Mindfulness in Facilitating Pelvic Floor Botulinum Toxin Injection in Women with Chronic Pelvic Pain.

Botulinum toxin (BoNT) injection can safely be done as an office-based procedure, but can be painful itself, especially when injecting pelvic floor muscles to treat chronic pelvic pain (CPP). Mindfulness interventions may reduce procedure-associated acute anxiety and pain. We applied mindfulness techniques to increase the tolerability of office-based pelvic floor BoNT injections in women with CPP. Women enrolled in a clinical trial of BoNT for endometriosis-associated CPP were offered a brief, guided mindfulness session before and/or after transvaginal injection. Anxiety, pain, and dysphoria were rated on a 0-10 numerical rating scale (NRS) before and after each mindfulness session. Eight women underwent mindfulness sessions. Five participants had a session before and two after the transvaginal injection. One participant had two sessions: one before and one after separate injections. All six women completing a session prior to injection had at least moderate anxiety, which lessened after the mindfulness session (median NRS change: -3.3/10). All three women reporting injection-associated pain experienced less intense pain following the post-injection session (median NRS change: -3/10). Three women experiencing dysphoria improved after the session (median NRS change: -3/10). A brief, guided mindfulness session may lessen acute pain, anxiety, and dysphoria associated with office-based transvaginal BoNT injection.

Prevalence and Impact of Poorly Controlled Modifiable Risk Factors Among Patients Who Underwent Atrial Fibrillation Ablation.

Managing atrial fibrillation (AF) risk factors (RFs) improves ablation outcomes in obese patients. However, real-world data, including nonobese patients, are limited. This study examined the modifiable RFs of consecutive patients who underwent AF ablation at a tertiary care hospital from 2012 to 2019. The prespecified RFs included body mass index (BMI) ≥30 kg/m2, >5% fluctuation in BMI, obstructive sleep apnea with continuous positive airway pressure noncompliance, uncontrolled hypertension, uncontrolled diabetes, uncontrolled hyperlipidemia, tobacco use, alcohol use higher than the standard recommendation, and a diagnosis-to-ablation time (DAT) >1.5 years. The primary outcome was a composite of arrhythmia recurrence, cardiovascular admissions, and cardiovascular death. In this study, a high prevalence of preablation modifiable RFs was observed. More than 50% of the 724 study patients had uncontrolled hyperlipidemia, a BMI ≥30 mg/m2, a fluctuating BMI >5%, or a delayed DAT. During a median follow-up of 2.6 (interquartile range 1.4 to 4.6) years, 467 patients (64.5%) met the primary outcome. Independent RFs were a fluctuation in BMI >5% (hazard ratio [HR] 1.31, p = 0.008), diabetes with A1c ≥6.5% (HR 1.50, p = 0.014), and uncontrolled hyperlipidemia (HR 1.30, p = 0.005). A total of 264 patients (36.46%) had at least 2 of these predictive RFs, which was associated with a higher incidence of the primary outcome. Delayed DAT over 1.5 years did not alter the ablation outcome. In conclusion, substantial portions of patients who underwent AF ablation have potentially modifiable RFs that were not well controlled. Fluctuating BMI, diabetes with hemoglobin A1c ≥6.5%, and uncontrolled hyperlipidemia portend an increased risk of recurrent arrhythmia, cardiovascular hospitalizations, and mortality after ablation.

Predictive value of interatrial block on electrocardiogram among obese patients undergoing atrial fibrillation ablation.

BACKGROUND: Determine a predictive value of interatrial block (IAB) on atrial fibrillation (AF) ablation outcomes in obese patients. METHODS: Medical records were retrospectively reviewed for 205 consecutive patients with body mass indices (BMI) ≥ 30 kg/m2 who underwent initial AF ablation. Evidence of partial IAB defined as P-wave duration (PWD) ≥ 120 ms and advanced IAB with PWD ≥ 120 ms and biphasic or negative P-wave in inferior leads was examined from sinus electrocardiograms (ECGs) within 1-year pre-ablation. The primary outcome was recurrent atrial arrhythmia after 3-month blanking period post-ablation. RESULTS: The mean BMI was 36.9 ± 5.7 kg/m2. Partial IAB and advanced IAB were observed in 155 (75.61%) and 42 (20.49%) patients, respectively. During the median follow-up of 1.35 (interquartile range 0.74, 2.74) years, 115 (56.1%) patients had recurrent atrial arrhythmias. In multivariable analysis adjusting for age, gender, persistent AF, use of antiarrhythmic drugs (AADs), left atrial volume index (LAVI), partial IAB, and advanced IAB were independent predictors of recurrent arrhythmia with hazard ratio (HR) of 2.80 (95% confidence interval [CI] 1.47-6.05; p = 0.001) and HR 1.79 (95% CI 1.11-2.82; p = 0.017), respectively. The results were similar in a subgroup analysis of patients who had no severe left atrial enlargement and a subgroup analysis of patients who were not on AADs. CONCLUSIONS: IAB is highly prevalent in patients with obesity and AF. Partial IAB, defined as PWD ≥ 120 ms, and advanced IAB with evidence of biphasic P-wave in inferior leads were independently associated with increased risk of recurrent arrhythmia after AF ablation. Its predictive value is independent of other traditional risk factors, LAVI, or use of AADs.

Widespread myofascial dysfunction and sensitisation in women with endometriosis-associated chronic pelvic pain: A cross-sectional study.

BACKGROUND: Chronic pelvic pain persists in some women with endometriosis even after lesion removal and optimized hormonal treatment. OBJECTIVE: Characterize the presence and distribution of pain, myofascial dysfunction and sensitisation beyond the pelvis in women with endometriosis-associated chronic pelvic pain. METHODS: Cross-sectional study of 30 women prior to participation in a clinical trial. Evaluation included pain-focused abdominopelvic gynaecologic examination with the identification of pelvic floor muscle spasm. Neuro-musculoskeletal examination assessed paraspinal allodynia and hyperalgesia bilaterally and myofascial trigger points in 13 paired muscles. Pressure-pain thresholds were measured over interspinous ligaments and trigger points. Women completed the body territories element of the Body Pain Index. RESULTS: All women had a pelvic floor muscle spasm that they self-identified as a major focus of pain. Twenty of 30 women described their pelvic pain as focal. However, all demonstrated widespread myofascial dysfunction with low pressure-pain thresholds and trigger points in over two-thirds of 26 assessed regions. Widespread spinal segmental sensitisation was present in 17/30, thoracic in 21/30 and lumbosacral/pelvic in 18/30. Cervical sensitisation manifested as low pressure-pain thresholds with 23/30 also reporting recurrent, severe headaches and 21/30 experiencing orofacial pain. Those reporting diffuse pelvic pain were more likely to have widespread (p = .024) and lumbosacral/pelvic (p = .036) sensitisation and report over 10 painful body areas (p = .009). CONCLUSIONS: Women with endometriosis-associated chronic pelvic pain often have myofascial dysfunction and sensitisation beyond the pelvic region that may be initiated or maintained by on-going pelvic floor spasm. These myofascial and nervous system manifestations warrant consideration when managing pain in this population. Clinicaltrials.gov identifier: NCT01553201. SIGNIFICANCE: Women with endometriosis often have pelvic pain persisting after surgery despite hormonal therapies and these women have regional pelvic sensitisation and myofascial dysfunction. Pelvic floor muscle spasm is a major pain focus in this population. Sensitisation and myofascial dysfunction are widespread, beyond the pelvic region. On-going pelvic floor spasm may initiate or maintain sensitisation. Myofascial/sensitisation manifestations warrant consideration when managing pain in this population.

Myofascial Pain Syndrome: A Narrative Review Identifying Inconsistencies in Nomenclature.

There is currently confusion surrounding the phenotype of and diagnostic criteria for myofascial pain syndrome (MPS) in the published literature. This narrative literature review investigated whether there is consensus regarding the descriptive terminology used for MPS and the trend of MPS publications over time. The phrase "myofascial pain syndrome" was used to search PubMed and Web of Science, returning 923 articles. Of these, we included only full-text, primary research articles containing "myofascial pain syndrome" in the title, reducing the total articles reviewed to 167. We identified 116 descriptors and categorized them under one of five clusters that shared similar findings and are commonly associated with MPS: "trigger points," "muscle," "pain," "nervous system," and "fascia." The frequency of the clinical criteria of Travell and Simons was tabulated. Terms pertaining to the clusters "trigger points," "muscle," or "pain" appeared in approximately 90% of the articles; "nervous system" in 46%; and "fascia" in 20%. Only 42% used the criteria of Travell and Simons. Most articles (122) included a combination of three or four clusters to describe MPS. In addition, MPS publications have doubled since 2010 compared to the prior decade. The publication patterns, determined by changes in which specialty journals articles on MPS have been published, have shifted from investigational to intervention studies. This may have been influenced by heterogeneity in the usage of MPS terminology. This underscores the lack of a reliable MPS diagnosis and limits human subjects research. Improved consistency in terminology is needed to establish consensus within the field and to inform future research studying the pathophysiology of MPS.

Botulinum toxin for chronic pelvic pain in women with endometriosis: a cohort study of a pain-focused treatment.

BACKGROUND AND OBJECTIVES: Many women with endometriosis continue to have pelvic pain despite optimal surgical and hormonal treatment; some also have palpable pelvic floor muscle spasm. We describe changes in pain, spasm, and disability after pelvic muscle onabotulinumtoxinA injection in women with endometriosis-associated pelvic pain, a specific population not addressed in prior pelvic pain studies on botulinum toxin. METHODS: We present an open-label proof-of-concept case series of women with surgically diagnosed endometriosis. Under conscious sedation and with topical anesthetic, 100 units of onabotulinumtoxinA was injected transvaginally into pelvic floor muscle spasm areas under electromyography guidance. Changes in pain intensity, muscle spasm, disability, and pain medication use were assessed at periodic visits for up to 1 year after injection. RESULTS: Thirteen women underwent botulinum toxin injection and were followed for at least 4 months. Before injection, 11 of the 13 women had spasm in >4/6 assessed pelvic muscles and reported moderate pain (median visual analog scale (VAS): 5/10; range: 2-7). By 4-8 weeks after injection, spasm was absent/less widespread (≤3 muscles) in all (p=0.0005). Eleven rated their postinjection pain as absent/mild (median VAS: 2; range: 0-5; p<0.0001); 7/13 reduced pain medication. Disability decreased in 6/8 women with at least moderate preinjection disability (p=0.0033). Relief lasted 5-11 months in 7 of the 11 patients followed for up to 1 year. Adverse events were mild and transient. CONCLUSIONS: These findings suggest pelvic floor spasm may be a major contributor to endometriosis-associated pelvic pain. Botulinum toxin injection may provide meaningful relief of pain and associated disability. TRIAL REGISTRATION NUMBER: NCT01553201.

Methodological approaches to botulinum toxin for the treatment of chronic pelvic pain, vaginismus, and vulvar pain disorders.

INTRODUCTION AND HYPOTHESIS: Botulinum toxin (BoNT) is increasingly used for pain, especially with muscle spasm. We describe our methodology for BoNT treatment of chronic pelvic pain (CPP) in women and place it in the context of the literature on techniques for this use. METHODS: Databases were searched using terms "botulinum toxin," "pelvic pain," and "vaginismus." Reports on vaginismus/vulvodynia/vestibulodynia (included if pelvic floor muscles were injected) were grouped as "vaginismus/vulvar pain disorders" (V/VPD). We analyzed the type of report, condition, toxin serotype/brand, dose/dilution, muscle selection, guidance technique, and anesthesia. Publications from the same authors without unique information were combined for specific analyses. RESULTS: Thirty-eight reports had analyzable information; many lacked complete information. Most were open-label prospective reports; there were four technical reports, one randomized comparison of doses and one placebo-controlled study of efficacy. Pelvic floor muscles were approached transvaginally, transperineally or transgluteally. BoNT brand/dose/dilution varied widely. Muscle localization techniques included anatomical landmarks only, electromyography, electrical stimulation with/without ultrasound, and fluoroscopy/CT scanning. Papers discussing analgesia utilized general anesthesia, conscious sedation with/without topical/local anesthesia, topical/local agent alone or pudendal block before or after injection. Cumulatively, 58-100% of patients with CPP and 71-100% of those with V/VPD improved. Serious adverse events (transient fecal incontinence/constipation, urinary incontinence/retention) were more frequent with higher doses. CONCLUSIONS: BoNT can be safely and tolerably injected into pelvic floor muscles in women as an out-patient procedure. This study identifies methodological factors to be considered in future studies and the critical need for high-quality clinical trials for this emerging treatment.