Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain

BACKGROUND: To enhance the understanding of the pathophysiology of women with peripartum pelvic pain, it is necessary to couple anatomical insights with relevant clinical research. In this context, the long dorsal sacroiliac ligament is especially of interest because it was noticed that women diagnosed with peripartum pelvic pain frequently experience pain within the boundaries of this ligament. Njoo (1) found a high intertester reliability and a high specificity for long dorsal sacroiliac ligament pain. The present article focuses on the possible role of the long dorsal sacroiliac ligament in the pain pattern of women with peripartum pelvic pain. The diagnostic and therapeutic consequences are considered. STUDY DESIGN: A cross-sectional analysis was performed in a homogenous group of women meeting strict criteria for posterior pelvic pain since pregnancy, diagnosed as having peripartum pelvic pain and excluded for any history of fracture, neoplasm or previous surgery of the lumbar spine, the pelvic girdle, the hip joint or the femur. The patients were also excluded for signs indicating radiculopathy: asymmetric Achilles tendon reflex and/or (passive) straight leg raising restricted by pain in the lower leg. METHODS: The study group comprised 178 women diagnosed with peripartum pelvic pain, selected from the outpatient clinic of a specialized rehabilitation center. Selection was based on criteria enabling a strict division between lumbar and pelvic complaints. Pain in the long dorsal sacroiliac ligament was detected by standardized palpation of the long dorsal sacroiliac ligament by specifically trained physicians and scored on a modified scale. Comparisons with the posterior pelvic pain provocation test and the active straight leg raise test was carried out. RESULTS: The present study confirms that the long dorsal sacroiliac ligament frequently shows tenderness on palpation in patients with peripartum pelvic pain. Sensitivity was 76%. Sensitivity in a group of 133 women of the study group that scored positive on both active straight leg raise and posterior pelvic pain provocation tests was 86%. When only severe pelvic patients were included, sensitivity increased to 98%. In comparisons between the posterior pelvic pain provocation and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.33 and 0.41, respectively. In comparisons between the active straight leg raise and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.35 and 0.41, respectively. CONCLUSIONS: The present study, carried out on a group of peripartum pelvic pain patients with strict in- and exclusion criteria, attempts to further elucidate the pathophysiology of patients with peripartum pelvic pain by adding a simple pain provocation test. It is concluded that the combination of the active straight leg raise, the posterior pelvic pain provocation and the long dorsal sacroiliac ligament pain tests combined with the proposed in- and exclusion criteria seems promising in differentiating between mainly lumbar and pelvic complaints. Although the sensitivity of the long dorsal sacroiliac ligament pain test seems promising, further clinical study is necessary in targeting specifically the long dorsal sacroiliac ligament. It is suggested that studies initiated to show the prevalence of sacroiliac joint pain in patients presenting nonspecific lumbopelvic pain, by using intra-articularly double block injection techniques, should include a peripheral injection of at least the long dorsal sacroiliac ligament.     

Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome).

Ovarian and pelvic (internal iliac) varices have long been recognized as a source of chronic pelvic pain in women. The technique of transcatheter embolotherapy for ovarian and pelvic varices requires selective catheterization of the ovarian and internal iliac veins, followed by contrast venography and embolization. The long-term effects of treatment are the subject of ongoing investigation. This article provides a concise background on ovarian and pelvic varices and reviews the recently published literature on their embolization for the treatment of pelvic venous incompetence (also known as pelvic congestion syndrome).     

The relation of pelvic pain and dense adhesions to Doppler ultrasound findings in patients with ovarian endometriomas

Purpose

To study the relation of pelvic pain symptoms and pelvic adhesions to Doppler ultrasound findings in patients with ovarian endometriomas.

Methods

62 patients who underwent laparoscopic surgery for endometrioma were divided into two groups according to their pelvic pain symptoms. Group 1 (n = 27) included patients with pelvic pain, group 2 (n = 35) asymptomatic patients. Patients were evaluated for the vascularization of endometrioma by transvaginal color and power Doppler ultrasonography before the surgery. The presence and amount of blood flow reported in terms of a color scale, pulsed Doppler indices, and dense pelvic adhesions were compared between the groups. The relation of Doppler ultrasound findings to the dense pelvic adhesions was also analyzed.

Results

Blood flow was present in 74.1 % (n = 20) of patients in group 1 and 68.6 % (n = 24) in group 2 (p = 0.63). The volume and vascularization of the endometriomas, pulsed Doppler indices, stage of endometriosis, and the presence of dense pelvic adhesions were also similar. Patients with dense pelvic adhesions had significantly higher amount of blood flow compared to patients without adhesions (p = 0.006), but the mean pulsatility index and resistance index were not different between the groups (p = 0.55 and 0.59, respectively).

Conclusions

Pelvic pain symptoms were not found to be related to endometrioma vascularization. On the other hand, we observed an association between higher vascularized endometrioma and the presence of dense pelvic adhesions.     

Laparoscopic evaluation of infertile patients with chronic pelvic pain

In this study over a 10-year period, 1584 patients complaining of infertility of more than 1 year duration were evaluated for their laparoscopic findings in relation to the presence or not of chronic pelvic pain (CPP). Infertility was the only complaint in 1215 cases (group 1), whereas 369 patients complained of infertility and CPP (group 2). All cases underwent routine infertility investigation and pelvic ultrasonography, followed by diagnostic laparoscopy, with infertility-only cases acting as a control group. At laparoscopy 76.7% of patients with CPP were found with pelvic pathology, compared with only 42.6% of cases without CPP (P < or = 0.0001). Omental-abdominal wall adhesions, advanced endometriosis, endometriomas with adhesions, pelvic venous congestion, and hydrosalpinges with pelvic adhesions were significantly more frequent in cases with CPP. Dysmenorrhoea was the most frequent type of CPP. Cases with CPP and a negative laparoscopy were further investigated using a multidisciplinary approach. In conclusion, chronic pelvic pain can be the result of several pelvic pathologies. Infertile patients with CPP are much more frequently found with an abnormal pelvis in comparison with cases without CPP. Laparoscopy is an invaluable diagnostic tool especially for symptomatic patients and should be used early in their diagnostic infertility work-up.     

CA-125 in menstrual discharge in patients with chronic pelvic pain.

CA-125 levels in menstrual discharge were determined in 55 patients with chronic pelvic pain to evaluate whether this test would be useful in differentiating between pelvic pain due to endometriosis and other causes. Of the 28 women with endometriosis, 25 (89%) had CA-125 concentration greater than or equal to 72,000 units/ml. The frequencies of elevated levels in Stage I, Stage II and Stages III/IV were 85.7, 85.7 and 92.8%, respectively. When used for the detection of endometriosis, the test had a sensitivity of 89.3% and a specificity of 96.3%. These results suggest that CA-125 in menstrual discharge may be helpful in the evaluation of women with chronic pelvic pain.     

Results of laparoscopic lysis of adhesions in patients with chronic pelvic pain]

A report is made about 153 women patients who underwent laparoscopic adhesiolysis, and who underwent laparoscopy primarily because of unclear chronic pelvic pain (57.5%), suspected adhesion (13.1%) or sterility (11.7%). For 86.9% of the patients a complete and only for 13.1% an incomplete adhesiolysis was possible. Out of the 123 patients (80.4%) suffering from pain before adhesiolysis 99 (80.5%) patients could be reexamined by questionnaire one to eight years later. 38.0% suffered from no pain any longer, 20.2% stated a clear improvement, 25.5% being temporarily free from pain only, and 16.2% stated unchanged pain. Because of the results laparoscopic adhesiolysis is recommended for women patients with mere adhesions and chronic pelvic pain and for patients without pain with adhesions who are exposed to a danger of ileus.     

Successful treatment of refractory endometriosis-related chronic pelvic pain with aromatase inhibitors in premenopausal patients

Objective

Not every patient with endometriosis responds to currently recommended conventional medical treatment regimens. The objective of this study was to determine the efficacy and side effects of aromatase inhibitors in the treatment of premenopausal patients with endometriosis associated with chronic pelvic pain refractory to conventional treatment.

Study design

Four premenopausal patients with documented refractory endometriosis and chronic pelvic pain were treated with aromatase inhibitors, either anastrazole (3) or letrozole (1), for 6 months. The treatment was combined with calcium 1.5 g per day and vitamin D 800 U per day. The main outcome measure was reduction in pelvic pain assessed by visual analogue scale. Side effects were documented and changes in serum LH, FSH and 17-β estradiol and bone density (Dexa scan) were measured before, during and after treatment.

Results

There was marked improvement in pelvic pain in the four patients. Their mean pain score fell from 9 prior to treatment to 4.5 at the end of treatment. One patient with infertility conceived immediately after completing the treatment. There were no changes in the hormone levels and bone scan scores. The most common side effect was irregular bleeding with anastrazole and joint pains with letrozole.

Conclusions

Aromatase inhibitors are beneficial in premenopausal women with chronic pelvic pain secondary to refractory endometriosis without compromising fertility and with minimal side effects. Further cohort and comparative studies are needed to confirm these observations.     

Thrombospondin-1 serum levels do not correlate with pelvic pain in patients with ovarian endometriosis

Objetive

Thrombospondin-1 serum levels is correlate with pelvic pain in patients with ovarian endometriosis.

Patients

Thrombospondin-1 serum levels were prospectively analysed in 51 patients (group A asymptomatic patients or patients presenting mild dysmenorrhea and women comprised group B severe dysmenorrhea and/or chronic pelvic pain and/or dyspareunia) who underwent surgery for cystic ovarian endometriosis to asses whether a correlation exists among thrombospondin-1 serum levels and pelvic pain.

Results

From 56 patients, five cases were ultimateley excluded, because the histological diagnosis was other than cystic ovarian endometriosis (2 teratomas and 3 haemorragic cysts). The mean thrombospondin-1 serum levels in group A was 256,69 pg/ml_+37,07 and in group B was 291,41 pg/ml + 35,59.

Conclusion

Pain symptoms in ovarian endometriosis is not correlated with thrombospondin-1 serum levels.     

Sonographic assessment of symphyseal joint distention during pregnancy and post partum with special reference to pelvic pain

OBJECTIVE: To elucidate whether there is a relationship between pregnancy-related pelvic pain and degree of symphyseal laxity. METHODS: Forty-nine women were interviewed and examined and ultrasonographic measurement of symphyseal width and vertical shift was conducted at 12 and 35 weeks of pregnancy and at 5 months post partum. The patients were retrospectively classified into four groups on the basis of presence and degree of pain in late pregnancy and presence or absence of pain at follow up. RESULTS: The prevalence of pelvic pain of any degree during pregnancy was 49%, of pronounced pain 16.3% and of severe pain 6.1%. Nineteen percent had any remaining pain at 5 months post partum. The median symphyseal width at 12 and 35 weeks of pregnancy and at 5 months post partum was 3.5 mm, 4.6 mm and 2.8 mm, the median vertical shift 0.0 mm, 0.8 and 0.9 mm respectively. Those with disabling pain during pregnancy and no pain at follow up had greater symphyseal width (6.3 mm) and vertical shift (1.8 mm) at 35 weeks of pregnancy than controls; 4.5 mm (p<0.01) and 0.5 mm (p<0.01) respectively. Those with disabling pain during pregnancy and persistent pain at follow up did not differ significantly from controls in symphyseal width or shift. The most severe cases were in this group. CONCLUSION: There is a minor pregnancy-induced physiological increase in laxity of the symphyseal soft tissue. There is no evidence that the degree of symphyseal distention determines the severity of pelvic pain in pregnancy or after childbirth.     

Measurement of blood flow in maternal pelvic artery and umbilical cord artery with the ultrasonic pulsed Doppler flow method

The maternal pelvic artery was detected with the B-mode, and volume of flow through it measured with the pulsed ultrasound Doppler device in the supine and left recumbent positions. The blood flow state and vascular resistance of the maternal pelvic artery and of the umbilical cord artery were investigated in gestosis and normal pregnancy. The volume of blood flow through the right maternal pelvic artery showed a tendency to increase after the posture was changed to the left recumbent position. The peak frequency (Fp) showed a tendency to increase in gestosis, particularly in the edema group. The spectral width (SWp)/Fp value showed a tendency to be lower in the edema group than in normal subjects, and showed a higher value in hypertension accompanied by proteinuria than in normal subjects. As an indication of peripheral vascular resistance, the pulsatility index (PI) in the maternal pelvic artery was determined, and resistance index (RI) in the umbilical cord artery was also determined. The PI showed a tendency to increase more in gestosis than in normal subjects, particularly in hypertension accompanied by proteinuria. The RI was higher in maternal hypertension accompanied by proteinuria than in normal pregnancy. The hematocrit and fibrinogen vales were slightly higher, though insignificantly, in gestosis than in normal subjects.     

Fourteen-year experience with laparoscopic ventrosuspension in patients with retroverted and retroflected uterus and pelvic pain syndromes

BackgroundIn women with a retroverted uterus, who have dyspareunia, chronic pelvic pain, or dysmenorrhea, laparoscopic ventrosuspension of the uterus has been reported effective in achieving symptom relief.Study ObjectiveTo critically review our experience with our method of laparoscopic ventrosuspension.DesignCohort study (Canadian Task Force classification II-3).SettingTertiary care center.PatientsSixty-three women who had undergone laparoscopic ventrosuspension for treatment of pain syndromes during 1995 through 2008.InterventionsLaparoscopic ventrosuspension, and a questionnaire about the long-term outcome of the operation.Measurements and Main ResultsThere were no adverse events except for 2 repeat operations within 3 postoperative days. Forty-nine women (77.8%) answered the questionnaire about long-term outcome, and in these patients, significant pain relief was achieved (p <.001). Pain levels decreased, based on a numeric rating scale, from a mean (SD) of 6.35 (1.92) to 0.97 (1.40) in patients without endometriosis, and from 6.93 (2.09) to 3.80 (2.08) in those with endometriosis. Of 34 patients without endometriosis, 1 (2.9%) stated that the operation had not led to symptom relief, compared with 4 of 15 (26.7%) with endometriosis (p = .03).ConclusionLaparoscopic ventrosuspension is clearly beneficial in women with a retroverted and retroflected uterus who have pelvic pain syndromes, even in the long term.     

盆底器官脱垂患者肛提肌的动态MRI研究

目的:探讨盆底器官脱垂(POP)患者肛提肌的动态MRI表现特征,建立基于MRI的盆底肌肉和韧带损伤的诊断技术。方法:POP组32例,对照组15例。分别比较两组肛提肌裂隙、髂尾肌厚度、耻骨直肠肌厚度、髂尾肌角度和肛提肌板角度的变化。结果:(1)POP组肛提肌裂隙面积较对照组明显增大(P=0.008);(2)POP组左右侧髂尾肌和右侧耻骨直肠肌厚度在静息位和最大腹压时均较对照组薄,差异有统计学意义(P均<0.05);对比腹压作用前后肛提肌厚度的变化,两组差异均无显著性(P均>0.05);(3)最大腹压时,POP组髂尾肌角度和肛提肌板角度较对照组明显增大(P=0.001和0.007);比较腹压作用前后的角度变化,POP组有显著差异(P=0.003和0.044)。结论:MRI检查可以很好地观察肛提肌的形态,动态检查还可以评价肛提肌的功能状态。     

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications

Application of vaginal mesh for stress urinary incontinence has seen widespread use due to its relatively short operative time in combination with its efficacy in treatment. However, vaginal mesh is not without its drawbacks and can lead to mesh erosion or extrusion, infection, dyspareunia, and recurrence of incontinence. Vaginal mesh complications can lead to feelings of hopelessness, isolation, shame, and emotional distress. Furthermore, failure to identify and address these complications in a timely manner can be permanently damaging to patient health. It is vital to be able to identify mesh complications early. Various imaging methodologies exist to visualize vaginal mesh placement and complications, including ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT). This invited review paper focuses on the role of ultrasound in mesh visualization, mesh complication identification, and operative planning in the event of subsequent surgical mesh revision. Polypropylene mesh is echogenic on ultrasound, making it a useful tool for visualizing post-operative mesh placement. Transperineal, translabial and endovaginal ultrasound technique use has been described in the pre- and peri-operative setting to identify mesh in complex cases. Efficacy and practicality of CT and MRI use in identifying mesh in these cases is limited.     

The prevalence of endometriosis in women with chronic pelvic pain

BACKGROUND: The 2004 American College of Obstetrics and Gynecology clinical management guideline states that the prevalence of endometriosis is approximately 33% in women with chronic pelvic pain (CPP). This estimate came from a review showing that 28% of adult women with CPP were found to have endometriosis. The prevalence of 28% in adult women was arrived based on a compilation of 11 published studies. Yet even within the 11 studies, the reported prevalence of endometriosis varies wildly, ranging from 2 to 74%. Such an astounding variation or heterogeneity raises the question whether it is appropriate to use a single prevalence of endometriosis for all women with CPP. METHODS: We sought to identify possible sources of heterogeneities in the estimation of prevalence of endometriosis in women with CPP. We included more studies that reported prevalence estimates than the review, and examined the effect of sample size and the year of publication on the heterogeneity. RESULTS: The year of publication is positively associated with the prevalence estimate, which may indicate an increasing awareness of various appearances of endometriosis, or the prevalence of endometriosis may have increased among women with CPP. An alternative analysis with removal of four studies reporting highest prevalence estimates indicated that sample size is negatively associated with the prevalence estimates while the year of publication became only marginally significant. CONCLUSIONS: There are identifiable sources of heterogeneity in prevalence estimates, with the year of publication, sample size, and difference in evaluation of CPP being three apparent sources. Having a single prevalence estimate for all women with CPP may be too simplistic at best. The true prevalence is very likely to be higher than 33%.     

Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis

Objective: To evaluate and compare the safety and efficacy of leuprolide versus placebo in managing chronic pelvic pain in women with clinically suspected endometriosis.Methods: Women 18–45 years of age with moderate to severe pelvic pain of at least 6 months’ duration underwent extensive, noninvasive diagnostic testing and laboratory evaluation, including pelvic ultrasound, complete blood count, determination of erythrocyte sedimentation rate, and endocervical cultures. Those with clinically suspected endometriosis were randomized to double-blind treatment for 3 months with depot leuprolide (3.75 mg/mo) or placebo. The accuracy of the clinical diagnosis of endometriosis was evaluated by posttreatment laparoscopy.Results: Of 100 women randomized, 95 completed the study: 49 in the leuprolide group and 46 in the placebo group. Women in the leuprolide group had clinically and statistically significant (P ≤ .001) mean improvements from baseline after 12 weeks of therapy in all pain measures. These mean improvements were significantly greater (P ≤ .001) than those in the placebo group. At 12 weeks, mean decreases in physician-rated scores for dysmenorrhea, pelvic pain, and pelvic tenderness were 1.7, 1.0, and 0.8 points greater, respectively, in the leuprolide group than in the placebo group (on a four-point scale). Thirty-eight (78%) of 49 and 40 (87%) of 46 patients in the leuprolide and placebo groups, respectively, had laparoscopically confirmed endometriosis after 12 weeks of treatment. No women withdrew from the study because of adverse events.Conclusion: Depot leuprolide was effective and safe for treating patients with chronic pelvic pain and clinically suspected endometriosis, confirming the potential of its empiric use in these patients.     

Conservative surgical management of endometriosis in women with pelvic pain

Endometriosis is a common cause of pelvic pain in women. This article addresses the conservative surgical treatment of endometriosis for this indication.