Abstract
Background: Although several treatments are currently available for chronic pelvic pain, 30–60% of patients do not respond to them. Therefore, these therapeutic options require a better understanding of the mechanisms underlying endometriosis-induced pain. This study focuses on pain management after failure of conventional therapy. Methods: We reviewed clinical data from 46 patients with endometriosis and chronic pelvic pain unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain from 2018 to 2021. Demographic data, clinical and exploratory findings, treatment received, and outcomes were collected. Results: Median age was 41.5 years, and median pain intensity was VAS: 7.8/10. Nociceptive pain and neuropathic pain were identified in 98% and 70% of patients, respectively. The most common symptom was abdominal pain (78.2%) followed by pain with sexual intercourse (65.2%), rectal pain (52.1%), and urologic pain (36.9%). A total of 43% of patients responded to treatment with neuromodulators. Combined therapies for myofascial pain syndrome, as well as treatment of visceral pain with inferior or superior hypogastric plexus blocks, proved to be very beneficial. S3 pulsed radiofrequency (PRF) plus inferior hypogastric plexus block or botulinum toxin enabled us to prolong response time by more than 3.5 months. Conclusion: Treatment of the unresponsive patient should be interdisciplinary. Depending on the history and exploratory findings, therapy should preferably be combined with neuromodulators, myofascial pain therapies, and S3 PRF plus inferior hypogastric plexus blockade.
Highlights
Conventional therapy for chronic pelvic pain (CPP) was defined as medical treatment [3,4] with first-line therapy being drugs such as combined oral contraceptives (COCs), progestins or dienogest; and second-line therapy being gonadotropin-releasing hormone analogues (GnRHa) and/or surgery
Success in pain reduction should be achieved through the administration of progestogens [14,15,16,17], just as the pro-inflammatory response should be controllable with NSAIDs
If we delve deeper into the pathophysiology of CPP in endometriosis, we find a complex field that justifies the lack of response to different treatment options
Summary
Combined therapies for myofascial pain syndrome, as well as treatment of visceral pain with inferior or superior hypogastric plexus blocks, proved to be very beneficial. Plus inferior hypogastric plexus block or botulinum toxin enabled us to prolong response time by more than 3.5 months. Depending on the history and exploratory findings, therapy should preferably be combined with neuromodulators, myofascial pain therapies, and S3 PRF plus inferior hypogastric plexus blockade. Endometriosis is an estrogen-dependent, chronic inflammatory disease, and is the major contributor to chronic pelvic pain (CPP). It is estimated that prevalence could be as high as 10% [2], with an annual incidence of 0.1% among women aged 15–49 years [3]. More than 80% of women diagnosed with CPP have endometriosis [4]
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