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1.
Am J Obstet Gynecol ; 229(5): 530.e1-530.e17, 2023 11.
Artigo em Inglês | MEDLINE | ID: mdl-37516398

RESUMO

BACKGROUND: Central sensitization is frequently associated with chronic pelvic pain and requires specific management. The pain is described as hypersensitivity to an innocuous stimulus that is both widespread and persistent. However, no study has evaluated if central sensitization can be measured objectively with neurophysiological tests in the pelvic and perineal area to prove this concept in women with chronic pelvic pain. OBJECTIVE: This study aimed to evaluate nociceptive thresholds (primary objective) and spatial and temporal diffusion of pain among women with chronic pelvic pain and high or low scores of central sensitization. STUDY DESIGN: This prospective, assessor-blinded, comparative study compared a cohort of women with chronic pelvic pain and a high (>5/10; n=29) vs low (<5/10; n=24) score of sensitization according to the Convergences PP criteria. Participants underwent a noninvasive bladder sensory test, a rectal barostat test, and a muscular (algometer) and a vulvar (vulvagesiometer) sensory test. Poststimulation pain (minutes), quality of life (Medical Outcomes Study 36-Item Short Form Survey), and psychological state, comprising anxiety (State-Trait Anxiety Inventory), depression (Beck Depression Inventory Short Form), and catastrophizing (Pain Catastrophizing Scale), were assessed. RESULTS: The participants mostly suffered from endometriosis (35.8%), irritable bowel syndrome (35.8%), bladder pain syndrome (32.1%), and vestibulodynia (28.3%). Baseline characteristics were similar. Women with a high sensitization score had more painful diseases diagnosed (2.7±1.3 vs 1.6±0.8; P=.002) and suffered for longer (11±8 vs 6±5 years; P=.028) than participants with a low score. The bladder maximum capacity was equivalent between participants (399±168 vs 465±164 mL; P=.18). However, the pain felt at each cystometric threshold was significantly increased in women with a high sensitization score. No difference was identified for the rectal pain pressure step (29.3±5.5 vs 30.7±6.5 mm Hg; P=.38). Rectal compliance was decreased in women with a high sensitization score with a considerable increase in pain felt. The average of pain pressure thresholds at the 5 vulvar sites tested was decreased in these participants (162.5±90.5 vs 358.7±196.5 g; P=.0003). Similar results were found for the average of the pain pressure thresholds at 6 muscles tested (1.34±0.41 vs 2.63±1.52 kg/m2; P=.0002). A longer period was needed for patients with high sensitization score to obtain a VAS <3 out of 10 after the stimulation of the bladder (4.52±5.26 vs 1.27±2.96 minutes; P=.01), the rectum (3.75±3.81 vs 1.19±1.23 minutes; P=.009), and the muscles (1.46±1.69 vs 0.64±0.40 minutes; P=.002). The psychological state was equivalent between groups. No association was found between the sensory thresholds and the psychological state results. The physical component of the quality of life score was reduced in women with high sensitization score (P=.0005), with no difference in the mental component. CONCLUSION: Using neurophysiological tests, this study showed that there are objective elements to assess for the presence of central sensitization, independently of psychological factors.


Assuntos
Sensibilização do Sistema Nervoso Central , Dor Crônica , Humanos , Feminino , Estudos Prospectivos , Qualidade de Vida , Medição da Dor , Dor Pélvica/diagnóstico , Dor Pélvica/psicologia
2.
Int Urogynecol J ; 33(4): 1001-1006, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-33822258

RESUMO

INTRODUCTION AND HYPOTHESIS: The objective was to report the management of post-operative urinary incontinence after midurethral sling (MUS) revision for chronic pelvic pain (CPP), and to report functional outcomes. METHODS: From November 2004 to February 2018, a total of 89 women who underwent removal or section of MUS for CPP, were enrolled. Patients were divided into the transobturator tape (TOT) group (50 patients) and the tension-free vaginal tape (TVT) group (37 patients); 2 patients had had both slings implanted. We report the rate of stress urinary incontinence (SUI) recurrence, the rate of de novo urge urinary incontinence (UUI), the need for subsequent SUI or UUI surgery, and functional outcomes (pain and continence). RESULTS: Median follow-up was 41.4 months [0.9-138.8]. SUI recurrence or de novo UUI occurred in 52 cases (58.4%): 19 (51.3%) patients in the TVT group, 31 (62%) in the TOT group, and both patients (100%) who underwent total removal of both slings. Among patients with SUI recurrence or de novo UUI, 39 (75%) had pain relief after sling removal. Seventeen patients (32.6%) refused any treatment, 14 (26.9%) were cured with conservative therapy, and 21 (40.3%) underwent SUI or UUI surgery. One patient had de novo pelvic pain after reoperation. The overall continence rate for all patients who underwent sling revision was 82% (73 out of 89) at the last follow-up. CONCLUSION: After MUS revision for CPP, post-operative UI may occur in 58.4% of patients, of which, one-fourth may be managed with conservative measures only. Forty percent of them had redo surgery with a low risk of pain recurrence and a high rate of urinary continence.


Assuntos
Slings Suburetrais , Incontinência Urinária por Estresse , Incontinência Urinária , Feminino , Humanos , Masculino , Dor Pélvica/etiologia , Dor Pélvica/cirurgia , Slings Suburetrais/efeitos adversos , Resultado do Tratamento , Incontinência Urinária/etiologia , Incontinência Urinária por Estresse/etiologia , Incontinência Urinária por Estresse/cirurgia , Incontinência Urinária de Urgência/etiologia , Incontinência Urinária de Urgência/cirurgia
3.
Neurourol Urodyn ; 37(7): 2177-2183, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29573029

RESUMO

AIMS: The objective of this study was to evaluate the efficacy of surgical removal of prosthetic material, possibly combined with nerve release, on chronic postoperative pain following placement of prosthetic material. MATERIAL AND METHODS: Single-tertiary-centre study on 107 patients managed between November 2004 and April 2016 for removal of prosthetic material responsible for postoperative chronic pain: retropubic suburethral sling (n = 32), transobturator suburethral sling (n = 50), prolapse mesh (n = 16), and hernia mesh (n = 9). The primary endpoint was at least 50% reduction of pain evaluated by a pain numerical rating scale (NRS). RESULTS: The mean interval between the initial operation involving placement of prosthetic material and reoperation for removal of prosthetic material was 41.2 ± 35.4 months. In all cases pain apperaed immediately following prosthetic material placement surgery. Pain presented neuropathic features in almost 30% of cases and was poorly systematized in more than one-half The mean follow-up of the study population was 8.4 ± 10.3 months. The mean pain NRS score for the overall population was seven preoperatively and three at last follow-up. At least 50% reduction of the pain NRS score was observed 67% of cases at last follow-up. During follow-up, 45% of patients experienced relapse of the disorder for which the prosthetic material was initially placed with, in particular, a 62% recurrence rate of urinary incontinence after removal of transobturator suburethral tape. CONCLUSION: Surgical removal of prosthetic material to treat chronic postoperative pain, achieved global improvement of pain in about two-thirds of cases, but with a risk of recurrence of the initial disorders.


Assuntos
Dor Crônica/cirurgia , Dor Pós-Operatória/cirurgia , Slings Suburetrais/efeitos adversos , Telas Cirúrgicas/efeitos adversos , Incontinência Urinária/cirurgia , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Adulto , Idoso , Dor Crônica/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação
4.
Pain Med ; 19(10): 2009-2015, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-29522121

RESUMO

Background: The evaluation of chronic pelvic and perineal pain (CPP) is often complex. The patient's description of the pain often appears to be disproportionate to the limited findings on physical examination and/or complementary investigations. The concept of central sensitization may allow better understanding and management of patients with CPP. Objective: The aim of this study was to elaborate a clinical evaluation tool designed to simply identify sensitization in pelvic pain. Methods: A list of 63 items was submitted to 22 international CPP experts according to the Delphi method. Results: Ten clinical criteria were adopted for the creation of a clinical evaluation tool: 1) pain influenced by bladder filling and/or urination, 2) pain influenced by rectal distension and/or defecation, 3) pain during sexual activity, 4) perineal and/or vulvar pain in response to normally nonpainful stimulation, 5) pelvic trigger points (e.g., in the piriformis, obturator internus, and/or levator ani muscles), 6) pain after urination, 7) pain after defecation, 8) pain after sexual activity, 9) variable (fluctuating) pain intensity and/or variable pain distribution, 10) migraine or tension headaches and/or fibromyalgia and/or chronic fatigue syndrome and/or post-traumatic stress disorder and/or restless legs syndrome and/or temporomandibular joint dysfunction and/or multiple chemical sensitivity. Conclusions: This process resulted in the elaboration of a clinical evaluation tool designed to identify and appropriately manage patients with CPP comprising a sensitization component.


Assuntos
Sensibilização do Sistema Nervoso Central , Dor Crônica/fisiopatologia , Dor Pélvica/fisiopatologia , Períneo , Defecação , Técnica Delphi , Dispareunia , Síndrome de Fadiga Crônica , Fibromialgia , Humanos , Transtornos de Enxaqueca , Síndrome das Pernas Inquietas , Transtornos de Estresse Pós-Traumáticos , Síndrome da Disfunção da Articulação Temporomandibular , Cefaleia do Tipo Tensional , Pontos-Gatilho , Micção
5.
Palliat Med ; 29(6): 564-8, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25739966

RESUMO

BACKGROUND: Non-drug treatments should be systematically associated to the medical analgesic treatment during the terminal phase of cancer. CASES PRESENTATION: Patient 1, a 23-year-old woman, presented an adenocarcinoma of the rectum, with liver and lung metastases. Pain was initially treated by oral morphine and a combination of pregabalin and amitriptyline. Ketamine and intrathecal administration of morphine were both ineffective. Patient 2, a 69-year-old woman, presented a cutaneous T-cell lymphoma. She was admitted to the palliative care unit with mixed pain related to cutaneous lymphomatous infiltration. World Health Organization (WHO) step 3 analgesics had not been tolerated. CASES MANAGEMENT: Both patients received five consecutive 20-min sessions of repetitive transcranial magnetic stimulation to the right motor cortex. CASES OUTCOME: Patient 1 experienced a marked improvement of her pain over the days following the first repetitive transcranial magnetic stimulation session. Medical treatment was able to be rapidly decreased by about 50%, which restored an almost normal level of consciousness and lucidity. Patient 2's pain was also markedly decreased over the days following these five consecutive sessions, and repetitive transcranial magnetic stimulation also appeared to have had a beneficial effect on the patient's anxiety and mood. CONCLUSION: In the context of palliative care of cancer patients experiencing refractory pain that is difficult to control by the usual treatments, motor cortex repetitive transcranial magnetic stimulation, due to its noninvasive nature, can be used as an adjuvant therapy to improve various components of pain, including the emotional components. By reducing the doses of analgesics, repetitive transcranial magnetic stimulation decreases the severity of their adverse effects and improves the patient's quality of life.


Assuntos
Analgesia/métodos , Córtex Motor/fisiologia , Neoplasias/complicações , Dor Intratável/terapia , Cuidados Paliativos/métodos , Estimulação Magnética Transcraniana/métodos , Idoso , Feminino , Humanos , Manejo da Dor/métodos , Resultado do Tratamento , Adulto Jovem
6.
Eur J Obstet Gynecol Reprod Biol ; 294: 170-179, 2024 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-38280271

RESUMO

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines). PREOPERATIVE PATIENTS' INFORMATION: Each patient must be informed concerning the risks associated with POP surgery (EO). HEMORRHAGE, HEMATOMA: Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO). BLADDER INJURY: When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO). URETER INJURY: After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO). RECTAL INJURY: Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO). VAGINAL WALL INJURY: After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO). MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS): Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient. BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM: Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO). URINARY RETENTION: Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO). POSTOPERATIVE PAIN: Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO). POSTOPERATIVE DYSPAREUNIA: When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO). VAGINAL MESH EXPOSURE: To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO). SUTURE THREAD VAGINAL EXPOSURE: For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed. BLADDER AND URETERAL MESH EXPOSURE: When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).


Assuntos
Discite , Dispareunia , Síndromes da Dor Miofascial , Neuralgia , Prolapso de Órgão Pélvico , Doenças da Bexiga Urinária , Humanos , Feminino , Telas Cirúrgicas/efeitos adversos , Polipropilenos , Qualidade de Vida , Abscesso/etiologia , Discite/etiologia , Dispareunia/etiologia , Hiperalgesia/etiologia , Prolapso de Órgão Pélvico/cirurgia , Prolapso de Órgão Pélvico/etiologia , Vagina , Próteses e Implantes , Doenças da Bexiga Urinária/etiologia , Dor Pós-Operatória/etiologia , Antibacterianos , Estrogênios , Síndromes da Dor Miofascial/etiologia , Neuralgia/etiologia , Dor Pélvica/etiologia , Poliésteres , Resultado do Tratamento
7.
Eur J Pain ; 26(1): 7-17, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34643963

RESUMO

BACKGROUND: Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE. METHODS: The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid. RESULTS: The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication. CONCLUSION: These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care. SIGNIFICANCE: Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.


Assuntos
Neuralgia do Pudendo , Consenso , Humanos , Medição da Dor , Neuralgia do Pudendo/diagnóstico , Neuralgia do Pudendo/terapia , Estados Unidos
8.
Ann Phys Rehabil Med ; 64(1): 101354, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31981833

RESUMO

BACKGROUND: Many studies have demonstrated a link between pelvic floor myofascial syndromes and chronic pelvic pain. Botulinum toxin has been extensively used for several years in the field of pain, especially due to its action on muscle spasm. However, the efficacy of botulinum toxin in the context of chronic pelvic pain remains controversial. OBJECTIVES: This multicentre, randomized, controlled, double-blind study was designed to compare the efficacy of botulinum toxin and local anaesthetic (LA) injection versus LA injection alone for pelvic floor myofascial syndrome and chronic pelvic pain. METHODS: According to the number of painful trigger points detected on physical examination, patients received from 1 to 4 injections of botulinum toxin with LA (BTX) or LA alone. The primary endpoint was Patient Global Impression of Improvement (PGI-I) score on day 60 after infiltration. Secondary endpoints were pain intensity, number of painful trigger points on palpation, analgesic drug consumption and quality of life. RESULTS: We included 80 patients, 40 in each group. This study failed to demonstrate a significant difference between the 2 groups on day 60 in the primary endpoint or secondary endpoints (PGI-I score≤2=20% [LA] versus 27.5% [BTX], P=0.43). However, both groups showed significant alleviation of global pain. CONCLUSION: This study does not justify the use of botulinum toxin in the context of chronic pelvic pain with myofascial syndrome but does justify muscle injections with LA alone. ClinicalTrials.gov: NCT01967524.


Assuntos
Anestésicos Locais/uso terapêutico , Toxinas Botulínicas Tipo A , Fármacos Neuromusculares , Manejo da Dor , Diafragma da Pelve/fisiopatologia , Toxinas Botulínicas Tipo A/uso terapêutico , Método Duplo-Cego , Humanos , Fármacos Neuromusculares/uso terapêutico , Dor , Qualidade de Vida , Resultado do Tratamento
9.
J Gynecol Obstet Hum Reprod ; 49(9): 101769, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32461069

RESUMO

INTRODUCTION: To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain. MATERIAL AND METHOD: Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain. RESULTS: 40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant's sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria. DISCUSSION: The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.


Assuntos
Dor Crônica/classificação , Dor Crônica/fisiopatologia , Dor Pélvica/classificação , Períneo/fisiopatologia , Transtornos Puerperais/classificação , Adulto , Dor Crônica/epidemiologia , Dor Facial/epidemiologia , Feminino , França/epidemiologia , Humanos , Neuralgia/epidemiologia , Neuroma/epidemiologia , Medição da Dor , Dor Pélvica/fisiopatologia , Gravidez , Estudos Prospectivos , Transtornos Puerperais/epidemiologia , Transtornos Puerperais/fisiopatologia , Síndrome
10.
Urology ; 123: 87-92, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30170094

RESUMO

OBJECTIVE: To compare the data of score symptoms (Interstitial Cystitis Problem Index, Interstitial Cystitis Symptom Index, Pelvic Pain and Urgency/Frequency Patient Symptom Scale and SF-36quality of life), voiding diaries, urodynamic studies, and cystoscopy under general anesthesia according to the anatomical bladder capacity for patients with interstitial cystitis/bladder pain syndrome (IC/BPS). MATERIAL AND METHOD: Single-centre descriptive observational epidemiological study based on retrospective review of 134 patients managed for IC/BPS between January 2010 and December 2016. Patients were stratified into 2 groups according to anatomical bladder capacity measured under general anesthesia: ≤400 mL (n = 40) and >400 mL (n = 94). RESULTS: Patients with an anatomical bladder capacity less than 400 of mL presented significantly different results for voiding diary data: higher total frequency (P = .0023) especially at night (P = .0008), lower functional bladder capacity (P = .0082) and lower maximum bladder capacity (P = .0001); urodynamic data: earlier onset of painful urge during bladder filling (P = .0002), lower maximum bladder filling capacity (P = .0001) and lower compliance (P = .0067); and the findings of cystoscopy under general anesthesia: more Hunner's lesions (P = .00013). These patients presented poorer Pelvic Pain and Urgency/Frequency Patient Symptom Scale symptom scores (P = .0176) but associated with better overall quality of life as assessed by SF-36 (P = .0295). CONCLUSION: The anatomical bladder capacity, measured under general anesthesia, can be used objectively to define 2 distinct groups of patients with symptoms of IC/BPS.


Assuntos
Cistite Intersticial/diagnóstico , Cistite Intersticial/fisiopatologia , Bexiga Urinária/fisiopatologia , Idoso , Cistite Intersticial/classificação , Cistoscopia , Estudos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Bexiga Urinária/anatomia & histologia
11.
Pain Physician ; 20(1): E161-E167, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28072808

RESUMO

BACKGROUND: Chronic pelvic, perineal and gluteal neuralgia is often experienced in a similar way to neuropathic pain, in the territories of four nerves: ilio-inguinal, pudendal, inferior cluneal and posterior gluteal nerves. These pains are often refractory to medical treatment based on the use of systemic molecules with disabling adverse effects and surgical procedure may be necessary. OBJECTIVE: The objective of this study was to evaluate the efficacy and safety of treatment with a high-concentration capsaicin patch in these indications. STUDY DESIGN: This study was prospective, nonrandomized, and observational. SETTING: Federative Center of Pelvi-Perineology in the University Hospital of Nantes, France. METHODS: Sixty patients with pelvic neuralgia were treated with high-concentration capsaicin patch. The primary endpoint was Patient Global Impression of Change (PGIC) and secondary endpoints included pain intensity on a Numerical Rating Scale (NRS), maximum sitting duration at the end of the day, Medication Consumption Score (MQS), and patient global improvement (from -100% to + 100%). RESULTS: Twenty four percent of the 60 patients included in the study declared that they felt "very much improved" or "much improved" (PGIC = 1 or 2) and these patients reported an average 58% improvement and a 3.4-point reduction on the NRS. Among the "good responder" patients, patients with coccygodynia appear to obtain the bestresults, as 37% of these patients declared that they were much improved with an average 63% improvement No serious adverse effects were observed and treatment was well tolerated. LIMITATION: This study is limited by its relatively small sample size and non-randomized study. CONCLUSION: These results suggest the value of high-concentration capsaicin 8% patch in the treatment strategy for patients with chronic pelvic, perineal and gluteal neuralgia. This treatment would be particularly indicated in the management of coccygodynia.Key words: Pelvic pain, neuropathic pain, pudendal nerve, ilio-inguinal nerve, inferior cluneal nerve, posterior gluteal nerve, capsaicin, capsaicin patch, coccygodynia.


Assuntos
Capsaicina , Dor Pélvica/tratamento farmacológico , Fármacos do Sistema Sensorial , Capsaicina/administração & dosagem , Capsaicina/uso terapêutico , Humanos , Pacientes Internados , Neuralgia/tratamento farmacológico , Medição da Dor , Estudos Prospectivos , Fármacos do Sistema Sensorial/administração & dosagem , Fármacos do Sistema Sensorial/uso terapêutico , Resultado do Tratamento
12.
J Endourol ; 31(7): 655-660, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28467725

RESUMO

OBJECTIVES: Evaluation of the feasibility, morbidity, learning curve, and functional results of robotic supratrigonal cystectomy with augmentation ileocystoplasty (RSCAI). MATERIALS AND METHODS: RSCAI was performed in 19 patients between 2012 and 2016. Thirteen patients (66.4%) presented refractory detrusor overactivity or impaired compliance and 6 patients (31.6%) had painful bladder syndrome. A combined robot-assisted laparoscopy and mini-laparotomy approach was performed. Early (<30 days) and late (>30 days) complications were reported according to the Clavien-Dindo classification. Functional results were analyzed according to the surgical indication. RESULTS: Mean total operating time was 288.7 ± 92.1 minutes. Mean intraoperative blood loss was 147.4 ± 144.8 mL. Mean length of hospital stay in the surgical ward was 9.4 ± 3.7 days. Mean duration of bladder drainage was 23.3 ± 4.1 days. For surgeons who regularly performed robot-assisted laparoscopy, the learning curve of this technique, as assessed by the operating time, required almost five operations. No major (Clavien-Dindo >2) early (0%) or late (0%) postoperative complication was observed. Early minor complications were observed in 47.4% of cases, usually consisting of pyelonephritis (21.1%). Late minor complications (10.5%) were Clavien-Dindo grade I. Mean follow-up was 13.6 ± 10.1 months. The majority of patients (94.7%) obtained functional improvement of their disease in terms of pain, functional bladder capacity, or bladder compliance. CONCLUSION: Our RSCAI technique is a reliable technique with no early or late major postoperative complications reported in this series. This technique allows patients to be operated by minimally invasive surgery with very satisfactory long-term functional results.


Assuntos
Cistectomia/métodos , Cistite Intersticial/cirurgia , Íleo/cirurgia , Laparoscopia/métodos , Laparotomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias da Bexiga Urinária/cirurgia , Adulto , Idoso , Anastomose Cirúrgica/métodos , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos
13.
Pain Physician ; 20(1): E137-E143, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28072805

RESUMO

BACKGROUND: Several studies have described the course and anatomical relations of the pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with pudendal neuralgia in order to guide the surgeon in the choice of surgical approach for pudendal nerve decompression. OBJECTIVES: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the pudendal nerve in a cohort of operated patients. STUDY DESIGN: Observational study. SETTING: University hospital. METHODS: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for pudendal neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. RESULTS: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with pudendal neuralgia, the pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. LIMITATIONS: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. CONCLUSIONS: This is the first study to describe the surgical anatomy of the pudendal nerve in a population of patients with pudendal neuralgia. In more than 70% of cases, pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, pudendal, neuralgia, transgluteal approach.


Assuntos
Nervo Pudendo/patologia , Neuralgia do Pudendo , Humanos , Síndromes de Compressão Nervosa/cirurgia , Neuralgia , Dor Pélvica/patologia , Dor Pélvica/cirurgia , Estudos Prospectivos , Neuralgia do Pudendo/patologia , Neuralgia do Pudendo/cirurgia
14.
Pain Physician ; 20(6): E823-E828, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28934788

RESUMO

BACKGROUND: The ganglion impar is the first pelvic ganglion of the efferent sympathetic trunk that relays pelvic and perineal nociceptive messages and therefore constitutes a therapeutic target. OBJECTIVE: The objective of this single-center study was to evaluate the effectiveness of 3 repeated ganglion impar blocks in patients with chronic pelvic and perineal pain on intention-to-treat. STUDY DESIGN: Retrospective single-center study. SETTING: We reviewed the medical records of 83 patients with chronic refractory pelvic and perineal pain. On intention-to-treat analysis, 62 (74.7%) of the patients received 3 ganglion impar blocks. METHODS: Ganglion impar block was performed with 0.75% ropivacaine via a lateral approach over the Co1-Co2 coccygeal joint with computed tomography (CT) guidance. The effectiveness of ganglion impar blocks was evaluated by visual analogue scale (VAS) before and 30 minutes after the blocks. Evaluation at least one month after the block was also performed by Patient Global Impression of Change (PGI-C). RESULTS: A total of 220 blocks were performed, 193 (87.7%) of which were considered to be positive with immediate but transient improvement of pain by more than 50% and complete but transient pain relief after the procedure in 119 (54.1%) procedures. The variation of the VAS score before and after each block was statistically significant (P < 0.001). Similarly, the VAS score before repeated blocks was significantly improved with decreased pain intensity over time (P = 0.001). Analysis of the PGI-C one month after the block demonstrated improvement in 41% of cases in the overall population and in 43.6% of cases in the subgroup of 62 patients treated by 3 blocks. LIMITATIONS: Retrospective study, short term follow-up. CONCLUSIONS: Repeated ganglion impar blocks allowed short-term reduction of pain intensity with a moderate intermediate-term effect. Ganglion impar appears to be a useful therapeutic target to block the nociceptive message by acting on sensitization phenomena.Key words: Pudendal neuralgia, impar block, pain, perineal, coccygodynia.


Assuntos
Bloqueio Nervoso Autônomo/métodos , Gânglios Simpáticos/diagnóstico por imagem , Dor Pélvica/diagnóstico por imagem , Dor Pélvica/terapia , Neuralgia do Pudendo/diagnóstico por imagem , Neuralgia do Pudendo/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Medição da Dor/métodos , Estudos Retrospectivos , Raízes Nervosas Espinhais/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adulto Jovem
15.
Discov Med ; 19(104): 185-92, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25828522

RESUMO

The management of chronic pelvic and perineal pain has been improved by a better understanding of the mechanisms of this pain and an optimized integrated multidisciplinary approach to the patient. The concept of organic lesions responsible for a persistent nociceptive factor has gradually been replaced by that of dysregulation of nociceptive messages derived from the pelvis and perineum. In this setting, painful diseases identified by organ specialists are usually also involved and share several common denominators (triggering factors, predisposing clinical context). These diseases include painful bladder syndrome, irritable bowel syndrome, vulvodynia, and chronic pelvic pain syndrome. The painful symptoms vary from one individual to another and according to his or her capacity to activate pain inhibition/control processes. Although the patient often attributes chronic pain to a particular organ (with the corollary that pain will persist until the organ has been treated), this pain is generally no longer derived from the organ but is expressed via this organ. Several types of clinical presentation of complex pelvic pain have therefore been pragmatically identified to facilitate the management of treatment failures resulting from a purely organ-based approach, which can also reinforce the patient's impression of incurability. These subtypes correspond to neuropathic pain, central sensitization (fibromyalgia), complex regional pain syndrome, and emotional components similar to those observed in post-traumatic stress disorder. These various components are also often associated and self-perpetuating. Consequently, when pelvic pain cannot be explained by an organ disease, this model, using each of these four components associated with their specific mechanisms, can be used to propose personalized treatment options and also to identify patients at high risk of postoperative pelvic pain (multi-operated patients, central sensitization, post-traumatic stress disorder, etc.), which constitutes a major challenge for prevention of these types of pain that have major implications for patients and society.


Assuntos
Manejo da Dor/métodos , Dor Pélvica/fisiopatologia , Dor Pélvica/psicologia , Dor Pélvica/terapia , Períneo/patologia , Sintomas Afetivos/complicações , Terapia Combinada , Feminino , Fibromialgia/patologia , Humanos , Masculino , Nociceptividade , Equipe de Assistência ao Paciente , Psicoterapia/métodos , Delitos Sexuais , Transtornos de Estresse Pós-Traumáticos/complicações , Síndrome , Pontos-Gatilho
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