIVE

The aims of the study were to evaluate the technique of selective digestion decontamination (SDD) in preventing the development of nosocomial infections in a selected population and to assess the effects on colonization of the oropharynx, nares, and bronchi. A financial assessment was also performed.

DESIGN

Prospective, double-blind, randomized placebo-controlled trial using amphotericin B, colistin sulfate (polymixin E), and gentamicin applied to the nares, the oropharynx, and enterally; no parenteral antibiotics were given during the study period. The SDD was applied every 6 h during the study period.

SETTING

Multidisciplinary ICU in a university hospital.

PATIENTS

A total of 148 trauma patients admitted emergently and intubated within less than 24 h were enrolled. Seventy-two patients who received placebo and 76 treated patients were analyzed on an "intention-to-treat" basis.

INTERVENTIONS

Microbiologic surveillance samples of oropharyngeal and bronchial secretions, urine, and any other potentially infected sites were taken at the time of ICU admission and twice weekly thereafter until discharge from the unit.

MEASUREMENTS AND RESULTS

With the use of SDD, colonization was significantly reduced in the oropharynx and nares (<0.05) but not in bronchi. However, episodes of bronchopneumonia were significantly reduced (19 in the active group vs 37 in the placebo group; p,0.01). Staphylococcus aureus remained the main potential pathogen causing bronchial colonization and subsequent bronchopneumonia. There was no reduction in the incidence of other infections. Days in the ICU, duration of mechanical ventilation, and mortality rate were unchanged. After the use of SDD, Gram-positive colonization tended to increase and this was mainly due to methicillin-resistant coagulase-negative staphylococci. The total cost of antibiotic therapy ($62,117 [US] in the placebo group and $36,008 in the SDD group) was decreased by 42% with the use of SDD. Clinically important complications of SDD were not encountered.

CONCLUSIONS

The use of SDD in this population of trauma patients reduced the incidence of bronchopneumonia and the total charge for antibiotics. Stay in the ICU, mechanical ventilation, and mortality rate were unchanged. Methicillin-resistant coagulase-negative staphylococci were selected by SDD in some patients and the clinical relevance of this colonization needs further evaluation.

Comparing two heat and moisture exchangers with one vaporizing humidifier in patients with minute ventilation greater than 10 L/min

STUDY OBJECTIVE

To evaluate in patients submitted to minute ventilation > 10 L/min the ability to preserve patients' heat and humidity of two heat and moisture exchangers (HMEs) and one vaporizing humidifier (VH).

DESIGN

Prospective, randomized, comparative, non-blinded study.

SETTING

Intensive care unit of a university hospital.

PATIENTS

Nine tracheally intubated, mechanically ventilated patients, sedated and submitted to mechanical ventilation with minute ventilation > 10 L/min.

INTERVENTIONS

Using the psychrometric method, relative humidity (RH) and absolute humidity (AH) of inspired gas were obtained as well as temperature of inspired gas and tracheal temperatures (maximal and minimal). Following a randomized order, each patient was ventilated for two 24-h periods with a vaporizing humidifier (Bennett Cascade 2, Bennett; France) and one of two HMEs: Pall Ultipor filter BB50 (Pall Biomedical; France) or DAR Hygroster filter (Peters; France). Both were first tested for a 45-min period and then the HME that achieved the best performance in terms of temperature and water preservation was tested for 24 h.

MEASUREMENTS AND RESULTS

During the 45-min test period, the Pall Ultipor HME achieved a lower performance than the other two systems for any of the studied parameters (p < 0.05 to p < 0.0001). The DAR Hygroster HME achieved lower temperature of inspired gas (29.9 vs 32.0 degrees C, p < 0.005) and lower absolute humidity (29.3 vs 33.2 mg H2O/L, p < 0.005) than the Bennett Cascade 2. After 24 h of use, lower values of temperature of inspired gas (28.5 vs 32.0 degrees C, p < 0.002) and of AH (28.0 vs 33.6 mg H2O/L, p < 0.001) were obtained with the DAR Hygroster HME than with the Bennett Cascade 2. No differences were found between the two systems for the other tested parameters. At that time, no patients had RH lower than 97% and absolute humidity lower than 23 mg H2O/L with the use of the DAR Hygroster HME.

CONCLUSIONS

In patients with minute ventilation > 10 L/min, the DAR Hygroster HME showed a thermic and humidification capability similar to the reference system, the Bennett Cascade 2 VH. In these patients, the Pall Ultipor HME had a significantly lower capability.

[Selective digestive decontamination in patients under reanimation]

Nosocomial infections increase morbidity and mortality in hospitalized patients. ICU patients are at high risk of sustaining them, due to the high rate of invasive procedures and their poor health state. Conventional methods for decreasing the incidence of infection in ICU patients include handwashing, catheter care, strict antibiotic policy, and reduction of environmental sources of infection. Despite these measures, the colonization in these patients is always high, because of the presence of pathogens in the own patients' flora. Nosocomial pneumonia which is a major cause of mortality in ICU patients arises from retrograde colonization of the lung by pathogens originating from oro-pharyngeal and gastric secretions. Since 1984, selective decontamination of the digestive tract (SDD) has been advocated in ICUs to prevent from bacterial and fungal gastrointestinal/oropharyngreal colonization, nosocomial infection, subsequent multiple organ failure (MOF) and death. The SDD regimen is usually an extemporaneously prepared suspension of antimicrobial agents. Appropriate antibiotics for this regimen should ideally be nonabsorbable, to prevent from the development of resistant pathogens and avoid systemic toxicity. They should also be able to selectively eliminate enterobacteriaceae and yeasts, without decreasing the protective anaerobic flora. The most used combination is a suspension of colistin, amphotericin B and aminoglycoside, administered four times day through the nasogastric tube, in association with a paste consisting of 2 p. 100 colistin/amphotericin B/aminoglycoside, applied to the oropharynx. A parenteral antibiotic is also often co-administered during the first four days to prevent from early infections until the SDD regimen reaches its full effect; cefotaxime is usually used for this. SDD significantly decreases colonization rates in the oropharynx, gastrointestinal (GI) tract and trachea. This effects is primarily attributable to a decrease of Gram-negative bacilli (GNB) and yeasts, although several studies also reported decreased isolates of Gram-positive cocci (GPC). Oropharyngeal and GI colonization significantly decrease after four days of such a regimen, but tracheal decontamination in uncertain. Several studies recognized an emergence of GPC during or after SDD and resistance occurrence in GNB (especially against aminoglycosides). Recolonization occurs rapidly, about 4 to 8 days after the discontinuation of SDD. SDD decreases significantly the nosocomial infections, especially Gram-negative pneumonia. This benefit is most obvious in trauma patients, severely burned patients and after orthopic liver transplantation. Several studies reported a significant decrease in the overall rate of infections, especially extrapulmonary infections, including blood, urinary tract, wounds, abdominal, and catheter related infections. Despite a major decrease in infection rates with SDD, most studies did not show lowered mortality rates.(ABSTRACT TRUNCATED AT 400 WORDS)