Treatment Of Chronic Pelvic Pain Research Articles

Systematic review and meta-analysis of the efficacy of gabapentin in chronic female pelvic pain without another diagnosis

BackgroundWhile widely used for the treatment of chronic pelvic pain, limited data exists on efficacy of gabapentin, especially in the subgroup of women suffering from chronic pelvic pain without a known diagnosis, such as endometriosis.ObjectiveThis study aimed to assess the efficacy of gabapentin when administered to women with chronic pelvic pain without another diagnosis.Study DesignWe performed a Systematic Review and Meta Analysis including all controlled clinical trials addressing the use of gabapentin for the treatment of chronic pelvic pain without another diagnosis. We searched PubMed, Scopus, Web of Science, ClinicalTrials.Gov, MEDLINE, and The Cochrane Library from inception of each database to April 30, 2021. We included all the studies that fulfilled the following criteria: (1) population: women suffering from chronic pelvic pain without another identified diagnosis (such as endometriosis); (2) intervention: gabapentin (regardless of the dosage); (3) comparator:placebo; (4) outcomes: pain score (visual analog scale) after 3 months and pain score (visual analog scale) after 6 months as primary outcomes; and (5) study design: we only included randomized or controlled clinical trials. Our exclusion criteria included (1) uncontrolled clinical trials, (2) studies that did not report data or measures for any of our selected outcomes, (3) studies that included patients with surgically or clinically diagnosed endometriosis, or (4) studies with no full-text manuscript available. Risk of bias assessment was performed using the Cochrane risk of bias tool. We analyzed dichotomous outcomes as percentages and totals, whereas continuous outcomes were analyzed using mean difference, standard deviations, and relative 95% confidence intervals using the inverse variance method.ResultsWe included 4 placebo-controlled randomized controlled trials. Analysis was hindered because half of the studies (n=2) used the visual analog scale pain score and the other half (n=2) used the numerical rating scale. The analysis showed that when compared with the placebo, gabapentin significantly lowered the visual analog scale pain score at 3 months (mean difference, 0.79; 1.23 to 0.35; P=.005) and 6 months (mean difference, 1.68; 2.30 to 1.05; P=.001) and the numerical rating scale pain score at 3 months (mean difference, 0.20; 0.25 to 0.15; P=.001). However, in terms of the numerical rating scale pain score after 6 months, the 2 groups showed no significant difference (mean difference, 0.27; 0.80 to 0.26; P=.32).CONCLUSIONGabapentin may hold benefit for the management of chronic pelvic pain, with significant improvement in pain seen in both scales at 3 months when compared with the placebo, but only in the visual analog scale group at 6 months of usage. Secondary to the differences in the nature of the 2 scales, a further weighted combined analysis was not possible.

Transvaginal Photobiomodulation for the Treatment of Chronic Pelvic Pain: A Pilot Study

Background: Chronic pelvic pain (CPP) is a common and debilitating condition that affects millions of U.S. women. Most treatments are ineffective and innovative new therapies are desperately needed. Large, controlled studies show that photobiomodulation (PBM) can reduce pain in patients with other chronic pain conditions, such as low back pain, neck pain, and fibromyalgia. The objective of this pilot study was to determine if transvaginal PBM (TV-PBM) can reduce pain in women with CPP.Methods: We conducted a before and after, observational, pilot study. Patients completed the Short Form-McGill Pain Questionnaire (SF-MPQ) at baseline, 1 week, 3 months, and 6 months after nine treatments of TV-PBM. Clinicians completed the Clinical Global Impression Scale (CGI) assessing patient illness severity at the same time. Wilcoxon rank-sum t-tests and effect size using Cohen's d coefficient (low effect size if d < 0.2, medium if 0.2 < d > 8, and high if d > 0.8) was used to measure degree of pain improvement, which was also considered clinically significant if pain reduction was >30%.Results: Thirteen women completed 9 treatments, and 10 women were successfully followed to 6 months. At baseline, the mean SF-MPQ score was 19.7 (standard deviation [SD] ± 5.9). Compared with baseline, 60% improved; the mean SF-MPQ score decreased to 10.0 (SD ±7.5, p = 0.004, d = 1.6) at 1 week after treatment, to 9.7 (SD ±7.9, p = 0.005, d = 1.7) at 3 months, and 8.2 (SD ±8.1, p = 0.002, d = 1.9) at 6 months.Conclusion: Transvaginal PBM provided significant and sustained pain relief to women with CPP up to 6 months. Further controlled studies are needed to confirm these findings, however, in this initial pilot, TV-PBM shows promise.

Conservative treatment of pelvic venous disease

Pelvic venous incompetence (PVI), although usually asymptomatic, may cause pelvic venous disease (PeVD), which may clinically manifest through pelvic symptoms, particularly chronic pelvic pain (CPP). There is no standard approach to manage PeVD and, therefore, the treatment should be individualized based on symptoms and the patient"s needs. To date, many treatment methods have been proposed, including conservative treatment, pelvic vein embolization, and reparative surgery. Medical treatment of CPP due to PVI includes non-steroidal anti-inflammatory drugs (NSAIDs), medical suppression of ovarian function, venoprotective agents, vasoconstrictor drugs, and psychotropic agents. The NSAIDs have a short-term efficacy and, due to side effects after longer use, they should be avoided as a long-term solution. Pharmacological suppression of ovarian function may result in CPP relief and may be achieved using medroxyprogesterone acetate, gonadotropin-releasing hormone (GnRH) agonist, long-acting reversible contraceptives, and danazol. They have been proven to be effective in the treatment of pelvic symptoms of PeVD. Venoactive drugs (VADs), particularly micronized purified flavonoid fraction (MPFF) and psychotropic agents, also provide an improvement in CPP related to PVI. A conservative approach represents the first-line treatment modality. It is reasonable to offer such treatment initially, reserving more invasive approaches for resistant cases and patients who present with side effects to the conservative management.

Skeletal Muscle Relaxants for the Treatment of Myofascial Pelvic Pain and High Tone Pelvic Floor Disorders in Women: A Scoping Review

Study Objective To review the evidence of muscle relaxants and non-injectable drugs with muscle relaxant properties for the treatment of chronic pelvic pain. This includes investigation of whether the concept of skeletal muscle relaxant use for lower back striated muscle strain is a valid construct to apply to the context and treatment of women with chronic pelvic pain due to myofascial and hypertonic muscular dysfunction. The clinical effectiveness, side effects, and toxicology risk of the investigated drugs were characterized. Design A scoping review was conducted in accordance with PRISMA-ScR guidelines and protocols. Online databases were searched using MeSH and subject terms. Articles reporting evidence on skeletal muscle relaxant use were reviewed by two independent reviewers with a third reviewer for any discrepancies. Setting Scoping review. Patients or Participants N/A. Interventions N/A. Measurements and Main Results Comparison studies have not shown any skeletal muscle relaxant to be superior. Skeletal muscle relaxants are divided into two categories: antispastic and antispasmodic agents. Antispastic agents reduce muscle hypertonicity and involuntary jerks associated with neurological disorders. Antispasmodic agents aim to treat striated muscle spasms from musculoskeletal conditions such as low back pain and myofascial pain. Cyclobenzaprine is heavily studied, with demonstrated effectiveness for isolated conditions. Intravaginal diazepam may be beneficial, while other drugs have limited investigation. Considerable knowledge gaps remain regarding appropriate use of these medications in the context of pelvic pain. Conclusion Scant high-quality data exist to support the use of skeletal muscle relaxants for chronic pelvic pain secondary to myofascial and hypertonic muscular dysfunction. Antispastic agents have limited evidence. Antispasmodic agent usage should be based on side-effect profile, patient preference, abuse potential, and possible drug interactions. Future prospective research on antispasmodic agents in women with myofascial dysfunction is necessary to define medication safety, route, dosage, and clinical outcomes. To review the evidence of muscle relaxants and non-injectable drugs with muscle relaxant properties for the treatment of chronic pelvic pain. This includes investigation of whether the concept of skeletal muscle relaxant use for lower back striated muscle strain is a valid construct to apply to the context and treatment of women with chronic pelvic pain due to myofascial and hypertonic muscular dysfunction. The clinical effectiveness, side effects, and toxicology risk of the investigated drugs were characterized. A scoping review was conducted in accordance with PRISMA-ScR guidelines and protocols. Online databases were searched using MeSH and subject terms. Articles reporting evidence on skeletal muscle relaxant use were reviewed by two independent reviewers with a third reviewer for any discrepancies. Scoping review. N/A. N/A. Comparison studies have not shown any skeletal muscle relaxant to be superior. Skeletal muscle relaxants are divided into two categories: antispastic and antispasmodic agents. Antispastic agents reduce muscle hypertonicity and involuntary jerks associated with neurological disorders. Antispasmodic agents aim to treat striated muscle spasms from musculoskeletal conditions such as low back pain and myofascial pain. Cyclobenzaprine is heavily studied, with demonstrated effectiveness for isolated conditions. Intravaginal diazepam may be beneficial, while other drugs have limited investigation. Considerable knowledge gaps remain regarding appropriate use of these medications in the context of pelvic pain. Scant high-quality data exist to support the use of skeletal muscle relaxants for chronic pelvic pain secondary to myofascial and hypertonic muscular dysfunction. Antispastic agents have limited evidence. Antispasmodic agent usage should be based on side-effect profile, patient preference, abuse potential, and possible drug interactions. Future prospective research on antispasmodic agents in women with myofascial dysfunction is necessary to define medication safety, route, dosage, and clinical outcomes.

A Novel Introduction to Treatment of Chronic Pelvic Pain with Extracorporeal Shock Wave Therapy (ESWT)

<h3>Study Objective</h3> To examine the effects of Extracorporeal shock wave therapy (ESWT) on women experiencing chronic pelvic pain. <h3>Design</h3> This is a case series study. Patients receive four treatments over the course of two weeks. Each patient will receive a follow-up survey after each treatment and within three months from their first treatment. <h3>Setting</h3> An Obstetrics and Gynecology private practice. <h3>Patients or Participants</h3> The study included 15 women with chronic pelvic pain for at least 6 months. <h3>Interventions</h3> In this clinical study, ESWT (Extracorporeal shock wave therapy) is a nonsurgical/noninvasive technique widely used to treat musculoskeletal diseases. This technology was applied directly to the perineum and site of pelvic pain over a course of four treatments. <b>Measurements and Main Results:</b> This data is preliminary. <h3>Conclusion</h3> Patients will be evaluated within three months to determine if this treatment has an impact on pain perception in our group of treated patients.

Gabapentin has Longer-Term Efficacy for the Treatment of Chronic Pelvic Pain in Women: A Systematic Review and Pilot Meta-analysis.

IntroductionGabapentin has potential analgesic benefits in patients with neuropathic pain, such as post-herpetic neuralgia and diabetic peripheral neuropathy neuropathic pain. However, its efficacy in women with chronic pelvic pain (CPP) remains contradictory. In the present study, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to ascertain the efficacy of this treatment.MethodsWe systematically reviewed RCTs published in PubMed, Embase, the Cochrane Library, Web of Science, and Google Scholar databases, up to July 2021. These articles compared gabapentin with placebo or any other active treatment for CPP in women, with ‘the change in pain scores from the baseline during the first 3 and 6 months of treatment’ taken as the primary outcome. We considered reductions equivalent to 1.0 cm for primary outcomes to be clinically important.ResultsFour studies, comprising 469 participants, were included in our meta-analysis. Results revealed that the gabapentin group had significantly higher change in pain intensity scores from baseline to 3 months [weighted mean difference (WMD) − 0.61 cm; 95% confidence interval (CI) − 0.97 to − 0.25; I2 = 0%; p = 0.0009] and 6 months (WMD − 1.38 cm; 95% CI − 1.89 to − 0.88; I2 = 0%; p < 0.00001), relative to the control group. The difference of 6-month pooled result was more clinically important. Results from analysis of secondary outcomes showed that gabapentin had no beneficial efficacy during the first 3 months of treatment. Although gabapentin treatment was associated with a higher risk of dizziness and somnolence, no statistically significant differences were observed with regards to the total incidence of adverse events.ConclusionsOverall, gabapentin could be a potential treatment option for CPP in women. However, as a pilot study, further studies are needed to explore the longer-term benefits and definite safety of this therapy in the future.Registration NumberPROSPERO registration number CRD42021249421.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-021-00330-4.

Advances of Laparoscopy for the Diagnosis of Pelvic Congestion Syndrome.

The objective of this review is to describe the effectiveness of laparoscopy in the diagnosis and treatment of pelvic congestion syndrome (PCS). PCS is a cause of chronic pelvic pain (CPP) and is associated with dysfunction of the pelvic venous system. PCS is more common in women of reproductive age, and hormonal changes are associated with its development along with other reasons (e.g., working and living habits). There is an urgent need to establish an effective algorithm for the diagnosis and treatment of CPP, which could have a dramatic effect in patients’ everyday life. This algorithm should be able to overcome known issues that lead to the underdiagnosis of PCS, such as the overlap of its symptoms with other diseases. Here, we present our findings from literature articles about the methods used in practice today for the diagnosis of this syndrome. We also compare the methods to propose the most promising technique for providing a diagnosis with high accuracy. In our understanding, laparoscopy is superior when compared to other methods. It can provide a diagnosis of PCS while excluding or identifying other comorbidities and can also lead toward the next steps for the treatment of PCS.

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.

PD01-11 SENSORY GLIAL GQ-GPCR SIGNALING ALLEVIATES VISCERAL PAIN AND IMPROVES MICTURITION FUNCTION IN AN ANIMAL MODEL OF UROLOGICAL CHRONIC PELVIC PAIN SYNDROME

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Interstitial Cystitis (PD01)1 Sep 2021PD01-11 SENSORY GLIAL GQ-GPCR SIGNALING ALLEVIATES VISCERAL PAIN AND IMPROVES MICTURITION FUNCTION IN AN ANIMAL MODEL OF UROLOGICAL CHRONIC PELVIC PAIN SYNDROME Alison Xie, Randall Meacham, and Anna Malykhina Alison XieAlison Xie More articles by this author , Randall MeachamRandall Meacham More articles by this author , and Anna MalykhinaAnna Malykhina More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001965.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with urological chronic pelvic pain syndrome (UCPPS) experience chronic pelvic pain (CPP) and lower urinary tract symptoms (LUTS). Afferent hypersensitivity in bladder-projecting sensory neurons plays an important role in the generation and maintenance of UCPPS symptoms, especially visceral pain and urinary frequency. We found that Gq-GPCR activation in satellite glial cells (SGCs) in the sensory ganglia decreases afferent sensitivity in lumbar nociceptive pathways, and could be a promising and highly innovative approach to alleviate the symptoms of bladder overactivity and pain. In this study, we aimed to test if activation of lumbosacral sensory glial Gq-GPCR signaling alleviates visceral pain, and improves LUTS in UCPPS mouse models. METHODS: A mouse model of UCPPS was induced by intravesical instillation of recombinant mouse vascular endothelial growth factor (VEGFA). VEGF levels were associated with CPP in UCPPS patients, and in animal models of bladder overactivity. In mice, VEGFA induces sensory nerve remodeling in the urinary bladder, visceral mechanical hypersensitivity. Pharmacogenetic activation of spinal and sensory ganglionic glia was achieved by expressing Gq-coupled Designer Receptors Exclusively Activated by Designer Drugs (Gq-DREADD) in GFAP+ glia via Gfap-hM3Dq transgenic mice or targeted adeno-associated viral vector (AAV) delivery. Gq-DREADD agonist, clozapine N-oxide (CNO), was used to selectively activate Gq-GPCR signaling in GFAP+ glia and to decreases sensory neuronal excitability in vivo in awake animals. Afferent sensitivity and bladder function were evaluated by clinically-relevant visceral nociceptive assays and awake cystometry. RESULTS: Lumbosacral glial Gq-GPCR activation significantly attenuated VEGFA-induced visceral hypersensitivity, increased micturition efficiency, and shortened intermicturition intervals. The glia-mediated neuromodulatory effects were long-lasting and dose-dependent, suggesting broader implication of neuromodulation in treating pain and hypersensitivity in pelvic diseases. CONCLUSIONS: Our data demonstrated that sensory glial-mediated neuromodulation effectively alleviated visceral pain and regulated micturition in animal model of UCPPS by inhibiting afferent excitability in the lumbosacral spinal cord and respective sensory ganglia. These results suggest a strong therapeutic potential of targeting GFAP-expressing glia for the treatment of chronic pelvic pain and LUTS in UCPPS patients. Source of Funding: Colorado Pilot Program Mentored Award, CCTSI, PI: Alison Xiaoqiao XieR01 DK121506-01, PI: Anna Malykhina © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e35-e35 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alison Xie More articles by this author Randall Meacham More articles by this author Anna Malykhina More articles by this author Expand All Advertisement Loading ...

Incidence and predictors of persistent pelvic pain following hysterectomy in women with chronic pelvic pain

Chronic pelvic pain is a debilitating problem that afflicts 15% to 20% of women in the United States. Although more than 200,000 hysterectomies are performed annually for the treatment of chronic pelvic pain, previous studies indicate that 1 in 4 women undergo the discomfort and morbidity of hysterectomy without the relief of pain. The factors that predict treatment failure remain poorly characterized. To describe the incidence of persistent pelvic pain 6 months following hysterectomy in women with chronic pelvic pain and determine whether a simple, self-reported measure of central sensitization is associated with a greater risk of persistent pelvic pain following hysterectomy. We conducted a prospective, observational cohort study of women undergoing hysterectomy at an academic tertiary care center for a benign indication. Patients with preoperative chronic pelvic pain, defined as average pelvic pain ≥3 on a 0 to 10 numeric rating scale for >3 months before hysterectomy, were included in this analysis. The patients completed validated assessments of pain, anxiety, depression, and centralized pain (using the 2011 Fibromyalgia Survey Criteria, 0-31 points) preoperatively and 6 months after hysterectomy. The demographic information, surgical history, intraoperative findings, and surgical pathology were abstracted from the electronic medical records. Multivariate logistic regression was used to identify the independent predictors of persistent pelvic pain 6 months following hysterectomy, defined as <50% improvement in pelvic pain severity. Among 176 participants with pelvic pain before hysterectomy, 126 (71.6%) were retained at 6 months, and 15 (11.9%) reported persistent pelvic pain. There was no difference in age (P=.46), race (P=.55), average pain severity during menses (P=.68), average overall pelvic pain (P=.10), or pain duration (P=.80) in those with and without persistent pelvic pain. Whereas intraoperative findings of endometriosis (P=.05) and uterine fibroids (P=.03) were associated with a higher incidence of persistent pain on univariate analysis, the surgical route (P=.46), pelvic adhesions (0.51), uterine weight (P=.66), and adenomyosis on histopathology (P=.27) were not related to the risk of persistent pain. Higher preoperative centralized pain scores (P=.01) but not depression (P=.64) or anxiety (P=.45) were more common in women with persistent pelvic pain. Multivariate logistic regression adjusting for age, preoperative pain severity, anxiety, depression, and operative findings of endometriosis and fibroids indicated that every 1-point increase in centralized pain before hysterectomy was associated with a 27% increase in the odds of persistent pelvic pain (odds ratio, 1.27; 95% confidence interval, 1.03-1.57) 6 months after surgery. Although the majority of women with chronic pelvic pain report considerable improvement in pain following hysterectomy, higher degrees of centralized pain before hysterectomy is a robust predictor of persistent pelvic pain.

Treatment of Dyspareunia with Botulinum Neurotoxin Type A: Clinical Improvement and Influence of Patients' Characteristics.

The treatment of chronic pelvic pain (CPP) with botulinum neurotoxin type A (BoNT/A) has increased lately, but more studies assessing its effect are needed. This study aimed to evaluate the evolution of patients after BoNT/A infiltration and identify potential responders to treatment. Twenty-four women with CPP associated with dyspareunia were treated with 90 units of BoNT/A injected into their pelvic floor muscle (PFM). Clinical status and PFM activity were monitored in a previous visit (PV) and 12 and 24 weeks after the infiltration (W12, W24) by validated clinical questionnaires and surface electromyography (sEMG). The influence of patients’ characteristics on the reduction in pain at W12 and W24 was also assessed. After treatment, pain scores and the impact of symptoms on quality of life dropped significantly, sexual function improved and sEMG signal amplitude decreased on both sides of the PFM with no adverse events. Headaches and bilateral pelvic pain were risk factors for a smaller pain improvement at W24, while lower back pain was a protective factor. Apart from reporting a significant clinical improvement of patients with CPP associated with dyspareunia after BoNT/A infiltration, this study shows that clinical characteristics should be analyzed in detail to identify potential responders to treatment.

Application of Bioinformatics Methods to Identify Key Genes and Functions in Chronic Pelvic Pain.

Neuropathologic pain (NPP) occurs in most patients with chronic pelvic pain (CPP), and the unique physiological characteristics of visceral sensory neurons make the current analgesic effect of CPP patients not optimistic. Therefore, this study explored the possible biological characteristics of key genes in CPP through the bioinformatics method. CPP-related dataset GSE131619 was downloaded from Gene Expression Omnibus to investigate the differentially expressed genes (DEGs) between lumbar dorsal root ganglia (DRG) and sacral DRG, and the functional enrichment analysis was performed. A protein-protein interaction (PPI) network was constructed to search subnet modules of specific biological processes, and then, the genes in the subnet were enriched by single gene set analysis. A CPP mouse model was established, and the expression of key genes were identified by qPCR. The results showed that 127 upregulated DEGs and 103 downregulated DEGs are identified. Functional enrichment analysis showed that most of the genes involved in signal transduction were involved in the pathway of receptor interaction. A subnet module related to neural signal regulation was identified in PPI, including CHRNB4, CHRNA3, and CHRNB2. All three genes were associated with neurological or inflammatory activity and are downregulated in the sacral spinal cord of CPP mice. This study provided three key candidate genes for CPP: CHRNB4, CHRNA3, and CHRNB2, which may be involved in the occurrence and development of CPP, and provided a powerful molecular target for the clinical diagnosis and treatment of CPP.

Medical and social aspects in women of reproductive age with chronic pelvic pain

The objective: a study of the medical and social characteristics of women in reproductive age with chronic pelvic pain on the basis of retrospective analysis.Materials and methods. The analysis of medical documentation of 314 patients in reproductive age with a verified diagnosis of chronic pelvic pain (CPP) was performed on the basis of studying of case histories and outpatient cards. Data were analyzed: anthropometric data, age, body mass index, place of residence, gynecological pathology, duration and nature of the menstrual cycle, comorbidities, previous treatment, disease duration, pain intensity, bad habits, number of pregnancies and births, reproductive plans and other methods examination.Results. It was found that more than a third of women, who were treated for pathologies that cause CPP, need medical help again. 58 % of patients sought help for CPP for the first time, 42 % had already received treatment for CPP. Concomitant non-gynecological pathology is more often observed in such patients (48.7 %).The most commonly diagnosed were interstitial cystitis (42 %) and irritable bowel syndrome (34 %). The combination of gynecological, urological and surgical pathology was found in 22 % of patients. Patients with CPP had deficiency in vitamin D (68 % of the 162 patients tested for vitamin D) and had subjectively more severe pain. At the same time, the lack of routine examination of thyroid function and vitamin D status attracted attention. Simultaneously, women with CPP are much more likely than the general population to have infertility (56.4 %), and the incidence of miscarriage is twice as high as the population, with a tendency to recurrent pregnancy loss.Conclusions. Concomitant non-gynecological pathology, infertility, miscarriage, vitamin D deficiency and subjectively more severe pain are more common in women with chronic pelvic pain. However, the level of diagnosing thyroid pathology and determining the concentration of vitamin D in such patients is insufficient.

An integrated approach to the treatment of pelvic pain associated with adenomyosis

Dysmenorrhoea and intermenstrual pelvic pain are the most common symptoms of clinical manifestations of adenomyosis, which significantly impair the quality of women’s life. Adequate and long-term pain correction and alternative therapeutic approaches became extremely important for patients with adenomyosis during the COVID-19 pandemic. Research objective: to examine the clinical efficacy of nitric oxide donor (L-arginine) in the complex treatment of pelvic pain syndrome associated with adenomyosis.Materials and methods. The study included 63 women diagnosed with adenomyosis. Patients were divided into 2 groups by simple randomization: I (D) group (n = 31) received dydrogesterone 30 mg from 5 to 25 days of the menstrual cycle, II (D+T) group (n = 32) in addition to dydrogesterone received a nitric oxide donor L-arginine (Тivortin) according to the scheme. Pelvic pain was assessed before treatment with a Visual Analogue Scale and a McGill Pain Questionnaire, and an assessment of the overall pain impact on women's well-being was based on the SF-36 Health Status Survey. The effectiveness of pelvic pain therapy was assessed after the first and third months of treatment, as well as three months after the end of therapy with the above methods.Results. Researchers achieved a therapeutic effect in the treatment of chronic pelvic pain in both study groups, but in group II (D + T) after 3 months of treatment there was a significant reduction in pelvic pain, while patients of the standard therapy group have prolonged progestogen intake. There was a further improvement in the clinical condition in group I (D) after 6 months of follow-up, as well as no recurrence of pain in group II (D + T).Conclusions. The results of study demonstrate a significant effect of Tivortin as part of complex therapy on the rate of achievement and duration of therapeutic effect in the treatment of pelvic pain associated with adenomyosis.

Effect of BoNT/A in the Surface Electromyographic Characteristics of the Pelvic Floor Muscles for the Treatment of Chronic Pelvic Pain.

Chronic pelvic pain (CPP) is a complex condition with a high economic and social burden. Although it is usually treated with botulinum neurotoxin type A (BoNT/A) injected into the pelvic floor muscles (PFM), its effect on their electrophysiological condition is unknown. In this study, 24 CPP patients were treated with BoNT/A. Surface electromyographic signals (sEMG) were recorded at Weeks 0 (infiltration), 8, 12 and 24 from the infiltrated, non-infiltrated, upper and lower PFM. The sEMG of 24 healthy women was also recorded for comparison. Four parameters were computed: root mean square (RMS), median frequency (MDF), Dimitrov’s index (DI) and sample entropy (SampEn). An index of pelvic electrophysiological impairment (IPEI) was also defined with respect to the healthy condition. Before treatment, the CPP and healthy parameters of almost all PFM sides were significantly different. Post-treatment, there was a significant reduction in power (<RMS), a shift towards higher frequencies (>MDF), lower fatigue index (<DI) and increased information complexity (>SampEn) in all sites in patients, mainly during PFM contractions, which brought their electrophysiological condition closer to that of healthy women (<IPEI). sEMG can be used to assess the PFM electrophysiological condition of CPP patients and the effects of therapies such as BoNT/A infiltration.

The role of the multi-disciplinary team and multi-disciplinary therapeutic protocol in the management of the chronic pelvic pain: There is strenght in numbers!

Introduction: The aim of the study is to evaluate the effectiveness of a Multi-disciplinary team (MDT) and multi-disciplinary approach in the treatment of Chronic Pelvic Pain (CPP). Methods: The data of all consecutive patients referred for a CPP from 11/2016 to 2/2019 has been prospectively collected. The sample was divided in two groups: Group A, made by patients managed after the institution of our MDT, and Group B, made of patients managed before this date. The MDT is composed by three urogynecologists, a psychologist and a physiotherapist. All Group A patients underwent a weekly bladder instillation with dimethyl sulfoxide (DMSO), kinesiotherapy for trigger points and Percutaneous Tibial Nerve Stimulation for 10 consecutive weeks. Patients were asked to perform a self-treatment following the Stanford Protocol and to adhere to a specific diet. All Group B patients were managed only with DMSO instillations and a strict diet. Results: The Group A was made of 41 females and 6 males while the Group B was made of 38 females and 5 males. The Group A patients showed a statistically significant improvement in the Pelvic Pain Urgency Frequency, in the frequency times reported at the 6 months voiding diary, and a better Patient Global Impression of Improvement. Conclusions: Our data support the efficacy of the MDT in the management of CPP. The multimodal approach might represent an effective and reproducible non-invasive option to manage successfully CPP.

Pain syndrome in adenomyosis. Finding new pathogenesis links and non-hormonal correction opportunities. Literature review

Adenomyosis is characterized by polymorphism of clinical manifestations and is the cause of chronic pelvic pain associated with endometriosis in 53–80% of cases. Heavy dysmenorrhea in adenomyosis is a key factor that reduces the quality of life and, moreover chronic pain reduces stress resistance and launches the rehabilitation cytokines cascade, which causes exacerbation of endometriosis. Formation of painful syndrome with adenomyosis may be due to: changes in neurohumoral regulation, stimulation of nerves and blood vessels growth and myometrium inflammatory remodeling against the background of circulatory disorders and vascular sclerosis. These processes lead to violation of neuroimmune relationships that determine the increase in the number and sensitivity of nociceptors against the background of the chronic immuno-inflammatory process in endometrials and myometry.Experimental studies have shown that the supraspinal role of the nitric oxide (NO) is to indirect mechanical nociceptive reflexes. The dose-dependent L-arginine role in the pain syndrome formation also was shown; it was found that small doses of L-arginine lead to the activation of nNO-synthase and analgesic effect. Large doses are activated by cotorphine synthase to form a dipeptide of cortorphine (L-tyrosine-L-arginine), which induces the met-enkephalin release and analgesic effect. Individual studies have demonstrated a decrease in the symptoms of urinary pain syndrome during L-arginine treatment, which made it possible to include it into the European Association of Urologists recommendations on the chronic pelvic pain treatment in 2017.Clinical comparative study (2013) of the NO donator (L-arginine) effectiveness in the treatment of endometriosis-associated intermenstrual pelvic pain and dysmenorrhea showed a high efficiency of a 3-month course of combination therapy (dienogest 2 mg + Tivortin 4.2 g). Supplement of basic therapy by NO donator (L-аrginine) has shown a faster reaching the clinical effect on reducing endometriosis-associated symptoms and sustainable maintenance of the result achieved. The multifaceted pharmacological effects of L-arginine directly affect a number of essential factors for the adenomyosis development and progression, which allows using this drug in clinical practice.

Chronic Pelvic Pain Educational Experience Among Minimally Invasive Gynecologic Surgery Fellows and Recent Graduates: A Needs Assessment

Learning to evaluate and treat chronic pelvic pain (CPP) is an established curriculum objective within the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Our aim was to investigate current educational experiences related to the evaluation and management of CPP and the impacts of those experiences on FMIGS fellows and recent fellowship graduates, including satisfaction, confidence in management, and clinical interest in CPP. The AAGL-Elevating Gynecologic Surgery Special Interest Group for pelvic pain developed a 33-item survey tool to investigate the following topics: (1) current educational experiences with the assessment and management of patients with CPP, (2) satisfaction with fellowship training in CPP, (3) perceived preparedness to treat patients with CPP, (4) plans to incorporate management of CPP into clinical practice, and (5) perceived desires to expand CPP exposure. Composite scores were created to examine experiences related to diseases associated with CPP and pharmaceutical and procedural treatment options. Electronic survey. Not applicable. The survey was distributed via AAGL email lists and offered on FMIGS social media sites from August 2017 to November 2017 to all active FMIGS fellows and individuals who graduated the fellowship during the preceding 5 years. Fifty-three of 82 (65%) current FMIGS fellows and 104 of 169 (62%) recent fellowship graduates completed the survey. Only 66% of current fellows endorsed working with a fellowship faculty member whose clinical work focused on CPP. Most current fellows reported having a "good amount" of experience or "extensive" experience with superficial endometriosis (39/53, 74%) and deeply infiltrative endometriosis (34/53, 64%), whereas the majority reported having "no" or "little" experience with frequently comorbid conditions like irritable bowel syndrome (68%), pelvic floor tension myalgia (55%), and interstitial cystitis/painful bladder syndrome (51%). For both current fellows and recent graduates, increased CPP Disease Experience composite scores were associated with satisfaction with CPP training (current fellows odds ratio [OR] 1.9, p=.002; recent graduates OR 1.5, p< .001), perceived preparedness to treat patients with CPP (current fellows OR 2.0, p=.0021; recent graduates OR 1.5, p<.001), and the desire to incorporate the treatment of CPP into future clinical practice (current fellows OR 1.8, p=.0099; recent graduates OR 1.3, p=.0178). More than 80% (43/53) of current fellows indicated that they believed an expanded pelvic pain curriculum should be part of the FMIGS fellowship. This needs assessment of FMIGS fellows and recent graduates suggests that there are gaps between FMIGS curriculum objectives and current educational experiences, and that fellows desire increased CPP exposure. Expansion and standardization of the CPP educational experience is needed and could lead to increased focus on this disease process among subspecialty benign gynecologic surgeons.

Attachment of the levator ani muscle extends to the superior ramus of the pubic bone through electrophysiological and anatomical examinations

Myofascial pelvic pain (MFPP) of pelvic floor muscles is a common cause of chronic pelvic pain (CPP). The pathological mechanisms and treatments of MFPP are complex and still unclear until now. The levator ani muscle (LAM) is the major pelvic floor muscle. The purpose of this study was to examine the fascia and attachment of LAM through the electromyogram (EMG) and cadaver dissection. Electrophysiological stimulation of the obturator fascia above the arcus tendinous levator ani (ATLA) could trigger contraction and electrophysiological changes in LAM insertion. The LAM of embalmed adult cadavers was examined especially in the area above the ATLA. Some skeletal muscle fibers were found above the ATLA within the obturator fascia and were confirmed by Masson’s trichrome section staining. Our electromyography (EMG) and anatomical data implied that the attachment of LAM aponeurosis extended beyond ATLA to the inferior border of the superior ramus of the pubic bone. The new discovered attachment of LAM could provide a reference position for clinical diagnosis and treatment of MFPP or CPP.

Feasibility of Ultrasound-Guided Peritoneal Perfusion with Ozone in the Treatment of Chronic Pelvic Pain: A Bicenter Retrospective Analysis

Numerous therapies have been developed for the treatment of chronic pelvic pain (CPP). Oxygen-ozone therapy is a new method for the treatment of CPP. This article evaluated the feasibility of ultrasound-guided peritoneal perfusion with ozone in patients with CPP. This is a bicenter retrospective study. The study was conducted at 2 pain centers of a university hospital. The medical records of patients with CPP (n = 60) from March 2016 until October 2018 were collected and reviewed. Group A contained 19 patients who were treated with a 1500 mcg dose of ozonated water (10 mcg/mL concentration and 150 mL volume), group B contained 23 patients using the same dose of ozonated water but a 15 mcg/mL concentration and 100 mL volume. Group C included 18 patients using a similar ozone dose but delivered in an oxygen-ozone mixture (15 mcg/mL concentration and 100 mL volume oxygen-ozone mixture). Visual Analog Scale (VAS) scores for pain of the 3 groups were compared at pretreatment, posttreatment, 1, 3, and 6 months posttreatment. The injection pain was evaluated using a 4-point verbal rating scale. Quality of life (QoL), anxiety, and depression were assessed at pretreatment and at 6 months posttreatment. The VAS scores of the 3 groups decreased over time following treatment. Group A showed much higher pain scores compared with groups B and C at 1, 3, and 6 months posttreatment. However, the injection pain for groups B and C was higher than group A, but there was no difference seen between group B and C. At 6 months posttreatment, the QoL for all patients improved compared with pretreatment, whereas the anxiety and depression did not demonstrate differences. The main limitations of this study are the retrospective study design, limited case number, and short follow-up period. Ultrasound-guided peritoneal perfusion with ozone is a feasible therapy for patients with CPP.