Musculoskeletal causes of chronic pelvic pain: a systematic review of diagnosis: part I

Chronic pelvic pain in women has multifactorial etiology, but pelvic musculoskeletal dysfunction is not routinely evaluated as a cause by gynecologists. Whether diagnostic tests can reliably identify women with such conditions is unclear. The objective of this study was to determine the level of support in the literature for diagnostic tests of pelvic musculoskeletal problems. We used a set of key words pertaining to pain and the pelvic musculoskeletal structures to initially review the PUBMED database. Study inclusion was restricted to English-language publications that reported a patient-related chronic pelvic pain diagnostic test. Relevant bibliographies were also searched, and outside consultation with a pain researcher was sought to identify additional needed studies. For each selected article, 2 investigators separately summarized relevant data on study characteristics, patient profiles, and test efficacy. Discrepancies were resolved by discussion. Six diagnostic studies were identified that met entry criteria. No gold standard diagnostic tests exist for pelvic musculoskeletal problems, and the methodologic quality of available studies is low. Studies defining such clinically useful tests are needed to further refine a rational approach to chronic pelvic pain management. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the paucity of evidence-based literature and valid consensus of diagnostic criteria and modalities in defining the musculoskeletal causes of chronic pelvic pain in women, to recall that there is no gold standard diagnostic test for pelvic musculoskeletal problems, and to recall that the statistical evaluation of the methods described were wanting.     

Psychological therapies for chronic pelvic pain: systematic review of randomized controlled trials

Chronic pelvic pain (CPP), a common cause of disability in women, is a condition best viewed in the biopsychosocial framework. Psychological interventions are frequently considered alongside medical and surgical treatments. Our objective was to evaluate the effectiveness of psychological therapies for the treatment of CPP. Electronic literature searches were conducted in Medline, Embase, PsycInfo and DARE databases from database inception to April 2010. Reference lists of selected articles were searched for further articles. The studies selected were randomized controlled trials of psychological therapies in patients with CPP compared with no treatment, standard gynecological treatment or another form of psychological therapy. Two reviewers independently selected articles without language restrictions and extracted data covering study characteristics, study quality and results. Reduction in pain, measured using visual analog scales or other measurements, was the main outcome measure. Of the 107 citations identified, four studies satisfied the inclusion criteria. Compared with no psychological intervention, therapy produced a standardized mean pain score of -3.27 [95% confidence interval (CI) -4.52 to -2.02] and 1.11 (95% CI -0.05 to 2.27) at 3 months and -3.95 (95% CI -5.35 to -2.55) and 0.54 (95% CI -0.78 to 1.86) at 6 months and greater, based on a visual analog scale score of 0-10. The current evidence does not allow us to conclude whether psychological interventions have an effect on self-reported pain scores in women with CPP.     

Systematic review of therapies for noncyclic chronic pelvic pain in women

Drug screening is often limited to cell-free assays involving purified enzymes, but it is arguably best applied against systems that represent disease states or complex physiological cellular networks. Here, we describe a high-content, cell-based drug discovery platform based on phosphospecific flow cytometry, or phosphoflow, that enabled screening for inhibitors against multiple endogenous kinase signaling pathways in heterogeneous primary cell populations at the single-cell level. From a library of small-molecule natural products, we identified pathway-selective inhibitors of Jak-Stat and MAP kinase signaling. Dose-response experiments in primary cells confirmed pathway selectivity, but importantly also revealed differential inhibition of cell types and new druggability trends across multiple compounds. Lead compound selectivity was confirmed in vivo in mice. Phosphoflow therefore provides a unique platform that can be applied throughout the drug discovery process, from early compound screening to in vivo testing and clinical monitoring of drug efficacy.     

Hypnotherapy for chronic pelvic pain: A scoping systematic review and meta-analysis

BackgroundChronic pelvic pain (CPP) is typically managed with anti-inflammatory analgesics and opioids; however, these do not adequately manage the pain or address the associated negative impact on quality of life. Hypnotherapy has been found to reduce pain associated with a range of disorders, including some with symptoms of chronic pain.AimThe aim of this review is to systematically scope research investigating the use of hypnosis on chronic pelvic pain, quality of life, anxiety, depression and fatigue.MethodThe scoping review was guided by the method described by Arksey and O'Mallee [1]. A systematic search was conducted in six databases. The Covidence Risk of Bias tool and the National Institutes of Health (NIH) quality assessment tool were used.ResultsNine studies (four RCT's and five case series) were suitable for inclusion. Meta-analysis of the RCT's found no significant difference in pain or quality of life for the intervention group compared to controls. Only one study reported a reduction in pain after hypnotherapy and did not outperform controls. These results are limited due to lack of a standardised intervention and heterogeneity of the included studies.ConclusionThere is a need for further research using well designed randomized controlled trials with validated measures of pain, quality of life, anxiety, depression and fatigue. Hypnotherapy interventions utilised in further research should be grounded in evidence-based best practice for dealing with pain.     

Quality of life instruments in studies of chronic pelvic pain: a systematic review.

The use of quality of life (QoL) instruments in chronic pelvic pain (CPP) will allow a more objective assessment of patient-centred clinical outcomes. However, there is concern that not enough emphasis is placed on clinical face validity (i.e. issues which are of importance to patients and reflect their experiences and concerns). To explore this issue, we performed a systematic review of published research. Relevant papers were identified through electronic scanning of six electronic databases and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with CPP for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for the quality of their QoL instruments using a 17-item checklist, including 10 items for clinical face validity and seven items for measurement (psychometric) properties. A total of 19 articles were eligible for inclusion in the review. The generic Short Form 36 Health Survey Questionnaire (SF-36) was used most frequently, being employed in 10/19 (53%) of the studies. Three studies developed disease-specific QoL instruments for CPP complying with 59 - 77% of the quality criteria. Overall, quality assessment showed that only 4/18 (22.2%) studies complied with more than half the criteria for face validity, whereas 12/18 (66.6%) studies complied with more than half of the criteria for measurement properties (P = 0.0001). Among existing QoL instruments, compliance with the quality criteria for measurement properties is higher than for clinical face validity. There is a need to develop disease specific QoL instruments for CPP with face validity in addition to sound measurement properties.     

Ultrasound for pelvic pain II: nongynecologic causes

Acute pelvic pain in women is a common presenting complaint that can result from various conditions. Because these conditions can be of gynecologic or nongynecologic origin, they may pose a challenge to the diagnostic acumen of physicians, including radiologists. A thorough workup should include clinical history, physical examination, laboratory data, and appropriate imaging studies, all of which should be available to the radiologist for evaluation. Ultrasound is the primary imaging modality in women with acute pelvic pain because of its high sensitivity, low cost, wide availability, and lack of ionizing radiation, particularly when a gynecologic disorder is suspected as the underlying cause. However, other modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) may be very helpful, especially when a nongynecologic condition is suspected.     

Prevention of and therapies for nipple pain: a systematic review

OBJECTIVE: To review the literature on nipple pain and to delineate effective strategies for the prevention and treatment of nipple pain in breastfeeding mothers. DATA SOURCES: Computerized searches on MEDLINE, Pre-MEDLINE, CINAHL, and the Cochrane Library. STUDY SELECTION: Articles from indexed journals relevant to the objective were reviewed from January 1983 to April 2004. Preference was given to research-based studies in English. DATA EXTRACTION: Data were extracted and organized under two headings: prevention of nipple pain or trauma and treatment of nipple pain or trauma. The Critical Appraisal Form by J. Briggs was used to extract the data from research-based articles. DATA SYNTHESIS: The health benefits of breastfeeding for mother and infant are well documented; however, nipple pain is a common reason reported by women for the early termination of breastfeeding. Several studies have compared various treatments for either the prevention of or treatment for nipple pain. These treatments include warm water compresses, tea bag compresses, heat, application of expressed mother's milk, lanolin, vitamin A, collagenase, dexpanthenol, hydrogel therapy, glycerin gel therapy, moist occlusive dressing, education regarding proper latch-on and positioning, and no treatment. CONCLUSIONS: No one topical agent showed superior results in the relief of nipple discomfort. The most important factor in decreasing the incidence of nipple pain is the provision of education in relation to proper breastfeeding technique and latch-on as well as anticipatory guidance regarding the high incidence of early postpartum nipple pain.     

The prevalence of chronic pelvic pain in women in the United Kingdom: a systematic review

Objective Toobtain a prevalence estimate for chronic pelvic pain in women in the United Kingdom by analysing published data.
Design Systematic review of published papers.
Setting The general population or hospitals in the United Kingdom.
Population Women participating in relevant community surveys or control women participating in hospital-based studies.
Methods Papers were retrieved by systematically searching the databases MEDLINE, EMBASE and PsycLit, and by hand searching. Studies were included if they 1. were community-based and reported prevalence rates of chronic pelvic pain, dyspareunia, dysmenorrhoea, or abdominal pain, or 2. referred to a clinical population but reported prevalence rates in a disease-free control group.
Main outcome measures Prevalence rates for chronic pelvic pain including any overlap with dyspareunia, dysmenorrhoea and abdominal pain.
Results No community-based study has been performed that provides an estimate of the prevalence of chronic pelvic pain in the general UK population. A rate of 39% was reported in women undergoing laparoscopy for sterilisation or investigation of infertility in the single study from the United Kingdom investigating chronic pelvic pain unrelated to menstruation or intercourse. Prevalence rates for dyspareunia, dysmenorrhoea, and abdominal pain found in UK community-based studies were 8%, 45%, to 97%, and 23% to 29%, respectively, but definitions used varied greatly.
Conclusions Because chronic pelvic pain can reduce the quality of life and general wellbeing, there is a need for a community-based study into the prevalence of chronic pelvic pain and its effect upon the lives of women in the UK.     

Acupuncture for pelvic and back pain in pregnancy: a systematic review

The objective of our study was to review the effectiveness of needle acupuncture in treating the common and disabling problem of pelvic and back pain in pregnancy. Two small trials on mixed pelvic/back pain and 1 large high-quality trial on pelvic pain met the inclusion criteria. Acupuncture, as an adjunct to standard treatment, was superior to standard treatment alone and physiotherapy in relieving mixed pelvic/back pain. Women with well-defined pelvic pain had greater relief of pain with a combination of acupuncture and standard treatment, compared to standard treatment alone or stabilizing exercises and standard treatment. We used a narrative synthesis due to significant clinical heterogeneity between trials. Few and minor adverse events were reported. We conclude that limited evidence supports acupuncture use in treating pregnancy-related pelvic and back pain. Additional high-quality trials are needed to test the existing promising evidence for this relatively safe and popular complementary therapy.     

Physical therapy for pregnancy-related low back and pelvic pain: a systematic review

BACKGROUND: A systematic review of prospective controlled clinical trials was performed to assess the effectiveness of physical therapy interventions for the prevention and treatment of pregnancy-related back and pelvic pain. Pregnancy-related low back and pelvic pain has an impact on daily life for many women. Prevention and treatment of back and pelvic pain is therefore an important issue for all those concerned with women's health. METHODS: All prospective controlled clinical trials retrieved by systematic searching of electronic databases, checking of reference lists and contacting of authors were examined. Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials. Authors were contacted to obtain missing information. RESULTS: Nine trials with a total of 1350 patients were reviewed. Except for three high-quality studies, the validity of the trials was moderate to low. Two high-quality studies showed no difference in pain intensity and functional status between the exercise groups and the control groups. In the third high-quality study significant reduction in sick leave was found in favor of water gymnastics compared with no intervention. Because the included trials were considered heterogeneous with regard to study design, population intervention and outcome, no meta-analysis was performed. CONCLUSIONS: Because of heterogeneity and the varying quality of the studies no strong evidence exists concerning the effect of physical therapy interventions on the prevention and treatment of back and pelvic pain related to pregnancy. Future studies should meet current methodological standards, and interventions to be evaluated should be based on established theoretical framework.     

Pharmacologic therapies in endometriosis: a systematic review

To assess the literature on preclinical and clinical efficacy and safety data of pharmacologic groups proposed in the treatment of endometriosis, we performed a systematic review of publications from March 2002 to January 2012 via PubMed search. Additional relevant articles were identified from citations within these publications. A high number of medications were tested in preclinical models of endometriosis due to their theoretic capacity of disrupting important pathophysiologic pathways of the disease, such as inflammatory response, angiogenesis and cell survival, proliferation, migration, adhesion, and invasion. Tumor necrosis factor α-blockers, nuclear factor κB inhibitors, antiangiogenic agents, statins, antioxidants, immunomodulators, flavonoids, histone deacetylase inhibitors, matrix metalloproteinase inhibitors, metformin, novel modulators of sex steroids expression, and apoptotic agents were all effective in in?vitro/animal models. Most of these agents have not been tried in the clinical setting, mainly because of the high risk of adverse effects. However, some of them can be used in humans. Dopamine agonists and valproic acid have already been tested in pilot studies with good results. Etanercept, metformin, and statins are used in humans for other indications, and endostatin is now being tested in phase 2 oncologic trials. These drugs may constitute alternatives to conventional therapy with estrogen inhibitors and anti-inflammatory agents.     

Women's experiences of pregnancy related pelvic girdle pain: A systematic review

Objectiveto systematically review the available studies which relay the experience of pregnancy related pelvic girdle pain and how this affects women psychologically and emotionally.Methoda systematic review and meta-synthesis of the experiences of pregnancy related pelvic girdle pain was conducted for qualitative studies dated between 2005 and 2016. Predefined terms were used to search nine central databases and hand searches of two reference lists of identified studies were carried out.Findings614 records were identified, eight studies met the inclusion criteria for review. Pain from pelvic girdle pain impacted on women's daily lives both at home and the workplace. This had a negative emotional and psychological impact on women as it took away their feeling of independence. Women reported feelings of frustration, guilt, irritability and upset at being unable to carry out their normal roles. Pelvic girdle pain also affected the women's sense of identity and ability to care for their children.Conclusions and implications for practiceHealth professionals working with pregnant and postnatal women need to be aware of the anger, frustration and negative emotions resulting from PGP. These women may become socially isolated and there is a risk they could abuse analgesics in attempt to manage the pain especially if they do not have the social support. For women with young children, it is important to be aware of safety issues they face with carrying babies and controlling toddlers. It is therefore important that health professionals recognise PGP as a serious health issue, approach this condition sensitively and refer to appropriate treatment as soon as PGP is suspected.     

Musculoskeletal pelvic pain in a pediatric and adolescent gynecology practice

Background: Pelvic pain is a common complaint encountered in pediatric and adolescent gynecology. Etiologies are similar to those found in adult women, but the incidence and presentations vary with age. The purpose of this study is to review musculoskeletal (MS) pelvic pain in a pediatric and adolescent gynecology setting. Methods: A retrospective review of charts of 63 patients presenting to a private practice pediatric and adolescent gynecologist between 7/1/97 and 6/30/99 was performed. To be included in analysis, patients had a diagnosis of pelvic pain which could not be explained by standard gynecologic history, physical exam, laboratory, and ultrasound evaluation or did not respond to standard treatments for known endometriosis. A history of laparoscopy was not required, but when it was performed it could be used to exclude patients from analysis if a reason for the pain was identified. All patients who fulfilled these criteria had been screened for MS etiologies of pelvic pain using the leg lift (Carnett test) and/or head lift. Results: Sixty-three patients aged 9-23 (mean 15.21, SD 2.71) fulfilled the criteria for evaluation. Diagnoses included irritable bowel syndrome (N = 4, 6.35%), interstitial cystitis (N = 1, 1.56%), unexplained (N = 7, 11.11%), endometriosis not responding to ablation & GnRH agonists (N = 2, 3.17%), endometriosis not responding to ablation & GnRH agonists & MS pain (N = 7, 11.11%), and MS pain (N = 42, 66.67%). Mean age of those with MS pain was 15. 27 (SD 2.94), and mean duration of symptoms prior to diagnosis was 17.97 mo (SD 20.90, range 1 week-7 yr). On physical exam, trigger points were identified as causative factors in 5 (10.20%), and 40 (81.63%) had a + Carnett test. Of those with a final diagnosis of MS pain, only 5/31 (16.31%) responded to nonsteroidal anti-inflammatory agents, 6/30 (20.0%) responded to OCPs, and 3/11 (27.27%) responded to DMPA-2/3 also had a diagnosis of endometriosis. Nineteen (38.78%) had been surgically explored for the pain in the past, 1 by laparotomy & 18 by laparoscopy. Only 3 (15.79%) had symptomatic improvement after surgery. Physical therapy resulted in resolution of symptoms in 20/21 (95.24%) who completed treatment. Four of 5 (80%) who underwent trigger point injections responded.Conclusions: MS etiologies of pelvic pain are common in the adolescent age group and respond well to physical therapy. Physical therapy might be employed as an early intervention prior to surgery in adolescent girls with unexplained pelvic pain.     

妇科急性盆腔痛的病因

学习目的：了解盆腔痛的病理生理过程。根据临床特征进行鉴别诊断。病因包括：异位妊娠，经间痛(mittelschmerz)，卵巢囊肿破裂、扭转、出血，急性盆腔炎，流产，子宫肌瘤变性，外伤等。     

Retroperitoneal myoma and chronic pelvic pain: case report and literature review

We present a case of a postmenopausal diabetic hypertensive female with a solitary retroperitoneal myoma (2,025 g) and no smooth muscle (myomatic) nodules on visceral and parietal peritoneum. She complained of chronic pelvic pain in absence of internal female genitalia (except uterine cervix), high frequency of urination, pelvic discomfort, and feeling of heaviness. The patient had undergone hysterectomy with bilateral adnexectomies 13 years ago and she had not had any exposure to exogenous hormones during her reproductive and postmenopausal period of life (oral contraception and hormone-replacement therapy). Several suppositions were made, supporting hormonal genesis of myoma with retroperitoneal localization in postmenopausal age and the significance of eventual presence of concomitant metabolic disturbance for its origin in that age was also emphasized. The known risk factors for growth and development of myoma were also affected by the presence of collateral dismetabolic conditions, which influenced and aggravated the disturbed hormonal balance. That is why they could be considered as a possible additional risk factor.     

Nonsurgical management of chronic pelvic pain: a multidisciplinary approach

Experience with multidisciplinary management of CPP has demonstrated the importance of ruling out and of treating nongynecologic conditions such as myofascial syndrome, irritable bowel syndrome, urethral syndrome, and psychogenic pain in women with CPP and normal laparoscopies. Moreover, current data suggest that availability of a multidisciplinary pelvic pain clinic can reduce the frequency of hysterectomy for this disorder.