Hysterectomy For Chronic Pelvic Pain Research Articles

Myofascial Pain in Hysterectomy Patients

To assess the prevalence of myofascial pain in women undergoing uncomplicated, minimally invasive hysterectomy for chronic pelvic pain, to identify clinical and demographic factors associated with preoperative myofascial pain, and examine the association between myofascial pain and postoperative pain in hysterectomy patients. A retrospective cohort study. A tertiary care teaching hospital. A total of 353 adult women who underwent uncomplicated, minimally invasive hysterectomy between January 2014 and 2016. All women underwent a preoperative pelvic floor examination. Myofascial pain was diagnosed as tenderness and reproduction of pain symptoms in at least 2 of 6 pelvic floor muscles. Demographics, comorbidities, and intraoperative characteristics were compared between women with and without preoperative myofascial pain. Of the 353 women who underwent hysterectomy, the prevalence of myofascial pain was 42.7% (86.0% in patients with chronic pelvic pain [CPP] compared with 13.7% without CPP). Women with myofascial pain were more likely younger, Caucasian, sexually active, and with comorbid pain conditions. Patients with myofascial pain used a greater number of adjuvant pain medications before surgery including opiates (29.5%) but were only half as likely to use muscle relaxants (12.1%) for preoperative pain control. Contrastingly, in women without myofascial pain before surgery, controlled substances such as opiates (8%, p <.01) and benzodiazepines (3%, p <.01) were used at a three- fold lower frequency. Postoperative pain score was higher in patients with myofascial pain, with 37% reporting a visual analog scale score greater than 5 at the routine postoperative visit compared with only 1% of patients without myofascial pain. Myofascial pelvic pain must be considered in the evaluation of CPP, especially in surgical candidates. Women with myofascial pelvic use a greater amount of pain medication preoperatively and have higher pain scores postoperatively. Identification of these high-risk patients before surgery may improve pre and postoperative pain management with a multimodal therapy approach.

A Unique Approach for Total Laparoscopic Hysterectomy and Excision of Endometriosis at Time of Abdominoplasty

Video Objective We describe a unique technique to hide trocar scars while performing concurrent laparoscopic hysterectomy and excision of endometriosis at the time of abdominoplasty. Setting This patient is a 40 y/o female undergoing concomitant abdominoplasty and hysterectomy for chronic pelvic pain, abnormal uterine bleeding, and suspected endometriosis. Combining abdominoplasty with gynecologic surgery reduces total anesthesia and operative times, intraoperative blood loss, hospitalization and total recovery time when compared with having both of the procedures performed separately. Additionally, combined surgery does not appear to be associated with an increase in complications. Interventions We perform a total laparoscopic hysterectomy (TLH) and excision of endometriosis with concomitant abdominoplasty. First, the abdominoplasty flap is raised by the plastic surgeon. Then, the TLH and excision of endometriosis is performed. Finally, the rectus is plicated, excess tissue is excised, and the abdominoplasty is completed. Conclusion Performing concomitant total laparoscopic hysterectomy and abdominoplasty offers many benefits to the patient including shorter total operative and anesthesia, as well as shorter recovery when compared to 2 separate procedures. There are no large fascial defects when the hysterectomy is performed laparoscopically with 5 mm ports, so there is minimal concern for hernia or fascial dehiscence. The laparoscopic approach also offers a detailed survey for endometriosis lesions which can be excised at the same time as hysterectomy for definitive therapy. Aesthetically, the laparoscopic trocar sites are hidden when utilizing this technique, which is advantageous for cosmesis.

Prevalence of Endometriosis During Abdominal or Laparoscopic Hysterectomy for Chronic Pelvic Pain

(Abstracted from Obstet Gynecol 2016;127:1045–1053) Chronic pelvic pain is common in reproductive-aged women. A large number of women with chronic pelvic pain or endometriosis undergo hysterectomy: 10% to 32% for chronic pelvic pain and 5% to 19% for endometriosis.

Prevalence of Endometriosis During Abdominal or Laparoscopic Hysterectomy for Chronic Pelvic Pain.

To estimate the prevalence of surgically confirmed endometriosis in women undergoing laparoscopic or abdominal hysterectomy, including those with and without preoperative indications of chronic pelvic pain or endometriosis, and to describe characteristics and operative findings associated with surgically confirmed endometriosis in women undergoing hysterectomy for chronic pelvic pain. A retrospective cohort study was performed with 9,622 women who underwent laparoscopic or abdominal hysterectomy for benign indications in the Michigan Surgical Quality Collaborative from January 1, 2013, to July 2, 2014. The prevalence of surgically confirmed endometriosis, determined by review of the operative report and surgical pathology, was calculated for the entire cohort and for subgroups of women with and without chronic pelvic pain or endometriosis. Multivariate logistic regression models were used to identify characteristics associated with surgically confirmed endometriosis at the time of hysterectomy among women with chronic pelvic pain. Of the 9,622 hysterectomies available for analysis during the study period, 15.2% (n=1,465) had endometriosis at the time of hysterectomy. Among the 3,768 women with a preoperative indication of chronic pelvic pain, fewer than one in four had endometriosis (806/3,768 [21.4%]). Even among those with preoperative indication of endometriosis, many women did not actually have endometriosis at the time of hysterectomy (527/1,232 [42.8%]). The rate of unexpected endometriosis in women without a preoperative indication of chronic pelvic pain or endometriosis was 8.0% (434/5,457). Among women with a preoperative indication of chronic pelvic pain (n=3,786), multivariate analysis showed endometriosis was more common in women of younger age, white race, lower body mass index, and those who failed another treatment previously. Among those with pelvic pain, oophorectomy was more commonly performed in women with surgically confirmed endometriosis than those without (47.4% compared with 33.3%, P<.001). Fewer than 25% of women undergoing laparoscopic or abdominal hysterectomy for chronic pelvic pain have endometriosis at the time of surgery.

Characteristics of Women Undergoing Hysterectomy for Chronic Pelvic Pain: Prevalence and Risk Factors for Endometriosis

Characteristics of Women Undergoing Hysterectomy for Chronic Pelvic Pain: Prevalence and Risk Factors for Endometriosis

Does the Uterine Cervix Become Abnormally Reinnervated After Subtotal Hysterectomy and What Is the Association With Future Trachelectomy?

Study ObjectiveTo compare nerve fiber density in the cervices removed by trachelectomy from women with pelvic pain with those cervices removed for nonpain indications. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingTwo university hospitals. PatientsSubjects who underwent trachelectomy during a 10-year time frame were identified. InterventionsTwo tissue sections were obtained from each preserved cervix specimen and stained for S100 antibody. The numbers of S100-immunoreactive peripheral nerve fibers were assessed in 6 high-powered fields (HPFs) per tissue section (12 total HPFs per patient). Information collected included patient characteristics and surgical findings. We excluded any patients with dysplasia/cancer and those without an available adequate specimen. Measurements and Main ResultsWe evaluated the cervix specimens from 35 patients who underwent trachelectomy for pain (n = 25, group 1) and nonpain (n = 10, group 2) indications in addition to control cervices (n = 15, group 3) from benign hysterectomies performed for nonpain indications. There were increased numbers of nerve fibers in trachelectomy patients with pain versus those without pain (group 1 vs group 2, p = .02). There were also increased numbers of nerve fibers in both trachelectomy groups compared with the control group (group 1 vs group 3, p < .01; group 2 vs group 3, p = .04). Adjusted average cervical nerve counts/HPF were 17.8 (95% confidence interval [CI], 13.2–22.3) for pain-indicated trachelectomies, 11.5 (95% CI, 4.8–18.2) for nonpain, and 6.3 (95% CI, 0.8–11.8) for controls. Regardless of trachelectomy indication, adjusted average nerve counts/HPF were 17.7 (95% CI, 13.4–22.0) for patients with endometriosis and 14.6 (95% CI, 12.2–17.1) for patients without endometriosis. ConclusionNerve fibers in the cervical stump after supracervical hysterectomy are significantly increased in women undergoing trachelectomy for pain indications compared with those who underwent trachelectomy for nonpain indications and controls. Although not statistically significant, endometriosis may be an independent risk factor for increased nerve fibers. These histopathologic observations may support the idea that the cervix should be removed in women undergoing hysterectomy for chronic pelvic pain or endometriosis.

Long Term Outcomes after a Hysterectomy for Chronic Pelvic Pain: A Pelvic Pain Center Experience

Long Term Outcomes after a Hysterectomy for Chronic Pelvic Pain: A Pelvic Pain Center Experience

Role of Hysterectomy in the Treatment of Chronic Pelvic Pain

Chronic pelvic pain affects nearly 15% of women annually in the United States. It is associated with significant comorbidity, and annual costs to the health care system are estimated at approximately 2 billion dollars per year. The multifactorial nature of chronic pelvic pain makes it difficult to evaluate and treat. Therapies vary and may include surgical interventions such as hysterectomy. Although hysterectomy is an accepted treatment for chronic pelvic pain, it has important limitations that need to be discussed with the patient before surgery. Women can expect improvement in pain levels and function from their preoperative baseline. However, studies show that in the absence of any obvious pathology, 21-40% of women having a hysterectomy for chronic pelvic pain may continue to experience pain after the surgery and 5% may have new onset of pain. Women may experience improvements in mental health, physical function, social function, and dyspareunia; however, sexual frequency is not likely to change. Comorbidities such as preoperative depression may lower the chances of pain resolution after hysterectomy. Approximately 14% of women report having results worse than expected and almost 26% may have a slower recovery than expected. To maximize the chances of pain resolution, all women with chronic pelvic pain should undergo a full evaluation of the urologic, gastroenterologic, neurologic, and musculoskeletal organ systems before surgery to exclude nonreproductive causes of pain.

Uterine innervation after hysterectomy for chronic pelvic pain with, and without, endometriosis

Chronic pelvic pain is associated with a wide range of clinical conditions that include endometriosis. The precise cause, mechanisms of pain, and natural history are imprecise. Patterns of uterine innervation have been studied after hysterectomy for chronic pelvic pain with and without endometriosis. Tissue blocks were taken from the lower one half of the uterus after hysterectomy for advanced endometriosis (n = 16 specimens; group 1) and for chronic pelvic pain without endometriosis (n = 15 specimens; group 2). The control group consisted of uteri that were removed for painless gynecologic conditions (n = 25 specimens; group 3). Tissue sections from the lower one half of the uterus were stained with anti-S100 to demonstrate patterns of innervation, and nerve fiber profiles were counted by standardized techniques; qualitative differences were also recorded. In uteri from women with advanced endometriosis, there were increased numbers of nerve fiber profiles compared with control specimens (group 1 vs group 3; P = .0013, Mann Whitney U test). There were also increased numbers of nerve fiber profiles in uteri that were associated with chronic pelvic pain without endometriosis (group 2 vs group 3; P = .04, Mann Whitney U test). There were no differences in nerve fiber count in uteri from groups 1 and 2 (P = .35, Mann Whitney U test). Comparing both groups of uteri with controls (groups 1 and 2 vs 3) demonstrated marked differences in nerve fiber counts (P = .002, Mann Whitney U test). Two distinctive patterns of reinnervation that were observed: disruption of nerve bundles (collateral sprouting with microneuroma formation) and ingrowth around blood vessels (perivascular nerve fiber proliferation). There were increased numbers of microneuromas (groups 1 and 2 vs 3; P = .001, chi-squared test with Yates correction) and perivascular nerve fiber proliferation (groups 1 and 2 vs 3; P = .008, chi-squared test with Yates correction) in the myometrium in chronic pelvic pain with, and without, endometriosis compared with the control group. Nerve fiber proliferation and other features of reinnervation have been observed in the isthmic regions of uteri that were removed at hysterectomy for chronic pelvic pain with and without endometriosis. There were no quantitative differences between the groups with chronic pelvic pain and endometriosis. These observations provide an alternative explanation for the source of pain and other clinical symptoms in these clinical settings.

The effectiveness of hysterectomy for chronic pelvic pain

To evaluate the effectiveness of hysterectomy in treating chronic pelvic pain, and to identify risk factors for persistent pelvic pain. A group of 308 women who had hysterectomy for chronic pelvic pain of at least 6 months' duration was followed-up for 1 year after surgery, as part of a large, prospective, multicenter cohort study. Persistent pain was defined as a trichotomous variable, and ordinal logistic regression was used to identify independent predictors of the trichotomous outcome. Overall, 74% of women experienced complete resolution of pelvic pain, 21% reported continued but decreased pain, and 5% reported either unchanged or increased pain after hysterectomy. In unadjusted analyses, women at increased risk for persistent pain (eg, continued but decreased, and unchanged or increased) included those who were under age 30 (36 versus 22%, P < .05), had a history of pelvic inflammatory disease (41 versus 25%, P < .05), were uninsured or covered under Medicaid (41 versus 22%, P < .001), had no identified pelvic pathology (38 versus 23%, P < .05), or had a history of at least two pregnancies (31, 27, and 15% for those with at least four, two or three, and one or none, respectively; P < .05). After adjustment, an increased probability of persistent pain was observed among women who had no identified pelvic pathology (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.0-3.6), were uninsured or covered under Medicaid (OR 2.3, 95% CI 1.2-4.3), or had experienced at least two pregnancies (OR 2.3, 95% CI 1.0-5.3). Most women with chronic pelvic pain have long-term improvement after hysterectomy. However, up to 40% of women in specific subgroups may continue to experience long-term pain.

Adenomyosis as a major cause for laparoscopic-assisted vaginal hysterectomy for chronic pelvic pain

Ninety-three women in whom conservative surgical therapy for chronic pelvic pain failed required hysterectomy for control of their disabling condition. In 22 of these 93 patients (24%), adenomyosis was the major pathologic finding. In 10 of the 22 (45%) women who had adenomyosis and required hysterectomy for control of their pain, tubal ligation had been previously performed. Only 15% (11/71) of patients without adenomyosis had had a tubal ligation. Over 23% of patients requiring hysterectomy for control of chronic severe pelvic pain had adenomyosis, and almost half of these women had had a tubal ligation performed. The possible relationship of adenomyosis to a previous tubal ligation has been explored.

Availability of a multidisciplinary Pelvic Pain Clinic and frequency of hysterectomy for pelvic pain

AbstractTwo hundred and two women with chronic pelvic pain of at least 6 months’ duration were referred to a multidisciplinary Chronic Pelvic Pain Clinic at a large military teaching hospital following negative laparoscopy. One hundred and forty patients completed evaluation and were followed for a minimum of 6 months following completion of therapy. Subjective improvement was achieved for an average of 17 months (range of follow-up 6–41 months) in only 81 (58%) of the 140 subjects. Subsequent to initiation of the clinic, however, the percentage of hysterectomies performed for chronic pain within a defined catchment area decreased from 16.3% to 5.8% (p < 0.0001). To date, only six (4.3%) of the 140 women completing therapy in the pain clinic have undergone hysterectomy. Our results suggest that the availability of a multidisciplinary clinic can reduce the utilization of hysterectomy for chronic pelvic pain.

Hysterectomy not always effective for relief of chronic pelvic pain : Hysterectomy for chronic pelvic pain of presumed uterine etiology. Stovall T, Ling F, Crawford D. obstet gynecol 75:676, 1990

Hysterectomy not always effective for relief of chronic pelvic pain : Hysterectomy for chronic pelvic pain of presumed uterine etiology. Stovall T, Ling F, Crawford D. obstet gynecol 75:676, 1990