Identifying Gaps in Pelvic Pain Education: A Scoping Review and Structured Analysis of Obstetrics and Gynecology Training Milestones.

OBJECTIVE: Several clinical practice guidelines on the evaluation and management (EM) of chronic pelvic pain (CPP) have been published; however, it is not known whether obstetrics and gynecology (OBGYN) educational milestones are aligned with current practice recommendations. Therefore, this scoping review and structured analysis aims to identify gaps between clinical guidelines for the EM of CPP and OBGYN training milestones published by educational authorities like the Accreditation Council for Graduate Medical Education (ACGME) and the AAGL. DATA SOURCES: The literature search was performed in MEDLINE, PubMed Central, and Bookshelf on the PubMed interface from January 2018 to September 2022. Peer-reviewed publications were included if they were a systematic review of recent practice guidelines and focused on female CPP. Publications that focused on a single pelvic pain condition or focused on a specific treatment were excluded. METHODS OF STUDY SELECTION: Two reviewers extracted the data and appraised the study quality following the Critical Appraisal Skills Programme Checklist for systematic reviews. Four articles met inclusion criteria for thematic analysis. A reflexive thematic analysis via the inductive approach was performed to develop clinical themes common to all review articles and presumed important in the EM of CPP. Pelvic pain experts and Delphi methodology was used to assess validity and relevance of each theme in OBGYN training. Validated themes were used in a strengths weaknesses opportunities threats (SWOT) analysis of the ACGME and the AAGL Milestones used for training OBGYN residents and fellows. A SWOT analysis is an organizational tool used to analyze processes in terms of strengths, weaknesses, opportunities for improvement, and threats to implementing a potential change. TABULATION, INTEGRATION, AND RESULTS: Twelve clinical themes were conceptualized and achieved ≥ 90% consensus as being important in the EM of CPP. Clinical themes pertained to pathophysiology, biopsychosocial approach, trauma-informed care, history and physical examination, diagnostic testing, multimodal/multidisciplinary management, pain education, and medical and surgical management. SWOT analysis showed that the ACGME Milestones lacked milestones specific to CPP, while the AAGL Milestones had 6 CPP-focused competencies with multiple milestones. Milestones on trauma-informed care and application of biopsychosocial assessment were notably absent. CONCLUSION: OBGYN educational milestones published by the ACGME and the AAGL are not yet aligned with current clinical guidelines for the EM of CPP.

Time to move beyond surgical classification systems for endometriosis.

Endometriosis is a common condition associated with chronic pelvic pain and infertility. Its pathogenesis is poorly understood, diagnosis relies on laparoscopy, and staging is based on extent of disease. Unfortunately, the current staging systems do not correlate well with pain severity and impact, nor do they predict prognosis, i.e., treatment success and recurrence of disease. In this article, we discuss the strengths and limitations of current staging systems and propose modifications that will enable better classification systems to be developed in the future.

Evaluating the discordant relationship between Tarlov cysts and symptoms of pudendal neuralgia.

BACKGROUND: Pudendal neuralgia is a painful neuropathic condition involving the pudendal nerve dermatome. Tarlov cysts have been reported in the literature as another potential cause of chronic lumbosacral and pelvic pain. Notably, they are often located in the distribution of the pudendal nerve origin at the S2, S3, and S4 sacral nerve roots and it has been postulated that they may cause similar symptoms to pudendal neuralgia. Literature has been inconsistent on the clinical relevance of the cysts and if they are responsible for symptoms. OBJECTIVE: To evaluate the prevalence of S2-S4 Tarlov cysts at the pudendal nerve origin (S2-S4 sacral nerve roots) in patients specifically diagnosed with pudendal neuralgia, and establish association of patient symptoms with location of Tarlov cyst. STUDY DESIGN: A retrospective study was performed on 242 patients with pudendal neuralgia referred for pelvic magnetic resonance imaging from January 2010 to November 2012. Dedicated magnetic resonance imaging review evaluated for presence, level, site, and size of Tarlov cysts. Among those with demonstrable cysts, subsequent imaging data were collected and correlated with the patients' clinical site of symptoms. Statistical analysis was performed using χ2, Pearson χ2, and Fisher exact tests to assess significance. RESULTS: Thirty-nine (16.1%) patients demonstrated at least 1 sacral Tarlov cyst; and of the 38 patients with complete pain records, 31 (81.6%) had a mismatch in findings. A total of 50 Tarlov cysts were identified in the entire patient cohort. The majority of the Tarlov cysts were found at the S2-S3 level (32/50; 64%). Seventeen patients (44.7%) revealed unilateral discordant findings: unilateral symptoms on the opposite side as the Tarlov cyst. In addition, 14 (36.8%) patients were detected with bilateral discordant findings: 11 (28.9%) had bilateral symptoms with a unilateral Tarlov cyst, and 3 (7.9%) had unilateral symptoms with bilateral cysts. Concordant findings were only demonstrated in 7 patients (18.4%). No significant association was found between cyst size and pain laterality (P = .161), cyst volume and pain location (P = .546), or cyst size and unilateral vs bilateral pain (P = .997). CONCLUSION: The increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition.

Successful Treatment of Penile Numbness and Erectile Dysfunction Resulting From Pudendal Nerve Entrapment.

Pudendal nerve decompression surgery has not been studied or reported for the treatment of penile numbness in the absence of pain. Herein, we report a case of a male patient with chronic numbness of the penis and erectile dysfunction in the absence of pelvic pain who was found to have pudendal nerve entrapment. This patient was treated with surgical decompression of the pudendal nerves that resulted in the return of genital sensation and erections. Thus, we propose that pudendal nerve entrapment may be considered as a cause of penile numbness and that pudendal nerve decompression surgery in these patients may be effective.

Repeat operation for treatment of persistent pudendal nerve entrapment after pudendal neurolysis.

STUDY OBJECTIVES: To describe a new approach to transgluteal pudendal neurolysis and transposition and to review the outcome in 10 patients who underwent repeat operation because of persistent pudendal neuralgia after failing to improve after initial surgical decompression. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Academic chronic pelvic pain practice at St. Joseph's Hospital and Medical Center in Phoenix, Arizona. PATIENTS: Women and men with persistent pudendal neuralgia after undergoing transgluteal pudendal neurolysis and transposition. INTERVENTION: Transgluteal decompression of the pudendal nerve was performed in all 10 patients. In brief, a transgluteal incision was made, and the pudendal nerve was identified via a nerve integrity monitoring system. Adhesiolysis was performed from the piriformis muscle to the distal Alcock canal using a Zeiss NC-4 surgical microscope. The nerve was then enclosed in NeuraWrap Nerve Protector and coated with activated platelet-rich plasma. An ON-Q PainBuster catheter was place along the nerve into the Alcock canal, and 0.5% bupivacaine was infused at 2 mL/hr. The sacrotuberous ligament was repaired using an Achilles or gracillis cadaver ligament. The overlying subcutaneous tissue and skin were then closed. MEASUREMENTS AND MAIN RESULTS: From June 2008 to March 2010, 10 consecutive patients (7 women and 3 men; age range, 29-81 years) underwent repeat operation with transgluteal decompression of the pudendal nerve. Neuropathic pain was unilateral (n = 8) or bilateral (n = 2), in the clitoris or penis (30%), vulva or scrotum (70%), perineum (40%), and rectum (50%). Of the 10 patients, 1 patient was lost to follow-up. Mean follow-up was 23 months. Eight of 9 patients reported global improvement, with 2 patients reporting complete resolution of symptoms. One patient reported no change. Pain, as measured using an 11-point numerical scale, improved from a mean of 7.2 to 4.0 (p = .02), with 5 patients reporting clinically significant improvement (change, ≥2). Comfortable sitting or maximum time that the patient was able to sit without exacerbation of pain improved in 8 patients, with a change in median time of 5 to 45 minutes (p = .008). Change in the ability to sit correlated well with patient-reported global improvement (correlation coefficient, 0.86). No patient experienced worsening of symptoms. CONCLUSION: Patients with persistent pudendal neuralgia after surgical decompression may benefit from repeat operation via our novel approach. Ability to sit correlates well with reported improvement due to surgery.

Variability of the retropubic space anatomy in female cadavers.

OBJECTIVE: To characterize the anatomic relationships of clinically relevant structures in the retropubic space. STUDY DESIGN: Detailed dissections were performed in 15 female cadavers. RESULTS: The obturator vein was the closest of the obturator neurovascular structures to the ischial spine, median distance 3.4 cm (range, 1.8-4.8 cm). The vesical venous plexus included 2-5 rows of veins that coursed within the paravaginal tissue parallel to the bladder and drained into the internal iliac veins. The internal iliac vein was formed cephalad to the level of the ischial spine; the closest distance between these structures was 3.8 cm (1.6-6.2 cm). CONCLUSION: The complexity and proximity of the large internal iliac venous system to the bony landmarks used for passage of trocars is described in this study. A thorough understanding of the vascular anatomy in this space should help avoid serious operative complications.