A randomized double-blind placebo-controlled trial on the effect of local analgesia on postoperative gluteal pain in patients undergoing sacrospinous ligament colpopexy.

BACKGROUND: The incidence of temporary gluteal pain after sacrospinous ligament colpopexy ranges from 6.1% to 15.3%. Gluteal pain may occur as a result of injury to S3 to S5 nerve roots that course over the mid-portion of the coccygeus-sacrospinous ligament complex at the time of suspension suture placement. There are no data on the use of injections to prevent postoperative pain from nerve entrapment at the time of suture placement. OBJECTIVE: The purpose of this study was to determine whether intraoperative local analgesia that is administered at the level of the sacrospinous ligament can lessen the gluteal pain felt by patients postoperatively after sacrospinous ligament colpopexy. STUDY DESIGN: In a randomized double-blind placebo-controlled trial, women with vaginal apex prolapse who were undergoing surgical treatment with sacrospinous ligament colpopexy underwent intraoperative injection with either 0.25% bupivacaine or normal saline solution. Subjects completed visual analog pain scales (0-10) and the Activities Assessment Scale and recorded the use of pain medications over a 6-week period. The primary outcome was postoperative gluteal pain. A sample size of 50 subjects (25 in each arm) was planned to test the hypothesis that local analgesia administration will lessen postoperative pain compared with placebo. RESULTS: Between April 2014 and March 2016, 51 women were enrolled in the study, and 46 women underwent sacrospinous ligament colpopexy. On postoperative day 1, 90.2% of all subjects (n=41) reported gluteal pain. At weeks 1 and 2, 63.8% (n=29) and 44.1% (n=20) women reported pain; at weeks 4 and 6, 33.3% (n=15) and 26.9% (n=12) women continued to have some pain. On day 1, the mean score for gluteal pain was 3.7±2.9. By week 1, the score was 1.8±2.6; by week 6, the mean score was 0.1±0.3. There were no differences in pain scores for patients who had undergone injection with 0.25% bupivacaine and those who were injected with normal saline solution. Patients in the placebo group used significantly more nonsteroidal antiinflammatory drugs than the treatment group: adjusted odds ratio, 1.25; 95% confidence interval, 1.04-1.35; P=.01). By 6 weeks, 87.5% of patients had returned to their baseline "light" activity level. There was no difference in time to return to baseline between the groups. CONCLUSION: Intraoperative administration of local analgesia does not reduce patients' perceptions of postoperative gluteal pain after sacrospinous ligament colpopexy; however, it may reduce the need for pain medication after surgery.

Gluteal and posterior thigh pain in the postoperative period and the need for intervention after sacrospinous ligament colpopexy.

INTRODUCTION: Sacrospinous ligament (SSL) colpopexy is a transvaginal surgical option for the treatment of vaginal apex prolapse. The objective of this study was to determine the rate of gluteal and posterior thigh pain after SSL colpopexy using the Capio device in the immediate postoperative period, at the 6-week postoperative visit, and to determine the risk of needing intervention for this type of pain. METHODS: This was a retrospective cohort study of women who underwent SSL colpopexy with the Capio device for the treatment of vaginal apex prolapse between 2007 and 2012. The electronic inpatient and outpatient medical record was queried for demographic, intraoperative, and immediate and 6-week postoperative data. RESULTS: Two hundred forty-two subjects underwent SSL colpopexy with the Capio device for vaginal apex prolapse. Mean age and body mass index were 66 (10) years and 28.7 (5.4) kg/m, respectively. One hundred thirty-four (55.4%) subjects were found to have immediate gluteal or posterior thigh pain and 36 (15.3%) were found to have persistent pain at 6 weeks. Five (2.1%; 95% confidence interval, 0.8%-4.7%) subjects required intervention: physical therapy (3), trigger point injection (1), both (1), and no patients required reoperation. Concomitant midurethral sling placement was associated with pain at 6 weeks (P = 0.008). Need for intervention was associated with the number of sutures placed (2 or 3 vs 4; P = 0.03). Concomitant hysterectomy and approach to SSL colpopexy were not associated with gluteal or posterior thigh pain. CONCLUSIONS: The rate of immediate postoperative gluteal and posterior thigh pain is high in patients undergoing SSL colpopexy for vaginal apex prolapse; however, the rate of pain at 6 weeks is much lower, and the need for intervention is even lower.

Spinal cord stimulation for intractable vulvar pain. A case report.

BACKGROUND: Vulvodynia is a complex pain syndrome with few effective treatments. We present a case of complex persistent vulvar pain effectively managed with spinal cord stimulation. CASE: A 21-year-old woman had a long history of burning vulvar pain exacerbated by exercise and sexual intercourse. Her symptoms began after termination of pregnancy and were not improved by diet changes or medical therapy. A partial vulvar vestibulectomy with Bartholin gland excision was performed, without an improvement. After referral to a pain management specialist, the patient had temporary relief of symptoms following bilateral hypogastric plexus blocks. With these favorable but temporary results, a permanent spinal cord stimulator was implanted, with sustained symptom relief. CONCLUSION: Spinal cord stimulation may offer a new treatment for women with intractable neuropathic vulvar pain.