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.

Multimodal and Interdisciplinary Interventions for the Treatment of Localized Provoked Vulvodynia: A Scoping Review of the Literature from 2010 to 2023.

Introduction: Localized provoked vulvodynia (LPV) is a chronic condition characterized by pain in the vulvar vestibule, which can be provoked by pressure or touch and which is not tied to a clear underlying cause. Research into the etiology of and most appropriate treatment strategy for LPV is still limited. Methods: Using Arksey and O'Malley's model for scoping reviews, we evaluated the research question: what is the current evidence regarding the efficacy/effectiveness of multimodal or interdisciplinary interventions for the treatment of LPV? We collated and analyzed articles from 2010 to 2023 to capture the current research landscape. Results: Our review identified 27 studies, which either compared treatments between classes (eg pharmacologic versus psychologic modalities) or described interdisciplinary treatment programs. We identify several trends in the literature. First, outcome measures are inconsistent between studies, often unvalidated, and may not adequately mirror patient concerns. Second, the absence of appropriate comparator groups in many studies restricts providers' ability to appraise which treatments may be most efficacious. Third, selection bias and demographic homogeneity limit generalizability. Finally, we highlight the need for head-to-head trials of vestibulectomy with other treatments considered first line for vulvodynia management. Conclusion: There is insufficient evidence to suggest the superiority of one treatment modality for LPV relative to others or to recommend a particular interdisciplinary management strategy. Future research should use a head-to-head design where sham control is impossible, incorporate patient-centered outcome measures, and investigate impacts of treatment among diverse samples of LPV patients.

The impact of rurality on vulvodynia diagnosis and management: Primary care provider and patient perspectives.

Objective: The objective of this study was to better understand how rurality impacts the knowledge, diagnosis and management of vulvodynia by primary care providers (PCPs) practising in the geographically disparate province of Newfoundland and Labrador, Canada. Design: This was a qualitative case study using questionnaires and semi-structured interviews with PCPs, compared with semi-structured focus groups and interviews with vulvodynia patients conducted in a previous study phase. Results: Ten family physicians and 6 nurse practitioners participated. Over half had baseline knowledge that vulvodynia has a relatively high prevalence, but most underestimated the likelihood they would see a patient with vulvodynia in their practice. Three barriers to discussing and managing vulvodynia emerged: (1) discomfort initiating sexual/vulvar health conversations; (2) concerns about protecting patient privacy and confidentiality; and (3) time constraints and building therapeutic relationships. These issues were largely corroborated by previous findings with vulvodynia patients. Rural-informed solutions might include: (1) supporting increased education in vulvodynia and sexual health more broadly, including funding to attend continuing professional education and developing more clinical tools; (2) following practice guidelines regarding standardised initiation of sexual health conversations; (3) incentivising retention of rural providers and extending appointment times by reconsidering fee-for-service structures; and (4) researching a tailored vulvodynia toolkit and the potential advantage of mobile health units. Conclusion: Rurality exacerbates common concerns in the identification and management of vulvodynia. Acting on recommended solutions may address the impact of rurality on the provision of timely care for those experiencing vulvodynia and other sexual health concerns.

Résumé Objectif: Mieux comprendre l'impact de la ruralité sur la connaissance, le diagnostic et la prise en charge de la vulvodynie par les prestataires de soins primaires exerçant dans la province géographiquement disparate de Terre-Neuve-et-Labrador, au Canada. Conception: Étude de cas qualitative utilisant des questionnaires et des entretiens semi-structurés avec des prestataires de soins primaires, comparés à des groupes de discussion semi-structurés et à des entretiens avec des patientes atteintes de vulvodynie menés lors d'une phase précédente de l'étude. Résultats: Dix médecins de famille et six infirmières praticiennes y ont participé. Plus de la moitié d'entre eux savaient au départ que la vulvodynie a une prévalence relativement élevée, mais la plupart sous-estimaient la probabilité de voir une patiente atteinte de vulvodynie dans leur pratique. Trois obstacles à la discussion et à la prise en charge de la vulvodynie sont apparus: (1) la gêne à entamer des conversations sur la santé sexuelle/vulvaire; (2) les préoccupations relatives à la protection de la vie privée et de la confidentialité des patientes; et (3) les contraintes de temps et l'établissement de relations thérapeutiques. Ces problèmes ont été largement corroborés par les résultats obtenus précédemment avec des patientes atteintes de vulvodynie. Les solutions adaptées au milieu rural pourraient inclure (1) soutenir une meilleure formation sur la vulvodynie et la santé sexuelle en général, notamment le financement de la formation professionnelle continue et l'élaboration d'outils cliniques supplémentaires; (2) suivre les directives de pratique concernant l'amorce normalisée des conversations sur la santé sexuelle; (3) encourager la rétention des fournisseurs ruraux et prolonger les délais de rendez-vous en reconsidérant les structures de rémunération à l'acte; et 4) faire des recherches sur une trousse d'outils sur mesure pour la vulvodynie et sur l'avantage potentiel des unités de santé mobiles. Conclusion: La ruralité exacerbe les problèmes courants liés à l'identification et à la prise en charge de la vulvodynie. La mise en œuvre des solutions recommandées peut permettre de remédier à l'impact de la ruralité sur la fourniture de soins en temps opportun aux personnes souffrant de vulvodynie et d'autres problèmes de santé sexuelle. Mots-clés: Douleur vulvaire, dyspareunie, santé rurale, santé sexuelle, éducation sexuelle, structures tarifaires, administration des soins de santé, disparités géographiques dans les soins de santé, recherche qualitative, étude de cas qualitative.

Pharmacological Treatments for Localized Provoked Vulvodynia: A Scoping Review.

Introduction: Localized provoked vulvodynia (LPV) is a chronic pain condition without an identifiable cause that is localized to a portion of the vulva and provoked by pressure or touch. LPV is a commonly occurring but poorly understood condition lacking consensus on management. Method: This scoping review used Arksey and O'Malley's approach to identify and evaluate literature published between 2010 and 2023 that addressed the question: What is the current evidence on the efficacy or effectiveness of pharmacological treatments in the management of LPV? Results: This review evaluated 18 papers reporting on the efficacy or effectiveness of oral, topical, and injectable medications. Seven of the studies were randomized controlled trials. Oral gabapentin and oral desipramine showed some improvement in sexual function compared to placebo. Small sample sizes and methodological issues limited confidence in interpreting findings. Pain was reduced in descriptive studies of tricyclic antidepressants, milnacipran, injectable anesthetics, and botulinum toxin. Where pain did not improve with treatment, some oral medications improved participants' mood and sexual function. Some topical agents may be effective in reducing peripherally mediated neuropathic pain. Botulinum toxin was the most well-studied injectable but yielded mixed outcomes related to pain, quality of life, and sexual function. Conclusion: There is a lack of convincing evidence to draw conclusions about the efficacy or effectiveness of pharmacological therapies for LPV. The breadth of therapies for treating LPV warrants the development of evidence-based, consensus guidelines for measuring treatment outcomes and improving comparisons across studies. Recommendations for research include addressing methodological shortcomings and diversifying the participant pool to increase the generalizability of findings.

Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies.

STUDY OBJECTIVE: The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. DESIGN: A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. SETTING: Canada. PATIENTS: All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different. CONCLUSION: The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.

Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives.

INTRODUCTION: Persons with vulvodynia (a chronic vulvar pain condition) suffer many barriers to diagnosis and treatment, several of which may be exacerbated by the sociocultural and geographical context in which they live. AIM: We drew on the experiences of patients with vulvodynia who were living in small urban and rural communities to learn what they perceived as the major barriers to diagnosis and treatment as well as to probe for possible solutions. METHODS: For this qualitative case study, we conducted 3 focus groups with a total of 10 participants, drawn from patients seen at our academic tertiary referral center, with a goal of understanding their lived experience with vulvodynia. MAIN OUTCOME MEASURES: The patient dialogue was coded into themes and temporally grouped to illustrate struggles and victories in diagnosis and treatment. RESULTS: Participants confirmed that healthcare provider knowledge and attitudes as well as system challenges (specialist and allied healthcare provider availability) are major barriers to timely diagnosis. Of novel interest are other factors that exacerbate distress and delay diagnosis such as patients' inadequate knowledge of sexual functioning and sociocultural messages regarding "normal" sexual activity. Our work suggests that a disease prevention framework that includes comprehensive sexual education before or at the onset of sexual activity may be of benefit in reducing the burden of vulvodynia when added to strategies to increase healthcare provider knowledge and improve access to effective treatments. CONCLUSION: While healthcare provider knowledge and attitudes are often at the forefront of barriers to diagnosis, our study suggests that to minimize patient distress and expedite diagnosis, resources must also be directed to promoting comprehensive sexual health education. Webber V, Miller ME, Gustafson DL, et al. Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives. Sex Med 2020;8:757-766.

No. 279-Female Sexual Health Consensus Clinical Guidelines.

OBJECTIVE: To establish national guidelines for the assessment of women's sexual health concerns and the provision of sexual health care for women. EVIDENCE: Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library from May to October 2010, using appropriate controlled vocabulary (e.g., sexuality, "sexual dysfunction," "physiological," dyspareunia) and key words (e.g., sexual dysfunction, sex therapy, anorgasmia). Results were restricted, where possible, to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by The Society of Obstetricians and Gynaecologists of Canada. VALUES: The quality of evidence was evaluated and recommendations made using the use of criteria described by the Canadian Task Force on Preventive Health Care (Table).

No. 279-Female Sexual Health Consensus Clinical Guidelines.

OBJECTIVE: To establish national guidelines for the assessment of women's sexual health concerns and the provision of sexual health care for women. EVIDENCE: Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library from May to October 2010, using appropriate controlled vocabulary (e .g., sexuality, "sexual dysfunction," "physiological," dyspareunia) and key words (e .g ., sexual dysfunction, sex therapy, anorgasmia). Results were restricted, where possible, to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by The Society of Obstetricians and Gynaecologists of Canada. VALUES: The quality of evidence was evaluated and recommendations made using the use of criteria described by the Canadian Task Force on Preventive Health Care (Table).

Diagnosis of adverse events after hysterectomy with postoperative self-care web applications: A pilot study.

Increased pressures from multiple sources are leading to earlier patient discharge following surgery. Our objective was to test the feasibility of self-care web applications to inform women if, when, and where to seek help for symptoms after hysterectomy. We asked 31 women recovering at home after hysterectomy at two centers to sign into a website on a schedule. For each session, the website informed them about normal postoperative symptoms and prompted them to complete an interactive symptom questionnaire that provided detailed information on flagged responses. We interviewed eight women who experienced an adverse event. Six of these women had used the web application regularly, each indicating they used the information to guide them in seeking care for their complications. These data support that self-care applications may empower patients to manage their own care and present to appropriate health care providers and venues when they experience abnormal symptoms.

A pilot feasibility multicenter study of patients after excision of endometriosis.

OBJECTIVE: To serve as a pilot feasibility study for a randomized study of excision versus ablation in the treatment of endometriosis by (1) estimating the magnitude of change in symptoms after excision only at multiple referral centers and (2) determining the proportion of women willing to participate in a randomized trial. METHODS: We performed a multicenter prospective study of women undergoing excision for endometriosis (Canadian Task Force class II-3) at Duke University Center for Endometriosis Research & Treatment (currently the Saint Louis University Center for Endometriosis), Center for Endometriosis Care, Northshore University Health System, Memorial University (Canada), and Florida Hospital. The study comprised 100 female patients, aged 18 to 55 years, with endometriosis-suspected pelvic pain. The intervention was laparoscopic excision only of the abnormal peritoneum suspicious for endometriosis. The main outcome measures were quality of life, pelvic pain, dysmenorrhea, dyspareunia, and bowel and bladder symptoms. RESULTS: The mean follow-up period was 8.5 months. Excision of endometriosis showed a significant reduction in all pain scores except bowel symptoms, as well as significant improvement in quality of life. Of the patients, 84% were willing to participate in a randomized study. CONCLUSIONS: Quality of life is a needed primary outcome for any randomized study comparing excision versus ablation. A multicenter comparative trial is feasible, although quality assurance would have to be addressed. Patients were willing to be randomized even at surgical referral centers.

A national survey of endoscopic practice among gynaecologists in Canada.

OBJECTIVE: To assess the current status of endoscopic gynaecological surgery in Canada, as well as the attitudes, perceptions, and educational preferences regarding endoscopy among Canadian obstetrician-gynaecologists. METHODS: An electronic online survey was sent to 630 obstetrician-gynaecologists in Canada through the Society of Obstetricians and Gynaecologists of Canada electronic mailing list. Survey respondents were asked about demographic variables, level of training and current practice of endoscopic procedures, reasons for and barriers to performing endoscopy, and interest in continuing surgical education in laparoscopy and hysteroscopy. RESULTS: A total of 178 responses (28.3%) were collected and 152 (85.4%) analyzed. The majority of respondents were general obstetrician-gynaecologists (78.0%). More gynaecologic surgeons performed abdominal (92.7%) and vaginal hysterectomies (89.7%) than laparoscopic (68.4%) and robotic hysterectomies (2.2%). Even though 93.2% of respondents selected the endoscopic approach as the preferred approach to surgery for their patients, 38.7% of respondents did not feel that they had adequate training during residency to perform endoscopy. Lack of operating room resources and lack of time and opportunity for further training were frequently selected as major barriers to performing endoscopy. Participants identified weekend continuing medical education courses and trained endoscopic surgeon outreach as preferred methods of acquiring endoscopic skills. CONCLUSION: This survey provides a contemporary assessment of the current endoscopic practice patterns of Canadian obstetrician-gynaecologists, and it helps to identify some potentially modifiable factors hindering the practice of endoscopy and some possible solutions to overcoming these barriers.