Guideline No. 445: Management of Chronic Pelvic Pain.

OBJECTIVE: To provide evidence-based recommendations for the management of chronic pelvic pain in females. TARGET POPULATION: This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain. BENEFITS, HARMS, AND COSTS: The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability. EVIDENCE: Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals. TWEETABLE ABSTRACT: Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments. SUMMARY STATEMENTS: RECOMMENDATIONS.

[Functional-neurosurgical treatment options for functional pelvic floor disorders : Value of sacral neuromodulation]. / Funktionell-neurochirurgische Therapieoptionen bei Funktionsstörungen des Beckenbodens : Stellenwert der sakralen Neuromodulation.

BACKGROUND: Sacral neuromodulation is an established minimally invasive therapy indicated for the treatment of functional pelvic floor disorders. While it received its original US Food and Drug Administration (FDA) approval for the treatment of overactive bladder symptoms, it is now regarded as a therapeutic option to treat both urinary/fecal incontinence and retention. In addition, it has proven to be a valuable tool in the treatment of chronic pelvic pain, and preliminary results indicate a potential to elicit improvements in sexual functioning. OBJECTIVE: This article serves to provide a summary of the therapy and its applications. METHOD: Selective literature review. RESULTS: Sacral neuromodulation implants allow for the controlled shifting of the autonomic control of bladder and rectum towards an inhibition or facilitation of voiding, dependent on the patient's needs and under the patient's control. At the same time and depending on the applied stimulation, the implants can interfere with the nerve's conduction of pain signals. This makes them a therapeutic option for pelvic pain that fails to respond to conventional treatment. Finally, there have been first reports suggesting improvements in sexual dysfunction under sacral neuromodulation, thus, potentially opening up a new line of therapy for those disorders. DISCUSSION: Sacral neuromodulation is a flexible and efficient form of therapy for functional disorders of the pelvic floor. Specifically, the same intervention can treat seemingly contradictory disorders such as urinary/fecal incontinence and retention as well as chronic pain.

Feasibility and outcomes of Desarda vs Lichtenstein hernioplasty by local anesthesia for inguinal hernia: a noninferiority randomized clinical trial.

INTRODUCTION: The Desarda autologous tissue repair is comparable to the Lichtenstein hernioplasty for inguinal hernia regarding recurrence, chronic groin pain, and return to work activities. This study was designed to establish the outcomes of Desarda's repair versus Lichtenstein's hernioplasty concerning post-operative recovery to normal gait and its feasibility under local anesthesia (LA). MATERIALS AND METHODS: This study was a single-center, prospective, double-blinded, non-inferiority, randomized trial. Patients undergoing open hernia repair for primary inguinal hernia were included. Patients were randomly assigned and followed up for 2 years. The primary endpoint was the time to return to normal gait post-surgery with comfort (non-inferiority margin fixed as 0.5 days). The secondary outcomes studied were post-operative pain score, the time required to return to work (all previously performed activities), and surgical-site occurrences (SSO). RESULTS: One hundred ten eligible patients were randomly assigned [56 patients (50.9%) in the Desarda group and 54 patients (49.1%) in the Lichtenstein group]. All the procedures were safely performed under LA. The median (interquartile range) time for resuming gait post-surgery with comfort was 5 days in the Desarda vs 4 days in Lichtenstein's arm (P = 0.16), thereby failing to demonstrate non-inferiority of Desarda against Lichtenstein hernioplasty. However, there were no significant differences in days to return to work, SSO, chronic groin pain, and recurrence within two years of surgery. CONCLUSIONS AND RELEVANCE: This study could not demonstrate the non-inferiority of the Desarda repair versus Lichtenstein hernioplasty regarding the time taken to return to normal gait. Comparing the days to return to work, pain score, SSO, and chronic groin pain, including recurrence rate, Desarda repair faired equally with Lichtenstein hernioplasty, thereby highlighting its feasibility and efficacy under LA. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03512366.

Laparoscopic surgery for endometriosis.

BACKGROUND: Endometriosis is associated with pain and infertility. Surgical interventions aim to remove visible areas of endometriosis and restore the anatomy. OBJECTIVES: To assess the effectiveness and safety of laparoscopic surgery in the treatment of pain and infertility associated with endometriosis. SEARCH METHODS: This review has drawn on the search strategy developed by the Cochrane Gynaecology and Fertility Group including searching the Cochrane Gynaecology and Fertility Group's specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, reference lists for relevant trials, and trial registries from inception to April 2020. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) that compared the effectiveness and safety of laparoscopic surgery with any other laparoscopic or robotic intervention, holistic or medical treatment, or diagnostic laparoscopy only. DATA COLLECTION AND ANALYSIS: Two review authors independently performed selection of studies, assessment of trial quality and extraction of relevant data with disagreements resolved by a third review author. We collected data for the core outcome set for endometriosis. Primary outcomes included overall pain and live birth. We evaluated the quality of evidence using GRADE methods. MAIN RESULTS: We included 14 RCTs. The studies randomised 1563 women with endometriosis. Four RCTs compared laparoscopic ablation or excision with diagnostic laparoscopy only. Two RCTs compared laparoscopic excision with diagnostic laparoscopy only. One RCT compared laparoscopic ablation or excision with laparoscopic ablation or excision and uterine suspension. Two RCTs compared laparoscopic ablation and uterine nerve transection with diagnostic laparoscopy only. One RCT compared laparoscopic ablation with diagnostic laparoscopy and gonadotropin-releasing hormone (GnRH) analogues. Two RCTs compared laparoscopic ablation with laparoscopic excision. One RCT compared laparoscopic ablation or excision with helium thermal coagulator with laparoscopic ablation or excision with electrodiathermy. One RCT compared conservative laparoscopic surgery with laparoscopic colorectal resection of deep endometriosis infiltrating the rectum. Common limitations in the primary studies included lack of clearly described blinding, failure to fully describe methods of randomisation and allocation concealment, and poor reporting of outcome data. Laparoscopic treatment versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic treatment on overall pain scores compared to diagnostic laparoscopy only at six months (mean difference (MD) 0.90, 95% confidence interval (CI) 0.31 to 1.49; 1 RCT, 16 participants; very low quality evidence) and at 12 months (MD 1.65, 95% CI 1.11 to 2.19; 1 RCT, 16 participants; very low quality evidence), where a positive value means pain relief (the higher the score, the more pain relief) and a negative value reflects pain increase (the lower the score, the worse the increase in pain). No studies looked at live birth. We are uncertain of the effect of laparoscopic treatment on quality of life compared to diagnostic laparoscopy only: EuroQol-5D index summary at six months (MD 0.03, 95% CI -0.12 to 0.18; 1 RCT, 39 participants; low quality evidence), 12-item Short Form (SF-12) mental health component (MD 2.30, 95% CI -4.50 to 9.10; 1 RCT, 39 participants; low quality evidence) and SF-12 physical health component (MD 2.70, 95% CI -2.90 to 8.30; 1 RCT, 39 participants; low quality evidence). Laparoscopic treatment probably improves viable intrauterine pregnancy rate compared to diagnostic laparoscopy only (odds ratio (OR) 1.89, 95% CI 1.25 to 2.86; 3 RCTs, 528 participants; I2 = 0%; moderate quality evidence). We are uncertain of the effect of laparoscopic treatment compared to diagnostic laparoscopy only on ectopic pregnancy (MD 1.18, 95% CI 0.10 to 13.48; 1 RCT, 100 participants; low quality evidence) and miscarriage (MD 0.94, 95% CI 0.35 to 2.54; 2 RCTs, 112 participants; low quality evidence). There was limited reporting of adverse events. No conversions to laparotomy were reported in both groups (1 RCT, 341 participants). Laparoscopic ablation and uterine nerve transection versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic ablation and uterine nerve transection on adverse events (more specifically vascular injury) compared to diagnostic laparoscopy only (OR 0.33, 95% CI 0.01 to 8.32; 1 RCT, 141 participants; low quality evidence). No studies looked at overall pain scores (at six and 12 months), live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage. Laparoscopic ablation versus laparoscopic excision There was insufficient evidence to determine whether there was a difference in overall pain, measured at 12 months, for laparoscopic ablation compared with laparoscopic excision (MD 0.00, 95% CI -1.22 to 1.22; 1 RCT, 103 participants; very low quality evidence). No studies looked at overall pain scores at six months, live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy, miscarriage and adverse events. Helium thermal coagulator versus electrodiathermy We are uncertain whether helium thermal coagulator compared to electrodiathermy improves quality of life using the 30-item Endometriosis Health Profile (EHP-30) at nine months, when considering the components: pain (MD 6.68, 95% CI -3.07 to 16.43; 1 RCT, 119 participants; very low quality evidence), control and powerlessness (MD 4.79, 95% CI -6.92 to 16.50; 1 RCT, 119 participants; very low quality evidence), emotional well-being (MD 6.17, 95% CI -3.95 to 16.29; 1 RCT, 119 participants; very low quality evidence) and social support (MD 5.62, 95% CI -6.21 to 17.45; 1 RCT, 119 participants; very low quality evidence). Adverse events were not estimable. No studies looked at overall pain scores (at six and 12 months), live birth, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage. AUTHORS' CONCLUSIONS: Compared to diagnostic laparoscopy only, it is uncertain whether laparoscopic surgery reduces overall pain associated with minimal to severe endometriosis. No data were reported on live birth. There is moderate quality evidence that laparoscopic surgery increases viable intrauterine pregnancy rates confirmed by ultrasound compared to diagnostic laparoscopy only. No studies were found that looked at live birth for any of the comparisons. Further research is needed considering the management of different subtypes of endometriosis and comparing laparoscopic interventions with lifestyle and medical interventions. There was insufficient evidence on adverse events to allow any conclusions to be drawn regarding safety.

Alternative Treatment Utilization Before Hysterectomy for Benign Gynecologic Conditions at a Large Integrated Health System.

STUDY OBJECTIVE: To investigate rates of utilization of alternative treatments before hysterectomy for benign gynecologic indications within a large integrated health care system. DESIGN: Retrospective cohort study of patients who underwent hysterectomies for benign gynecologic conditions between 2012 and 2014 (Canadian Task Force classification II-2). SETTING: Kaiser Permanente Northern California, a community-based integrated health system. PATIENTS: Women who underwent hysterectomy for a benign gynecologic condition between 2012 and 2014. INTERVENTIONS: From an eligible cohort of 6892 patients who underwent hysterectomy, a stratified random sample of 1050 patients were selected for chart review. Stratification was based on the proportion of indications for hysterectomy. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the use of alternative treatments before hysterectomy. Alternative treatments included oral hormone treatment, leuprolide, medroxyprogesterone intramuscular injections, a levonorgestrel intrauterine device, hormonal subdermal implants, endometrial ablation, uterine artery embolization, hysteroscopy, and myomectomy. Of the 1050 charts reviewed, 979 (93.2%) met the criteria for inclusion in this study. The predominant indication for hysterectomy was symptomatic myomas (54.4%), followed by abnormal uterine bleeding (29.0%), endometriosis (5.8%), pelvic pain (3.1%), dysmenorrhea (3.4%), and other (4.3%). The major routes of hysterectomy were laparoscopy (68.7%) and vaginal hysterectomy (13.4%). Before hysterectomy, 81.2% of patients tried at least 1 type of alternative treatment (33.8% with 1 treatment and 47.4% with at least 2 treatments), and 99.3% of patients were counseled regarding alternative treatments. Compared with younger women age <40 years, women age 45 to 49 years were less likely to use alternative treatments before hysterectomy (adjusted odds ratio, 0.41; 95% confidence interval, 0.21-0.76). There were no variations in treatment rates by socioeconomic status or between major racial and ethnic groups. The final pathological analysis identified myomas as the most common pathology (n = 637; 65.1%); 96 patients (9.8%) had normal uterine pathology. CONCLUSION: More than 80% of patients received alternative treatments before undergoing hysterectomy for a benign gynecologic condition. Additional investigation is warranted to assess alternative treatment use as it relates to preventing unnecessary hysterectomies.

The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do when surgery fails.

PURPOSE OF REVIEW: To provide an update on nonsurgical and nonpharmacologic strategies for the management of chronic pelvic pain (CPP). RECENT FINDINGS: Effective treatment of patients with CPP requires a multifaceted approach, with thoughtful consideration of surgical, pharmacologic, and nonpharmacologic strategies. Evidence for physical therapy and trigger point injections for treatment of myofascial components of CPP is increasing. Neuromodulation techniques, such as percutaneous tibial nerve stimulation and transcutaneous electrical stimulation, have limited but favorable preliminary data in patients with CPP. Behavioral strategies, such as exercise, cognitive behavioral therapy, and mindfulness, have demonstrated significant improvements in pain, function and quality of life in patients with a variety of chronic pain conditions and are promising avenues for future research in CPP. SUMMARY: Nonpharmacologic therapies are important adjuncts to surgical and pharmacologic treatment for CPP and should be considered integral to a comprehensive treatment approach.

Surgical therapy of prostatitis: a systematic review.

PURPOSE: The clinical term "prostatitis" refers to a clinical syndrome defined by the following 4 distinct entities: acute bacterial prostatitis (category 1), chronic bacterial prostatitis (category 2), chronic prostatitis/chronic pelvic pain syndrome (category 3), and asymptomatic prostatitis (category 4) The etiology of the chronic forms is still not fully understood and choice of therapy is often debated. The objective of this systematic review is to collect evidence on the surgical treatment of the chronic form of prostatitis and to evaluate its clinical implication. METHODS: We performed a systematic literature search and identified 6683 relevant publications, of which 16 were included in the review. RESULTS: Transurethral prostate resection was performed in 110 patients; 78 patients (70%) were reported as "cured", 16 patients (15%) as improved, and 16 patients (15%) as unchanged. Radical prostatectomy was performed in 21 patients; a full resolution of prostatitis related symptoms was reported for 20 patients (95%). No increased rates of complications or unusual complications were noted. CONCLUSIONS: Surgical therapy of chronic bacterial prostatitis or chronic pelvic pain syndrome might be a viable option; however, since little evidence is currently available and no randomized controlled trials have been conducted, the presently available data does not provide a base for clinical decisions.

Recurrent symphysitis culminating in pelvic ring fracture after hyperextended transurethral prostate resection and vaporization with symphysis erosion: a case report.

BACKGROUND: Short-term and long-term complications of transurethral prostate resection can be different in nature. Capsule perforation and subsequent fistulation after resection and electrovaporization is seldom reported in the literature. CASE PRESENTATION: Here we report the case of a 79-year-old caucasian man with capsule perforation after transurethral prostate resection and electrovaporization resulting in a severe and recurrent symphysitis and subsequent pelvic ring fracture. The bladder-symphysis fistulation was surgically removed and additional orthopedic surgery could be avoided after definitely solving the urological problem. CONCLUSIONS: Urologists should be aware of rare complications after transurethral resection and electrovaporization of the prostate.

Comparative pilot study of implantation techniques for pudendal neuromodulation: technical and clinical outcome in first 20 patients with chronic pelvic pain.

PURPOSE: Neurostimulation of the pudendal nerve (PN) is considered for patients who have failed sacral neuromodulation. Previous techniques for PN localization are described to be uncomplicated and promise to achieve accuracy in electrode placement. However, in clinical use, they appear challenging. We developed a puncture technique using fixed anatomical landmarks for a fast and reproducible localization of the PN. METHODS: Full-body cadavers and dissected anatomical preparations were studied for the course of the PN. Fluoroscopically controlled fixed anatomical landmarks locating the pudendal trunk were defined. Lead placement following established techniques was performed, and the topographic relationship to the PN was documented by dissection. In a pilot series of 20 patients with chronic pelvic pain, pudendal neuromodulation (PNM) was performed uni- and bilateral using the different approaches. Technical and clinical outcomes of the various techniques were compared. RESULTS: Fixed anatomical landmarks such as ischial spine, ischial tuberosity, acetabulum and anal rim resulted in a right-angled triangle with a new start and target point for puncture. Initials of the landmarks add up to the teaching acronym STAR. STAR technique including a puncture angle of 60° and a gluteal lead exit places 3-4 electrode poles at the nerve. In clinical trial, mean operation time for bilateral PNM in STAR was 85 min with mean puncture attempts of 3.5 to reach the nerve. Pain decreased statistically significant only in bilateral PNM. CONCLUSIONS: The STAR approach appears to achieve technical standardisation and optimized reproducibility in pudendal lead placement resulting into an increased feasibility of PNM.

Post-laparoscopic oral contraceptive combined with Chinese herbal mixture in treatment of infertility and pain associated with minimal or mild endometriosis: a randomized controlled trial.

BACKGROUND: Endometriosis affects fertility negatively. The study aims to evaluate whether laparoscopic surgery combined with oral contraceptive or herbs were more effective than laparoscopic alone in improving fecundity and pelvic pain in women with minimal/mild endometriosis. METHODS: A randomized controlled trial (RCT) was conducted in 156 infertile women with minimal/mild endometriosis. After laparoscopic surgery, patients were randomized to three groups: in Group A (n = 52) oral contraceptive (OC) was administered one pill a day, continuous for 63 days without intervals, in Group B (n = 52) OC was administered as above and then Dan'e mixture was added 30 g/day for the latter 30 days, and in control Group C (n = 52) patients tried to get pregnant after surgery without complementary treatment. The follow-up periods were 12 months in Group C and 14 months in complementary medical treatment Group A and B. The pregnant women were further followed up, and labor and pregnancy outcomes were assessed. Primary outcome was pregnancy rate (PR) and live birth rate (LBR). Secondary outcomes included changes of pelvic pain visual analog scale scores and side effects. Analyses were done as intention-to-treat. RESULTS: The PR was 46.80% (73/156), and the LBR was 69.86% (51/73). Of the 73 pregnancies, 60 occurred within 12 months of follow-up and 7 of the remaining 13 patients underwent assisted reproductive technology for >1 year. No significant difference was observed in PR and LBR among the three groups. Patients given medical treatment (OCs or OCs plus herbal medicine) had significantly decreased pain scores compared with the laparoscopy alone group. CONCLUSIONS: Combination of laparoscopy with OCs or OCs and herbal medicine does not have more advantages than laparoscopy alone in improving fertility of women with minimal/mild endometriosis. TRIAL REGISTRATION: ChiCTR-TRC-11001820.

Multidisciplinary laparoscopic treatment for bowel endometriosis.

Endometriosis is a handicapping disease affecting young females in the reproductive period. It mainly occurs in the pelvis and affects the bowel in 3-37%. Endometriosis can cause menstrual and non-menstrual pelvic pain and infertility. Colorectal involvement results in alterations of bowel habit such as constipation, diarrhoea, tenesmus, and rarely rectal bleeding. A precise diagnosis about the presence, location and extent is necessary. Based on clinical examination, the diagnosis of bowel endometriosis can be made by transvaginal ultrasound, barium enema examination and magnetic resonance imaging. Multidisciplinary laparoscopic treatment has become the standard of care and depending on size of the lesion and site of involvement full-thickness disc excision or bowel resection is performed by an experienced colorectal surgeon. Anastomotic complications occur around 1%. Long-term outcome after bowel resection for severe endometriosis is good with a pregnancy rate of 50%.

Chronic pelvic pain syndromes--traditional and novel therapies: part I surgical therapy.

PURPOSE: To describe the role of various surgical therapies for the relief of pelvic pain. METHODS: The latest studies involving surgical therapies for relief of pelvic pain are reviewed and the pros and cons are discussed. RESULTS: Laparoscopic removal of endometriotic implants should be performed if the surgical procedure is being performed for diagnostic purposes. Laparoscopic utersacral nerve ablation of endometriotic implants and presacral neurectomy may provide additional relief but require greater surgical skills and have significant risks, especially bleeding. There still is a role for complete hysterectomy usually with bilateral salpingo-oophorectomy. CONCLUSIONS: Recurrence rates following surgery relegate surgical procedures behind medical therapy, i.e., to be used only if medical therapy is failing. Not all pelvic pain is related to endometriosis. Some novel concepts as to common mechanisms involved in a large percentage of these pelvic pain syndromes leading to some novel highly effective medical therapies will be discussed in part II.

Medical, surgical and alternative treatments for chronic pelvic pain in women: a descriptive review.

Several causes of chronic pelvic pain (CPP) are recognised, but in many women a definite diagnosis cannot be made. Few randomised controlled trials on treatment of CPP have been conducted. In a Cochrane systematic review, only medroxy-progesterone acetate, counselling, a multidisciplinary approach and lysis of deep adhesions had a proven benefit. The aim of this descriptive review is to describe the management of CPP, which can focus on treating the pain itself, the underlying cause, or both. Combination drug therapy with medications with different mechanisms of action may improve therapeutic results. Pelvic denervating procedures should be indicated in selected circumstances, as the magnitude of the effect is undefined. Several alternative non-invasive treatments have been proposed including exercise programmes, cognitive and behavioural medicine, physical therapy, dietary modification, massage and acupuncture. When the woman has completed her family and particularly when pelvic varices have been demonstrated, hysterectomy can be considered after a careful pre-operative assessment. However, substantial pain relief may be achieved in no more than 60-70% of the cases. A minority of patients (3-5%) will experience worsening of pain or will develop new symptoms after surgery. Treatment of CPP, generally, requires acceptance of the concept of managing rather than curing symptoms.

The use of capsaicin in loin pain-haematuria syndrome.

OBJECTIVE: To highlight the implications of the use of capsaicin in managing loin pain-haematuria syndrome (LPHS). PATIENTS AND METHODS: Between February 2002 and February 2007, three patients (one male and two females; mean age 31.7 years) with LPHS were managed with capsaicin and followed up for a period of 8-48 months. All were diagnosed with LPHS after negative urological investigations including urine culture, urine cytology, renal tract ultrasonography, intravenous urography and flexible cystoscopy; and nephrological work-ups including normal blood pressure measurements, creatinine clearance, urinary protein estimation and serum urea/creatinine. Five original papers were reviewed in detail for this article. Including our own experience, a total of 52 (including five bilateral) cases of LPHS treated with capsaicin are reviewed. RESULTS: Our patients received a total of four capsaicin instillations producing an average duration of pain relief per instillation of 17 weeks. There was evidence of renal deterioration in one, while another had worsened symptoms. The third patient continued his pain management within the pain clinic. The former two patients eventually underwent nephrectomy for poor function and extreme symptoms. CONCLUSION: Intrarenal capsaicin at best produces only short-term pain relief in more than half of patients with LPHS. It produces significant side-effects, i.e. UTI, bladder pain, and in up to half of patients, deteriorating symptoms. Further loss of functional renal tissue and a nephrectomy rate of 20-67% should be weighed against the benefits. We have therefore abandoned its use in treating LPHS or renal pain, and recommend that patients should be adequately counselled on its potential side-effects, including nephrotoxicity and increased nephrectomy rate.

Laparoscopic treatment of pelvic pain associated with minimal and mild endometriosis with use of the Helica Thermal Coagulator.

OBJECTIVE: To investigate the clinical efficacy and safety of Helica Thermal Coagulator (TC) in the treatment of pelvic pain associated with minimal (stage I) and mild (stage II) endometriosis. DESIGN: A clinical observational study. SETTING: A referral center for laparoscopic treatment of endometriosis. PATIENT(S): Eighty-one women with pelvic pain symptoms associated with minimal and mild endometriosis diagnosed at laparoscopy. INTERVENTION(S): Helica TC to treat endometriotic lesions. The revised American Fertility Society (rAFS) classification was used to stage endometriosis. Pain symptoms and patient satisfaction were assessed subjectively at 3 and 6 months follow-up. MAIN OUTCOME MEASURE(S): Improvement or relief of pelvic pain symptoms, and intra- or postoperative complications. RESULT(S): A total of 79 women completed the study to 6 months follow-up. At 3 months, 59 (74.7%) women reported resolution and satisfactory improvement of symptoms, whereas 20 (25.3%) women continued to experience painful symptoms. At 6 months, 69 (87.4%) women reported resolution and satisfactory improvement of symptoms, whereas 9 (11.4%) women reported no changes and 1 (1.2%) woman experienced worsening symptoms. No significant differences were found between minimal and mild disease. No side effects or surgical complications occurred. CONCLUSION(S): Meaningful improvements and relief in clinical symptoms can be obtained with conservative laparoscopic surgery. Helica TC is a simple, effective, and safe device for the treatment of pelvic pain in women with stages I and II endometriosis. This approach requires further evaluation as part of randomized controlled trials.

Therapeutic effect of transurethral needle ablation in non-bacterial prostatitis: chronic pelvic pain syndrome type IIIa.

AIM: Non-bacterial prostatitis is difficult to manage with conventional treatment. This study was undertaken to evaluate the therapeutic effect of transurethral needle ablation (TUNA) on men with chronic inflammatory non-bacterial prostatitis. METHODS: Thirty-two patients with non-bacterial prostatitis (type IIIa) were treated with TUNA. The TUNA procedure, which uses radiofrequency energy, heats the prostate tissue to approximately 90-110 degrees C over a 5-min period. Evaluation consisted of a prostatitis symptom severity score chart, the monitoring of the leukocyte count in the expressed prostatic secretion (EPS) and a subjective global assessment. RESULTS: The decrease in the prostate symptom severity score chart at 3 and 6 months compared with the baseline assessment was statistically significant. Analysis of the leukocyte levels in the EPS in 14 patients was available. All 14 patients had a decrease in the EPS leukocyte count 3 months after treatment. However, six of these men (43%) still had EPS leukocyte levels above the normal indices (>10 white blood cells per high-power field). A second session of TUNA on these partial responders resulted in three of the six men obtaining a normal EPS leukocyte count. At 6 months following treatment, complete, partial and poor improvement in terms of subjective global assessment were noted in 60, 35 and 5% of patients, respectively. No major complications, including those of sexual dysfunction or retrograde ejaculation, were noted in this cohort. CONCLUSIONS: Transurethral needle ablation appears to be an easy, safe and effective treatment for men with chronic inflammatory non-bacterial prostatitis.

Microlaparoscopy under local anesthesia and conscious pain mapping for the diagnosis and management of pelvic pain.

Chronic pelvic pain is a complex disorder with multiple etiologies. Recently, the technique of microlaparoscopy under local anesthesia has been applied to chronic pelvic pain. The specialized technique of conscious pain mapping has been developed to aid in the diagnosis of these patients. This paper will review the history and usage of office and microlaparoscopy in general. It will then discuss specific applications for patients with acute or chronic pelvic pain.

Office microlaparoscopy under local anesthesia.

Office laparoscopy under local anesthesia is especially suited to meet the current pressures of quality versus cost in an era of managed care. It is likely that this technique will soon become a major part of the practicing gynecologist's diagnostic operative armamentarium. Advantages of office microlaparoscopy under local anesthesia are realized by the practitioner, the patient, and the managed care provider. Office microlaparoscopy under local anesthesia is a safe, effective, and less costly tool for the evaluation of patients with many different indications. To date, the procedure has been primarily used for patients with infertility, chronic pelvic pain, and tubal ligation. The ease of scheduling, reduced costs, and rapid recovery suggest that it may be the preferred initial procedure for these patients.

Office microlaparoscopy under local anesthesia in the diagnosis and treatment of chronic pelvic pain.

STUDY OBJECTIVE: To evaluate the safety of diagnostic and operative microlaparoscopy performed in the office under local anesthesia in the diagnosis and treatment of chronic pelvic pain. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: Office-based, free-standing private obstetrics and gynecology practice. PATIENTS: Twenty women with chronic pelvic pain. INTERVENTION: Diagnostic and operative microlaparoscopy performed under local anesthesia with conscious sedation. MEASUREMENTS AND MAIN RESULTS: All 20 patients had diagnostic microlaparoscopy and 19 had conscious pain mapping. Nine of 14 patients with endometriosis underwent fulguration of lesions and 7 of 8 with pelvic adhesions had lysis of adhesions. Four women with uterosacral ligament involvement had laparoscopic uterosacral nerve ablation. All patients tolerated office diagnostic and operative procedures without difficulty and had no complications. CONCLUSION: In selected women, several laparoscopic procedures traditionally done in a hospital or ambulatory surgery center under general anesthesia can be performed safely in the office laparoscopy suite under local anesthesia with conscious sedation.

Surgical interruption of a midline dorsal column visceral pain pathway. Case report and review of the literature.

A punctate midline myelotomy performed in a patient effectively eliminated residual, intractable pelvic pain, which remained after resolution of uterine cervical cancer. The authors describe the case history of the patient, in whom pain assessments were made, and a surgical procedure performed. Despite large doses of opiate analgesic medications, the patient experienced constant pressure pain in the right lower pelvis, with excruciating pain on bowel movement. Severe weight loss necessitated better pain control. A minimally invasive surgical procedure, a 5-mm deep puncture using a 16-gauge needle on either side of the median septum in the dorsal column of the spinal cord (T-8), resulted in no new neurological deficits. Narcotic medication was tapered, no pain was reported, and the patient resumed daily household activity. Midline myelotomy has typically been performed with the intention of eliminating the crossing fibers of the spinothalamic tract in the anterior white matter commissure. The punctate midline myelotomy described here was performed with the specific intention of interrupting a newly described visceral pain pathway that ascends to higher brain centers through the midline of the dorsal column. The effectiveness of the pain relief seen in this patient suggests that visceral pain of the pelvis in humans may be transmitted in the midline of the dorsal column, as has been recently reported in studies using rats. The effectiveness of the punctate midline myelotomy performed in this one case of pelvic visceral pain suggests that the surgery may eventually be effective in greatly reducing or replacing opiate narcotic medication for visceral pain management.