Improvement In Pelvic Pain Research Articles

(272) Botulinum Toxin Injection in Vulva and Vagina: Evidence from a Literature Systematic Review

Abstract Introduction Vaginismus, vulvodynia and chronic pelvic pain are a group of pain syndromes that may have, in addition to pain, other types of symptoms. Often no specific etiology can be identified, and the choice of treatment is complicated. Although several treatment methods have been proposed, evidence-based therapies are limited. Therapies can be classified in medical, surgical and interventional treatment. Interventional therapy contemplates injection therapy with botulinum toxin, proposed in 1997 Objective To evaluate the BoNT injection in the comprehensive care of vaginismus, vulvodynia and chronic pelvic pain and to enhance the impact on the sexual arousal. Methods 1108 patients, Randomized Controlled Trials (RCT) were 7. The Retrospective Studies Without a control group were 4, With a control group: 1. Besides, the Prospective Studies Without a control group were, . 2 patients were With a control group. The BoNT Dosage Range was: Minimum: 12 UI Maximum: 500 UI Types of BoNT Products: Botox® (onabotulinumtoxinA): 14 Xeomin® (incobotulinumtoxinA): 3 Dysport® (abobotulinumtoxinA): 3 Unspecified BoNT Product: 1 EMG-Guided Injection: 5 I used as BoNT Administration Techniques, the Digital Palpation: 12, the unspecified Injection Procedure: 4. My methods were 17 patients in Intramuscular Injection, 3 patients with Vaginal Submucosal Plane, and one patient with Subcutaneous Injection. Results For Vaginismus, Significant improvement in sexual and orgasmic dysfunction Successful intercourse Reduction of vaginal muscle resistance Improved sexual function (evaluated by Female Sexual Function Index) Pain reduction and improved quality of life (Short-Form Health Survey) BoNT reduced muscular hyperactivity. Both BoNT and placebo improved sexual pain, function, and distress for patients with vulvodynia, Significant improvement in pain 4, improved quality of life 2 and increase of sexual activity due to the reduced pelvic hypertonicity. Other Study Results: Significant improvement in pelvic pain [22, 23, 31, 32] Reduction of vaginal pressure [32] Improvement in quality of life, sexual activity, and reduced pelvic floor muscles myoelectrical activity [31] Conclusions Different endpoints and different methods of analysis. Different types of participants. Various techniques and timing. Adverse events. For this reason, even though BoNT seems a promising treatment, a clear standardization in clinical guidelines is still lacking. A clear standardization is needed for practical guidelines. Future perspectives should address reproducible protocols for BoNT administration. Disclosure No.

RECURRENTHEMATOCOLPOS DUE TO ISOLATEDATRESIA OF THE LOWERTHIRD OF THE VAGINA: A CASE REPPORT

Reccurent hematocolpos is a rare condition that can be due to many malformations . One of them is the atresia of the lower third of vagina, wich is due to an anomaly in the development of the terminal part of the Müller’s canals. Case: We report the clinical case of a 15-year-old patient who presented primary amenorrhea associated with cyclic pelvic pain, in whom speculum examination revealed a blind vagina. The after finds the notion of hematocolpos cure with recurrence on 2 occasions. MRI revealed isolated atresia of the lower third of the vagina. The diagnosis of aplasia of the lower third of the vagina on a functional uterus was retained. The patient had a vaginal plasty by vaginal route. The evolution was good with regular cycles and improvement of pelvic pain. The follow-up is one year. Conclusion: Regardless of the surgical technique used, vaginoplasty allows in this rare condition to restore good life quality and prevent endometriosis.

Laparoscopic removal of Essure device techniques, perioperative findings and evaluation of patient's satisfaction: A case series

To evaluate perioperative outcomes and symptom resolution in women undergoing Essure removal. Single centre cohort study at a large University Teaching Hospital in the UK. Symptoms and Quality of life (QoL) were assessed using a standardised questionnaire administered at 6-months and up to 10-years following removal of Essure® devices. 61 women underwent surgical removal of Essure® devices representing 61/1087 (5.6%) of all women undergoing this hysteroscopic form of sterilization. Patients who had Essure® removal were more likely to have a previous caesarean section [38% vs 18%; OR 0.4, 95% CI 0.2-0.6; P <0.001]. The main indication for removal was pelvic pain (49/61, 80%). Removal was achieved by laparoscopic bilateral salpingectomy/cornuectomy (44/61,71%) or hysterectomy (17/61, 28%). At surgery, perforated device was seen in 4/61 (7%) cases. 26/61 (43%) of patients had concomitant pelvic pathology; 12/26 (46%) had fibrous adhesions, 8/26 (31%) endometriosis, 4/26 (15%) adenomyosis, and 2/26 (8%) had endometriosis and adenomyosis. 10 patients underwent further procedure following removal for ongoing symptoms. 55/61 women (90%) responded to the post removal symptom questionnaire. Most respondents to the quality of life survey 42/55 (76%) reported total or some improvement. 42/53 (79%) had total or some improvement in pelvic pain, 9/13 (69%) in mental health and 10/12 (83%) in bleeding. Surgical removal of Essure® devices appears to improve symptoms thought to be attributable to the presence of these uterine implants in most women. However, patients should be counselled that one in five women may experience persistent or even worsening symptoms.

Pelvic Pain and Pelvic Floor Muscle Dysfunction in Women Seeking Treatment for Prolapse.

Pelvic floor muscle dysfunction (PFMD) can cause pelvic pain, but its associations with pelvic organ prolapse (POP) and POP treatment outcomes are poorly understood. The objectives of this study were to determine (1) if pelvic pain is associated with PFMD in women seeking POP treatment and (2) if baseline PFMD in women seeking management of POP is associated with improvement in pelvic pain at 12 months. This was an ambispective cohort study of women enrolled at one site of the Pelvic Floor Disorders Registry. Pelvic floor muscle dysfunction was identified if tenderness was reported on a standardized pelvic floor muscle examination at baseline. Outcomes included a pelvic pain questionnaire (score 0-70, assessed pain in the past 24 hours in 7 pelvic locations) and the Global Health-10 overall average pain rating (0-10). One hundred forty-four women planning surgery (118) or pessary (26) were included. Twenty (13.9%) had baseline PFMD. Women with PFMD versus no PFMD had greater baseline Pelvic Pain scores (median [IQR], 9.7 [4-23] vs 2.5 [0-7], P < 0.001) and overall average pain (4 [3-6] vs 1 [0-3], P < 0.001). In 107 women with 12-month treatment outcomes, those with PFMD at baseline had greater improvement in pelvic pain compared with those without PFMD (change score -6.5 [-15.2 to 0] vs 0 [-3 to 0] respectively, P = 0.03). Overall pain improved after treatment in the no PFMD group but not in the PFMD group. Patients with baseline PFMD vs none undergoing treatment for prolapse had higher baseline pelvic pain and greater improvement in pelvic pain at 12 months.

Laparoscopic Resection of Rudimentary Horn for Treatment of Pelvic Pain

<h3>Study Objective</h3> To provide a brief overview of symptomatology of rudimentary uterine horns, as well as to demonstrate a minimally invasive resection of a rudimentary horn for treatment of pelvic pain. <h3>Design</h3> Surgical video. <h3>Setting</h3> Academic tertiary care hospital. <h3>Patients or Participants</h3> 24-year-old G0P0 initially evaluated for worsening menorrhagia and dysmenorrhea. Pelvic MRI showed a unicornuate uterus with a 2.5 cm nondistended noncommunicating right rudimentary horn. <h3>Interventions</h3> A laparoscopic resection of a rudimentary uterine horn was planned. The right pelvic sidewall was opened. The origin of the uterine artery was dissected out and cauterized. The round ligament was divided, and the anterior leaf of the broad ligament was undermined and incised to the end of the rudimentary horn. The right fallopian tube was followed to its fimbriated end, and a total salpingectomy was performed, and the remaining portion of the rudimentary horn was resected. A posterior colpotomy was created, and a specimen retrieval bag was inserted through the colpotomy. The specimen was completely removed in the bag. The colpotomy was then closed in a running fashion. <h3>Measurements and Main Results</h3> The patient was discharged on post operative day zero. She had a follow-up visit after 1 week, meeting all milestones and without complications. Upon long term follow up she reported improved pain. <h3>Conclusion</h3> Uterine rudimentary horns represent a mullerian anomaly that can be associated with cyclic pelvic pain. Laparoscopic resection of rudimentary horn can offer a minimally invasive option for immediate improvement in pelvic pain.

Pelvic pain is a common prolapse symptom and improvement after ventral mesh rectopexy is more frequent than deterioration or de novo pain.

The aim of this work was to assess the relationship between pelvic pain and rectal prolapse both before prolapse surgery and in the long term after ventral mesh rectopexy (VMR). Patients undergoing VMR between 2004 and 2017 were contacted. Outcomes including the severity of pelvic pain were recorded using a numeric rating scale. Four hundred and seventy eight of the 749 patients (64%) were successfully contacted. Of these, 39% reported pre-existing pelvic pain prior to VMR (group A) and 61% were pain free (group B). The median follow-up time was 8.0 years (interquartile range 5.0-10.0 years). Symptoms of obstructed defaecation were significantly more common (p= 0.002) in group A (91/187, 49%) than in group B (101/291, 35%). In contrast, faecal incontinence was more common (p= 0.007) in group B (75/291, 26%) than in group A (29/187, 15%). In group A, 76% showed improvement in pelvic pain after VMR: 61% were pain free and 39% had partial improvement in their pre-existing pelvic pain. Patients with persistent pelvic pain were younger (p= 0.01) and more likely to have revisional surgery after VMR (p= 0.0003), but there was no relation to the indication for surgery (p= 0.59). In group B, 15% reported de novo pelvic pain after VMR, and this was more common in women under 50 years old (p= 0.001), when obstructed defaecation was the indication (p= 0.03), in mesh erosion (p= <0.05) and when associated with revisional surgery (p= 0.005). Pelvic pain is common (39%) in patients undergoing prolapse surgery, and VMR improves this pain in most patients (76%). However, a significant number of patients fail to improve (12%), experience worsening of pain (12%) or develop de novo pelvic pain (15%).

Management of Nonrelaxing Pelvic Floor Dysfunction and Pain: Identifying the Gaps [A111

INTRODUCTION: Nonrelaxing pelvic floor dysfunction (PFD) is a condition characterized by tension of the pelvic floor musculature, often resulting in pelvic pain. The objective of this study was to review patient-reported pain outcomes following treatment of nonrelaxing pelvic floor dysfunction to identify gaps in current evidence. METHODS: A systematic review of the following databases from inception to July 2020 was performed: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Two authors reviewed titles and abstracts for relevance, and full articles were obtained and evaluated for inclusion. Studies were included if they assess interventions for nonrelaxing PFD characterized by pelvic pain. The third author was consulted in instances of disagreement. RESULTS: Of the 1,184 abstracts identified and reviewed, 36 full text articles were reviewed. Treatments for nonrelaxing PFD included biofeedback, botulinum toxin injections, electrical stimulation, intravaginal diazepam, massage, osteopathy, psychiatric interview, physical therapy, sacral nerve stimulation, trigger point injection, and combined therapies. Nineteen studies assessed the effectiveness of treatment based on patient reported pain outcomes. All studies demonstrated an improvement in pelvic pain. Several limitations were identified including varied pre-treatment diagnostic evaluation, small sample size, retrospective and single arm design, heterogeneity in treatment administration within and between studies, lack of standardized pain assessments, and limited long term outcome data. CONCLUSION: Nonrelaxing PFD is a debilitating condition. There is a paucity of high-quality clinical trials evaluating the effectiveness of pelvic floor muscle dysfunction treatments. Although preliminary studies support multi-modal treatment options, robust trials assessing patient-centered outcomes are necessary.

Multidisciplinary evaluation of chronic pelvic pain patients increases compliance with pelvic floor physical therapy

Pelvic floor physical therapy (PFPT) is widely accepted as a first line therapy for pelvic floor dysfunction. Despite studies demonstrating a 50-90% improvement in pelvic pain in women undergoing PFPT, adherence and follow up with PFPT is poor. The primary aim of this study was to evaluate whether the presence of a pelvic floor physical therapist at the initial consultation for chronic pelvic pain (CPP) resulted in greater compliance with PFPT. Secondary aims evaluated patient characteristics and provider practice patterns. We performed a retrospective chart review of all patients evaluated for CPP from June 2019- June 2020 in both a CPP multidisciplinary center as well as a traditional gynecology office. In both settings, patients were evaluated by fellowship-trained minimally invasive gynecologic surgeon. At the multidisciplinary center, patients were evaluated by the same surgeons, in addition to a pelvic floor physical therapist. Descriptive analyses compared patients who were referred to, attended, and completed PFPT, stratified by whether they saw PFPT the same day as their initial consultation. Kruskal-Wallis test or Pearson's chi-square test were used to determine whether distributions of continuous or categorical variables differed by clinics. 556 patients included in this study, 172 (31%) were seen in the CPP multidisciplinary center and 384 were seen in the traditional gynecology office. A total of 177 (32%) were referred to PFPT. A greater percentage of referrals were made from those patients in the CPP center (n=86;50%) as compared to the traditional office (n=91; 24%). Patients seen by a PFPT at the initial evaluation in the multidisciplinary center were more likely to complete at least one PFPT visit (n=57; 66%) when compared to those seen in a traditional gynecology clinic (n=26;29%, p <0.001). Patients seen in the multidisciplinary center who were also seen by PFPT at the time of referral had more PFPT visits on average as compared to those patients when referred from the traditional office (5.8 vs 2.0 respectively; p<0.001). A multidisciplinary approach to CPP increases the number of patients who establish care with PFPT. Future studies should focus on developing interventions to increase compliance to prescribed physical therapy regimens.

Laparoscopic Myomectomy: Surgical Tips and Tricks

<h3>Study Objective</h3> The objective of this video is to provide surgical and suturing tips for successful laparoscopic myomectomy of an enlarged fibroid uterus. <h3>Design</h3> Video case presentation. <h3>Setting</h3> The surgery in this video was performed in the operating room at an academic medical center. The patient was positioned in dorsal lithotomy position. Laparoscopic myomectomy and closure were completed using a 12mm umbilical port, a 12mm left lower quadrant port, a 5mm left upper quadrant port, and a 5mm right lower quadrant port. <h3>Patients or Participants</h3> The patient is a 38-yo G0 with symptomatic uterine fibroids including heavy menstrual bleeding and bulk symptoms, desiring future fertility. She had a preoperative pelvic MRI demonstrating a 15cm multifibroid uterus with 6 fibroids, the largest being a 7.5cm Type II-V fibroid at the uterine fundus. She's had a prior laparoscopic right salpingo-oophorectomy for an ovarian stromal tumor and reports that 2 small fibroids were also removed at that time. <h3>Interventions</h3> Laparoscopic enterolysis, laparoscopic myomectomy <h3>Measurements and Main Results</h3> This patient underwent an uncomplicated laparoscopic myomectomy. Total operative time was 201 minutes. Estimated blood loss was 100cc. Eight fibroids were removed, weighing 459g. The endometrial cavity was entered, and she will need a cesarean section with future deliveries. The patient was doing well at her 2-week post-operative visit with improvement in pelvic pain and bleeding. She will have an in-office flexible hysteroscopy 3 months post-op during the early proliferative phase prior to pursuing fertility goals. <h3>Conclusion</h3> Laparoscopic myomectomy of a large fibroid uterus can be successfully completed with minimal blood loss using the techniques described in this video. Closure of deep myometrial and endometrial defects can be done under good visualization utilizing ipsilateral ports for efficient suture placement and recovery.

An observational cohort study of pelvic floor photobiomodulation for treatment of chronic pelvic pain.

Aim: This research is the first to evaluate the effectiveness of trans-vaginal photobiomodulation therapy (TV-PBMT) for chronic pelvic pain. Materials & methods: Observational analysis of 128 women, undergoing TV-PBMT for chronic pelvic pain. Minimal clinically important difference, defined as ≥2-point drop on a 0-10 numeric pain rating scale (NPRS), and effect size Cohen d coefficient, was calculated over nine treatments for overall pain, and pain with activities. Results: Compared with baseline, 64.5% of women showed improvement in overall pain, pain with bowel movement, intercourse, exercise, urination, sittingand vulvar pain (minimal clinically important difference=-2.4, -2.0, -2.4, -2.1, -2.1, -2.0, -3.1; d=0.9, 0.7, 0.9, 0.7, 0.7, 0.7, 0.9) by treatment 9. Conclusion: In this cohort, TV-PBMT resulted in improvement of pelvic pain without serious adverse events.

1836 Outcomes of Laparoscopic Management of Chronic Pelvic Pain and Endometriosis

Study Objective To analyze the rate of re-operation and pelvic pain outcomes for patients who underwent laparoscopic surgery for chronic pelvic pain and endometriosis. Secondary objectives were to study the impact of surgery on quality of life and fertility outcomes. Design This is a retrospective study and a prospective online or telephone questionnaire of patients who underwent laparoscopic surgery for pelvic pain and/or endometriosis. The 12-Item Short Form Health Survey (SF-12) and the Female Sexual Function Index (FSFI) were used in part to develop the prospective questionnaire. Setting Tertiary care university referral center for minimally invasive gynecologic surgery. Patients or Participants Sixty-nine patients who underwent laparoscopic surgery for chronic pelvic pain. Interventions Retrospective chart review and prospective telephone or internet-based questionnaire. Measurements and Main Results Sixty-nine subjects consented and filled out a comprehensive questionnaire. Mean follow-up time was 28.3 months. Forty-three subjects who completed the questionnaire were visually found to have endometriosis. The rate of reoperation was 8.60% for patients with pathologic confirmation of endometriosis. 23.3% of patients with endometriosis underwent hysterectomy. The rate of re-operation was 9.09% for patients who did not undergo hysterectomy. 67.4% of patients with endometriosis were still pain-free at the time of the survey. The rate of re-operation for those without endometriosis was 0%. 30.2% of patients with endometriosis had a history of infertility for an average of 1.889 years prior to surgery. Following surgery, 83.3% of previously infertile patients with endometriosis attempted to conceive with 80.0% success rate. Subjects had significant improvement in each quality of life measurement and most sexual function indices analyzed. Conclusion Laparoscopic surgery for endometriosis had a low rate of re-operation, and long-term improvement in pelvic pain, sexual function, quality of life and fertility outcomes, with a high satisfaction rate.

Functioning gonadotroph adenoma with severe ovarian hyperstimulation syndrome: A new emergency in pituitary adenoma surgery? Surgical considerations and literature review

The authors reported 2 cases of functioning gonadotroph pituitary adenoma (FGPA) revealed by an ovarian hyperstimulation syndrome (OHSS) in young women. In the first case, OHSS was observed after GnRH analog injection. Pelvic echography revealed multiple voluminous ovarian cysts. Dopamine agonist posology failed in estradiol hypersecretion control, which necessitated endoscopic endonasal transsphenoidal surgery. The patient experienced improvement in pelvic pain as estradiol hypersecretion decreased during the first few postoperative days. Outcome was favorable, and her menstrual cycle was normal after two months. The second case was a young girl with spontaneous pelvic pain and elevated plasma FSH and estradiol levels. FGPA was confirmed on cerebral MRI. Dopamine agonists were introduced, and surgical removal of the pituitary tumor was scheduled for 7 days later. In the meantime, the patient was admitted and underwent surgery for bilateral adnexal torsion related to OHSS. The pituitary tumor was removed one week later. Outcome was favorable, and estradiol and FSH plasma levels were normal after 3 months. The ovarian cysts were no longer visible on echography after 3 months. Given the lack of efficacy of the current standard medical therapy, surgical removal of pituitary adenomas is the reference treatment for FGPA. The authors suggest that severe OHSS related to FGPA should be considered as a relative surgical emergency and that surgery should not be unduly delayed, given the unpredictable risk of adnexal torsion, particularly in case of voluminous ovarian cysts. The authors performed a literature review on this topic.

92: Long-term outcomes of laparoscopic surgery for endometriosis

To analyze the rate of recurrent pain and reoperation for patients who underwent laparoscopic excision of endometriosis. Secondary objectives were to study the impact of surgery on long-term quality of life and the effect on fertility following laparoscopic excision of endometriosis. This is a retrospective study of patients who underwent laparoscopic surgery for pelvic pain and/or endometriosis at a tertiary care university referral center for minimally invasive gynecologic surgery. A retrospective chart review as well as a prospective online and telephone questionnaire were performed to analyze long term outcomes, pain recurrence, reoperation and fertility outcomes. Quality of life validated questionnaire (SF-12) and the Female Sexual Function Index (FSFI) were used. Two hundred thirty-nine subjects underwent laparoscopic surgery for pelvic pain from July 2010 to June 2015 who were identified from ICD-9 codes representing various pelvic pain symptoms. Sixty-nine subjects consented and filled out a comprehensive questionnaire. Thirty-nine of these subjects had endometriosis confirmed on pathology. Mean follow-up time was 27.13. Of the patients with endometriosis, 84.6% underwent laparoscopic excision, and 7.7% of the patients with endometriosis needed further surgical intervention following the index procedure. Two thirds of the patients with endometriosis (N=26) were still pain-free at the time of the survey. Of those that had recurrence of pain following surgery, they were pain free for an average of 1.958 years before recurrence. One third of the endometriosis patients (N=13) had a history of infertility for an average of 1.889 years prior to surgery. Following surgery, 76.9% of previously infertile patients attempted to conceive with 80% success rate. The endometriosis subjects had significant improvements in each quality of life measurement and most sexual function indices analyzed. Laparoscopic surgery for endometriosis had a low rate of reoperation, and long-term improvement in pelvic pain, sexual function, quality of life and fertility outcomes, with a high satisfaction rate.

Pelvic Pain and Quality of Life Before and After Laparoscopic Bowel Resection for Rectosigmoid Endometriosis: A Prospective, Observational Study.

Surgery for rectosigmoid endometriosis carries a substantial risk of short- and long-term complications, which has to be counterbalanced against the potential effect of the procedure. Prospective data are scarce in the field of deep infiltrating endometriosis surgery. The study aimed to assess pelvic pain and quality of life before and after laparoscopic bowel resection for rectosigmoid endometriosis. The study involved prospectively collected data regarding pelvic pain and quality of life before and after surgery. It was conducted at a tertiary endometriosis referral unit at Aarhus University Hospital. A total of 175 women were included. Patients underwent laparoscopic bowel resection for endometriosis. Questionnaires for pain (Numerical Rating Scale) and quality of life (RAND Short Form-36) were answered before and 1 year after surgery. Data on analgesic and hormone treatment were collected. Preoperative and postoperative pelvic pain and quality-of-life scores were compared, and risk factors for improvement/worsening were identified. A total of 97.1% of the women completed the 1-year follow up. A significant decrease (p = 0.0001) was observed on all pelvic pain parameters. Most profound was the decrease in dyschezia. A significant improvement on all quality-of-life scores was observed (p = 0.0001). A surgical complication did not have a negative impact on outcome 1 year after surgery. The postoperative outcome was not related to the type of surgery. This is an observational study without a control group. Risk factor data should be interpreted with caution, because the study was relatively underpowered for some of the rare outcomes. A significant and clinically relevant improvement in pelvic pain and quality of life 1 year after laparoscopic bowel resection for endometriosis was found. We strongly recommend surgery for rectosigmoid endometriosis that is unresponsive to conservative treatment. See Video Abstract at http://links.lww.com/DCR/A472.

Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain

BackgroundIt has been reported that in 13–32% of patients with chronic low back pain, the pain may originate in the sacroiliac (SI) joints. When treatment of these patients with analgesics and physiotherapy has failed, a surgical solution may be discussed. Results of such surgery are often based on small series, retrospective analyses or studies using a minimal invasive technique, frequently sponsored by manufacturers. PurposeTo report the clinical outcome concerning pain, function and quality of life following anterior arthrodesis in patients presumed to have SI joint pain using validated questionnaires pre- and post-operatively. An additional aim was to describe the symptoms of the patients included and the preoperative investigations performed. Material and methodsOver a 6 year period we treated 55 patients, all women, with a mean age of 45 years (range 28–65) and a mean pelvic pain duration of 9.1 years (range 2–30). The pain started in connection with minor trauma in seven patients, pregnancy in 20 and unspecified in 28. All patients had undergone long periods of treatment including physiotherapy, manipulation, needling, pelvic belt, massage and chiropractic without success, and 15 had been operated for various spinal diagnoses without improvement. The patients underwent thorough neurological investigation, plain X-ray and MRI of the spine and plain X-ray of the pelvis. They were investigated by seven clinical tests aimed at indicating pain from the SI joints. In addition, all patients underwent a percutaneous mechanical provocation test and extra-articular local anaesthetic blocks against the posterior part of the SI joints. Before surgery all patients answered the generic Short-Form-36 (SF-36) questionnaire, the disease specific Balanced Inventory for Spinal Disorders (BIS) questionnaire and rated their level of pelvic and leg pain (VAS, 0–100). At follow-up at a mean of 2 years 49 patients completed the same questionnaires (89%). ResultsAt follow-up 26 patients reported a lower level of pelvic pain than before surgery, 16 the same level and six a higher level. Applying Svensson's method RPpelvic pain=0.3976, with 95% CI (0.2211, 0.5740) revealed a statistically significant systematic improvement in pelvic pain. At follow-up 28 patients reported a higher quality of life and 26 reported sleeping better than pre-operatively. In most patients the character of the pelvic pain was dull and aching, often accompanied by a stabbing component in connection with sudden movements. Referred pain down the leg/s even to the feet and toes was noted by half of the patients and 29 experienced frequency of micturition. ConclusionsIt is apparent that in some patients the SI joints may cause long-term pain that can be treated by arthrodesis. We speculate that continued pain despite a healed arthrodesis may be due to persistent pain from adjacent ligaments. The next step should be a prospective randomized study comparing posterior fusion and ligament resection with non-surgical treatment. ImplicationsAnterior arthrodesis can apparently relieve pain in some patients with presumed SI joint pain. The problem is how to identify these patients within the low back pain group.

Laparoscopic Essure Removal

Essure contraceptive device is an FDA approved tubal occlusive sterilization method that has been available for over a decade. There has been a steady increase in the number of patients requesting Essure removal due to perceived relationship to pelvic pain and other symptoms. Patients presenting for consultation request complete removal of the device. They are counseled that their symptoms may persist despite Essure removal. This video presents three techniques of laparoscopic Essure removal. In the first technique, the fallopian tubes and the uterine cornua are removed. In the second technique, the distal fallopian tube is incised and the Essure device is extracted, followed by a salpingectomy while preserving the cornua. Some patients elect to undergo a total laparoscopic hysterectomy with bilateral salpingectomy. In 11 patients surveyed, 73% reported improvement in pelvic pain and quality of life.

Dienogest in the treatment of endometriosis: systematic review.

Endometriosis is a prevalent disease that affects 5-15 % of women of reproductive age. The aim of this study is to assess the effect of dienogest in the treatment of endometriosis. The search was applied to electronic databases PubMed, Cochrane, EMBASE and Lilacs until September 2014, in a public tertiary hospital. We performed a systematic literature search of randomized trials comparing dienogest to other medical therapies in the treatment of endometriosis, as well as their references list, using the keywords "dienogest" and "endometriosis" by two independent authors. The data extraction were performed by two authors using predefined data fields. Nine randomized trials were included. Dienogest 2 mg/day was superior to placebo in reducing pelvic pain (27.4 versus 15.1 mm, P < 0.0001), with similar results to buserelin, leuprorelin, leuprolide acetate and triptorelin, in controlling symptoms associated with endometriosis. Dienogest 2 mg/day was effective in reducing endometriotic lesions (11.4 ± 1.71-3.6 ± 0.95, P < 0.001). The extended therapy with dienogest 2 mg/day also showed an improvement in pelvic pain after 24-52 weeks (-22.5 ± 32.1 and -28.4 ± 29.9 mm, respectively) with tolerable side effects. Dienogest should be considered as an alternative for controlling symptoms related to endometriosis. Nevertheless, in this systematic review, no studies were found comparing dienogest with first-line therapy, such as progestins and estrogen-progestogen combinations, which are proved to be effective in the treatment of endometriosis, are less expensive, and also can be used for contraception.

PIH9 - Budget Impact of Dienogest in Treating Endometriosis Associated Pelvic Pain in Brazil: A Public Perspective Analysis

Evaluate the budget impact to the public health care system in Brazil after introducing dienogest (2 mg) as a treatment option in detriment of GnRH analogues (GnRHa) for patients with endometriosis-associated pelvic pain (EAPP). The analysis was conducted from the public perspective over a five-year time horizon. The budget impact model (BIM) specifically considered women with EAPP. A recently cost-minimization (CM) model developed for EAPP provided the estimates of average treatment cost in Brazil based on local guidelines. This CM model compared different treatment pathways for women with EAPP and used a 50% improvement in pelvic pain as a definition of a treatment response. A patient flow was developed based on epidemiological and demographical data. Based on market uptake assumptions, results from the CM model and the patient flow, the BIM estimated the incremental budget impact after adopting dienogest. The model assumed that during the first year, 6.76% of EAPP patients receive dienogest in detriment of GnRHa. After five years, it was assumed that dienogest would capture 30% of the GnRHa market in EAPP. Based on the patient flow developed, approximately 0.52% of the population were estimated to be diagnosed with EAPP and receiving treatment with GnRHa. In the year after introduction of dienogest, the overall budget used to treat EAPP was estimated to decrease by up to 2.98% with the budget saving estimated to increase to around 12.98% by Year 5. This analysis portends that the budgetary impact of adding dienogest to the public health care system in Brazil, in detriment of the GnRHa, result in a budgetary cost saving alternative.

Anxiety, Sleep, Pain Sensitivity and the Response to Laparoscopic Management of Pelvic Pain

To determine differences in pain sensitivity and psychological risk factors between women reporting improvement in pelvic pain from prior surgery vs. no improvement. The mechanisms responsible for underlying variable improvement in pain after surgery are poorly understood.

Successful treatment of radiation-induced vaginal soft tissue radionecrosis with HBO2

Introduction: Radiation therapy to the pelvis can result in radiation-induced vaginal soft tissue necrosis. This significantly impacts quality of life. Studies evaluating the efficacy of HBO2 are limited. Methods: In this retrospective report, we reviewed the medical records of patients treated with once-daily HBO2 for radiation-induced vaginal soft tissue necrosis. We included females between the ages of 18 to 90 with history of pelvic cancer treated with radiotherapy and resultant soft tissue radionecrosis. Data collected included age, comorbid disease, cancer type, radiation dose, HBO2 treatment pressure, time, and total treatments. Primary outcome was improvement of radionecrosis; secondary outcomes were improvement of pelvic pain, reduction in need for analgesia, and improvement of vaginal bleeding. Results: Seven patients were identified, of which six received HBO2. One patient had a vaginal fistula. Four patients had documented improvement of radionecrosis. Four out of five patients with pelvic pain had resolution of their pain, with two patients no longer requiring opioid analgesia. Two patients who presented with vaginal bleeding showed improvement with one resolved and one significantly decreased requiring no further hospitalization or transfusion. One patient experienced no documented improvement in any of the measured outcomes. Conclusion: In this case series, five out of six (83%) patients treated with HBO2 for radiation-induced vaginal necrosis improved in at least one outcome measure. While the sample size is small, these results add to the data available that supports the use of HBO2 in suitable candidates without contraindications who have symptoms related to radiation-induced vaginal soft tissue necrosis.