Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence

Pregnancy-related lumbopelvic pain has puzzled medicine for a long time. The present systematic review focuses on terminology, clinical presentation, and prevalence. Numerous terms are used, as if they indicated one and the same entity. We propose "pregnancy-related pelvic girdle pain (PPP)", and "pregnancy-related low back pain (PLBP)", present evidence that the two add up to "lumbopelvic pain", and show that they are distinct entities (although underlying mechanisms may be similar). Average pain intensity during pregnancy is 50 mm on a visual analogue scale; postpartum, pain is less. During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. The mechanisms behind disabilities remain unclear, and constitute an important research priority. Changes in muscle activity, unusual perceptions of the leg when moving it, and altered motor coordination were observed but remain poorly understood. Published prevalence for PPP and/or PLBP varies widely. Quantitative analysis was used to explain the differences. Overall, about 45% of all pregnant women and 25% of all women postpartum suffer from PPP and/or PLBP. These values decrease by about 20% if one excludes mild complaints. Strenuous work, previous low back pain, and previous PPP and/or PLBP are risk factors, and the inclusion/exclusion of high-risk subgroups influences prevalence. Of all patients, about one-half have PPP, one-third PLBP, and one-sixth both conditions combined. Overall, the literature reveals that PPP deserves serious attention from the clinical and research communities, at all times and in all countries.

Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic micro-bleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the sub-peritoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as location indicating pain. A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic management of endometriosis in a context of pain.

Abuse-related posttraumatic stress disorder and alterations of the hypothalamic-pituitary-adrenal axis in women with chronic pelvic pain

OBJECTIVE

Although numerous organic conditions may cause chronic pelvic pain (CPP), diagnostic laparoscopy reveals a normal pelvis in many patients with CPP. However, psychological studies yield a high frequency of psychopathology and increased prevalences of chronic stress and traumatic life events, ie, sexual and physical abuse, in women with CPP, suggesting a relationship between posttraumatic stress disorder (PTSD) and CPP. As chronic stress and PTSD have been associated with specific alterations of the hypothalamic-pituitary-adrenal (HPA) axis, we explored stress history, psychopathology and HPA axis alterations in women with CPP.

METHOD

We recruited 16 patients with CPP and 14 painfree, infertile controls from a general hospital where diagnostic laparoscopy was performed. Psychological assessment included standardized interviews on clinical symptoms, abuse experiences and major life events as well as psychometric testing for PTSD-like symptoms and depression. Endocrinological evaluation involved determinations of diurnal salivary cortisol levels and hormonal responses to a corticotropin-releasing factor (CRF) stimulation test (100 microg human CRF) and a low-dose dexamethasone suppression test (0.5 mg).

RESULTS

We observed increased prevalences of abuse experiences and PTSD in women with CPP as well as a higher total number of major life events, whereas the mean extent of depression was within the normal range. With respect to endocrine measures, women with CPP demonstrated normal to low diurnal salivary cortisol levels, normal plasma-adrenocorticotropin (ACTH), but reduced salivary cortisol levels in the CRF stimulation test, and an enhanced suppression of salivary cortisol by dexamethasone.

CONCLUSION

Women with CPP demonstrate HPA axis alterations, that partly parallel and partly contrast neuroendocrine correlates of PTSD, but show marked similarity to findings in patients with other stress-related bodily disorders. These findings suggest that a lack of protective properties of cortisol may be of relevance for the development of bodily disorders in chronically stressed or traumatized individuals.

Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy

STUDY DESIGN

A cross-sectional analysis was performed in a group of women meeting strict criteria for posterior pelvic pain since pregnancy (PPPP). The scores on the Active Straight Leg Raise Test (ASLR test) were compared with the scores of healthy controls.

OBJECTIVES

To develop a new diagnostic instrument for use in patients with PPPP. The objectives of the present study were to assess the validity and reliability of the ASLR test.

SUMMARY OF BACKGROUND DATA

Various diagnostic tools are used to diagnose PPPP, but there is still a need for simple tests with high reliability, sensitivity, and specificity.

METHODS

Reliability of the ASLR test was assessed in a group of 50 women with lumbopelvic pain of various etiologies and various degrees of severity. Sensitivity was assessed in 200 patients with PPPP and specificity in 50 healthy women. Sensitivity and specificity of the ASLR test were compared with the posterior pelvic pain provocation test (PPPP test).

RESULTS

The test-retest reliability measured with Pearson's correlation coefficient between the two ASLR scores 1 week apart was 0.87. The intraclass correlation coefficient (ICC) was 0.83. Pearson's correlation coefficient between the scores of the patient and the scores of a blinded assessor was 0.78; the ICC was 0.77. In the patient group, the ASLR score ranged from 0-10; in the control group it ranged from 0-2. The best balance between specificity and sensitivity was found when scores 1-10 are designated as positive and zero as negative. With this cut-off point sensitivity of the test was 0.87 and specificity was 0.94. The sensitivity of the ASLR test is higher than the sensitivity of the PPPP test; an advantage of the ASLR test is the simplicity of measuring the score.

CONCLUSION

The ASLR test is a suitable diagnostic instrument to discriminate between patients who are disabled by PPPP and healthy subjects. The test is easy to perform; reliability, sensitivity, and specificity are high. It seems that the integrity of the function to transfer loads between the lumbosacral spine and legs is tested by the ASLR test.

Mechanisms in prostatitis/chronic pelvic pain syndrome

PURPOSE

We reviewed the current literature on mechanisms involved in the pathogenesis of prostatitis/chronic pelvic pain syndrome (CPPS).

MATERIALS AND METHODS

A literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine.

RESULTS

National Institutes of Health categories I and II prostatitis result from identifiable prostatic infections, whereas patients with category IV are asymptomatic. The majority of symptomatic cases are category III or chronic prostatitis (CP)/CPPS. The etiology of CP/CPPS is unknown. The traditional marker of inflammation, namely white blood cells in prostatic fluids, does not correlate with the predominant symptom of pelvic pain. An imbalance toward increased proinflammatory and decreased anti-inflammatory cytokines has been implicated and a few studies have shown some correlation of this with pelvic pain. The imbalance in some men may result from polymorphisms at the cytokine loci. An autoimmune process may be involved and experimental evidence indicates that this can be under hormonal influence. Recent findings include possible defects in the androgen receptor. The prostate may not even be the source of the symptoms. Pelvic pain also correlates with the neurotrophin nerve growth factor implicated in neurogenic inflammation and central sensitization. Finally, psychological stress may produce measurable biochemical changes and influence the other processes. The role of normal prostatic bacterial flora in inciting the inflammatory response has also been reconsidered.

CONCLUSIONS

The symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.

Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up

This study is a prospective, consecutive, 3-year cohort study of women with back pain in an index pregnancy. The aim was to describe the physical status and disability among women with back pain 3 years after delivery. Pain was identified as lumbar back pain, posterior pelvic pain or combined lumbar as well as posterior pelvic pain. Previous studies have established that all three types of pain can be reduced by structured physiotherapy during pregnancy, and the beneficial effect may last for several years. Though it is known that some women have residual pain for a long time, the relative incidence of the three pain types and their degree of disability associated with each have never been reported. Neither has any study presented findings of a physical examination of women 3 years post partum with a focus on the type of pain. All women who were registered as having experienced back pain during an index pregnancy were interviewed by mail 3 years post partum. Women who had residual back pain filled in an additional questionnaire and were physically examined. Out of 799 pregnant women, 231 had some type of back pain during the index pregnancy, and 41 women had pain 3 years later. Women with combined lumbar and posterior pelvic pain were significantly more disabled ( P<0.05) and had significantly lower endurance in the lumbar back and hip abduction muscles ( P<0.01). Some 5% of all pregnant women, or 20% of all women with back pain during pregnancy, had pain 3 years later. The key problem may be poor muscle function in the back and pelvis.

Anastrazole and oral contraceptives: a novel treatment for endometriosis

OBJECTIVE

To establish the use of aromatase inhibitors as a therapeutic option for endometriosis.

DESIGN

Prospective open-label Food and Drug Administration phase 2 trial with Institutional Review Board approval.

SETTING

Outpatient tertiary care centers.

PATIENT(S)

Fifteen premenopausal patients with documented refractory endometriosis and chronic pelvic pain.

INTERVENTION(S)

After a 1-month washout of endometriosis hormone therapies, women took 1 mg anastrazole (Arimidex; AstraZeneca, Wilmington, DE) and one tablet of 20 microg ethinyl estradiol/0.1 mg levonorgestrel (Alesse; Wyeth, Madison, NJ) daily for 6 months.

MAIN OUTCOME MEASURE(S)

An analog pain scale recorded pelvic pain in daily diaries and surveys at baseline and after each treatment month. Side effects, blood counts, liver and renal function tests, cholesterol levels, and bone density were monitored.

RESULT(S)

Fourteen of 15 patients achieved significant pain reduction. Median pain scores decreased 55% after 6 months, while mean pain scores decreased 40%. Pain reduction comparing each treatment month to baseline achieved statistical significance. Average pain scores began dropping after only 1 treatment month and continued decreasing each additional month. No organ system experienced adverse effects. Estradiol levels were suppressed during treatment. Side effects were mild and improved over time.

CONCLUSION(S)

Fourteen of 15 patients with refractory endometriosis achieved significant pain relief using anastrazole and 20 microg ethinyl estradiol/0.1 mg levonorgestrel with minimal side effects. This treatment for endometriosis is a promising new modality that warrants further investigation.

Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain

STUDY DESIGN

Cross-sectional study of electromyographic onsets of trunk and hip muscles in subjects with a clinical diagnosis of sacroiliac joint pain and matched control subjects.

OBJECTIVES

To determine whether muscle activation of the supporting leg was different between control subjects and subjects with sacroiliac joint pain during hip flexion in standing.

BACKGROUND

Activation of the trunk and gluteal muscles stabilize the pelvis for load transference; however, the temporal pattern of muscle activation and the effect of pelvic pain on temporal parameters has not been investigated.

METHODS

Fourteen men with a clinical diagnosis of sacroiliac joint pain and healthy age-matched control subjects were studied. Surface electromyographic activity was recorded from seven trunk and hip muscles of the supporting leg during hip flexion in standing. Onset of muscle activity relative to initiation of the task was compared between groups and between limbs.

RESULTS

The onset of obliquus internus abdominis (OI) and multifidus occurred before initiation of weight transfer in the control subjects. The onset of obliquus internus abdominis, multifidus, and gluteus maximus was delayed on the symptomatic side in subjects with sacroiliac joint pain compared with control subjects, and the onset of biceps femoris electromyographic activity was earlier. In addition, electromyographic onsets were different between the symptomatic and asymptomatic sides in subjects with sacroiliac joint pain.

CONCLUSIONS

The delayed onset of obliquus internus abdominis, multifidus, and gluteus maximus electromyographic activity of the supporting leg during hip flexion, in subjects with sacroiliac joint pain, suggests an alteration in the strategy for lumbopelvic stabilization that may disrupt load transference through the pelvis.

Leuprolide acetate depot and hormonal add-back in endometriosis: a 12-month study. Lupron Add-Back Study Group

OBJECTIVE

To evaluate the efficacy and safety of a GnRH agonist, leuprolide acetate depot, alone and in combination with three hormonal add-back regimens in the management of endometriosis-associated pelvic pain.

METHODS

Two hundred and one patients were enrolled in this multicenter, randomized, double-blind, 1-year trial. All patients were given an intramuscular injection of leuprolide acetate depot 3.75 mg every 4 weeks. Patients were assigned to one of four treatment groups: Group A received placebos for progestin and estrogen, group B received norethindrone acetate 5 mg daily and placebo for estrogen, group C received norethindrone acetate 5 mg and conjugated equine estrogens 0.625 mg daily, and group D received norethindrone acetate 5 mg and conjugated equine estrogens 1.25 mg daily. Pelvic pain scores were assessed monthly, and bone density was measured after 24 and 52 weeks.

RESULTS

By week 8, all four groups showed significant improvement in pelvic pain scores compared with baseline levels. A higher proportion of group D patients terminated the study prematurely due to a lack of improvement in symptoms. Group A experienced a 6.3 +/- 2.3% (P < or = .001) loss in bone density after 52 weeks of treatment, whereas bone density was preserved in all three add-back groups.

CONCLUSION

The use of leuprolide acetate depot in combination with norethindrone acetate 5 mg alone, or with norethindrone acetate and conjugated equine estrogens 0.625 mg, provides effective suppression of pelvic pain symptoms associated with endometriosis while protecting against bone loss.

Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain

Pain in the pelvic joints and lower back, a major problem for pregnant women, has proved resistant to precise measurement and quantification. To develop a classification system, the clinical tests used must be able to separate pelvic from low back pain; they must also have a high inter-examiner reliability, sensitivity and specificity, and preferably be easy to perform. The aim of this study was to describe a standardised way of performing tests for examining the pelvis, and to evaluate inter-examiner reliability, and establish the sensitivity and specificity of 15 clinical tests. It was designed as a longitudinal, prospective, epidemiological cohort study. First, 34 pregnant women were examined by blinded examiners to establish inter-examiner reliability. Second, a cohort of 2269 consecutive pregnant women, each responded to a questionnaire and underwent a thorough and highly standardised physical examination (15 tests with 48 possible responses) of the pelvic joints and surrounding areas. The 535 women who reported daily pain from the pelvic joints and had objective findings from the joints were divided, according to symptoms, into four classification groups and one miscellaneous group. The results of the study showed inter-examiner agreement of the tests was high, calculated in percentage terms, at between 88 and 100%. Using the Kappa coefficient, most tests kept the high agreement: six tests had an inter-examiner agreement of between 0.81 and 1.00, three between 0.61 and 0.80, and two between 0.60 and 0.41. Five tests showed superior sensitivity. The specificity of the tests was between 0.98 and 1.00, except the value for pelvic topography, which was 0.79. These results show that it is possible to standardise examination and interpretation of clinical tests of the pelvic joints, resulting in a high degree of sensitivity, specificity and inter-examiner reliability.

Chronic pelvic pain in the community--symptoms, investigations, and diagnoses

OBJECTIVES

This study was undertaken to investigate the overlap between chronic pelvic pain, dysmenorrhea, dyspareunia, irritable bowel syndrome, and genitourinary symptoms in the community and also to examine associated investigations and diagnoses.

STUDY DESIGN

A postal questionnaire was used to survey 3916 women aged 18 through 49 randomly selected from the Oxfordshire Health Authority Register. The number of responders was 2304 (74% of 3106 questionnaire recipients). Chronic pelvic pain was described as recurrent or constant pelvic pain of > or =6 months' duration unrelated to periods, intercourse, or pregnancy. Case patients (n = 483) were subgrouped as follows: (1) chronic pelvic pain only, (2) chronic pelvic pain and irritable bowel syndrome, (3) chronic pelvic pain and genitourinary symptoms, and (4) chronic pelvic pain, genitourinary symptoms, and irritable bowel syndrome.

RESULTS

Half the women with chronic pelvic pain also had either genitourinary symptoms or irritable bowel syndrome, or both. Prevalences of dysmenorrhea and dyspareunia were higher among women with chronic pelvic pain (81% and 41%, respectively) than among women without chronic pelvic pain (58% and 14%, respectively); rates did not differ among the chronic pelvic pain subgroups. Irritable bowel syndrome and stress were the most common diagnoses received by patients with chronic pelvic pain, but 50% had never received a diagnosis.

CONCLUSIONS

There is substantial overlap between chronic pelvic pain and other abdominal symptoms in the community. Despite a high prevalence of chronic pelvic pain, many women have never had the condition diagnosed.

Biopsy features are associated with primary symptoms in interstitial cystitis: results from the interstitial cystitis database study

The purpose of this study was to investigate associations between bladder biopsy features and urinary symptoms for patients enrolled in the Interstitial Cystitis Database (ICDB) Study. Bladder biopsies were obtained during baseline screening in the ICDB Study and were evaluated for histopathologic features. Multivariable models for nighttime voiding frequency, urinary urgency, and pain were developed, incorporating biopsy features from the most diseased area of the bladder as predictors, adjusting for significant clinical factors, and clinical center variation. Among 204 interstitial cystitis (IC) patients providing biopsy specimens, cystoscopic pathology findings were not statistically associated (P >0.1) with primary IC symptoms, although the presence of Hunner's ulcer (n = 12) was suggestive of increased urinary frequency. Within a multivariable predictive model for nighttime voiding frequency, adjusting for age and minimum volume per void, 4 pathology features were noted: (1) mast cell count in lamina propria on tryptase stain; (2) complete loss of urothelium; (3) granulation tissue in lamina propria; and (4) vascular density in lamina propria on factor VIII (F8) stain were statistically significant (P <0.01). Similarly, in a multivariable model for urinary urgency, minimum volume, and percentage of submucosal granulation tissue remained statistically significant (P <0.01). Finally, the percentage of mucosa denuded of urothelium and the percentage of submucosal hemorrhage remained highly associated (P <0.01) with pain in a multivariable predictive model. The fact that the presence or severity of glomerulations was not selected for any of these predictive models suggests that cystoscopic findings of glomerulations are not predictive of IC symptoms. Furthermore, these results suggest an important role for certain pathologic features in the predictive modeling of IC symptoms.

Salivary cortisol concentrations, stress and quality of life in women with endometriosis and chronic pelvic pain

The objective of this study was to evaluate the perceived stress index, quality of life, and hypothalamus-pituitary-adrenal axis activity in women with endometriosis and chronic pelvic pain. For the study, 93 women with endometriosis and 82 healthy women volunteered. The visual analogue scale (VAS) (0=no pain; 10=severe pain) was used to determine pain intensity; the perceived stress questionnaire (PSQ) defined stress index, and the health-related quality-of-life (HRQOL)-SF-36 questionnaire was used to evaluate quality of life. Salivary cortisol was measured at 0800, 1600, and 2000 h and the awakening cortisol response was assessed to evaluate the hypothalamus-pituitary-adrenal axis activity. The results show that women with endometriosis and chronic pelvic pain of moderate intensity (4.1+/-0.58, mean+/-SEM) have higher levels of perceived stress (0.55+/-0.01 versus 0.42+/-0.01, p<0.05), a poorer quality of life expressed as lower scores for all items of the inventory and hypocortisolism. Lower levels of salivary cortisol were observed in all three samples collected, as well as in the awakening cortisol response, for women with endometriosis (0.19+/-0.09 microg/dl) when compared with controls (0.78+/-0.08 microg/dl, p<0.05 l), and it was independent of pain intensity and Mental health (MH) scores in SF-36. We concluded that women with endometriosis and chronic pelvic pain show low concentrations of salivary cortisol and a high level of perceived stress, associated with a poor quality of life. Whether the hypocortisolism was an adaptive response to the aversive symptoms of the disorder or a feature related to the etiology of endometriosis remains to be elucidated.

Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning

STUDY DESIGN

A cohort study in pregnancy.

OBJECTIVES

To differentiate between pregnancy-related pelvic girdle pain (PPGP) and lumbar pain, and to study the prevalence of each syndrome and its consequences in terms of pain, functioning, and health.

SUMMARY OF BACKGROUND DATA

When studying prevalence, etiology, and consequences, differentiation between PPGP and lumbar pain is important, and, to our knowledge, its consequences for functioning and health during pregnancy have not previously been studied.

METHODS

All women answered questionnaires (demographic data, EuroQol). Women with lumbopelvic pain completed the Oswestry Disability Index, pain intensity measures, in addition to undergoing a mechanical assessment of the lumbar spine, pain provocation tests, and active straight leg raising test.

RESULTS

Of 313 women, 194 had lumbopelvic pain. The PPGP subgroup comprised 54% of those women with lumbopelvic pain, lumbar pain 17%, and combined PPGP and lumbar pain 29%. Women having both PPGP and lumbar pain reported the highest consequences in terms of health and functioning.

CONCLUSIONS

Pain intensity, disability, and health measurements differentiate subgroups of lumbopelvic pain in pregnancy.

Functional Connectivity is Associated With Altered Brain Chemistry in Women With Endometriosis-Associated Chronic Pelvic Pain

In contrast to women with relatively asymptomatic endometriosis, women with endometriosis-associated chronic pelvic pain (CPP) exhibit nonpelvic hyperalgesia and decreased gray matter volume in key neural pain processing regions. Although these findings suggest central pain amplification in endometriosis-associated CPP, the underlying changes in brain chemistry and function associated with central pain amplification remain unknown. We performed proton spectroscopy and seed-based resting functional connectivity magnetic resonance imaging to determine whether women with endometriosis display differences in insula excitatory neurotransmitter concentrations or intrinsic brain connectivity to other pain-related brain regions. Relative to age-matched pain-free controls, women with endometriosis-associated CPP displayed increased levels of combined glutamine-glutamate (Glx) within the anterior insula and greater anterior insula connectivity to the medial prefrontal cortex (mPFC). Increased connectivity between these regions was positively correlated with anterior insula Glx concentrations (r = .87), as well as clinical anxiety (r = .61, P = .02), depression (r = .60, P = .03), and pain intensity (r = .55, P = .05). There were no significant differences in insula metabolite levels or resting-state connectivity in endometriosis patients without CPP versus controls. We conclude that enhanced anterior insula glutamatergic neurotransmission and connectivity with the mPFC, key regions of the salience and default mode networks, may play a role in the pathophysiology of CPP independent of the presence of endometriosis.

PERSPECTIVE

Similar to other chronic pain conditions, endometriosis-associated pelvic pain is associated with altered brain chemistry and function in pain processing regions. These findings support central pain amplification as a mechanism of chronic pelvic pain, and clinicians should consider the use of adjunctive therapies that target central pain dysfunction in these women.

Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms?

OBJECTIVE

The objective of this study was to determine the minimum threshold level at which maximum anatomic prolapse predicts bothersome pelvic floor symptoms.

STUDY DESIGN

We performed a cross-sectional study of women older than 40 years undergoing gynecologic and urogynecologic examinations using Pelvic Organ Prolapse Quantification (POP-Q) examinations to assess support and Pelvic Floor Distress Inventory questionnaires to assess symptoms. Across the spectrum of prolapse severity, we calculated receiver operating characteristic (ROC) curves and areas under the curves (AUCs) for each symptom.

RESULTS

Of 296 participants, age was 56.3 +/- 11.2 years, and 233 (79%) were white. POP-Q stage was 0 in 39 (13%), 1 in 136 (46%), 2 in 89 (30%), and 3 in 33 (11%). ROC analysis for each symptom revealed an AUC of 0.89 for bulging/protrusion; 0.81 for splinting to void; 0.55-0.62 for other prolapse and urinary symptoms; and 0.48-0.56 for bowel symptoms. Using a threshold of 0.5 cm distal to the hymen, the sensitivity (69%) and specificity (97%) were high for protrusion symptoms but poor for most other symptoms considered.

CONCLUSION

Vaginal descensus 0.5 cm distal to the hymen accurately predicts bulging/protrusion symptoms; however, we could not identify a threshold of prolapse severity that predicted other pelvic floor symptoms.

Rehabilitation of the short pelvic floor. I: Background and patient evaluation

Pelvic floor physical therapists have traditionally focused on rehabilitation of the weak pelvic floor of normal length. With the recognition that many urogynecologic symptoms arise from the presence of a short, painful pelvic floor, the role of the physical therapist is expanding. Clinically, the pelvic floor musculature is found to be short, tender, and therefore weak. There are associated trigger points and characteristic extrapelvic connective tissue abnormalities. We report the characteristic patterns of myofascial and connective tissue abnormalities in 49 patients presenting with this syndrome.

Catastrophizing and Pain-Contingent Rest Predict Patient Adjustment in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome

Cognitive/behavioral and environmental variables are significant predictors of patient adjustment in chronic pain. Using a biopsychosocial template and selecting several pain-relevant constructs from physical, cognitive/behavioral, and environmental predictors, outcomes of pain and disability in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) were explored. Men (n = 253) from a North American multi-institutional NIH-funded Chronic Prostatitis Cohort Study in 6 US and 1 Canadian centers participated in a survey examining pain and disability. Measures included demographics, urinary symptoms, depression, pain, disability, catastrophizing, control over pain, pain-contingent rest, social support, and solicitous responses from a significant other. Regressions showed that urinary symptoms (beta = .20), depression (beta = .24), and helplessness catastrophizing (beta = .29) predicted overall pain. Further, affective pain was predicted by depression (beta = .39) and helplessness catastrophizing (beta = .44), whereas sensory pain was predicted by urinary symptoms (beta = .25) and helplessness catastrophizing (beta = .37). With regard to disability, urinary symptoms (beta = .17), pain (beta = .21), and pain-contingent rest (beta = .33) were the predictors. These results suggest cognitive/behavioral variables (ie, catastrophizing, pain-contingent rest) may have significant impact on patient adjustment in CP/CPPS. Findings support the need for greater research of such pain-related variables in CP/CPPS.

PERSPECTIVE

This article explores predictors of patient adjustment in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Cognitive/behavioral variables of catastrophizing and pain-contingent rest respectively predicted greater pain and disability. Catastrophic helplessness was a prominent pain predictor. These findings inform clinicians and researchers on several new variables in CP/CPPS outcomes and suggest future research.

The efficacy, side-effects and continuation rates in women with symptomatic endometriosis undergoing treatment with an intra-uterine administered progestogen (levonorgestrel): a 3 year follow-up

BACKGROUND

Side-effects and choice of drugs influence compliance during treatment for endometriosis. Progestogen administered by a device with a 5-year lifespan, has been shown to be an effective medical alternative with several advantages. The aims of this study were to investigate its efficacy, continuation rates and side-effects in women with endometriosis over a 3-year period.

METHODS

Thirty-four women with laparoscopically confirmed minimal to moderate symptomatic endometriosis offered insertion of an intrauterine device at diagnostic laparoscopy were followed up at 1, 3 and 6 months, and then every 6 months for 3 years. A symptom diary for side-effects, documentation of symptoms on a visual analogue scale (VAS), a verbal rating scale (VRS) and quantified menstrual loss using the pictorial blood loss chart was used to assess response to treatment.

RESULTS

The continuation rates were respectively 85%, 68%, 62% and 56% at, 6, 12, 24 and 36 months. Discontinuation rates were highest at <12 months, and most of these were for irregular and intolerable bleeding and persistent pain. An improvement in symptoms was observed throughout the 36 months. The greatest changes in pain assessed by either the VAS or VRS were between the pretreatment scores and those after 12 months (7.7 +/- 1.3 versus 3.5 +/- 1.8 for VAS, P < 0.001; and 25 +/- 13.8 versus 14 +/- 9.4 for VRS, P < 0.002). The monthly quantified blood loss fell from 204 (196) pretreatment to 60 (50) at 12 months (P < 0.001) and then to 70 (30) after 36 months. The most common side-effects were bleeding irregularities (14.7%), one-sided abdominal pain (11.8%) and weight gain (8.8%).

CONCLUSIONS

Intrauterine progestogen is effective in symptom control throughout the 3 years on the device, and discontinuation is greatest between 3 and 6 months. For those patients with improvement in symptoms, it is an acceptable long-term alternative.

Validity of the active straight leg raise test for measuring disease severity in patients with posterior pelvic pain after pregnancy

STUDY DESIGN

A cross-sectional analysis was performed with a group of women meeting strict criteria for posterior pelvic pain after pregnancy. The active straight leg raise test and common severity measurement scales of lumbopelvic pain were scored.

OBJECTIVE

To assess the validity of the active straight leg raise test as a disease severity scale for patients with posterior pelvic pain after pregnancy.

SUMMARY OF BACKGROUND DATA

Various diagnostic tools are used to measure disease severity in patients with posterior pelvic pain after pregnancy, but simple tests with high reliability and validity still are needed.

METHODS

The investigation was performed with 200 women who had posterior pelvic pain after pregnancy. The validity of the active straight leg raise test as a severity scale was investigated by comparing the test score with the medical history, scores on self-reported disability scales, pain and tiredness, and pain provocation tests. The usefulness of the active straight leg raise test as a severity scale was compared with that of the Québec Back Pain Disability Scale. The influence of several demographic and anthropometric variables on the active straight leg raise score was investigated.

RESULTS

The active straight leg raise score ranged from 0 to 10 and correlated as expected with all severity scales. The correlation between the scores on the active straight leg raise test and the Québec Back Pain Disability Scale was 0.70. No association was found between the active straight leg raise score and age, parity, duration of the postpartum period, height, or weight.

CONCLUSION

The active straight leg raise test can be recommended as a disease severity scale for patients with posterior pelvic pain after pregnancy.

Neurogenic inflammation and chronic pelvic pain

Chronic pelvic pain is a puzzling disease entity. The pathophysiological mechanisms of chronic pelvic pain are not clear and current treatment strategies are often not successful, leaving patients as well as health care providers frustrated. In a subgroup of patients with chronic pelvic pain (e.g., interstitial cystitis, irritable bowel syndrome, vulvar vestibulitis, prostatodynia/prostatitis, and loin pain/hematuria syndrome) inflammatory changes are observed, for which no etiology has been identified. These inflammatory changes might be due to neurogenic inflammation. Applying the concept of neurogenic inflammation to chronic pelvic pain provides new insights into the pathophysiological mechanisms of these pain syndromes, makes it possible to account for the heterogeneity and variability observed in the clinical presentation, and might lead to the development of novel therapies.

The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III

Recent studies suggest that the symptoms of chronic non-bacterial prostatitis (CP) or Chronic Pelvic Pain Syndrome (CPPS) may be due to or associated with pelvic floor muscle dysfunction. Therapies aimed to improve relaxation and proper use of the pelvic floor muscles such as biofeedback physical therapy and pelvic floor re-education are expected to give symptom improvement. The objective of this study was to evaluate the effect of biofeedback physical therapy on the symptoms of men with CPPS.

MATERIALS AND METHODS

Between March 2000 to March 2004, 33 consecutive men were diagnosed with CP/CPPS based on history including the NIH-CPSI questionnaire and physical examination including pelvic floor muscle tonus, urinalysis, uroflowmetry with residual urine measurement and transrectal ultrasonography of the prostate. All patients participated in a pelvic floor biofeedback re-educating program. A rectal EMG probe was used to measure resting tone of the pelvic floor muscles and was helpful for instruction pelvic floor muscles contraction and relaxation.

RESULTS

Two of the 33 men dropped out. In the remaining 31 men, mean age 43.9 years (range 23-70), the mean total Chronic Prostatitis Symptom Index (NIH-CPSI) changed from 23.6 (range 11-34) at baseline to 11.4 (range 1-25) after treatment (p<0.001). The mean value of the pelvic floor muscle tonus was 4.9 at diagnosis (range 2.0-10.0) and decreased to 1.7 (range 0.5-2.8) after treatment (p<0.001).

CONCLUSIONS

Our study clearly demonstrates a significant effect of biofeedback physical therapy and pelvic floor re-education for CP/CPPS patients, leading to a significant improvement of the symptom score. The correlation between the pelvic muscle tonus results with NIH-CPSI score is highly suggestive that the pelvic floor plays an important role in the pathophysiology of CP/CPPS.

Influence of endometriosis on pain behaviors and muscle hyperalgesia induced by a ureteral calculosis in female rats

Endometriosis and urinary calculosis can co-occur. Clinical studies have shown that both painful and non-painful endometriosis in women are associated with enhanced pain and referred muscle hyperalgesia from urinary calculosis, but the mechanisms underlying this phenomenon are still poorly understood. The aim of this study was to develop an animal model adequate to explore this viscero-visceral interaction in standardized conditions. Using a model of endometriosis previously developed to study reduced fertility and vaginal hyperalgesia, endometriosis (endo) or sham-endometriosis (sham-endo) was induced in rats by autotransplantation of small pieces of uterus (or, for sham-endo, fat) on cascade mesenteric arteries, ovary, and abdominal wall. After the endometrial, but not the fat autografts had produced fluid-filled cysts (3 weeks), urinary calculosis was induced by implanting an artificial stone into one ureter. Pain behaviors were monitored by continuous 24-h videotape recordings before and after stone implantation. Referred muscle hyperalgesia was assessed by measuring vocalization thresholds to electrical stimulation of the oblique musculature (L1 dermatome). The data were compared with previously reported data from rats that had received only the stone. Neither endo nor sham-endo alone induced pain behaviors. Following stone implantation, in endo rats compared to sham-endo and stone-only rats, pain behaviors specifically associated with urinary calculosis were significantly increased and new pain behaviors specifically associated with uterine pathology became evident. Muscle hyperalgesia was also significantly increased. To explore the relationship between the amount of endometriosis and that of ureteral pain behavior, two separate groups of endo rats were treated with either a standard non-steroidal anti-inflammatory drugs (ketoprofen) or placebo from the 12th to the 18th day after endometriosis induction. The stone was implanted on the 21st day. Ketoprofen treatment compared to placebo significantly reduced the size of the cysts and both ureteral and uterine pain behaviors post-stone implantation. The size of the cysts showed a significant linear correlation with the post-stone ureteral pain behaviors. In conclusion, endo increased pain crises and muscle hyperalgesia typically induced by a ureteral calculosis, and the ureteral calculosis revealed additional pain behaviors typically induced by uterine pathophysiology; and this enhancement was a function of the degree of endometriosis. This result closely reproduces the condition observed in humans and could be due to a phenomenon of 'viscero-visceral' hyperalgesia, in which increased input from the cyst implantation sites to common spinal cord segments (T10-L1) facilitates the central effect of input from the urinary tract.

Effect of three different physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: a randomized clinical trial with 3, 6, and 12 months follow-up postpartum

STUDY DESIGN

A randomized assessor-blinded clinical trial was conducted.

OBJECTIVE

To compare 3 different physical therapy treatments with respect to pain and activity in women with pelvic girdle pain during pregnancy and 3, 6, and 12 months postpartum.

SUMMARY OF BACKGROUND DATA

In spite of the high prevalence of back pain during pregnancy, documented treatment programs are limited.

METHODS

Based on a clinical examination, 118 women with pelvic girdle pain diagnosed during pregnancy were randomized into 3 different treatment groups: Information Group, use of a nonelastic sacroiliac belt and oral/written information about pelvic girdle pain (n = 40); Home Exercise Group, same as in the Information Group, with the addition of a home exercise program (n = 41); and the In Clinic Exercise Group, same as in the Information Group, plus participation in a training program (n = 37). Pain intensity was rated on a visual analogue scale (0-100 mm) and marked on a pain drawing concerning localization. The activity ability was scored using the Disability Rating Index, covering 12 daily activity items. Outcome measures were obtained at inclusion, on average in gestation week 38, and 3, 6, and 12 months postpartum.

RESULTS

There was no significant difference among the 3 groups during pregnancy or at the follow-ups postpartum regarding pain and activity. In all groups, pain decreased and the activity ability increased between gestation week 38 and at 12 months postpartum.

CONCLUSIONS

Women with pelvic girdle pain seemed to improve with time in all 3 treatment groups. Neitherhome nor in clinic exercises had any additional value above giving a nonelastic sacroiliac belt and information.

Etiology and prognosis of pregnancy-related pelvic girdle pain; design of a longitudinal study

BACKGROUND

Absence of knowledge of pregnancy-related pelvic girdle pain (PPGP) has prompted the start of a large cohort study in the Netherlands. The objective of this study was to investigate the prevalence and incidence of PPGP, to identify risk factors involved in the onset and to determine the prognosis of pregnancy-related pelvic girdle pain.

METHODS/DESIGN

7,526 pregnant women of the southeast of the Netherlands participated in a prospective cohort study. During a 2-year period, they were recruited by midwives and gynecologists at 14 weeks of pregnancy. Participants completed a questionnaire at baseline, at 30 weeks of pregnancy, at 2 weeks after delivery, at 6 months after delivery and at 1 year after delivery. The study uses extensive questionnaires with questions ranging from physical complaints, limitations in activities, restriction in participation, work situation, demographics, lifestyle, pregnancy-related factors and psychosocial factors.

DISCUSSION

This large-scale prospective cohort study will provide reliable insights in incidence, prevalence and factors related to etiology and prognosis of pregnancy-related pelvic girdle pain.