Using botulinum toxin for pelvic indications in women

Background: Botulinum toxin (BoNT) is a potent neurotoxin. Its ability to cause muscle paralysis is increasingly being utilised for the management of a number of conditions of interest to the gynaecologist.
Aims: This review aims to give the reader an overview of the use of BoNT for conditions presenting a management challenge for the gynaecologist, such as chronic pelvic pain and idiopathic detrusor overactivity.
Methods: The literature was reviewed regarding the use, side-effects and complications of BoNT in the pelvis, focussing on chronic pelvic pain, provoked vestibulodynia, conditions involving the lower gastrointestinal tract and detrusor overactivity.
Results: In terms of pain caused by pelvic floor spasm, daily pelvic pain and dyspareunia are the symptoms most likely to be improved by BoNT. Limited data regarding use for provoked vestibulodynia indicate an improvement in pain scores. In the lower gastrointestinal tract, injection into puborectalis has been showed to objectively improve intravaginal pressures, though there are no randomised controlled trials (class I studies) validating its use in this setting. Class I studies demonstrate a role for BoNT in the management of idiopathic detrusor overactivity, though long-term follow-up data are lacking. Potential problems with BoNT injection include toxin reactions, urinary and faecal incontinence, urinary retention and secondary treatment failure due to antibody production.
Conclusions: A single class I study supports the use of BoNT for refractory pelvic floor spasm; however, further adequately powered class I studies for this indication and for provoked vestibulodynia are warranted.     

Chronic pelvic pain

Chronic pelvic pain is a major public health problem that impacts all areas of a woman's life. The diagnosis is frequently difficult and delayed with women often presenting to a variety of specialties and undergoing multiple investigations before a diagnosis is reached. Aetiology is frequently multifactorial with both precipitating and perpetuating factors. Optimal management is within a multidisciplinary team who can fully address the range of factors that may maintain pelvic pain.     

Electrical stimulation in the treatment of pelvic pain due to levator ani spasm

OBJECTIVE: To evaluate experience with intravaginal electrical stimulation for the relief of pain when used as adjunctive therapy in women with chronic pelvic pain and levator ani spasm. STUDY DESIGN: A retrospective cohort of consecutively treated patients from 1999 and 2000 was identified using billing records. Systematic chart review was completed using standardized data collection forms for all patients receiving electrical stimulation for pain from levator ani spasm. Data collected were objective for major variables and subjective for outcomes. Demographic data were reported as means and standard deviations. Stimulation characteristics were compared using ANOVA. Survival analysis was performed using life table methods. RESULTS: Medical records from 66 consecutive patients treated during an 18-month interval were reviewed. Demographic characteristics included mean age of 38.7 years, 13 years of education and parity of 2. Married women composed 75% of the study group, with 81% white, 10% Hispanic and 9% black. Of the 66 patients studied, 50 had follow-up documentation with an average duration of 14.5 weeks. Overall, 34 patients (52%) demonstrated improvement in pelvic pain following vaginal electrical stimulation. Using survival analysis, 51% of patients had persistent improvement 30 weeks after treatment. There were no differences in age, race, education or parity between patients reporting a sustained benefit of stimulation and those not reporting a benefit. CONCLUSION: Vaginal electrical stimulation may help a selected population of women with pelvic pain due to levator ani spasm.     

Medical and surgical management of chronic pelvic pain

Chronic pelvic pain is common and is estimated to affect over one million women in the UK. It may be a symptom of a number of different conditions and is often multifactorial in nature, caused by a combination of physical, psychological and social factors. For many women, a primary cause cannot be identified. This can make both diagnosis and management difficult. Gynaecological causes of chronic pelvic pain include endometriosis, chronic pelvic inflammatory disease and adhesions. The gynaecologist must also consider non-gynaecological causes of pain related to the gastrointestinal, urinary, neurological, musculoskeletal and psychological systems if satisfactory management of the woman's pain is to be achieved.This review addresses the approach to diagnosis and management of women presenting with chronic pelvic pain. It details specific disease management but also seeks to encourage a holistic approach to all women with chronic pelvic pain, whether or not a primary diagnosis is established.     

Medical and surgical management of chronic pelvic pain

Chronic pelvic pain (CPP) affects over 1 million women in the UK, with subsequent impact on ability to work and the economy. It is often debilitating and can be difficult to treat. Gynaecologists have traditionally focussed on the organ-specific approach to the diagnosis of pain. Endometriosis is common as is chronic pelvic inflammatory disease and adenomyosis. Some causes are non-gynaecological such as irritable bowel syndrome and interstitial cystitis. However, as many as 55% of women presenting with CPP will have no obvious underlying pathology following completion of all investigations.This review focuses on the appropriate investigations, diagnosis and management of women with identified pathological causes of pelvic pain. It also considers the holistic approach to the management of the woman with chronic pelvic pain syndrome. Careful prescribing, assessment, interaction and support from a multidisciplinary team are required.     

Sleep disturbance among women with chronic pelvic pain

Objective

To investigate the effect of chronic pelvic pain (CPP), a debilitating condition, on sleep quality.

Methods

The present case–control study enrolled women older than 18 years attending the Gynecology Clinic of Çanakkale Onsekiz Mart University Hospital, Çanakkale, Turkey, with CPP between August 2011 and August 2012. The control group was selected from women attending the clinic for another complaint. Sleep quality was evaluated via the Pittsburgh Sleep Quality Index, and differences between the groups were compared by t and χ² tests.

Results

During the study period, 157 women were enrolled. Seventy-two had CPP symptoms, and 85 attended the clinic for other complaints. Poor sleep quality was found in 80% (n = 58) of the women with CPP, and 55% (n = 47) of the control group (P < 0.05).

Conclusion

Women with CPP were found to have poor sleep quality. Sleep education should be recommended in psychiatry and neurology clinics to increase the awareness of sleeping problems among these women.     

Medical and surgical management of chronic pelvic pain

Chronic pelvic pain is common and is estimated to affect over one million women in the UK. It may be a symptom of a number of different conditions and is often multifactorial in nature, caused by a combination of physical, psychological and social factors. For many women, a primary cause cannot be identified. This can make both diagnosis and management difficult. Gynaecological causes of chronic pelvic pain include endometriosis, chronic pelvic inflammatory disease and adhesions. The gynaecologist must also consider non-gynaecological causes of pain related to the gastrointestinal, urinary, neurological, musculoskeletal and psychological systems if satisfactory management of the woman's pain is to be achieved.This review addresses the approach to diagnosis and management of women presenting with chronic pelvic pain. It details specific disease management but also seeks to encourage a holistic approach to all women with chronic pelvic pain, whether or not a primary diagnosis is established.     

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.     

Significance of laparoscopy in the management of chronic pelvic pain

OBJECTIVE: Chronic pelvic pain is a complex disease and is far more common than generally recognized. STUDY DESIGN: Between 1 January 1979 and 31 December 2002 authors had performed 11,681 laparoscopic interventions. Among them, 1061 operations (9.08%) were done because of chronic pelvic pain. RESULTS: In 29.5% of these cases no anatomical abnormality was found. Analysis of data of laparoscopic operations performed from 1989 to 1990 and from 1998 to 1999 revealed that complaints dated back for a significantly longer period of time in patients presenting no obvious sign of pelvic anatomical anomaly when compared with those who had positive findings. In patients with positive pelvic findings laparotomy had previously been performed in a significantly higher number. When no apparent pelvic pathology was found medical history was also negative for ectopic pregnancy. Similarly, there were only three cases of previous adnexal operations. However, among patients with positive findings, medical history revealed 19 prior cases of ectopic pregnancy, 49 cases of previous adnexal operations, 82 appendectomy, and 26 cholecystectomy (p<0.01). Among patients with positive pelvic findings, diagnostic laparoscopy was immediately completed by adequate surgical treatment in the same session in more than two-third of cases. Most frequently this included adhesiolysis, ovarian cystectomy, uterosacral nerve ablation, electrocoagulation of areas of endometriosis, and ventrosuspension of the retroflected uterus. CONCLUSION: Based on our retrospective data analysis we believe that laparoscopy is an essential method for the diagnosis and management of chronic pelvic pain.     

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.     

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.     

History of childhood maltreatment and symptoms of anxiety and depression in women with chronic pelvic pain

Objective: To determine the prevalence of physical, sexual and emotional abuse and physical and emotional neglect suffered by women with chronic pelvic pain (CPP) during childhood and whether these occurrences are associated with symptoms of pain, anxiety and depression.

Methods: A case–control study was conducted on 154 women older than 18?years, 77 of them healthy and 77 with CPP. A history of sexual, physical, and emotional abuse and physical and emotional neglect was determined using the Childhood Trauma Questionnaire (CTQ). Anxiety and depression symptoms were determined using the Hospital Anxiety and Depression (HAD) scale. Pain intensity was determined using a visual analog scale (VAS). The quantitative variables were compared by the Wilcoxon test, and the qualitative variables were compared by the Chi-square test or exact Fisher test when appropriate. Correlation between the CTQ, HAD and VAS scores was estimated by the Spearman’s p coefficient. Independent association of the variables with the presence of CPP was determined by logistic multiple regression analysis.

Results: The prevalence of childhood maltreatment was 77.9% and 64.9%, respectively, for women with CPP and healthy women (p?=?0.07). Emotional neglect was more frequent among women with CPP than among healthy women (58.4% versus 41.5%, p?=?0.04). There was a moderate correlation between anxiety and depression symptoms and CTQ scores for women with CPP. Unemployment (OR?=?4.15, 95% CI 1.73–9.94; OR_adj?= 3.30, 95% CI 1.26–8.55) was independently associated with the presence of CPP.

Conclusions: Women with CPP reported emotional neglect abuse more frequently than healthy women. There was a direct correlation between maltreatment scores and anxiety and depression scores. On the other hand, CPP was independently associated only with unemployment.     

Impact of endometriosis on quality of life and mental health: pelvic pain makes the difference

Abstract

Introduction: No prior study of endometriosis has investigated the psychological impact of having asymptomatic endometriosis versus endometriosis with pelvic pain in a systematic way. This study aimed at examining the impact of endometriosis on quality of life, anxiety and depression by comparing asymptomatic endometriosis, endometriosis with pelvic pain, and healthy, pain-free controls. The psychological impact of different types of endometriosis pain was also tested.

Methods: One hundred and ten patients with surgically diagnosed endometriosis (78 with pelvic pain and 32 without pain symptoms) and 61 healthy controls completed two psychometric tests assessing quality of life, anxiety and depression. Endometriosis participants indicated on a numerical rating scale the intensity of four types of pain (dysmenorrhea, dyspareunia, non-menstrual pelvic pain and dyschezia).

Results: Endometriosis patients with pelvic pain had poorer quality of life and mental health as compared with those with asymptomatic endometriosis and the healthy controls. No significant differences were found between asymptomatic endometriosis and the control group. Dysmenorrhea had significant effects only on physical quality of life; non-menstrual pelvic pain affected all the variables; no significant effects were found for dyspareunia and dyschezia.

Conclusions: Pain significantly affects women’s experience of endometriosis. The medical treatment of endometriosis with pain may not be sufficient and psychological intervention is recommended.     

Schistosoma mansoni pseudo-cyst as a cause of chronic pelvic pain

A case of mansoni schistosomiasis causing peritoneal inflammation and chronic iliac pain is reported. The patient complained of iliac pain for 6 months. Physical examination and sonographic evaluation found a tumor in the left iliac fosse. A pseudocyst was removed from the pelvic region. The histopathology confirmed the diagnosis of S. mansoni. This is a rare case of S. mansoni in the pelvic cavity.     

Mast cells in chronic inflammation,pelvic pain and depression in women

Inflammatory and neuroinflammatory processes are increasingly recognized as critical pathophysiologic steps in the development of multiple chronic diseases and in the etiology of persistent pain and depression. Mast cells are immune cells now viewed as cellular sensors in inflammation and immunity. When stimulated, mast cells release an array of mediators to orchestrate an inflammatory response. These mediators can directly initiate tissue responses on resident cells, and may also regulate the activity of other immune cells, including central microglia. New evidence supports the involvement of peripheral and central mast cells in the development of pain processes as well as in the transition from acute, to chronic and neuropathic pain. That behavioral and endocrine states can increase the number and activation of peripheral and brain mast cells suggests that mast cells represent the immune cells that peripherally and centrally coordinate inflammatory processes in neuropsychiatric diseases such as depression and anxiety which are associated with chronic pelvic pain. Given that increasing evidence supports the activated mast cell as a director of common inflammatory pathways/mechanisms contributing to chronic and neuropathic pelvic pain and comorbid neuropsychiatric diseases, mast cells may be considered a viable target for the multifactorial management of both pain and depression.     

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.