Immediate postoperative pain control with ropivacaine following laparoscopic-assisted vaginal hysterectomy: A randomized double-blind pilot study

Objective

Although laparoscopic hysterectomy, a worldwide popular surgery, ensures faster recovery and less postoperative pain than with laparotomic hysterectomy, immediate pain control still improving postoperative care. We introduce an effective method, intraoperative injection of ropivacaine into both uterosacral ligaments, to control immediate postoperative pain.

腹腔镜子宫骶神经切断术治疗子宫内膜异位症疼痛的多中心前瞻性对照研究

目的:研究、评价腹腔镜子宫骶神经切断术(LUNA)治疗子宫内膜异位症疼痛的安全性和有效性。方法:应用多中心随机对照的前瞻性研究方法,收集82例中、重度痛经患者的临床资料,分析比较同时行LUNA对子宫内膜异位症保守手术后各种疼痛缓解率的影响,并评价手术的安全性。结果:71例患者纳入分析,LUNA组51例,对照组20例。LUNA组术后痛经缓解率90.2%,高于对照组的60.0%(P=0.02);LUNA组性交痛术后缓解率85.7%,高于对照组的50.0%(P=0.048);LUNA组慢性盆腔痛(CPP)缓解率100%,高于对照组的71.4%(P=0.041),差异均有统计学意义。手术安全性:LUNA组患者手术时间延长,术后肛门排气时间延长,但两组术中出血量、术后体温、住院时间、总住院费用以及手术费用均无统计学差异。所有研究对象均无手术并发症发生。结论:内异症保守手术同时行LUNA手术,术后2年内能有效的缓解内异症的各种疼痛。     

Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized,controlled trial

OBJECTIVE: To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea. DESIGN: Randomized controlled trial. SETTING: Two academic departments.One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis. INTERVENTION(S): Operative laparoscopy including uterosacral ligament resection or conservative surgery alone. MAIN OUTCOME MEASURE(S): Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery. RESULT(S): No complications occurred. Among the patients who were evaluable 1 year after operative laparoscopy, 23 of 78 (29%) women who had uterosacral ligament resection and 21 of 78 (27%) women who had conservative surgery only reported recurrent dysmenorrhea. The corresponding numbers of patients at 3 years were 21 of 59 (36%) women and 18 of 57 (32%) women, respectively. Time to recurrence was similar in the two groups. Pain was substantially reduced, and patients in both groups experienced similar and significant improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Overall, 68 of 90 (75%) patients in the uterosacral ligament resection group and 67 of 90 (74%) patients in the conservative surgery group were satisfied at 1 year. CONCLUSION(S): Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea.     

Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study

OBJECTIVE: To assess the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP). DESIGN: Prospective cohort study. Setting Gynaecology Department, UK District General Hospital. POPULATION: Forty-three women diagnosed with CPP. METHODS: The cohort was followed up for 18-24 months after diagnosis and treatment based on conscious pain mapping. MAIN OUTCOME MEASURES: Improvement of pain assessed by using visual analogue scale (VAS) pain scores at 6-month follow up. RESULTS: Thirty-nine women had successful conscious pain mapping. Pelvic pathology was identified in 18, pelvic congestion in 13 and 8 women had normal pelvic organs. In 35 women (90%), conscious pain mapping identified the cause of pain. Five out of eight women (63%) who were judged to have a normal pelvis had positive findings at pain mapping. VAS scores fell significantly from pre-treatment to post-treatment values at 6-month follow up (P < 0.01). Overall, 26 women (74%) felt that their symptoms had improved after treatment based on findings at pain mapping. However, we concluded that pain mapping only contributed to the diagnosis and treatment in seven women (27%), who may not have received appropriate diagnosis and treatment if they had a laparoscopy under general anaesthetic. Conclusions CONSCIOUS: pain mapping is a useful additional investigation in the management of women with CPP. It can be employed in women with a negative laparoscopy or with visible pathology where the conventional treatment has failed.     

Meta-analysis using individual patient data from randomised trials to assess the effectiveness of laparoscopic uterosacral nerve ablation in the treatment of chronic pelvic pain: a proposed protocol

Background  Currently, there are a number of clinical trials, but no international collaboration for collating research on effectiveness of laparoscopic uterosacral nerve ablation (LUNA) for alleviating chronic pelvic pain.
Objective  Meta-analysis was used by collecting individual patient data (IPD) from the existing trials, to provide a comprehensive assessment of the effectiveness of LUNA that will be generalisable in various clinical contexts.
Methods  IPD will be sought and collected from all relevant (both already finished and continuing) randomised trials identified through previous systematic reviews. After obtaining raw data and cleaning the database, analysis will be of all patients ever randomised based on the intention-to-treat principle using endpoints measured at 12 months following randomisation.
Proposal  We will update searches, contact all authors, obtain data in whatever form it can be provided, build a single database, produce results for individual studies, have them verified by original authors, explore of any heterogeneity and reasons behind it and finally pool all raw data in to a meta-analysis using appropriate statistical methods. The project will test the effectiveness of LUNA for women with chronic pelvic pain. It will also motivate collaborating primary investigators to undertake new primary studies to corroborate or improve upon the conclusions derived from the retrospective analysis.     

The prevalence of sexual dysfunction and associated risk factors in women with chronic pelvic pain: a cross-sectional study

The aims of the study were to determine the prevalence of sexual dysfunction, its subtypes and associated risk factors in women with chronic pelvic pain (CPP) as compared to a general female population. We evaluated 112 women (mean age 34.73 ± 8.07; age range 18–50) complaining of CPP with a comprehensive history including female sexual function index (FSFI) and several general assessment questions (GAQs), a complete physical examination and routine laboratory tests. A group of 108 healthy women (mean age 33.28 ± 7.95; age range 19–52) without CPP were enrolled as cross-sectional controls. According to the general population, the incidence of female sexual dysfunction (FSD) was 67.8% in women with CPP and 32.2% in women without CPP (P < 0.0001). Among 112 CPP patients, 78 (69.6%) of them had FSD and 34 (30.4%) patients did not have FSD in the study (P < 0.0001). In that 78 patients, 42 patients (53.8%) had hypoactive sexual desire disorder, 26 patients (33.3%) had sexual arousal disorder, 17 patients (21.7%) had orgasmic disorder and finally 58 patients (74.3%) had sexual pain disorder. The FSFI scores in both groups were as follows: (patients vs. controls; median value; P value, respectively): desire: 3.31 versus 3.98 (P < 0.0001); arousal: 3.58 versus 4.35 (P < 0.0001); lubrication: 4.20 versus 4.88 (P < 0.0001); orgasm: 3.70 versus 4.48 (P < 0.0001); sexual satisfaction: 3.80 versus 4.64 (P < 0.0001); sexual pain: 2.75 versus 4.98 (P < 0.0001) and total FSFI score: 21.35 versus 27.29 (P < 0.0001). The prevalence of FSD was higher in women with CPP than in a general healthy population not complaining of CPP. Investigation of female sexuality was essential for these patients.     

Ovarian vein incompetence: a potential cause of chronic pelvic pain in women

OBJECTIVE(S): To evaluate whether ovarian vein incompetence may be a source of chronic pelvic pain (CPP) in women. STUDY DESIGN: Twenty-two women, aged 19-50 years, with chronic pelvic pain, no laparoscopically detected pelvic pathology, and evidence of reflux in dilated pelvic veins on transvaginal color Doppler ultrasound underwent retrograde ovarian venography and sclerotherapy of the ovarian vein(s) if incompetent. The primary outcome was symptom change as assessed by a symptom questionnaire and visual analog pain scales (VAS) at 3, 6, and 12 months of follow-up. Changes in pelvic circulations after sclerotherapy procedure were also evaluated by serial ultrasound examinations. Differences between baseline and post-procedural VAS scores were analysed using the Wilcoxon signed-rank test. RESULTS: Twenty (91%) of the 22 women had venographic evidence of incompetent ovarian vein(s) and received sclerotherapy. There were no immediate or late complications. Variable symptom relief was observed in 17 (85%) of the 20 treated women, with follow-up at 12 months showing marked-to-complete relief in 15 patients and mild-to-moderate relief in the remaining 2 patients. Three (15%) women had no improvement in symptoms. Median VAS scores at 3 (2.0), 6 (2.5), and 12 months (3.0) were significantly lower than at baseline (8.0) (P<.001). Follow-up ultrasound examinations showed absence of pelvic venous reflux in all but 3 patients, in whom recurrence of reflux was seen at 3 months. CONCLUSION(S): Ovarian vein sclerotherapy provided symptomatic relief and improved pelvic circulation in most patients. These findings suggest that ovarian vein incompetence was the likely source of chronic pain in these women, and that sclerotherapy was a safe and effective treatment for this condition. CONDENSATION: Ovarian vein incompetence leading to pelvic circulatory changes may be a cause of chronic pelvic pain in women.     

Sexual behavior and findings on laparoscopy or laparotomy in women with severe chronic pelvic pain

OBJECTIVE: To identify features of sexual behavior in women with and without chronic pelvic pain. STUDY DESIGN: A group of 41 women with chronic pelvic pain of more than 6 months' duration and scheduled to undergo laparoscopy or laparotomy were surveyed to obtain information on their sexual activity. The results were compared with a control group of 86 women of similar age and socioeconomic status who underwent planned tubal ligation for permanent contraception. RESULTS: Women with pelvic pain initiated sexual relations at a later age and had a higher rate of dyspareunia than women in the control group. There were no significant differences between groups in any other characteristics of sexual behavior. CONCLUSION: Dyspareunia, the only feature of sexual relations that differed significantly between women with and without chronic pelvic pain, should be accorded greater attention as a painful symptom and not be dismissed as simply a type of sexual dysfunction.     

The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study

Objective  To evaluate the beneficial effects of Implanon on pelvic pain in women with pelvic congestion syndrome (PCS). The efficacy of pain control, amount and frequency of menstrual loss, degree of patient’s satisfaction and objective pelvic venography scores were investigated. Methods  In a prospective open-labelled study, 25 consecutive women complaining of chronic pelvic pain were recruited. Pretreatment objective peruterine venography and diagnostic laparoscopy of pure PCS together with subjective pelvic pain scores, prefilled questionnaire of Hospital Anxiety and Depression Scale (HADS), visual analogue scale (VAS), verbal rating scale (VRS) and quantified menstrual loss using the pictorial blood loss chart were documented in all cases. After identification, 23 subjects with pure PCS were randomly assigned to have either Implanon inserted subcutaneously (12 cases) or no treatment (11 cases). Patients were followed up at 1, 3, 6, 9 and 12 months. A symptom diary for side effects, VAS, VRS and menstrual scores were used to assess the subjective response to treatment. At the end of the study, all patients underwent repeat venography to assess the long-term objective response. After 12 months, subjects having Implanon inserted were requested to rate their overall degree of satisfaction with therapy. Results  All 25 women recruited in the study completed follow-up. Two cases were excluded from the study and referred to the psychiatry department after a negative evaluation for disease and HADS scores relevant for depression. An improvement in symptoms was observed throughout the 12 months amongst the Implanon group versus no treatment. The greatest changes in pain assessed using either the VAS or VRS were between the pretreatment scores and those after 6 months (7.7 ± 1.3 vs. 4.6 ± 3.0 for VAS, P < 0.001; and 25 ± 13.8 vs. 19 ± 18.9 for VRS, P < 0.002). The monthly quantified blood loss fell from 204 (196) pretreatment to 90 (157) at 6 months (P < 0.001) and then to 64 (32) at 9 months (P < 0.002). Objective repeat venography score was reduced significantly at 1 year after treatment compared with the baseline evaluation as well as with the control group (4.5 ± 1.2 vs. 8.6 ± 0.5; P = 0.001 and 4.2 ± 0.9 vs. 8.5 ± 0.6; P = 0.0002, respectively). At final satisfaction assessment, 2 (17%) women were very satisfied 8 (66%) were satisfied, and 2 (17%) were uncertain. The implant was retained by all women at the end of the study. Conclusion  Implanon seems to be an effective hormonal alternative for long-term treatment of properly selected patients with pure PCS-related pelvic pain.     

HPA axis reactivity in chronic pelvic pain: association with depression

Objectives.?Chronic pelvic pain (CPP) is a frequent gynecological complaint. The pathophysiology of CPP is not fully understood. The aim of this study was to determine whether the presence of depressive symptoms is associated with hypothalamic-pituitary-adrenal (HPA) axis dysfunction in CPP.

Methods.?We measured neuroendocrine responses to a standardized social stress test and to a standard adrenocorticotropin (ACTH)_1–24 stimulation test in 18 patients with CPP, stratified based on the presence of high versus low self-reported depressive symptoms, compared with 24 controls.

Results.?Women with CPP and low depression exhibited enhanced ACTH responses to psychosocial stress compared with women with CPP and high depression, whereas there were no differences in cortisol responses. In the ACTH_1–24 stimulation test, CPP patients with high depression demonstrated enhanced cortisol responses.

Conclusion.?These results suggest a relationship between self-reported depression and reactivity of the HPA axis in patients with CPP.     

Attitudes of women with chronic pelvic pain to the gynaecological consultation: a qualitative study

OBJECTIVE: To describe the attitudes that women with chronic pelvic pain (CPP) attending gynaecology clinics have to their consultations and to determine the ways in which their health care can be improved. DESIGN: Qualitative study using semistructured individual interviews. SETTING: UK gynaecology outpatient clinics in district general and teaching hospitals. SAMPLE: Twenty-six women with CPP. METHODS: Semistructured individual interviews were conducted. Data gathering and analysis followed a grounded theory approach. MAIN OUTCOME MEASURES: Women's wishes regarding their care and their actual experiences of care. RESULTS: Four main themes emerged. The women wanted (a) personal care, which they often did not receive; (b) to feel understood and to be taken seriously, although they often felt dismissed, which applied both to women with and without an explanation for their pain; (c) explanation as much as cure, but an adequate explanation was often not provided; and (d) to be reassured, which often they were not. Effective reassurance was complex as it included general reassurance and specific reassurance about cause and treatment. CONCLUSIONS: Improvements are needed in the outpatient care of women presenting with CPP. Changes should focus on providing more personal care, so that presenting problems are seen to be taken seriously, findings and management are appropriately explained, and women are more effectively reassured. Interventions need to be developed that meet these needs and tested to determine if they are feasible, acceptable, and improve outcomes.     

The value of laparoscopy in women with chronic pelvic pain and a "normal pelvis"

During the period January 1976--December 1982 laparoscopy was performed on 186 women complaining of pelvic pain of at least 6 months' duration. In all these cases, the routine pelvic examination and other medical and laboratory tests were negative. Laparoscopy revealed pelvic pathology in only 8.2%: in the vast majority (91.8%) entirely normal pelvic organs were seen. Evidence from the literature is compiling as to the psychogenic origin of most cases of chronic pelvic pain. Recently, it has been shown that laparoscopically negative pelvic pain can be relieved or abolished by psychological intervention. Since pathological findings on laparoscopy are of very low percentage and since the pain is psychogenic in most cases, the value of routine laparoscopy in chronic pelvic pain is very low. We propose that all women with chronic pelvic pain and normal pelvic examination should undergo psychological assessment and treatment if necessary. Laparoscopy should then be reserved for only those cases who show no amelioration on psychological intervention. Our estimation is that this approach would reduce the rate of laparoscopies performed for chronic pelvic pain by about 90%.     

The efficacy of laparoscopic uterosacral nerve ablation (LUNA) in the treatment of unexplained chronic pelvic pain: a randomized controlled trial

The aim of this work is to explore the efficacy , safety, and patients' satisfaction of laparoscopic uterosacral nerve ablation (LUNA) in relief of pain in women with chronic pelvic pain in whom diagnostic laparoscopy reveals either no pathology or mild endometriosis (AFS score ≤5). The study was a prospective, single-blind, randomized trial with 12 months follow-up. It was conducted at the endoscopy unit of the Gynecology Department of El Minia University Hospital, Egypt. One hundred ninety Egyptian women consented to participate in the study. These eligible patients were randomized using computer-generated tables and were divided into two equal groups, including the control group (diagnostic laparoscopy with no pelvic denervation) and the study group (diagnostic laparoscopy plus LUNA). Diagnostic laparoscopy with or without laparoscopic uterosacral nerve ablation was done. There were no statistically significant difference between both groups regarding the efficacy and the overall success rate (between group I and group II, it was 77.64%, 76.47%, and 74.11% versus 79.06%, 75.58%, and 73.25% at 3, 6, and 12 months, respectively) and the cumulative patients' satisfaction rate (it was 74.11%, 74.11%, and 71.76% versus 75.58%, 75.58%, and 72.09% at 3, 6, and 12 months between group I and group II, respectively; P ≤ 0.05). There was no statistically significant difference between both groups as regards the effectiveness of LUNA in the treatment of primary (spasmodic) and secondary (congestive) dysmenorrhea (P ≤ 0.05), while there was a statistically significant difference between both groups in the treatment of dyspareunia (P ≥ 0.05). LUNA can be a last alternative option in well-selected patients for control of chronic pelvic pain without endometriosis; however, its effectiveness may not extend to other indications. Also, preliminary experience in the treatment of primary deep dyspareunia presents a promising perspective on the management of deep dyspareunia, especially if it will involve a team of social, psychological, and gynecological specialists.