A life of pelvic pain

Pelvic pain associated with menstruation, i.e., dysmenorrhea, is a chronic pelvic pain that not only interferes with a woman's wellbeing for a large part of her life but also often co-occurs with other chronic painful conditions such as interstitial cystitis and irritable bowel syndrome and others. Little has been known about mechanisms underlying these chronic pelvic pains. This paper reviews 37 years of research in my laboratory at Florida State University on such mechanisms. Our research, mostly on rats, has contributed to the following findings: (1) Female reproductive organs are innervated in a topographic fashion by afferents in the pelvic (vagina/cervix) and hypogastric (cervix/uterine horn) nerves. (2) The input contributes to uterine and vaginal perceptions (nociception) that are modified by reproductive status. (3) Throughout the CNS, neurons responsive to stimulation of the reproductive tract also respond to stimulation of skin and other internal organs, in a manner modifiable by reproductive status and peripheral pathophysiology. (4) This dynamic physiological convergence may reflect extensive anatomical divergence of and interconnections between pathways entering the CNS via gateways through the spinal cord, dorsal column nuclei, and solitary nucleus. (5) The convergence also indicates the existence of extensive cross-system, viscero-visceral interactions within the CNS, that, while organized for coherent bodily functioning, serves as a substrate by which pathophysiology in one organ can influence physiology and responses to pathophysiology in other organs. (6) Some cross-system effects observed so far include: (a) Bladder inflammation reduces the rate of uterine contractions and the effects of drugs on the uterus. (b) Colon inflammation produces signs of inflammation in the otherwise healthy bladder and uterus. (c) A surgical model of endometriosis produces vaginal hyperalgesia, exacerbates pain behaviors induced by a ureteral stone, and reduces volume voiding thresholds if the bladder. These cross-system effects, which likely involve CNS mechanisms, likely also underlie co-occurrence of painful clinical conditions. Research continues on details of these mechanisms and their relevance for clinical diagnosis and therapy. None of this work could have been done without collegial support of colleagues and technical staff at Florida State University.     

Clinical anatomy of pelvic pain in women

Pelvic pain is a common symptom that affects women worldwide and usually presents with variable range of severity, duration, and location. Several gynecological conditions may result in pelvic pain, and may have a variable presentation among patients. Pelvic pain creates a significant challenge and frustration to both patients and clinicians, which also creates a significant burden on the economy. It is necessary to tailor the management of pelvic pain to each individual patient to achieve optimal outcomes. Endometriosis, adenomyosis, and fibroids result in pelvic pain and may occur simultaneously. This review highlights some of the common gynecological etiologies of pelvic pain with a focus on anatomy, diagnosis, and management. Clin. Anat. 9999:1–5, 2018. © 2018 Wiley Periodicals, Inc.     

Laparoscopic presacral neurolysis for endometriosis-related pelvic pain

BACKGROUND: Some patients with endometriosis are candidates for sympathectomy of the superior hypogastric plexus. The objective of this paper is to describe our technique of laparoscopic presacral neurolysis for sympathectomy and to report 1 year results of the first 15 cases. METHODS: To achieve this objective in a prospective observational study of 1 year follow-up; we performed laparoscopic presacral chemical neurolysis with phenol in 15 patients with pelvic pain and minimal-moderate endometriosis. The main outcome measures were: the impact of treatment on pelvic symptom resolution, non-opioid analgesic consumption during menses, sexual performance and observed complications and side effects during 1 year follow-up. RESULTS: We noted a significant reduction in total pelvic symptom score as compared with baseline mean (SD) of 9.04 (1.2). The mean difference [95% confidence interval (CI)] of reduction was 5.7 (4.9-6.5), 5.8 (5.0-6.6) and 5.8 (4.9-6.6) from the baseline at the 3rd, 6th and 12th postoperative month (P < 0.001). We observed a significant improvement in Sabbatberg Sexual Rating Scale as compared with baseline mean (SD) of 30.9 (4.3). The mean difference (95% CI) of increase was 33.4 (30.3-36.4), 33.2 (30.1-36.2) and 33.2 (30.1-36.3) from the baseline at the 3rd, 6th and 12th postoperative month. We observed a significant reduction in analgesic consumption during menses in terms of total naproxen sodium tablets as compared with baseline mean (SD) of 8.9 (1.1). The mean difference (95% CI) of reduction in the total number of naproxen sodium 250 mg tablets was 6.5 (5.5-7.5), 6.7 (5.7-7.7) and 6.6 (5.6-7.6) from the baseline at the 3rd, 6th and 12th postoperative month. The most common side effect was constipation. CONCLUSION: Laparoscopic presacral neurolysis is feasible and simple. More data is needed to support its efficacy and safety.     

Uropathogenic Escherichia coli induces chronic pelvic pain

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a debilitating syndrome of unknown etiology often postulated, but not proven, to be associated with microbial infection of the prostate gland. We hypothesized that infection of the prostate by clinically relevant uropathogenic Escherichia coli (UPEC) can initiate and establish chronic pain. We utilized an E. coli strain newly isolated from a patient with CP/CPPS (strain CP1) and examined its molecular pathogenesis in cell culture and in a murine model of bacterial prostatitis. We found that CP1 is an atypical isolate distinct from most UPEC in its phylotype and virulence factor profile. CP1 adhered to, invaded, and proliferated within prostate epithelia and colonized the prostate and bladder of NOD and C57BL/6J mice. Using behavioral measures of pelvic pain, we showed that CP1 induced and sustained chronic pelvic pain in NOD mice, an attribute not exhibited by a clinical cystitis strain. Furthermore, pain was observed to persist even after bacterial clearance from genitourinary tissues. CP1 induced pelvic pain behavior exclusively in NOD mice and not in C57BL/6J mice, despite comparable levels of colonization and inflammation. Microbial infections can thus serve as initiating agents for chronic pelvic pain through mechanisms that are dependent on both the virulence of the bacterial strain and the genetic background of the host.     

Pregnancy-related pelvic girdle pain: an update

A large number of scientists from a wide range of medical and surgical disciplines have reported on the existence and characteristics of the clinical syndrome of pelvic girdle pain during or after pregnancy. This syndrome refers to a musculoskeletal type of persistent pain localised at the anterior and/or posterior aspect of the pelvic ring. The pain may radiate across the hip joint and the thigh bones. The symptoms may begin either during the first trimester of pregnancy, at labour or even during the postpartum period. The physiological processes characterising this clinical entity remain obscure. In this review, the definition and epidemiology, as well as a proposed diagnostic algorithm and treatment options, are presented. Ongoing research is desirable to establish clear management strategies that are based on the pathophysiologic mechanisms responsible for the escalation of the syndrome's symptoms to a fraction of the population of pregnant women.     

Chronic pelvic pain as a somatoform disorder

BACKGROUND: The purpose of this study was to determine whether psychiatric disturbances, particularly somatization, and an increased number of traumatic and critical life events, which have been found in women with idiopathic chronic pelvic pain (ICPP), can also be observed in women with chronic pelvic pain and abdominal adhesions (ACPP). METHODS: Forty women who underwent diagnostic laparoscopy were subdivided into three groups according to blind rated somatic pathologies: ICPP patients (n = 16), ACPP patients (n = 10), infertile controls without pain (n = 14). Besides the standardized assessment of DSM-III-R diagnosis, questionnaires and semistandardized interviews were used to estimate depression, somatization, pain, the prevalence of sexual and physical abuse, and the number of critical life events. RESULTS: Diagnostic criteria for somatoform pain disorder were fullfilled in 73.3% of the ICPP patients, 60% of the ACPP patients and none of the controls. With respect to the somatization symptom checklist the two pain groups scored significantly higher than the controls (p < 0.05). Referring to perceived pain, ACPP patients differed from the ICPP patients by one out of seven subscales (higher persistence of pain; p < 0.05). No correlation was found between the intensity of pain and the severity of classified adhesions. The two groups of pain patients significantly differed from controls by a higher prevalence of sexual abuse (p < 0.05). Depression was found neither in the pain groups nor in the controls. CONCLUSIONS: Because high somatization and high prevalence rates of abuse were not only found in patients suffering from ICPP but also in ACPP patients, it seems to be doubtful that the somatic pathology may fully explain the psychopathology in patients with ACPP.     

Limbic associated pelvic pain: a hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain

Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly encountered in patients with chronic pelvic pain, including the presence of multiple pain diagnoses, the frequency of previous abuse, the minimal or discordant pathologic changes of the involved organs, the paradoxical effectiveness of many treatments, and the recurrent nature of the condition. These conditions include endometriosis, interstitial cystitis, irritable bowel syndrome, levator ani syndrome, pelvic floor tension myalgia, vulvar vestibulitis, and vulvodynia. The hypothesis is based on recent improvements in the understanding of pain processing pathways in the central nervous system, and in particular the role of limbic structures, especially the anterior cingulate cortex, hippocampus and amygdala, in chronic and affective pain perception. Limbic associated pelvic pain is hypothesized to occur in patients with chronic pelvic pain out of proportion to any demonstrable pathology (hyperalgesia), and with more than one demonstrable pain generator (allodynia), and who are susceptible to development of the syndrome. This most likely occurs as a result of childhood sexual abuse but may include other painful pelvic events or stressors, which lead to limbic dysfunction. This limbic dysfunction is manifest both as an increased sensitivity to pain afferents from pelvic organs, and as an abnormal efferent innervation of pelvic musculature, both visceral and somatic. The pelvic musculature undergoes tonic contraction as a result of limbic efferent stimulation, which produces the minimal changes found on pathological examination, and generates a further sensation of pain. The pain afferents from these pelvic organs then follow the medial pain pathway back to the sensitized, hypervigilant limbic system. Chronic stimulation of the limbic system by pelvic pain afferents again produces an efferent contraction of the pelvic muscles, thus perpetuating the cycle. This cycle is susceptible to disruption through blocking afferent signals from pelvic organs, either through anesthesia or muscle manipulation. Disruption of limbic perception with psychiatric medication similarly produces relief. Without a full disruption of both the central hypervigilance and pelvic organ dysfunction, pain recurs. To prevent recurrence, clinicians will need to include some form of therapy, either medical or cognitive, targeted at the underlying limbic hypervigilance. Further research into novel, limbic targeted therapies can hopefully be stimulated by explicitly stating the role of the limbic system in chronic pain. This hypothesis provides a framework for clinicians to rationally approach some of the most challenging patients in medicine, and can potentially improve outcomes by including management of limbic dysfunction in their treatment.     

大鼠心脏移植急性排斥反应模型的超声表现

目的评价大鼠心脏移植急性排斥反应模型的超声表现。方法建立大鼠心脏同系移植与同种异体移植模型。以14 MHz高频探头对手术后第1、3、6天移植心脏行超声心动图检查,于乳头肌水平左室短轴切面测量左室舒张末期内径（LVDd）、左室壁厚度（LVT）、室壁增厚率（LVTR）及左室射血分数（LVEF）,并比较同系移植与同种异体移植间差异。结果同系移植组移植心无急性排斥反应发生;同种移植组术后第3天的移植心病理分级为I～II级;移植后第6天的病理分级为III～IV级。同系移植组中,术后第1、3、6天动态观察各超声指标无明显变化（P〉0.05）。同时段两组间比较,LVDd无显著差异（P〉0.05）;术后第6天,同种异体移植组LVEF明显低于同系移植组（P〈0.05）;术后第3、6天,同种异体移植组LVT明显高于同系移植组（P〈0.01）,而LVTR则明显较低（P〈0.01）。结论高频超声检查可动态显示大鼠心脏移植的解剖形态、结构及功能的改变,判断不同程度急性排斥反应的发生,LVT和LVTR可作为其评价的敏感指标。     

Role of anaerobes in acute pelvic inflammatory disease

Pouch of Douglas aspirates were collected from 50 women with history and examination suggestive of acute pelvic inflammatory disease (PID) and 20 healthy women admitted for tubal ligation served as control. A total of 57 microorganisms were isolated from 37 patients out of 50 in study group. Of 37 positive cultures 21(56.7%) were monomicrobial and 16(43.2%) were polymicrobial. Most common symptom in study group was lower abdominal pain (90%), vaginal discharge (70%) and irregular bleeding (40%) and 30% patients had history of intrauterine contraceptive device (IUCD) implantation. The predominant aerobic isolates were Escherichia coli, Coagulase Negative Staphylococcus (CONS), Staphylococcus aureus, Klebsiella pneumoniae while common anaerobes were Bacteroides fragilis, Prevotella melaninogenica, Fusobacterium nucleatum and Peptostreptococcus spp. Our study shows that cefotaxime, cefuroxime and gentamicin may be used for gram negative aerobic bacilli; cloxacillin, cephaloridine and erythromycin for aerobic gram positive cocci and amikacin and ceftazidime for Pseudomonas aeruginosa. Thus for optimum therapy of acute PID it is beneficial to keep in mind major conceptual changes and therapeutic realities that have influenced current understanding of acute PID and have affected the choice of therapy.     

Ultrasonography in myofascial neck pain: randomized clinical trial for diagnosis and follow-up

Objective

A definitive diagnosis of chronic neck pain (CNP) is sometimes not possible. The aim of this study was to understand the possible role of the deep fasciae in CNP and the utility of the ultrasonography in the diagnosis of myofascial neck pain.

Methods

The morphometric and clinical data of 25 healthy subjects and 28 patients with CNP were compared. For all subjects, the active and passive cervical range of motion (ROM) was analyzed and the neck pain disability questionnaire (NDPQ) was administered. The fascial thickness of the sternal ending of the sternocleidomastoid and medial scalene muscles was also analyzed by ultrasonography.

Results

There were significant differences between healthy subjects and patients with CNP in the thickness of the upper side of the sternocleidomastoid fascia and the lower and upper sides of the right scalene fascia both at the end of treatment as during follow-up. A significant decrease in pain and thickness of the fasciae were found. Analysis of the thickness of the sub-layers showed a significant decrease in loose connective tissue, both at the end of treatment and during follow-up.

Conclusions

The data support the hypothesis that the loose connective tissue inside the fasciae may plays a significant role in the pathogenesis of CNP. In particular, the value of 0.15 cm of the SCM fascia was considered as a cut-off value which allows the clinician to make a diagnosis of myofascial disease in a subject with CNP. The variation of thickness of the fascia correlated with the increase in quantity of the loose connective tissue but not with dense connective tissue.