Hysteroscopic Botox: A Novel Pelvic Pain Treatment

Abstract

<h3>Study Objective</h3> The objectives of this video are to describe the patient selection criteria, procedural steps, and postoperative care for hysteroscopic onabotulinumtoxinA (Botox) injection as a treatment for pelvic pain. <h3>Design</h3> N/A<b>.</b> This tutorial video demonstrates the surgical technique of hysteroscopic Botox administration. <h3>Setting</h3> Hysteroscopic Botox injections are administered through an operative hysteroscope introduced into the endometrial cavity. The procedure is performed in an operating room setting with the patient in dorsal lithotomy position. <h3>Patients or Participants</h3> Hysteroscopic Botox treatment can be considered in patients with pain of uterine origin who have failed conservative pelvic pain therapy, have normal pelvic imaging, and a laparoscopy negative for endometriosis. Patients ineligible for the procedure include those with an allergy to Botox or with any contraindication to hysteroscopy. Caution is warranted in patients pursuing pregnancy, as the effect of treatment on fertility is unknown. <h3>Interventions</h3> After diagnostic hysteroscopy confirms a normal endometrial cavity, a resection device is used to thin the entirety of the endometrium. 200 Units of Botox mixed with 3 mL of injectable saline is drawn into a syringe which is loaded into a control flow administration device. A hysteroscopic needle is attached to the tip of the syringe. Hysteroscopy is resumed, the needle is advanced through the operative channel, and the dilute Botox solution is injected into the myometrium at even intervals throughout the endometrial cavity. <h3>Measurements and Main Results</h3> Patient response is evaluated two weeks following the procedure using a numeric pain scale. If the patient reports significant benefit, the procedure may be repeated at six months. <h3>Conclusion</h3> Hysteroscopic Botox administration is a novel treatment approach for refractory uterine pain. One observational study demonstrates improvement in patient pain scores postoperatively. A randomized control trial is needed to confirm the efficacy of this treatment.