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.

Botulinum toxin injection for chronic pelvic pain: A systematic review.

INTRODUCTION: Botulinum toxin has proven therapeutic effects in alleviating pain in several myofascial disorders, with an expanding potential in chronic pelvic pain. The objective of this systematic review is to evaluate the efficacy and safety of botulinum toxin injection as an off-label treatment for female chronic pelvic pain. MATERIAL AND METHODS: Using PRISMA guidelines, MEDLINE, EBM Reviews, PubMed, CINAHL, TRIP Database, EMBASE, Web of Science and gray literature were searched. Studies assessing the efficacy of botulinum toxin for chronic pelvic pain in adult females, with 10 or more women, published in English up to 13 January 2020, were included. All eligible studies were reviewed and data were extracted by two independent reviewers using a standardized form. Quality of evidence was graded using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Ottawa-Newcastle scale for observational studies. RESULTS: In all, 491 records were screened. Seventeen articles were included in the final review: 5 randomized controlled trials and 12 observational studies. The quality of evidence ranged from low to high. There was a large degree of heterogeneity in study designs, and thus a meta-analysis was not feasible. All observational studies concluded that botulinum toxin was an effective treatment for chronic pelvic pain, with the greatest change in visual analog scale from 8.69 at baseline to 3.07 at 24 months post-injection. However, only one of the five randomized controlled trials found statistical significant differences favoring botulinum toxin in the reporting of the EQ-5D (botulinum 0.78 [0.69-1.00], control 0.69 [0.25-0.81], P = .03) and frequency of intercourse (botulinum 1 [1-1.75], placebo 1 [0-1], P = .025). The most common adverse effect was transient localized pain at injection site (6%-88%). No serious adverse events were reported. CONCLUSIONS: Although observational studies were encouraging, there is insufficient high quality evidence to recommend botulinum toxin injection for chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality in its treatment efficacy are indicated.

Temporal Summation in Chronic Pelvic Pain.

OBJECTIVE: This study sought to characterize central sensitization further among women with chronic pelvic pain by identifying temporal summation using a cotton-tipped applicator test that can be used at the bedside. METHOD: A total of 36 women (18 with chronic pain and allodynia; 18 without pain) were recruited. Both groups were randomly assigned to receive 3 strokes of a benign stimulus on the abdomen at differing frequencies: 10, 30, or 100 seconds. Each group included 6 women. Pain was assessed using a rating scale of 1 to 10. Data were analyzed using the multivariate approach to repeated measures analysis of variance. RESULTS: The pattern of pain scores differed significantly between women with and without chronic pain (P = 0.002). Women with chronic pelvic pain and allodynia showed a statistically significant increase in pain with successive strokes of the cotton-tipped applicator (P = 0.012 for stroke 1 vs. 2, P = 0.026 for stroke 2 vs. 3, and P = 0.005 for stroke 1 vs. 3). CONCLUSION: Women with chronic pelvic pain and allodynia showed significant worsening of pain with successive strokes of a cotton-tipped applicator. This finding indicates that pain wind-up and central sensitization are present in women with chronic pelvic pain and allodynia. Identification of summation is further evidence of neuroplasticity, which is helpful in innovative therapies for chronic pelvic pain.

No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

No 164 - Directive clinique de consensus pour la prise en charge de la douleur pelvienne chronique.

OBJECTIF: Améliorer La compréhension de la douleur pelvienne chronique (DPC) et fournir des directives cliniques factuelles qui bénéficieront aux fournisseurs de soins de santé primaires, aux obstétriciens-gynécologues et aux spécialistes de la douleur chronique. FARDEAU DE LA SOUFFRANCE: La DPC est une pathologie débilitante courante qui affecte les femmes. Elle est à l'origine d'importantes souffrances personnelles et de dépenses de santé considérables associées aux interventions, dont de multiples consultations et un grand nombre de traitements médicaux et chirurgicaux. Puisque la pathophysiologie sous-jacente de cet état pathologique complexe est mal comprise, ces traitements n'ont obtenu que des taux de réussite variables. ISSUES: Efficacité des options diagnostiques et thérapeutiques (y compris l'évaluation du dysfonctionnement myofascial); soins multidisciplinaires; un modèle de réadaptation mettant l'accent sur l'obtention d'un fonctionnement supérieur malgré la présence d'une certaine douleur (plutôt que de chercher à obtenir une guérison totale); et utilisation appropriée des opiacés pour le soulagement de la douleur chronique. PREUVES: Des recherches ont été menées dans Medline et la base de données Cochrane en vue d'en tirer les articles de langue anglaise, publiés entre 1982 et 2004, portant sur des sujets liés à la DPC, dont la gestion des soins actifs, le dysfonctionnement myofascial et les options thérapeutiques médicales et chirurgicales. Les membres du comité ont analysé la littérature pertinente, ainsi que les données disponibles tirées d'une évaluation des besoins des personnes présentant une DPC; ils ont fait appel à une approche de consensus pour l'élaboration des recommandations. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur l'examen médical périodique. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport (Tableau 1). RECOMMANDATIONS: Les recommandations visent ce qui suit : (a) compréhension des besoins des femmes présentant une DPC ; (b) évaluation clinique générale ; (c) évaluation pratique des niveaux de douleur ; (d) douleur myofasciale ; (e) médicaments et interventions chirurgicales ; (f) principes de la gestion des opiacés; (g) utilisation accrue de l'imagerie par résonance magnétique (IRM) ; (h) documentation de l'étendue de La maladie constatée au moyen de la chirurgie ; (i) thérapies non conventionnelles; (j) accès à des modèles de soins multidisciplinaires faisant appel à des composantes de physiothérapie (comme l'exercice et la posture) et de psychologie (comme La thérapie cognitivo- comportementale), conjointement avec d'autres disciplines médicales, telles que La gynécologie et l'anesthésie ; (k) attention accrue portée à La DPC dans La formation des professionnels de La sante ; et (l) attention accrue portée à la DPC dans le domaine des recherches officielles et de haut calibre. Le comité recommande que les ministères provinciaux de La Sante prennent des mesures en faveur de la création d'équipes multidisciplinaires pouvant assurer La prise en charge de cette pathologie. Chapitre 2 : Portee et definition de La douleur pelvienne chronique Chapitre 3 : Anamnese, examen physique et évaluation psychologique Chapitre 4 : Explorations Chapitre 5 : Sources de douleur pelvienne chronique Chapitre 6 : Causes urologiques et gastro-intestinales de La douleur pelvienne chronique Chapitre 7 : Dysfonctionnement myofasclal Chapitre 8 : Therapie medicale - résultats en matiere d'efficacite Chapitre 9 : Chirurgie - résultats en matiere d'efficacite Chapitre 11 : Prise en charge multidisciplinaire de La douleur chronique Chapitre 14 : Orientations futures.

Evolutionary considerations in the development of chronic pelvic pain.

Chronic pelvic pain is common among women of reproductive age and is associated with significant morbidity and comorbidities. In this Viewpoint, we explore the evolutionary cause of pelvic pain and summarize evidence that supports a menstruation-related evolutionary cause of chronic visceral pelvic pain: (1) lifetime menstruation has increased; (2) severe dysmenorrhea is common in the chronic pelvic pain population, particularly among those with pain sensitization; and (3) a potential biological mechanism can be identified. Thus, chronic pelvic pain may arise from the mismatch between the slow pace of biological evolution in our bodies and the relatively rapid pace of cultural changes that have resulted in increased menstrual frequency due to earlier menarche, later mortality, and lower fecundity. One possible mechanism that explains the development of persistent pain from repeated episodes of intermittent pain is hyperalgesic priming, a physiological process defined as a long-lasting latent hyperresponsiveness of nociceptors to inflammatory mediators after an inflammatory or neuropathic insult. The repetitive severely painful menstrual episodes may play such a role. From an evolutionary perspective the relatively rapid increase in lifetime menstruation experience in contemporary society may contribute to a mismatch between lifetime menstruation and the physiological pain processes, leading to a maladaptive state of chronic visceral pelvic pain. Our current physiology does not conform to current human needs.

Allodynia and Dysmenorrhea.

OBJECTIVE: Cutaneous allodynia (pain from a non-painful stimulus) is a sign that can be observed among women with chronic pelvic pain. Dysmenorrhea is recognized as a common cause of chronic pelvic pain in women. This study was conducted to explore the frequency of allodynia and the relationship between allodynia and severe dysmenorrhea. METHODS: We enrolled women in this study if they had experienced chronic pelvic pain for more than six months. Women provided information regarding their chronic pelvic pain and menstrual function, specifically the severity of their menstrual pain. In addition to a gynaecological assessment, women were tested for allodynia and pain pressure thresholds. RESULTS: Abdominal allodynia was present in 62.1% of 181 women who participated. Women with allodynia had a significantly greater rate of severe dysmenorrhea and significantly greater duration of severe dysmenorrhea. Pain pressure thresholds were demonstrated to decrease significantly in relation to increasing duration of severe dysmenorrhea. CONCLUSION: There is a greater frequency of chronic pain among women with a history of severe dysmenorrhea. Women who experienced prolonged severe dysmenorrhea were shown to have a progressive increase in pain sensitivity (reflected in reduced pain pressure thresholds). These findings support efforts to manage dysmenorrhea early in a woman's life with approaches to suppress menstrual function.

Autologous Fat Grafting to the Breast Using REVOLVE System to Reduce Clinical Costs.

BACKGROUND: With the increasing popularity of fat grafting over the past decade, the techniques for harvest, processing and preparation, and transfer of the fat cells have evolved to improve efficiency and consistency. The REVOLVE System is a fat processing device used in autologous fat grafting which eliminates much of the specialized equipment as well as the labor intensive and time consuming efforts of the original Coleman technique of fat processing. This retrospective study evaluates the economics of fat grafting, comparing traditional Coleman processing to the REVOLVE System. METHODS: From June 2013 through December 2013, 88 fat grafting cases by a single-surgeon were reviewed. Timed procedures using either the REVOLVE System or Coleman technique were extracted from the group. Data including fat grafting procedure time, harvested volume, harvest and recipient sites, and concurrent procedures were gathered. Cost and utilization assessments were performed comparing the economics between the groups using standard values of operating room costs provided by the study hospital. RESULTS: Thirty-seven patients with timed procedures were identified, 13 of which were Coleman technique patients and twenty-four (24) were REVOLVE System patients. The average rate of fat transfer was 1.77 mL/minute for the Coleman technique and 4.69 mL/minute for the REVOLVE System, which was a statistically significant difference (P < 0.0001) between the 2 groups. Cost analysis comparing the REVOLVE System and Coleman techniques demonstrates a dramatic divergence in the price per mL of transferred fat at 75 mL when using the previously calculated rates for each group. CONCLUSIONS: This single surgeon's experience with the REVOLVE System for fat processing establishes economic support for its use in specific high-volume fat grafting cases. Cost analysis comparing the REVOLVE System and Coleman techniques suggests that in cases of planned fat transfer of 75 mL or more, using the REVOLVE System for fat processing is more economically beneficial. This study may serve as a guide to plastic surgeons in deciding which cases might be appropriate for the use of the REVOLVE System and is the first report comparing economics of fat grafting with the traditional Coleman technique and the REVOLVE System.

The Significance of Cutaneous Allodynia in a Woman With Chronic Pelvic Pain.

BACKGROUND: This is a case report of sensory assessment in a woman with severe chronic pelvic pain following uterine artery embolization, and a discussion of a commonly observed sensory manifestation (allodynia) associated with chronic pelvic pain due to gynaecological conditions. Allodynia, as a common sensory abnormality can be readily detected at the bedside and represents the development of pain sensitization. Emergence of abdominal and perineal allodynia (assessed by cotton swap stroking and/or questionnaire) is associated with the development of the clinical features of sensitization: continuous pelvic pain, muscle tenderness, and reduced pressure pain thresholds. CASE: A uterine artery embolization was performed on a 42-year-old woman to treat a postpartum hemorrhage. The woman experienced severe pain immediately following the procedure, and it had persisted for one year when she was referred for chronic unrelenting pain. She was found to have extensive allodynia, myofascial dysfunction, and reduced pain thresholds. A hysterectomy was undertaken. As the pain persisted, botulinum toxin was administered to the lower abdomen in the region of reduced pain thresholds. Partial resolution of pain, physical limitation, and allodynia resolved one year after the hysterectomy and shortly after the injections of four tender regions of the anterior cutaneous nerves with 2.5 and 5.0 IU of botulinum toxin. CONCLUSION: Testing for allodynia is a validated bedside test for pain sensitization. A clinical trial of botulinum toxin is indicated for the management of chronic pelvic pain associated with allodynia and pain sensitization.

Contexte : Cet exposé de cas présente une évaluation sensorielle menée chez une femme qui a connu de graves douleurs pelviennes chroniques à la suite d'une embolisation des artères utérines et traite d'une manifestation sensorielle courante (allodynie) qui est associée à des douleurs pelviennes chroniques attribuables à des troubles gynécologiques. L'allodynie (en tant qu'anomalie sensorielle courante) peut facilement être détectée au chevet de la patiente et représente le développement d'une sensibilisation douloureuse. L'apparition d'une allodynie abdominale et périnéale (déterminée par effleurement au moyen d'un écouvillon et/ou par l'administration d'un questionnaire) est associée à celle des caractéristiques cliniques de la sensibilisation : douleur pelvienne continuelle, endolorissement musculaire et baisse des seuils de la douleur provoquée par une pression. Cas : Une embolisation des artères utérines a été menée chez une femme de 42 ans pour la prise en charge d'une hémorragie postpartum. La patiente a connu de graves douleurs immédiatement à la suite de l'intervention; après une année de douleurs persistantes, elle a été orientée vers des services de prise en charge de la douleur chronique tenace. La présence d'une allodynie étendue, d'une dysfonction myofasciale et d'une baisse des seuils de la douleur a été constatée. Une hystérectomie a été menée. Puisque la douleur persistait, de la toxine botulinique a été administrée dans la partie inférieure de l'abdomen, en ciblant la région connaissant une baisse des seuils de la douleur. La résolution partielle de la douleur, les limites physiques et l'allodynie se sont résorbées un an à la suite de l'hystérectomie et peu après les injections de 2,5 et de 5,0 UI de toxine botulinique dans les quatre régions douloureuses des nerfs cutanés antérieurs. Conclusion : Le dépistage de l'allodynie constitue un test dont la tenue au chevet a été validée pour ce qui est de la sensibilisation douloureuse. La tenue d'un essai clinique portant sur l'utilisation de toxine botulinique pour la prise en charge de la douleur pelvienne chronique qui est associée à l'allodynie et à la sensibilisation douloureuse s'avère indiquée.

Prediction of postoperative pain after gynecologic laparoscopy for nonacute pelvic pain.

OBJECTIVE: The primary objectives of this study were to explore the pain experience after gynecologic laparoscopy that is performed for nonacute pain conditions and to determine whether preoperative psychologic tests and quantitative tests of sensitization can predict postoperative pain. STUDY DESIGN: Participants included 61 women who underwent laparoscopy for nonacute pain (n = 61). A second group of 16 women who had undergone tubal ligation was included to explore whether laparoscopy induced a painful postoperative response in women without preoperative pain. Subjective tests included numeric pain scale, pain catastrophizing scale, depression scale, global assessment of change, and the McGill Pain Questionnaire Short Form. Quantitative sensory testing included abdominal cutaneous allodynia, trigger points, and reduced pain thresholds. The nonacute pain sample had 80% power to detect a difference of 0.5 standard deviation in average pain levels. Analysis included parametric and nonparametric comparisons of groups and univariate and linear regression analysis of clinically relevant variables. RESULTS: In women who underwent tubal ligation, pain levels were low before and after the procedure. In women who underwent surgery for nonacute pain, pain levels at 6 months and all psychologic test scores were reduced significantly compared with baseline (P < .001 and P = .001, respectively). Among those women with positive results on the quantitative pain tests of sensitization at baseline, average postoperative pain was also significantly reduced (P < .001). Univariate analysis demonstrated only tests of sensitization that were correlated with change in average pain level (P = .01). Regression analysis suggested that baseline pain, catastrophizing, and the presence of cutaneous allodynia significantly predicted pain levels 6 months after surgery (P < .001). CONCLUSION: Pain after laparoscopic surgery for nonacute painful conditions can be predicted by baseline pain, catastrophizing, and the presence of allodynia, which is a simple swab test that indicates sensitization.

A flexible format interdisciplinary treatment and rehabilitation program for chronic daily headache: patient clinical features, resource utilization and outcomes.

OBJECTIVE: To describe the demographics, diagnoses, program duration, human resource utilization and outcomes of patients with chronic daily headache treated in an ambulatory, interdisciplinary, flexible format, treatment and rehabilitation program. BACKGROUND: Research indicates that multidisciplinary care is an effective approach to manage chronic daily headache, but little is known about the resources needed for effective care. METHODS: The study was a secondary data analysis within a cohort design of previously collected data. Patients completed questionnaires and outcome measures on admission and discharge. Diagnoses were extracted from patient charts by professional health records personnel. A central scheduling database provided patient-specific clinician care hours by discipline and type (direct, indirect, group) as well as overall program duration. RESULTS: One hundred and eighteen patients were studied (mean age 41.1 ± 10.4 [x ± SD], 80% female). Sixty-two patients (52.5%) completed the program ("completers"). Migraine was the most common diagnosis. Thirty-six percent of patients had medication overuse. Average pain, mood, disability, and quality of life were significantly improved in completers (P < .001). They utilized 76 ± 45.1 (x ± SD ) total hours of care delivered over a mean of 129.7 ± 66.1 weeks. CONCLUSION: Our study provides evidence that ambulatory, interdisciplinary, flexible format, treatment and rehabilitation programs are effective in the treatment of chronic daily headache, and we provide data on the resources used by our program in the treatment and rehabilitation of these patients.

Pain evoked by distension of the uterine cervix in women with dysmenorrhea: evidence for central sensitization.

OBJECTIVE: To study sensitization in women with dysmenorrhea using a standardized experimental model. Women with dysmenorrhea experience intense visceral pain during menstruation. The dysmenorrhea pain mechanisms are not known but sensitization may play a role. DESIGN: Prospective experimental study. SAMPLE: Ten women with dysmenorrhea and 10 control women having uterine cervical distensions in the mid-follicular period (days 6-10). SETTING: University clinic. METHOD: Cervical distension was delivered as three phasic stimuli with 1 min between distensions and as a prolonged (1 min) distension. MAIN OUTCOME MEASURE: Sensory intensity rated on a continuous visual analog scale. RESULTS: Distension-induced pain was described as dull and aching and referred to the pelvis, lower back and lower abdomen. Larger evoked referred pain areas were present in women with dysmenorrhea compared with control women (p < 0.05). The pain threshold to the first stimulus was significantly higher in patients than controls (p < 0.04), but decreased significantly with repeated distensions (p < 0.01). For the prolonged distension the pain rating increased significantly (p < 0.008) in women with dysmenorrhea, but decreased (p < 0.02) in control women. CONCLUSIONS: Pain sensitization (temporal summation, i.e. increase in pain during prolonged stimulation, and facilitation of referred pain areas as an indicator of central nervous system changes) is present in women with dysmenorrhea. The study provided new information on a poorly understood yet widespread condition and a basis for clinical studies to develop a biomarker tests for objective assessment of dysmenorrhea.

Characterization and bioactive properties of zirconia based polymeric hybrid for orthopedic applications.

Zirconia is a transition metal oxide with current applications to orthopedic implants. It has been shown to up-regulate specific genes involved in bio-integration and injury repair. This study examines the effects of zirconia and polydimethylsiloxane (PDMS) hybrids on the proliferation and viability of human primary osteoblast and fibroblast cells. In this study, zirconia-PDMS hybrid coatings were synthesized using a modified sol gel process. The hybrid material was characterized using optical microscopy, scanning electron microscopy, X-ray photoelectron spectroscopy, and contact angle analysis. This study demonstrates that Zr-PMDS surface materials display hydrophobic surface properties coupled with a preferential deposition of polymer near the surface. Primary osteoblast and fibroblast proliferation and viability on hybrid coated surfaces were evaluated via a rapid screening methodology using WST-1 and calcein AM assays. The cells were seed at 5,000 cells per well in 96-well plates coated with various composition of Zr-PDMS hybrids. The results showed increasing cell proliferation with increasing zirconia concentration, which peaked at 90 % v/v zirconia. Proliferation of osteoblasts and fibroblasts displayed similar trends on the hybrid material, although osteoblasts displayed a bi-phasic dose response by the calcein AM assay. The results of this current study show that Zr-PDMS may be used to influence tissue-implant integration, supporting the use of the hybrid as a promising coating for orthopedic trauma implants.

Cotton-tipped applicator test: validity and reliability in chronic pelvic pain.

OBJECTIVE: We sought to assess the concurrent validity and interrater reliability of the cotton-tipped applicator (CTA) test as a screening tool for diagnosis of cutaneous allodynia in patients with viscerally related chronic pelvic pain (CPP). STUDY DESIGN: We performed a prospective cohort comparative observational study of referred patients to a gynecology clinic with CPP. A total of 22 females with CPP were compared to 23 pain-free controls and 12 cyclic pain patients. Participants were evaluated by 2 clinicians. The CTA test was performed to detect the appearance of pain in dermatomes of T10-L1. RESULTS: Interrater reliability resulted in 98% agreement for the 3 study groups. CTA test showed 73% sensitivity and 100% specificity for differentiating patients with CPP from pain-free patients. CONCLUSION: The CTA test had excellent interrater reliability and concurrent validity for diagnosis of cutaneous allodynia in CPP patients with visceral diseases versus controls.

Quantitative sensory testing in gynaecology: improving preoperative and postoperative pain diagnosis.

Chronic pelvic pain presents difficulties for women suffering its complex presentation. It also presents difficulties for clinicians involved in diagnosing and managing the problem. We review here clinically relevant information related to visceral pathology and its association with peripheral and central aspects of pain hypersensitivity. We address why surgery appears to be successful in some cases but less than successful in others, and what cautionary indicators should be taken into account. A categorization of chronic pelvic pain based on our understanding of pain physiology and mechanisms involved is proposed. The benefits of multidimensional sensory and pain testing in gynaecological care are reviewed.

La douleur pelvienne chronique cause des difficultés aux femmes qui sont victimes de sa présentation complexe. Elle cause également des difficultés aux cliniciens qui participent à son diagnostic et à sa prise en charge. Nous analysons ici des renseignements cliniques pertinents en ce qui concerne la pathologie viscérale et son association aux aspects périphériques et centraux de l'hypersensibilité à la douleur. Nous traitons des raisons pour lesquelles la chirurgie semble plus réussie dans certains cas que dans d'autres et nous nous prononçons quant aux indicateurs de prudence qui devraient être pris en considération. Nous proposons une catégorisation de la douleur pelvienne chronique fondée sur notre compréhension de la physiologie de la douleur et des mécanismes mis en cause. Les avantages du dépistage multidimensionnel sensoriel et de la douleur dans le cadre des soins gynécologiques sont analysés.

Classification and management of seromas in immediate breast reconstruction using the tissue expander and acellular dermal matrix technique.

Tissue expander (TE)/acellular dermal matrix (ADM)-based breast reconstruction used in immediate postmastectomy breast reconstruction, although a popular technique, is not without complications.Although seroma formation is recognized and reported in the literature as a complication, little information addresses seroma(s) management. We conducted a retrospective review of 100 consecutive TE/ADM immediate reconstructions during a 2-year period, performed by a single surgeon. Data collection included patient demographics, adjuvant therapy, initial TE fill volume, time to completion of expansion, seroma formation, management of seroma, and wound complications, up to the time of definitive implant exchange. From December 2009 to December 2011, 67 patients (100 reconstructions) underwent TE/ADM immediate breast reconstruction. Thirty-one reconstructions were identified having clinically significant seroma(s). Eighteen of the reconstructions required multiple drainage procedures. With these data, a 3-group classification system was created based on the number of aspirations. In review of the 3 groups, 71% of group III required either Seroma-Cath or operative drainage beyond simple aspiration(s). Of the 100 reconstructions, 3 (3%) ended in TE explantation. Only 1 (3%) TE explantation, interestingly from group I, was attributable to seroma formation. Using the data, we devised a management strategy emphasizing attentiveness to seroma formation, recognition, and treatment. Seroma formation is a known entity linked to complications in TE/ADM reconstructive course. A seroma classification system and treatment algorithm is offered to minimize abandonment of the reconstruction and optimize outcomes.

Maternal and child biomonitoring strategies and levels of exposure in western Canada during the past seventeen years: The Alberta Biomonitoring Program: 2005-2021.

The Alberta Biomonitoring Program (ABP) was created in 2005 with the initial goal of establishing baseline levels of exposure to environmental chemicals in specific populations in the province of Alberta, Canada, and was later expanded to include multiple phases. The first two phases focused on evaluating exposure in pregnant women (Phase One, 2005) and children (Phase Two, 2004-2006) by analyzing residual serum specimens. Phase Three (2013-2016) employed active recruitment techniques to evaluate environmental exposures using a revised list of chemicals in paired serum pools from pregnant women and umbilical cord blood. These three phases of the program monitored a total of 226 chemicals in 285 pooled serum samples representing 31,529 individuals. Phase Four (2017-2020) of the ABP has taken a more targeted approach, focusing on the impact of the federal legalization of cannabis on the exposure of pregnant women in Alberta to cannabis, as well as tobacco and alcohol using residual prenatal screening serum specimens. Chemicals monitored in the first three phases include herbicides, neutral pesticides, metals, metalloids, and micronutrients, methylmercury, organochlorine pesticides, organophosphate pesticides, parabens, phthalate metabolites, perfluoroalkyl substances (PFAS), phenols, phytoestrogens, polybrominated compounds, polychlorinated biphenyls (PCBs), dioxins and furans, polycyclic aromatic hydrocarbons (PAHs), and tobacco biomarkers. Phase Four monitored six biomarkers of tobacco, alcohol, and cannabis. All serum samples were pooled. Mean concentrations and 95% confidence intervals (CIs) were calculated for the chemicals detected in ≥25% of the sample pools. cross the first three phases, the data from the ABP has provided baseline exposure levels for the chemicals in pregnant women, children, and newborns across the province. Comparison within and among the phases has highlighted differences in exposure levels with age, geography, seasonality, sample type, and time. The strategies employed throughout the program phases have been demonstrated to provide effective models for population biomonitoring.

Endometriosis and abdominal myofascial pain in adults and adolescents.

Endometriosis and myofascial pain are common disorders with significant impact on quality of life. Increasingly, these conditions are being recognized as highly interconnected through processes that have been described for more than a century. This review is directed to this interconnection through a description of the relationships of endometriosis to proposed mechanisms of pain and chronic pain physiology; the clinical assessment of myofascial representations of this pain; and an approach to the management of these interconnected disorders.