Didactic: Chronic Pelvic Pain 2.0: Decoding Peripheral and ... · mechanism contributes to the transparency and accountability of CME. Table ... physiology and neurobiology of acute

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AAGLAdvancing Minimally Invasive Gynecology Worldwide

Didactic: Chronic Pelvic Pain 2.0: Decoding Peripheral and Central Factors

to Optimize Patient Outcomes

PROGRAM CHAIR

Sawsan As-Sanie, MD, MPH

Michael Hibner, MD, PhD Georgine M. Lamvu, MD, MPHTracy Sher, MPT Frank F. Tu, MD, MPH

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1

Disclosure ...................................................................................................................................................... 2

When Pain Persists: What Every Surgeon Should Know about the Biology and Treatment of Chronic Pelvic Pain S. As‐Sanie ..................................................................................................................................................... 4

Does This Hurt? Why Surgeons Should Learn a Musculoskeletal Exam T. Sher ......................................................................................................................................................... 14

Autonomic Nervous System in Chronic Pain States – Friend vs. Foe?

F.F. Tu ............................................................................................................................................. 24 When Sex Hurts: Evaluation and Management of Painful Intercourse in Women G.M. Lamvu ................................................................................................................................................. 26

From Dysmenorrhea to Chronic Pelvic Pain: When to Perform Surgery and What Works S. As‐Sanie ................................................................................................................................................... 36

Perioperative Care of the Chronic Pain Patient G.M. Lamvu ................................................................................................................................................. 47

You Want Me to Do What? Physiotherapy Treatments for Chronic Pelvic Pain T. Sher ......................................................................................................................................................... 55

Neuropathy: A Forgotten Cause of Chronic Pelvic Pain M. Hibner .................................................................................................................................................... 61

Cultural and Linguistics Competency ......................................................................................................... 71

PELV-610: Didactic:

Chronic Pelvic Pain 2.0: Decoding Peripheral and Central Factors

to Optimize Patient Outcomes

Presented in affiliation with the International Pelvic Pain Society (IPPS) and in cooperation with the AAGL Special Interest Group on Pelvic Pain

Sawsan As-Sanie, Chair

Faculty: Michael Hibner, Georgine M. Lamvu, Tracy Sher, Frank F. Tu Although chronic pelvic pain (CPP) is one of the most common conditions for which women seek

medical care, the evaluation and management of pelvic pain patients presents many challenges to

practicing gynecologic surgeons. This course is designed to provide participants with a practical, state-of-

the-art approach to the CPP patient that reviews the clinical evaluation, appropriate multidisciplinary

diagnostic workup, and innovations in medical and surgical treatment options. This course will also

highlight the role of surgery in the management of pelvic pain, when surgery is not likely to be helpful,

and alternative options when standard medical and surgical therapies fail. The prevention and

management of perioperative pain and chronic post-surgical pain, including post-hysteroscopic

sterilization pain, will be discussed. Course faculty will utilize clinical vignettes and video demonstrations

to enhance the interactive experience between faculty and audience. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Discuss the

physiology and neurobiology of acute versus chronic pain; 2) formulate a comprehensive differential

diagnosis for the newly encountered chronic pelvic pain patient, including possible gynecologic, urologic,

gastrointestinal, musculoskeletal and neurologic sources; 3) describe the evaluation and management of

painful intercourse in women; 4) describe the indications and efficacy of surgical procedures used to

treat chronic pelvic pain; 5) discuss the prevention and management of perioperative and chronic

postsurgical pain; 6) describe medical and behavioral therapies for pelvic pain that is refractory to usual

therapies; and 7) integrate the evaluation and treatment of pelvic and abdominal musculoskeletal

dysfunction in the care of chronic pelvic pain patients.

Course Outline

12:30 Welcome, Introductions and Course Overview S. As-Sanie 12:35 When Pain Persists: What Every Surgeon Should Know about the

Biology and Treatment of Chronic Pelvic Pain S. As-Sanie 1:00 Does This Hurt? Why Surgeons Should Learn a Musculoskeletal Exam T. Sher 1:25 Autonomic Nervous System in Chronic Pain States – Friend vs. Foe? F.F. Tu 1:50 When Sex Hurts: Evaluation and Management of Painful Intercourse

in Women G.M. Lamvu 2:15 Questions & Answers All Faculty 2:25 Break 2:40 From Dysmenorrhea to Chronic Pelvic Pain: When to Perform Surgery

and What Works S. As-Sanie 3:05 Perioperative Care of the Chronic Pain Patient G.M. Lamvu 3:30 You Want Me to Do What? Physiotherapy Treatments for Chronic Pelvic Pain T. Sher 3:55 Neuropathy: A Forgotten Cause of Chronic Pelvic Pain M. Hibner 4:20 Questions & Answers All Faculty 4:30 Adjourn

1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Sawsan As‐Sanie Consultant: Myriad Genetics Lab R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As‐Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri‐Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Sawsan As‐Sanie Consultant: Myriad Genetics Lab Michael Hibner* Georgine M. Lamvu* Tracy Sher* Frank F. Tu

Consultant: AbbVie Contracted Research: AbbVie Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.

When pain persists: What every surgeon should know about the biology and treatment of chronic pelvic pain.

AAGL 45th Annual Congress on Minimally Invasive GynecologyOrlando, Florida 2016

PELV-610: Chronic Pelvic Pain 2.0: Decoding Peripheral and Central Factors to Optimize Patient Outcomes

Sawsan As-Sanie, MD, MPHAssistant Professor

Department of Obstetrics and GynecologyDirector, Minimally Invasive GYN Surgery & Fellowship

Director, Endometriosis CenterThe University of Michigan

Disclosures

Consultant: Myriad Genetics Lab

I will present off-label use of medications, best evidence will be provided.

2

3

Objectives

1. Review the physiology of chronic pain, with particular emphasis on central pain disorders

2. Present evidence that endometriosis and chronic pelvic pain may be central pain disorders

3. Discuss the clinical approach to integrate treatment of central sensitization to enhance patient care

4

The challenges of caring for patients with chronic pain...

CPP Patient CPP Practitioner

5 6

Who has pelvic pain?

Pain-free

5 days/month, 3/10 pain

20 days/month, 8/10 pain

4

Burden

Institute of Medicine Report on Pain 7/2011 approximately 116 million Americans suffer from pain

Treatment of pain costs the United States more than half a trillion dollars per year

Pain is one of the most common reasons people consult a physician. Yet it frequently is inappropriately treated.

8

Definition of Chronic Pelvic Pain (CPP)

Non-cyclic pain6 or more month’s durationlocalizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocksof sufficient severity to cause functional disability or lead to medical care

American College of Obstetricians and Gynecologists, 2004

9

Epidemiology

15 - 25% of women aged 18 to 50 years have pelvic pain lasting > 6 mo during their lifetime

Primary indication for10% outpatient gynecology clinic visits12% hysterectomies40% diagnostic laparoscopies

Only 25% of UK women surveyed had sought medical evaluation in the last year

Howard FM, Ob Gyn Surv 1993, Lee NC et al AJOG 1984, Zondervan K, et al Br J Gen Prac 2001, Tu FF, AJOG 2006 10

Chronic pelvic pain negatively impacts quality of life & physical function

Among women with CPPUse 3x more medicationsHave 4x more GYN surgeriesAre 5x more likely to have a hysterectomy

58% reduce normal activity >1 day/month26% stay in bed >1 day/month15% report lost time from work48% report reduced work productivity

Mathias SD et al Obstet Gynecol 1996, Reiter R et al. Obstet Gynecol 1998

11

Challenges of endometriosis

1. Little, if any, correlation between extent of disease and severity of pain.

2. Medical therapies are non-specific & effectively treat other causes of CPP.

GnRH agonists are effective therapy for cyclic-IBS and CPP without endometriosis

3. Medical and surgical therapies are inadequate for many patients.

30% non-response rate

4. Frequency of recurrent pain is high following medical and surgical therapies.

Pain recurs often in the absence of recurrent pathology.

No brain, no painChronic Pelvic Pain

• Endometriosis• Adenomyosis• Adhesions• Chronic PID• Uterine fibroids• Pelvic congestion• Ovarian remnant• Residual ovarian syndrome• Vaginal apex pain

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13

Mechanistic Classification of Pain

PAIN

NOCICEPTIVE NEUROPATHIC

PERIPHERAL CENTRAL

ACUTE PAIN CHRONIC PAIN14

PAIN

NEUROPATHIC

CENTRAL

Mechanistic Classification of Pain

Central disturbance in pain processing with no ongoing peripheral stimulation

NOCICEPTIVE

Chronic pain is not prolonged acute pain

Acute Pain

Symptom of injury or disease

Well defined, recent onset

Expected to end with removal of peripheral injury

Essential biological warning function

Chronic Pain

Onset often insidious and not clearly associated with specific injury

Unpredictable duration

Often progressive

Pain out of proportion to peripheral pathology

No apparent biological function

15 16

Facilitation

+

Inhibition

Supraspinal Influences on Sensory Processing = Volume Control

Substance P

Glutamate and EAA

Serotonin (5HT2a, 3a)

Neurotensin

Nerve growth factor

CCK

Descending anti-nociceptive pathways

Norepinephrine –serotonin

Opioids

GABA

Cannabanoids

Adenosine

Central amplification of pain processing can lead to chronic pain in the absence of peripheral pathology

Central amplification of pain processing can lead to chronic pain in the absence of peripheral pathology

17

Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. Am FamPhysician. 2001 May 15;63(10):1979-84. Review

+

18

Shared features of “central” pain syndromes

Typically characterized by –Multifocal pain

Endorse “neuropathic” verbal descriptors of pain

Higher current and lifetime history of pain

Multiple somatic symptoms (fatigue, memory difficulties, sleep disturbance)

Greater sensitivity to multiple sensory stimuli (sound, light)

High rates of co-morbidities with other related syndromes

Opioids do not effectively or consistently reduce pain symptoms

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19

1.5 – 2X more common in females

Strong familial/genetic underpinnings

Triggered or exacerbated by “stressors”

Shared features of “central” pain syndromes

Increased Pressure Pain Sensitivity in WomenWith Chronic Pelvic PainSawsan As-Sanie, MD, MPH, Richard E. Harris, PhD, Steven E. Harte, PhD, Frank F. Tu, MD, MPH,Gina Neshewat, MPH, and Daniel J. Clauw, MD

20

Obstet Gynecol, 2013, 122(5): 1047-55

Evidence of centralized pain in women with endometriosis-associated CPP

Changes in regional gray matter volume in women w ith chronic pelvic pain:A voxel-based morphometry study

Sawsan As-Sanie a, Richard E. Harrisb, Vitaly Napadow c, Jieun Kim c, Gina Neshewat a, Anson Kairysb,David Will iams b, Daniel J. Clauw b, Tobias Schmidt-Wilcke b,d,�

www.el sevi er.com/l ocat e/pai n

PAINÒ

153 (2012) 1006–1014

Dysmenorrhea Interstitial Cystitis Irritable Bowel Syndrome

Evidence of centralized pain in dysmenorrhea, bladder pain, IBS

Most chronic pain conditions are “mixed pain” conditions, with peripheral and central contributors to pain

22

Peripheral Centralized

Acute pain Osteoarthritis Fibromyalgia Rheumatoid Arthritis Tension HA

Low back pain TMJD IBSInterstitial Cystitis

Vulvodynia

CPP

Pain= balance between peripheral input and central volume control

DescendingInhibitory & Facilitatory

pathways

Central “volume control”

Peripheral signals

=

24

7

You must care, otherwise your might do more harm than good…

Identifying the underlying causes of pain should guide clinical care and decision for surgery

26

Clinical implications of central changes in pain processing

1. Chronic overlapping pain conditions… suggest common underlying pathophysiology and treatment

27

2. Patient with central pain changes respond differently to therapy

1. May be less likely to respond to “peripherally-directed” therapies (e.g. hormone suppression, surgery?)

2. More likely to experience more acute and chronic pain following surgery

28

29Brawn J, Morotti M, Zondervan KT, Becker CM, Vincent K. Central changes associated with chronic pelvic pain and endometriosis. Hum Reprod Update. 2014, Sep-Oct;20(5):737-47

3. There are many overlapping pathways that lead to chronic pain

4. Treat early to prevent transition from acute to chronic pain

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Proposed diagnostic approach to CPP*

Gynecologic Urologic Gastrointestinal Musculoskeletal

• Endometriosis• Adenomyosis• Adhesions• Chronic PID• Uterine fibroids• Pelvic congestion• Ovarian remnant• Residual ovarian syndrome• Vaginal apex pain

• Interstitial Cystitis• Urethral syndrome• Chronic UTI• Bladder stones

• IBS• Functional Bowel

disorders• Chronic appendicitis• Inflammatory bowel

disease• Hernias• Diverticular disease• Intermittent bowel

Obstruction

• Pelvic floor myalgia• Trigger points• Idiopathic low back pain• Disc disease• SI joint disease• Coccydynia

• Nerve entrapmentsyndromes

CNS

• central pain disorder

Comorbid pain conditions: Fibromyalgia, chronic fatigue syndrome, TMD, migraines, etc.

Comorbid psychological disease: Depression, anxiety, etc.

Cognitive and psychosocial traits: Coping, personality, maladaptive behavior 32

Treatment pearls

Begin with “gold-standard” therapies for contributing factors

Ex. Hormonal suppression for cyclic pain or chronic pain with cyclic exacerbationEx. Physical therapy for abdominal wall and pelvic floor myofascial painEx. Laparoscopy for excision/ablation of endometriosis

When standard treatments fail, then reconsider the diagnosis, re-evaluate comorbid psychosocial variables

33

Treatment pearls

Abnormalities in pain processing are a common mechanism in many chronic pain disorders (IBS, IC, fibromyalgia, etc.)

It is likely to be an underlying mechanism in at least some women with CPP

Consider adding centrally-acting medication when standard “gynecology” treatments fail

Consider using centrally-acting medication as part of first-line therapy

Chronic pelvic pain with negative laparoscopyPelvic nerve entrapment syndromes (ex. Pudendal nueralgia)

Treatments for Pain Based on Underlying Mechanisms1,2

Non-inflammatory

Inflammatory Peripheral Centralized

Opioids

NSAIDs/acetaminophen

Immunosuppressants, Anti-inflammatories

Alpha-2-delta ligand anticonvulsants

TricyclicsSNRIs

1Kroenke K, et al. Gen Hosp Psychiatry. 2009;31(3):206-219. 2Dray A. Rheum Dis Clin N Am. 2008

■ Injections, surgical procedures less effective or ineffective for individuals with centralized pain

TricyclicsSNRIs

NeuropathicPeripheral

Pharmacological Therapies for Fibromyalgia (i.e. Centralized Pain)

Modified from Goldenberg et al. JAMA. 2004;292:2388-95.

StrongEvidence

■ Dual reuptake inhibitors such as ■ Tricyclic compounds (amitriptyline, cyclobenzaprine)■ SNRIs and NSRIs (milnacipran, duloxetine, venlafaxine?)

■ Anticonvulsants (e.g., pregabalin, gabapentin)

ModestEvidence

■ Tramadol■ Older less selective SSRIs or NRIs■ Gamma hydroxybutyrate■ Low dose naltrexone

WeakEvidence

■ Cannabanoids; Growth hormone, 5-hydroxytryptamine, tropisetron, S-adenosyl-L-methionine (SAMe)

NoEvidence

■ Opioids, corticosteroids, nonsteroidal anti-inflammatory drugs, benzodiazepine and nonbenzodiazepine hypnotics, guanifenesin

36

Relative Serotonin and Norepinephrine Re-uptake Amongst Antidepressants

Serotonin Mixed Norepinephrine

Citalopram

Fluvoxamine

Sertraline

Paroxetine

Fluoxetine

Venlafaxine Amitriptyline

Duloxetine Milnacipran

Imipramine

Maprotiline

Desipramine

Nortriptyline

Reboxitine

Best for pain

9

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Antidepressant with analgesic properties

Drug Dosage Side-effects, contraindications

TCA’s Start at 5-10 mg nightly, increase by 10 mg per week up to 150 mg/day

Side effects: dry mouth, constipation, sedation, urinary retention, weight gain (tertiary amines have greater side effects).

Contraindications: cardiac conduction abnormalities, recent cardiac event, narrow-angle glaucoma

Venlafaxine Start at 37.5 mg per day, increase by 37.5 mg per week, up to 300 mg/day (BID dosing)

Side effects: headache, nausea, decreased appetite, sweating, sedation, hypertension, seizures, mania, hepatic/renal dysfunction

Duloxetine Start at 20 mg per day, increase by 20 mg per week, up to 60 (or 120 mg) per day (30 BID, 60 QD, or 60 BID)

Side effects: nausea, dry mouth, constipation, dizziness, insomnia

38

Antiepileptics with analgesic properties

Drug Dosage Side-effects, contraindications

Neurontin Start 100-300mg qhs,

Increase 100-300mg q3d

Up to 2400mg daily

(600mg, 600mg, 1200mg qhs)

Side effects: Drowsiness, dizziness, fatigue, nausea, sedation, weight gain

Pregabalin Start 50 mg BID

Increase to 100 mg BID-QIDSide effects: Drowsiness, dizziness, fatigue, nausea, sedation, weight gain

Titration protocols (examples)

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Titration protocols

https://dl.dropboxusercontent.com/u/18727766/titration%20protocols/Cymbalta(DuloxetineHydrochloride)ChronicPain_sas.pdf

https://dl.dropboxusercontent.com/u/18727766/titration%20protocols/Elavil(AmitripylineHCL)ChronicPain_sas.pdf

https://dl.dropboxusercontent.com/u/18727766/titration%20protocols/Neurontin(gabapentin)ChronicPain_sas.pdf

40

■ Pharmacological therapies to improve symptoms

■ Increased Distress

■ Decreased activity

■ Isolation

■ Poor sleep

■ Maladaptive illness behaviors

■ Nociceptive processes (damage or inflammation of tissues)

■ Disordered sensory processing

Clauw and Crofford. Best Pract Res Clin Rheumatol. 2003;17:685-701.

Symptoms of Pain, Fatigue, etc.

Functional Consequences of Symptoms

Dually FocusedTreatment

■ Nonpharmacological therapies to address dysfunction

Nonpharmacological therapies applicable to all chronic pain conditions

Goldenberg et al. JAMA. 2004;292:2388-95.

StrongEvidence

■ Education■ Aerobic exercise■ Cognitive behavior therapy

ModestEvidence

■ Strength training■ Hypnotherapy, biofeedback, balneotherapy

WeakEvidence

■ Acupuncture, chiropractic, manual and massage therapy, electrotherapy, ultrasound

NoEvidence

■ Tender (trigger) point injections, flexibility exercise

10

Cognitive Behavioral Therapy for Chronic Pain

Shown to be effective over a wide range of pain states

Effect sizes on function (.4 - .6) are much greater than typically seen with pharmacological therapies

Despite wide agreement that these help, barriers to implementation have been:

Physicians do not strongly recommend these therapies and there is no “industry” promoting these therapies

Not generally reimbursed by third parties

Not enough trained therapists to give one-on-one CBT to all chronic pain patients

44

Program features 10 CBT modules:

Understanding Fibromyalgia

Being Active

Sleep

Relaxation

Time for You

Setting Goals

Pacing Yourself

Thinking Differently

Communicating

Fibro Fog

fibroguide.com

• In a RCT of 118 FM patients comparing the earlier version of this website plus usual care, to usual care alone, Williams demonstrated statistically significant improvements in pain (29% in the WEB group had 30% improvement in pain vs 8% in usual care, p=.009) and function (i.e., 31% in WEB-SM had .5 SD improvement in SF-36 PF vs. 6% in standard care, p<.002)

Williams et. al. Pain. 2010;151(3):694-702

Exercise to Treat Chronic Pain

Fibromyalgia. Aerobic exercise improves global well being (SMD .49), function (SMD .66) and pain (SMD .65 but very wide CIs include 0).

Strength training may also be effective although far fewer studies have been performed.

Dysmenorrhea28% decrease in pelvic and back pain, 15% decrease in depression scores.

Cochrane Database: Fransen M, et. al. 2008, Issue 3. Bartels EM et. al, 2007, Issue 4. Busch et. al. 2007, Issue 3.

Ortiz MI, Cortes-Marquez SK, Romero-Quezada LC, Murguia-Canovas G, Jaramillo-Diaz AP. (2015). Effect of a physiotherapy program in women with primary dysmenorrhea. Eur J Obstet Gynecol Reprod Biol, 152: 73-7.

Patients with chronic pain have dysfunctional sleep

• Chronic pain patients have reduced short-wave sleep and abnormal α-rhythms, suggestive of wakefulness during non-REM (rapid eye movement) sleep.

• Sleep deprivation in healthy individuals can cause symptoms of fibromyalgia, including myalgia, tenderness and fatigue.

• sleep deprivation impairs descending pain-inhibition pathways that are important in controlling and coping with pain.

Choy EH. The role of sleep in pain and fibromyalgia. Nat Rev Rheumatol. 2015 Sep;11(9):513-20.

Improve sleep = improve pain

• Clinical trials of pharmacological and nonpharmacologicaltherapies have shown that improving sleep quality can reduce pain and fatigue

• Provide instruction on sleep hygiene and limit the drugs that alter restorative sleep

• Prevent REM sleep: long acting opioids, beta blockers, clonidine, SSRIs

• Prevents paralysis and timing of sleep: Dopaminergic blockers

• Vitamin D deficiency (and toxicity) associated with poor sleep

Choy EH. The role of sleep in pain and fibromyalgia. Nat Rev Rheumatol. 2015 Sep;11(9):513-20.

Neurostimulatory Therapies

Peripheral

1. TENS (Transcutaneous electrical nerve stimulation)■ Conventional TENS (C-TENS) is given at high stimulation frequency

with low intensity, and pain relief is almost immediate both short-lived.

■ Acupuncture like TENS (AL-TENS) is given at low frequency and high intensity (which is uncomfortable to many individuals), and generally has a longer lasting analgesic effect.

■ Improvement in pain, dyspareunia and QOL in endometriosis-CPP1, and primary dysmenorrhea2

2. Percutaneous tibial nerve stimulation Small RCT shows weekly Rx x12 = possible benefit up to 6 months

after treatment3

1Mira TA, Giraldo PC, Yela DA, Benetti-Pinto CL. Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2015 Nov;194:1-6.

2Proctor ML, Smith CA, Farquhar CM, Stones RW. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. Cochrane Database Syst Rev. 2002

3Istek et al. 2014. Arch Gynecol Obstet 290(2): 291-8.

11

Neurostimulatory Therapies

Central - New evidence suggests efficacy across a broad range of chronic pain conditions

Applied to scalpTranscranial magnetic stimulation (TMS)

Direct Current Stimulation (DCS)

ImplantableSpinal cord stimulation

Vagal nerve stimulation

Deep brain stimulation

SummaryCentralized pain or central sensitization can be identified in most individuals with conditions such as FM, and in sub-sets (typically at least 20 – 30%) of individuals with other chronic pain states such as CPP, RA, SLE, low back pain, osteoarthritis

Thus all chronic pain states may be “mixed” pain states with variable peripheral and central contributions in different individuals with the same clinical label

None of our pharmacological treatments of chronic pain have anything more than modest efficacy when used as stand-alone therapy in any chronic pain condition

In the US in particular, opioids, NSAIDs, injections and surgical procedures are overused (easy, high reimbursement), and centrally acting analgesics, non-pharmacological therapies e.g. exercise, CBT are underused (difficult, low to no reimbursement)

One size never fits all

51 52

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References

1. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol, 2004. 103(3): p. 589-605.

2. Schweinhardt, P. and M.C. Bushnell, Pain imaging in health and disease--how far have we come? J Clin Invest, 2010. 120(11): p. 3788-97.

3. Gottschalk, A. and D.S. Smith, New concepts in acute pain therapy: preemptive analgesia. Am Fam Physician, 2001. 63(10): p. 1979-84.

4. As-Sanie, S., et al., Increased pressure pain sensitivity in women with chronic pelvic pain. Obstet Gynecol, 2013. 122(5): p. 1047-55.

5. As-Sanie, S., et al., Changes in regional gray matter volume in women with chronic pelvic pain: a voxel-based morphometry study. Pain, 2012. 153(5): p. 1006-14.

6. Clauw, D.J., Pain management: Fibromyalgia drugs are 'as good as it gets' in chronic pain. Nat Rev Rheumatol, 2010. 6(8): p. 439-40.

7. Clauw, D.J. and G.P. Chrousos, Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation, 1997. 4(3): p. 134-53.

8. Clauw, D.J., et al., The relationship between fibromyalgia and interstitial cystitis. J Psychiatr Res, 1997. 31(1): p. 125-31.

9. Schmidt-Wilcke, T. and D.J. Clauw, Pharmacotherapy in fibromyalgia (FM)--implications for the underlying pathophysiology. Pharmacology & therapeutics, 2010. 127(3): p. 283-94.

10. De Graaff, A.A., et al., The significant effect of endometriosis on physical, mental and social wellbeing: results from an international cross-sectional survey. Hum Reprod, 2013.

11. Lebovic, D.I., M.D. Mueller, and R.N. Taylor, Immunobiology of endometriosis. Fertil Steril, 2001. 75(1): p. 1-

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References12. Sutton, C.J., et al., Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril, 1994. 62(4): p. 696-700.

13. Ferrero, S., et al., Irritable bowel syndrome and endometriosis. Eur J Gastroenterol Hepatol, 2005. 17(6): p. 687.

14. Sinaii, N., et al., High rates of autoimmune and endocrine disorders, fibromyalgia, chronic fatigue syndrome and atopic diseases among women with endometriosis: a survey analysis. Hum Reprod, 2002. 17(10): p. 2715-24.

15. Vercellini, P., et al., Repetitive surgery for recurrent symptomatic endometriosis: what to do? Eur J Obstet Gynecol Reprod Biol, 2009. 146(1): p. 15-21.

16. Mogil, J.S., The genetic mediation of individual differences in sensitivity to pain and its inhibition. Proc Natl Acad Sci U S A, 1999. 96(14): p. 7744-51.

17. Diatchenko, L., et al., Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum Mol Genet, 2005. 14(1): p. 135-43.

18. Ablin, K. and D.J. Clauw, From fibrositis to functional somatic syndromes to a bell-shaped curve of pain and sensory sensitivity: evolution of a clinical construct. Rheum Dis Clin North Am, 2009. 35(2): p. 233-51.

19. Williams, D.A. and D.J. Clauw, Understanding fibromyalgia: lessons from the broader pain research community. J Pain, 2009. 10(8): p. 777-91.

20. Ablin K, Clauw DJ. Rheum Dis Clin North Am. 2009;35:233-251

21. Wolfe F, Michaud K. J Rheumatol. 2006;33:1516-1522

22. Kato K, et al. Psychol Med. 2008;39:497-505

23. Watson NF, et al. Arthritis Rheum. 2009;60:2839-284

24. Clauw and Chrousos. Neuroimmunomodulation. 1997;4:134-53.

25. Kato K, et. al. Arch Intern Med 2006; 166(15):1649-54.

26. Goldenberg et al. JAMA. 2004;292:2388-95

27. Williams et. al. Pain. 2010;151(3):694-702

Cochrane Database: Fransen M, et. al. 2008, Issue 3. Bartels EM et. al, 2007, Issue 4. Busch et. al. 2007, Issue 3.

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Evaluation Question

Which of the following therapies does not have demonstrated efficacy for the treatment of “centralized” pain?

a)Aerobic exercise

b)Gabapentin

c)Oxycodone

d)Cognitive behavioral therapy

e)Education

56

13

Does This Hurt? Why Surgeons Should Learn a

Musculoskeletal Exam

AAGL – Advancing Minimally Invasive Gynecology Worldwide

45th Global Conference

Tracy Sher, MPT, CSCS

Email: [email protected]

www.pelvicguru.com

www.sherpelvic.com

Property of Tracy Sher, MPT, CSCS. All rights reserved

Financial DisclosuresI have no financial relationships to disclose.





Objectives to Discuss:

WHY the MUSCULOSKELETAL (MSK) system matters with regard to chronic pelvic pain (CPP) conditions.

HOW a GYN surgeon can integrate MSK screening into their exam.

WHAT important musculoskeletal structures and findings are associated with chronic pelvic pain

And… WHY this all matters....


Why Surgeons Should Learn a Musculoskeletal Exam

•Your patients will feel you listened and validated concerns

•Your differential diagnosis AND outcomes will improve

•You’ll have better medical “team” communication and refer appropriately

•Hero status


“Thermogram” Pelvic Pain Patient

Property of Tracy Sher, MPT, CSCS. All rights reserved Property of Tracy Sher, MPT, CSCS. All rights reserved

Permission to share from Visible Body

14

Why Does This Matter?• Surgery won’t “fix” a musculoskeletal issue typically (hypertonic/overactive muscle). Symptoms can become worse or additional complications happen.

• Post‐op patients may have a new‐onset MSK issue or neural issue that is presumed will get better on its own, though would benefit from timely MSK treatment to prevent longer‐term chronic pain issues

•MSK issue and only meds are provided only masking the underlying problem

• Patient may have multiple issues and if MSK is not addressed in addition to surgery, etc. – issue may not fully resolve

• So…Pelvic pain is complex and MSK should be screened.Property of Tracy Sher, MPT, CSCS. All rights reserved

Why Surgery Doesn’t Help All Pelvic Pain Patients. Examples

•Musculoskeletal source or contribution (leading to nerve compression/irritation)

•Sensitization of the nervous system (peripheral and/or central)

•Comorbidities (systemic, inflammatory, hormonal, etc)

•History of trauma

• Lack of multimodal approach to care – outcomes would improve with PT, pain management, counseling, mindfulness/meditation, etc.


Cases


What Pelvic Pain Patients Share

• “I wish Gynecologists would go back and do professional development in the pelvic floor muscles and nerves.

• “For years I had on and off one sided pain (that I now know was pelvic muscle pain‐ obturator internus and coccygeus). I had 2 laparoscopies to find the cause and of course nothing was found. Gynecologist told me to get a hysterectomy and it might cure me.( Thank God I didn't listen)”


What Pelvic Pain Patients Share

• “Pelvic pain is a real concern and involves a whole team of doctors to help the patient and GYNs are often the first doctor that a woman seeks out for help/treatment/diagnosis.”

• “Gynecologists think all pelvic pain has to be associated with your uterus or ovaries or a pyschissue! It's as if no other anatomy is located in the pelvis‐ so crazy!”


How Does a Pelvic Pain Patient Present?Complex and Multiple Issues or Specific

Painful Bladder Syndrome/IC

Vulvodynia and all of the subtypes

Coccygodynia

Endometriosis

Pudendal Neuralgia

Constipation

Dysfunctional voiding

(Comorbidity overlap)

Hartmann, Howard, Steege

Myofascial pain syndrome

Rectal pain/Proctalgia Fugax

Vaginismus

Dyspareunia

IBS

Urethral Pain

PGAD


15

Somatic NEURAL Visceral


http://wehelpwhathurts.homestead.com/nongastricabdominalpain.html

HOW Do We Assess Musculoskeletal?


Types of Musculoskeletal Findings

1. Extrapelvic Exam

2. Internal Pelvic Floor – Vaginal and/or Rectal

3. sEMG /Biofeedback


Muscles – “CORE” Pressure System


Understand Your Back & Pelvic Girdle Pain Written by Diane Lee Physiotherapist

Lee, D. The Pelvic Girdle, 3rd and 4th Elsevier 2011

Extrapelvic Exam

•Breathing Patterns/Diaphragmatic Excursion

•Positions Matter – “Always hurts when I sit vs. when I change positions”

•Bony Landmark Pain / Asymmetry

•Muscle Tightness/Tenderness

•Neural Sensitization/ Neural Tension•Spinal Mobilization Testing

•ROM Hip/Extremities & Pelvic Floor Excursion


Palpation Matters


16

Palpation, Palpation, Palpation. Based on History!

Palpation is VALIDATION for patient…and you. •Neuropathy? Neural pattern of referral? vs.•Tender everywhere? vs• Muscular

• tender to palpation: ”That’s my pain”

• tightness/shortness Hypertonic/overactive•Can possibly be reproduced with contracting the muscle or not able to relax muscle


Study (Tu 2008): CPP Musculoskeletal Findings

Women with chronic pelvic pain had more musculoskeletal dysfunction (20 control/19 cases)

• Asymmetrical iliac crests height

• Pubis symphysis height

• Positive posterior pelvic provocation test (SIJ)

• Higher abdominal and pelvic muscle tender points (R Psoas, B Rectus, L Obliques)

• More difficulty relaxing pelvic floor muscles after contract/relax 2/4 and 10/10

Common Findings in Other CPP StudiesPelvic floor muscle tenderness found more often in women with chronic pelvic pain (Fitzgerald 2011)

Myofascial pain and hypertonic pelvic floor dysfunction are present in more than 50% of patients with IC and/or CPPS. (FitzGerald MP 2009)

Men with CPPS have more abnormal pelvic floor muscular findings (Hetrick2003)

Key findings: (King 1991)

• “Pelvic pain posture: Lumbar lordosis, anterior pelvic tilt

• + Thomas test and/or decreased spine ROM in 75%

• Loss of 15‐25° hip internal rotation

• Poor sit, stand, sleep mechanics


General Extrapelvic Musculoskeletal Exam

Some of the Muscles that Attach or Influence the Pelvis

•Abdominals •Gluteals•Hamstrings •Piriformis•4 Hip Rotators

Fitzgerald, Lee

•Quadratus lumborum

•5 Hip Adductors •Ilioposas•Erector Spinae•Quadratus


MSK Extrapelvic Screening Helps with Differential DiagnosisPain Patterns Can be very distinct MSK source “That’s my pain” at muscle belly or tendinous(muscular/bony) area. Poor Discrimination in the pelvis – May think bladder, ovary. Could be diffuseMultiple referral patterns Possibly multiple sources Long‐term can have MSK symptoms and findings from another source (hx UTIs, Endo…)


17

Abdominal Wall – 3 Key Assessments


http://medicfrom.com/publicpress/Massage/Basic_Clinical_Massage_11.html

• Palpation – Tenderness, Tissue/muscle mobility, Trigger points with referral pattern, Reproduces Pain

• Abdominal Wall Stability –Diastasis Recti

• Scars – Mobility / Restrictions?

Scar Mobility

Near Bladder or other organs?

Reproduce pain with touch/pressure?

Sensitive to touch?


Types of Musculoskeletal Findings•Trigger Point – Focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders.

•Tender Point – Pain at the site of palpation only

•Spasm – Persistent increased tension and shortness in a muscle that cannot be released voluntarily

Property of Tracy Sher, MPT, CSCS. All rights reservedTravell and Simons; Alvarez (2002) ; Rummer, E.

Types of Musculoskeletal Findings

•Connective Tissue Restriction‐•Increased texture thickness with acute tenderness upon pinch‐rolling in the skin and subcutaneous tissue

•Hyperalgesia and trophic changes may be present

Property of Tracy Sher, MPT, CSCS. All rights reservedPrendergast and Rummer; Kotarinos

Abdominal/Pelvic Pain – Musculoskeletal?


DAVID D. ORTIZ, MD, CHRISTUS Santa Rosa Family Medicine Residency Program, San Antonio, TexasAm Fam Physician. 2008 Jun 1;77(11):1535‐1542.

18

Abdominal Pain – Carnett’s Test (Screening)(Takada, T 2011)

• 130 consecutive outpatients with abdominal tenderness. (Functional GI/IBS excluded)

• 84% + Test: Abdominal

Wall Pain

• 86% + Test: Psychogenic

Abdominal Pain

• 13% + Test:

Intra‐Abdominal

Source


http://clindx.wordpress.com/2011/05/26/carnetts‐test‐for‐excluding‐intra‐abdominal‐origens‐of‐abdominal‐tenderness/

External Muscles – Quadratus Lumborum


External Muscles – Psoas and Iliacus


External Muscles –Gluteals, Hamstrings, Piriformis

Property of Tracy Sher, MPT, CSCS. All rights reservedThanks to: http://medicfrom.com

External/Internal Muscle- Obturator Internus


“Hips Don’t Lie”?: Sacroiliac Joint and Hips

Property of Tracy Sher, MPT, CSCS. All rights reservedPicture courtesy of video by www.si‐bone.comhttp://www.youtube.com/watch?v=ukDJ_OxOuBY#t=79

Sacral Thigh Thrust

19

HIP LABRAL TEAR?

•Basic hip mobility testing•Research has produced NO tests with sufficient specificity to help confidently RULE IN dx of hip labrallesion.

•Negative finding for certain tests provides clinician with evidence‐based confidence that a hip labral tear is ABSENT.

Lebold, RM J Man Manip Ther. 2008; 16(2): E24–E41.PMCID: PMC2565117Concurrent Criterion‐Related Validity of Physical Examination Tests for Hip Labral Lesions: A Systematic Review

Property of Tracy Sher, MPT, CSCS and Loretta J. Robertson, PT, MS. Permission required to share or reproduce. 39 Property of Tracy Sher, MPT, CSCS. All rights reserved

2. Internal: Pelvic Floor Muscle Assessment

Pelvic Pain and Pelvic Floor Connection?

•Majority of pelvic pain conditions involve some kind of pelvic floor muscle dysfunction

•Patients with pain usually have muscle spasms/hypertoncity/shortening, NOT weakness (but can have both)

•Many unable to actively contract pelvic floor muscles

•Difficulty with release of contraction

•Poor awareness – “am I even contracting?”

Fitzgerald, Howard, Tu


Pelvic Floor – Muscle Function

External and Internal Observation/Palpation –Can you: Contract, Relax, Bulge? NOT just a KEGEL


Pelvic Floor – Muscle Function

Palpation

•Layers 1‐3. Tender, Trp, Decreased tissue mobility

•Differential ‐ Specific muscles or with cotton swab at vestibule only?

•Asymmetries ‐ each side?

•Referral to another place – to bladder, abdomen, etc.?

•Does it feel tight in spasm or “shortnened?”


Features of Pelvic Floor Muscle Dysfunction – Overactive, Hypertonicity, Shortened Pain with or after voiding – NOT like a UTI

Pain with penetration vaginally –tampon, digit, intercourse.

Urinary hesitancy/frequency Incomplete urinary voiding

Incomplete or difficulty passing stool and constipation via outlet obstruction

Not common to have urinary incontinence

Usually worse with “core” strengthening

Worse with KegelsProperty of Tracy Sher, MPT, CSCS. All rights reserved

20

Pelvic Floor Muscles

Functions of Pelvic Floor Muscles

•Core stability in conjunction with the respiratory diaphragm, back and abdominal muscles

•Transfer loads generated by body wt. and gravity •Sexual/reproductive function•Urinary and colorectal function

•Superficial layer: (pudendal nerve)•Bulbocavernosus•Ischiocavernosus•Superficial transverse perineal•External anal sphincter (EAS)Property of Tracy Sher, MPT, CSCS. All rights reserved Property of Tracy Sher, MPT, CSCS. All rights reserved


•Second layer - Urogenital: pudendalnerve•External urethral sphincter•Compressor uretherae•Sphincter urethrovaginalis

•Deep transverse perineal



•Deep layer /Pelvic diaphragm: sacral nerve roots S3-S5•Levator ani: Pubococcygeus(Pubovaginalis, Puborectalis), Illiococcygeus

•Coccygeus/ischiococcygeus•Piriformis•Obturator internus


21



3. Pelvic Floor sEMG /Biofeedack Testing

Vulvodynia.com

What Can YOU Do for MSK Evaluation ?


GYNs and MSK Evaluation Connection ?

Specific Evaluation for Pain Patient

Look for tissue that doesn’t move or hurts when you move it – external or internal

Looking for muscle spasms and “trigger points” which may be a source of pain.

Look for muscle dysfunction – can they contract, release and elongate muscles as needed?


GYNs and MSK Evaluation Connection ?

Typical Findings on Vaginal Exam Difficulty tolerating vaginal exam May only be able to use child speculum if any Pain with palpation of muscles – improved

differential with specific muscle identification. Residual pain following examination Reproduction of abdominal pain with palpation

of muscles Apparent weak or minimal contraction of muscles on command Paradoxical contraction with attempts to push

out or elongate muscles. Property of Tracy Sher, MPT, CSCS. All rights reserved

22

Recommendations if Patients Have MSK FindingsDo NOT start on Kegels and send them away

Consider holding off on surgeries planned until MSK treatment

Refer to Pelvic Physical Therapy if possible Will screen to rule out Back/Hip and other differentials

Restore Tissue mobility

Train patient in toileting postures, muscle re‐education, self help strategies

Suggestions for self care –

massage, meditation, counseling

(but do not infer they are ”crazy”

or it is “all in your head.”

Property of Tracy Sher, MPT, CSCS. All rights reservedProperty of Tracy Sher, MPT, CSCS. All rights reserved

References

Alvarez, DJ, Rockwell, PG. Trigger Points: Diagnosis and Management. Am FamPhysician. 2002 Feb 15;65(4):653‐661

Butler and Mosely, Explain Pain, 2003

FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for treatment of urologic chronic pelvic pain syndrome. J Urol. 2009;182:570–580.FitzGerald MP, Kotarinos, ER. Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J (2003) 14: 261–268

Hilton S, Vandyken C. Clinical Commentary. The puzzle of pelvic pain – a rehabilitation framework for balancing tissue dysfunction and central sensitization, I: Pain physiology and evaluation for the physical therapist J Women’s Health PT. 2011;35(3):103‐113

Lee, D. The Pelvic Girdle, 3rd and 4th Elsevier, 2004/ 2011.

Louw A, et al. The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Arch. Phys. Med. and Rehab 2011; 92(12):2041‐2056

Mannion AF, et al. [Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance] Schmerz 2001;15(6): 468‐73.


References

Takada T, Ikusaka M, Ohira Y, Noda K, & Tsukamoto T (2011). Diagnostic usefulness of Carnett’s test in psychogenic abdominal pain. Internal medicine (Tokyo, Japan), 50 (3), 213‐7 PMID: 21297322

Tu, FF. Physical therapy evaluation of patients with chronic pelvic pain: a controlled study. American Journal of Obstetrics & Gynecology Volume 198, Issue 3 , Pages 272.e1‐272.e7, March 2008

Travell, and Simon. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2, 1992

vanMiddelkoop M, et al. Exercise therapy for chronic nonspecific low‐back pain. Best Pract Res ClinRheumatol 2010;24(2):193‐204

Vandyken C, Hilton S. The puzzle of pelvic pain‐a rehabilitation framework for balancing tissue dysfunction and central sensitization, II: A review of treatment considerations. J Women's Health PT. 2012;36(1):44‐54

Wall LL. The muscles of the pelvic floor. Clin Obstet Gynecol 1993;36:910‐25

Weiss J.Chronic pelvic pain and myofascial trigger points. Complim Med and Pain. 2000 Dec:13‐18

Weiss JM, Prendergast SA. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol. 2003;46(4):773‐82

Hip References• Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of Sacroiliac Joint Pain: Validity of Individual Tests and Composites of Tests. Manual Therapy. 2005: 10; 207‐18.

• van der Wurff P, Hagmeijer RH, Meyne W. Clinical tests of the sacroiliac joint: A systematic methodological review. Part 1: Reliability. Man Ther. 2000;5:30–36.

• Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of selected motion and pain provocation tests for the sacroiliac joint. Man Ther. 2007;12:72–79.


Website References




http://medicfrom.com

23

Autonomic Nervous System in CPP States-- Friend or Foe?

Frank F. Tu, MD, MPH

Clin Assoc Prof

Dept of Ob/Gyn

Disclosures

• Consultant: AbbVie

• Contracted Research: AbbVie

• Off label use of medications will be reviewed

Objectives

• Identify the pertinent components of the autonomic nervous system for CPP states

• Recognize significant features of prior studies of ANS dysfunction in CPP states

• Discuss 3 potential ANS medication therapies of potential value for treating CPP

Uterine pain and CPP need more effective treatments

• Dysmenorrhea– OCPs I

– NSAIDs I – 15% of cases refractory

• CPP/endometriosis– Hormonal suppression (OCPs, progestins, GnRH

agonists and antagonists, AIs) Ib

– Surgical removal of endometriosis implants (Ib

– General neuromodulator drugs (III)

Autonomic targeting of visceral pain -rationale

Visceral innervation is autonomic

• Sympathetic and parasympathetic– arise from the sympathetic trunk and the sacral

spinal nerves,

• Converge on abdominopelvic plexus extending thoracoabdominal diaphragm superiorly to the pelvic diaphragm inferiorly.

• Initially only efferent aspects described

24

Sympathetic pelvic neuroanatomy

•SHP and IHP are major integrative center

•IHP Fans into middle rectal/ vesical/ pelvic plexi

•These supply most pelvic GU/GI/ reproductive structures

•Anterior part is paracervical ganglia

•Corpora cavernosa, vagina, periurethral tissues

Wesselmann U et al, Pain 73:3, 1997

Key constituents

Sympathetic

• Sympathetic trunk connections to…

• Lumbar (L1-L2) and sacral splanchnic nerves to

Parasympathetic

• Pelvic splanchnics (S2-S4)

• Through IHP to target pelvic organs, ganglia in walls, the postganglionic fibers to deeper layers –smooth muscle and glands

Overview of afferent visceral pathways

• 1. Pelvic splachnics – PS from IHP, anterior rami of S2-S2 (nervi erigentes) – uterus, bladder, vagina and inferior rectum

• 2. Sacral splanchnics – S from IHP, visa sympath chain to L1, L2, white rami comm to SC, also uterus, vagina, rectum

• 3. IHP -> hypogastrics to SHP, then pre-aortic plexus, then T and L splanchnics to sympathetic chain at T7-L2

• 4. S and PS bypass in adnexa to thoracic splanchnics, but also vagal PS

• 5. Middle and superior rectal S t along vessel to infemes plexus, then to lumbar splachnics

Complexity the norm

• Vs somatic fibers, visceral fibers are

• more divergent on entering SC, contacting multiple DH neurons.

• Visceral afferent fibers ascend and descend many more levels than typical somatosensory afferent fibers.

• Almost all visceral afferent fibers are convergent on DHneurons that also receive somatic primary afferent fibers.

Understanding the big scheme

• PFC-> RM -> NTS -> vagus -> bladder

• Bladder to thalamus to PFC

• RM to DH -> bladder (symp)

• Absence of vagal tone worsens things

• Gain of function

Background on parasympathetic contribution to wellness

• Reliable individual differences in cardiac vagal tone exist (Cacioppo et al., 1994) – Reduction with age (Craft and Schwartz, 1995).

• Unknown if impaired vagal tone is a cause or consequence of chronic disease

Cacioppo JT, et al. Psychophysiology 31, 412–419. Craft N, Schwart JB. American Journal of Physiology 268, 2005:H1441–H1452.

25

Autonomic ganglia contributions

• axon collaterals in an autonomic ganglion from pathologic organ afferents could excite ganglionic secretory and motor neurons innervating other organ

• several neuropeptides exert facilitatory/ inhibitory effects @ autonomic ganglia

Delepine, L., Aubineau, P., 1997. Exp. Neurol.147, 389–400; Brumovsky P & Gebhart GF. Auton Neurosci. 2010;153(1-2):106-15.

• El-Henafy – 2015 Urology 25917730 - SHG vs. HD for PBS

• C Rapp 2016 BJOG - 27292167 - postop hypogastric block for hysterectomy

So what is going on with ANS in chronic visceral pain?

• Output is exaggerated due to chronic hyperarousal– Clinical treatment goal

? wipe out sympathetic efferent drive TO uterus (ischemia, contraction, pain)

• DNIC is impaired

• Linked to comorbid conditions– Sleep impairment

– Fatigue

– Mood /anxiety d/o

Baseline and stress response

• Increased HR in IC (82) vs HC (63), 14 vs. 14 females (mean age 49)

• maintained during 25 min stressor application (∆ 19, p < 0.0001), but not different.– Speech, Stroop, and

serial subtractionLutgendorf S et al J Urol2004

ANS-R is GOOD

• greater capacity for context and goals to modulate emotion (output of vmPFC) vmPFC –system of systems” linking conceptualization, context, emotion and response. – Via connection to PAG bias more caudal brainstem

networks to specific modes that reflect particular behavior patterns and their autonomic accompaniments.

– ANS-R may be the “poor man’s” marker of vmPFCoutflow to the PAG

Resting HF-HRV – marker for emotional regulation?

• indicator of capacity for cognitive and affective regulation– low HF-HRV reflecting reduced ability to

psychologically modulate physiological responses4

• BUT, if decreased autonomic outflow predisposes to the development of IC/BPS, one might consider whether the vagal anti-inflammatory pathway has a role27

Williams, J Urol 2015

26

Causal role in CPP?

• unique ANS changes in response to stress occur in IC/BPS absent from other CPP disorders underlie the bladder dysfunction that characterizes IC/BPS

ANS responsiveness (ANS-R) in patients with IC/BPS, both at rest and during orthostatic challenge• in vagal tone, measured by high-frequency heart rate

variability (hfHRV)• in sympathetic reactivity, via baroreflex sensitivity (BRS)

Chelimsky -

Is exag SNS output more a predisposing issue?

• Sympathetic activity adverse chronic influence– Tissue vasoconstriction

– Facilitate pain pathways in DH (NE on a circuit is more synaptic conductance – Wolff)

HRV and functional somatic disorders

• lower PNS activity in FSD patients regardless of type of FSD (i.e., CFS, FM or IBS).

• Reliability limited by unexplained heterogeneity in effect sizes and potential publication bias.

• Key study design features– Appropriate controls, blinding personnel for HRV

measurements, reporting adequate HRV outcomes, and adjustment for potential confounders.

• Must consider influence of time of day, smoking, alcohol intake, caffeine intake, water or food ingestion

Tak et al Biol Psych 2009

IBS and ANS

• 24-h recording IBS patients vs. HC mean lnHF; mean square root LF/HF index

– shift in sympathetic/ parasympathetic balance toward sympathetic dominance, but due to vagal withdrawal.

Heitkemper M, et al. Dig Dis Sci 1998; 43: 2093–8.

Diagnostic/therapeutic blocks

Malignant

• Plancarte et al. 1997

• “vague, dull, poorly localized pain”

• Dx – 159/227 with “good pain relief”

• Tx – 115/227 with “good pain relief”

• Some 2nd procedures attempted

43% avg opioid dosage

Non-malignant

• Bosscher, 1996-2000

• Dx - 50% pain relief > 4 hrs – 10/22

• Tx – 50% relief > 1 mth4/11, only 1 with complete, long-lasting relief

Plancarte R et al. Reg Anesth. 1997;22(6):562-8; Bosscher H, Pain Practice; 1(2), 2001: 162–170

Pelvic pain in women Kindel 1939

• Review PSN

• 2 deaths.

27

Presacral neurectomy

• Italian RCT 2003– 162 women with >6 mths severe

dysmenorrhea + dx of endometriosis

– Tx with (A) EOE or (B) EOE + PSN

– Outcomes (12 mths F/U)» Dysmenorrhea – (B) 85.7% cured

vs. (A) 57.1%» Dyspareunia» Pelvic pain

– Complications (12 mths F/U)» 9/63 (14%) with constipation» 3/63 (5%) with urinary urgency

Zullo F et al, AJOG 2003

Case studies suggest efficacy for CPP states, clinical experience says not effective

Model of dysmenorrhea to CPP progression at target organ.

Brain RVM

UterusBladder

Severe menses

Regulation of pain/homeostasis

Sympathetic modulation of perfusion/ contractiility

∆ PGs, LTs, vasopressin, PAF concentration

Ascending pain pathways

Implications

• Diaphragmatic breathing can restore vagal tone – reverse LF/HF imbalance in FAP.

• Resonant frequency breathing in pilot study improves FM symptoms and transiently improves abnl HRV imbalance – N=12 , 50% achieved 50% improvement in 3 mths

in 10 session trial

– Baroreflex stimulation optimizes autonomic and emotion mediated reflexes (hypothal/limbic projections)

Sowder E. et al, Appl Psychophysiol Biofeedback Sep;35(3):199-206, 2010); Hasset A et al, Appl Psychophysiol Biofeedback. 2007 Mar;32(1):1-10.

Add’l thoughts

• Exercise, CBT similarly?

• benefits of autonomically focused psychosocial-behavioral interventions with respect to HTN and CHD have been demonstrated in a number of trials in adults

• Find solutions to reduce threat with reducing PFC -> PAG, RM (RM produces 80% of NE)

» Beta blockade?

Sanudo B et al, Clin Exp Rheumatol, 33 (suppl.) (2015), p. S41; ; Linden W et al, Ann Behav Med. 1994;16:35–45.

Acknowledgements

• Work funded by NIH R01 DK100368

• Thanks to

• Kevin Hellman, PhD

• Katlyn Dillane

• Ellen Garrison, RN

• Julia Kane, MS

• Nicole Steiner

28

When Sex Hurts Georgine Lamvu, MD, MPH

Gynecologic Surgeon and Pelvic Pain Specialist

Orlando VA Medical Center

Associate Clinical Professor University of Central Florida

Disclosure

I have no financial relationships to disclose.

Objectives

Identify the diagnostic criteria for sexual pain

Explain the impact of this very prevalent chronic pain syndrome

Describe the benefits of both physical and psychosocial therapies

54 yo married female presents to your office for management of fibromyalgia and her pain and medications. You are done with your visit, and as you are walking out the door she says ”I know you don’t have time but…” and she proceeds to report that over the last several months she has been experiencing pain during intercourse and loss of desire which is worrying her. She tells you she has no medical problems and her only medications (besides her pain meds) is her hormone pill. You perform a brief vaginal exam and you tell her you ‘see nothing wrong’. Which of the following should be your next step?

Test your knowledge

• A. You order a UA which is negative and you give her a short course of your favorite antibiotic

• B. You ask her some additional questions such as whether she has been experiencing any vaginal dryness, itching, hot flashes, insomnia

• C. You tell her you don’t see anything wrong and you recommend she go home and have more sex to see if it gets better

• D. You ask her whether she is being abused and if she denies you tell her there is nothing you can do.

Test your knowledge Sexual Pain Terminology• Dyspareunia – recurrent or persistent vaginal pain associated with sexual intercourse

• Vulvodynia – chronic vaginal or vulvar pain that can be unprovoked or provoked by contact such as intercourse

• Vestibulitis – pain localized to the vestibule, provoked or unprovoked,

• Both are usually a symptoms of an underlying condition rather than just a diagnosis in and of itself. But technical definitions are based on the ability to exclude ‘organic’ causes such as infection, neoplasm or dermatoses

• Vaginismus – involuntary muscle spams and fear of touch

• Hypoactive sexual desire disorder, arousal disorder‐ diagnoses that do not involve pain

Boardman L, et al. Clinical Obstetrics and Gynecology. 2009; 52(4), 682.Lamvu G, et al. Vulvodynia: a prevalent yet underdiagnosed chronic pain syndrome. Painweek Journal. 2015; Q1, 14.Kingsberg S, et al. Female Sexual Dysfunction. Obstetrics and Gynecology. 2015 125(2); 477.

29

Dyspareunia: Additional Terminology

• Situational dyspareunia: pain with intercourse that is limited to specific situations, positions or a particular partner

• General dyspareunia ‐ pain that is not situational

• Primary dyspareunia ‐ pain that presents with or since first intercourse

• Secondary dyspareunia ‐ pain with intercourse that occurs after a period of pain‐free intercourse

• Superficial dyspareunia ‐ pain limited to the vulvar vestibule or vaginal introitus

• Deep dyspareunia ‐ pain with deep penetration

MacNeill C. Dyspareunia. Obstetrics and Gynecology Clinics of North America. 2006; 33 (4):565Howard F. Dyspareunia. In Pelvic Pain: Diagnosis and Management. Lippincott New York 200.

Vulvodynia

• Chronic lower genital pain of “unknown etiology” that manifests as pain and occasional erythema of the vulva without obvious infectious, dermatologic, or neurologic disease

• Generalized vulvodynia – to the entire vulva

• Localized vulvodynia – to the vestibule

• Provoked vulvodynia – occurring with touch (tampon, sexual activity)

• Unprovoked vulvodynia‐ occurring spontaneously or continuous pain

Dyspareunia VulvodyniaSuperficial Generalized

ProvokedUnprovokedMixed

Deep LocalizedProvokedUnprovokedMixed

Epidemiology

• Mixed populations of vulvodynia and dyspareunia

• Vulvodynia prevalence estimated at 8.3%; 14 million women will experience pain at some point

• Dyspareunia 12‐21% in women and 1‐5% in men in U.S.

• Dyspareunia 8‐21% in women around the world

Pitts M, et al. The journal of sexual medicine. 2008; 5(5):1223.Reed BD, et al. American Journal of Obstetrics and Gynecology. 2012; 206(2):170.Latthe P, et al. BMC Public Health. 2006; 6:177.

54 Studies, 35,973 womenPrevalence: 8%-21%; 1.1% (Sweden) to 45% (US)

USA

Latthe P, 2006: WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity

Social and Economic Impact

• Poor health‐related quality of life, sexual dysfunction and high rates of psychological distress

• Vulvodynia patients 2‐3x more likely to have one or more chronic pain conditions such as fibromyalgia, PBS, TMD and IBS.

• Vulvodynia impact on U.S. healthcare system: 31‐72 Billion in direct, indirect and non‐healthcare costs

Reed BD, et al. American Journal of Obstetrics and Gynecology. 2012; 206(2):170.Xie Y, et al. Current Medical Research and Opinion. 2012; 28(4): 601.

Normal Vaginal Anatomy

30

Healthy Sexual Response

Masters and Johnson

• Relaxation of pelvic floor muscles• Vaginal canal lengthens by 3‐4 cm, widens by ~6cm

• Pelvic organs elevate ‘up and out’ of the way

• Clitoral retraction under the clitoral hood

• Labia minora enlarge and become red

• Contraction of pelvic floor muscles at the vaginal entrance during ‘orgasmic’ phase

Emotional Intimacy

Sexual Stimuli

Sexual Arousal

Emotional and

Physical Satisfaction

Arousal and Sexual Desire

Spontaneous Sexual Drive

Spontaneous Sexual Drive

Basson Intimacy – Based Model of Sexual Response Cycle -2001

Conditions Associated with Sexual Pain

Superficial / Insertional• Vulvar Dermatoses

• Lichen sclerosis• Lichen Planus• Contact dermatitis

• Vaginitis / Infections / Inflammatory

• Candidiasis• Bacterial vaginosis• DIV

• Vaginal atrophy / Hormonal

• Myalgias

• Neuralgia

Deep• Reproductive

• Endometriosis / Adenomyosis• Uterine or Ovarian Masses (Cysts, Fibroids)• Pelvic congestion• PID• Adhesions

• Myalgias / Spasm

• Neuralgia

• Trauma (vaginal surgery, mesh, hysterectomy)• Obstetrical• Surgical

• Urinary• IC / PBS• Urethral diverticulum

• Bowel• IBS• IBD• Constipation• Adhesions

How Do We Figure Out Diagnosis?90% History and Physical Examination

The Biopsychosocial Model Of Pain

Chronic Pain

Psychological Factors

Biological Factors

Social Factors

31

Timing

• Pain lasting >3 months

• Primary vs. Secondary; Constant vs. Intermittent; Provoked vs. Unprovoked

Impact

• Associated with disability, poor QOL (activity, sleep, distress)

• Poor sexual function

• Associated symptoms, itching vs. burning pain, bleeding, discharge, bladder and bowel symptoms

Location• Insertional vs. Deep; Generalized vs. Localized

Therapies• Pain not‐responsive to 'simple' therapies

TILT

THE BIOPSYCHOSOCIAL MODEL OF PAIN ASSESSMENT Screen for Reported Risk Factors that May Actually Impact Outcome

• Recurrent vulvovaginal infections

• Hormonal status

• Onset of pain prior to initiating intercourse

• Presence of dysmenorrhea

• Co‐morbid pain and psychiatric disorders

• Adverse life experiences

Physical Exam

Mood Affect Distress

Musculoskeletal Back Abdomen

External Visual External SensorySingle Digit Internal /

Musculoskeletal

Internal Speculum exam

Gynecologic Examination For Pain• Trust• Relaxation and decrease anxiety• Patient properly covered• Patient should have a sense of control

• Educate patient on what is examined during the evaluation• Explain sensory exam and pain severity scales• Explain difference between exam and ‘what you feel at home’• Give the option to stop and any point, may break up examination into two visits• Give the option of deferring speculum exam if no abnormal bleeding or discharge• Use the smallest speculum possible• Must have a ‘chaperone’

External Visual

• Fissures

• Dryness

• Erythema

• Hyperkatosis

• Ulcerations

• Derm 101: raised lesions, irregular edges, discolored lesions

External Sensory

• Sensory test with cotton tipped applicator to ‘soft’ and ‘pin prick’

• Anal wink reflex, allodynia, hyperalgesia in S1‐T12 distribution

• Allodynia to static ‘pressure’ or dynamic ‘brushing’ touch of the vestibule

NVR: 90% had pain localized to the vestibule, 10% had generalized pain

Lamvu et al. The Evidence –based Vulvodynia Assessment Project: A National Registry for the Study of Vulvodynia. The Journal of Reproductive Medicine. 2015; 60:223.

32

Single Digit Internal / Musculoskeletal

NVR: 90% had pain on palpation of vaginal muscles, 65% had high tone, 38% had low strength

• Single well lubricated digit

• Slow insertion

• Voluntary contraction, strength and tone

• “Deep” palpation of the pelvic floor muscles

• Palpation of the cervix, uterus and adnexa

Lamvu et al. The Evidence –based Vulvodynia Assessment Project: A National Registry for the Study of Vulvodynia. The Journal of Reproductive Medicine. 2015; 60:223.

Internal Speculum

• Well lubricated speculum

• Small, clear speculum to allow full visualization with less distention

• Slow insertion

• Vaginal pH

• Wet prep

• Vaginal cultures

• Vaginal biopsy only if vulvar cancers or dermatoses are suspected

Diagnostic Tests

• Urinalysis• Vaginal cultures / wet prep

• Pelvic imaging• Transvaginal ultrasound• Pelvic MRI

• Pelvic function imaging• Dynamic MRI• Defecography• Sitz Marker study• Urodynamics• Cystoscopy

• Colposcopy• Biopsy

• Neural blocks• Pudendal and pudendal branches• Prineal• Genifemoral• Ilioinguial• Iliohypogastric

Treatments: Treatment Plan• Define Expectations

• Patient expectations• Provider expectation• Derive a common ground

• Define Goals• Decreased pain vs. “cure” and pain free vs. sexually active• Improved quality of life

• Define Treatment Duration• Treatment duration varies (e.g. 6‐12 months)• “Treatment” is actually may involve a variety of therapies used at the same time

• Educate on Patient Participation

Available treatments of Dyspareunia and Vulvodynia• Education and vulvar care• Topical applications (lidocaine, estradiol, steroids)• Oral Therapy (analgesics, neuroleptics, TCA, SSRIs)• Intravaginal therapy• Physical Therapy• Behavioral Therapy: Cognitive‐Behavioral Therapy, Sex Therapy, Relationship Counseling

• Injections: Neuronal blocks & Trigger points• Surgical Therapy (vestibulectomy)

• Treatment often involves multiple therapies and is often highly individualized

Andrews JC. Vulvodynia Interventions‐ systematic review and evidence grading. Obstet & Gyn Survey, 2011

Treatment

Dermatoses / Inflammatory

Topical Steroids

Triamcinolone, Clobetasol

Emollient / Vulvar Care

Antimicrobials for chronic

superimposed vaginitis

Oral steroids for patients who fail topical therapy

Topical or oral immunosuppressant

Tacrolimus

Clinical Pearl•Non irritating bases and emollients: versa base, coconut oil, hydrophilic petrolatum – re-compound any topical that ‘burns’•Use ‘ointments’ vs. ‘creams’•Additional estradiol to promote regeneration of new mucosa•Anti-histamines to prevent scratching and itching

33

TreatmentAllodynia / Neuropathy

Topical anesthetics

2.5%‐5% Lidocaine

Oral TCAs e.g.

Amitriptyline Nortriptyline

Oral Anticonvulsants

e.g.

Gabapentin Pregabalin

Neural Blocks e.g.

Pudendalbranch blocks

Clinical Pearl•Non irritating bases and emollients: versa base, coconut oil, hydrophilic petrolatum – re-compound any topical that ‘burns’•Use ‘ointments’ vs. ‘creams’•Additional estradiol to promote regeneration of new vaginal mucosa•TCAs and Neuroleptics may be compounded for vaginal application•Vaginal pain that is localized to the ‘top’ of the vagina may require different blocks

TreatmentMyalgias

Muscle Relaxants e.g.

Oral or Intravaginal e.g.

Cyclobenzaprine Baclofen Diazepam

Physical therapy Vaginal Dilator Therapy

Intramuscular vaginal trigger point injection with anesthetics or Onabotulinum toxinA

Clinical Pearl• Change muscle relaxant if patient does not notice

effect• Dilators should be incremental in size up to the

partner size• Physical therapy should focus on voluntary and

involuntary relaxation techniques… make sure you have the right physical therapist

Treatments

Vaginal Atrophy / Hormonal

Premenopausal

Topical estrogens, low dose, uterine

protection not needed if still menstruating

Postmenopausal

Topical estrogens, uterine protection and HT side effects should

be considered

Oral SERMS Intravaginal estradiol

Vagifem Estring

Cancer Survivors

Topical lidocaine only for breast cancer

survivors

Clinical Pearl•Hypo-estrogenic effects can be seen before ‘menopause’

•Pre-formulated compounds, e.g. Estrace, Premarin are often too low dose•Start with daily application for 4-6 weeks and then decrease to maintenance 3x/week- it takes a long time to regenerate vaginal mucosa•Compounded estradiol doses 0.1-0.2mg/g base•May combine with anesthetic to provide pain relief•If the vaginal introitus is contracted consider dilator therapy, and physical therapy•Vulvar care and lubrication for maintenance

Treatments

Psychosocial

Treat mood disorders such as

anxiety and depression

CBT Relaxation Coping Stress control Sleep Relationship

Clinical Pearls• Many of these psychosocial issues do not become evident until providers

really ‘get to know’ their patients• Anxiety, poor coping may be more common than depression• Relationship therapy involves the partner

Assessing for Centralized Pain

• Pain body map (screen for co‐morbid pain syndromes)

• Somatic symptoms (fatigue, insomnia, dizziness)

• Psychological function (anxiety, depression, catastrophizing, rumination)

• Quantitative sensory testing at extra genital sites

Vulvar Care

• Avoid over‐washing and harsh cleansers

• Avoid ‘wiping’ emphasize gentle ‘pat’

• Avoid drying agents focus on lubrication during daily activities and intercourse

• Lubricants should be water based or ‘ointment’ that are preservative free, alcohol free, non irritating

• Avoid tight clothing

• Avoid over ‘analyzing’ and examination of the vagina

• Resuming intercourse only when not pain free

34

Physical Therapy

• Decrease hypertonicity THEN restore normal muscle function and strength

• Focus on voluntary and involuntary pelvic floor muscle relaxation• Internal manipulation

• Biofeedback with focus on relaxation

• Pelvic floor stretches

• Internal vaginal dilators

Sexual Cycle and ‘Fear of Intercourse’: Cognitive –Motivational

• Models explaining how patients become ‘trapped’ in a vicious circle of fear and pain that go beyond obvious physical markers:

• Pain and resultant anticipatory anxiety leads to fearful reactions, inhibit genital arousal, vaginal dryness, and pelvic floor hypertonicity

• Inhibition of automatic responses (outside awareness) that would lead sexually meaningful stimuli that normally lead to arousal

• Women may ‘like’ intercourse but not necessarily ‘want’ to have intercourse due to anticipation of pain

• Women have intercourse in spite of pain, because they want to avoid the consequence of relationship discord more than the consequence of pain

Dewitte M, et al. Pain. 2011; 152: 251

Treatment: CBT and “Desensitization”

• Before overcoming fear of pain, patients have to experience non‐painful insertion

• Vaginal dilators, internal PT and internal examination should be non‐painful before patients can overcome ‘fear of pain’

• Address motivational factors for avoiding pain or for continuing to have intercourse in spite of pain

• Identify factors that help reduce fear but also increase arousal and desire

• Address relationship issue that result from being in chronic pain (e.g. partners that don’t ‘believe’ the pain or partners that use pain for ‘gain’

Summary

• Dyspareunia is often multifactorial

• Treatment is usually involves the multidisciplinary approach: organic and psychosocial dysfunctions must be addressed

• Resolution of pain does not ensure return to normal sexual function; psychosocial and ‘fear of intercourse’ factors must be considered

• Chronic sexual or vaginal pain IS VERY SIMILAR to other chronic pain syndromes

• A. You order a UA which is negative and you give her a short course of your favorite antibiotic

• B. You ask her some additional questions such as whether she has been experiencing any vaginal dryness, itching, hot flashes, insomnia

• C. You tell her you don’t see anything wrong and you recommend she go home and have more sex to see if it gets better

• D. You ask her whether she is being abused and if she denies you tell her there is nothing you can do.

Test your knowledge

35

From dysmenorrhea to chronic pelvic pain: when to perform surgery and what works.

AAGL 45th Annual Congress on Minimally Invasive GynecologyOrlando, Florida 2016

PELV-610: Chronic Pelvic Pain 2.0: Decoding Peripheral and Central Factors to Optimize Patient Outcomes

Sawsan As-Sanie, MD, MPHAssistant Professor

Department of Obstetrics and GynecologyDirector, Minimally Invasive GYN Surgery & Fellowship

Director, Endometriosis CenterThe University of Michigan

Disclosures

1. Consultant: Myriad Genetics Lab

1. I will present off-label use of medications, best evidence will be provided.

2

3

Objectives

1. Identify the indications for laparoscopy in women with dysmenorrhea or chronic pelvic pain

2. Describe the efficacy of various surgical procedures for the treatment of chronic pelvic pain

3. Review the evidence regarding the utility of hysterectomy and/or bilateral salpingo-oophorectomy for the treatment of CPP

4. Review the incidence of and risk factors for persistent pelvic pain following hysterectomy

4

Case study

JD is a 24 year old G0 female who presents with complaints of progressive dysmenorrhea. She had previously been on OCPs, ages 15-22, for dysmenorrhea and cycle control. But her pain is no longer controlled on this regimen.

5

Clinical Scenario (continued)

JD’s history is notable for daily pelvic pain (mid-pelvic crampy pain) that worsens shortly before and during menses. +deep dyspareunia.

Physical exam is notable for small, retroverted tender uterus, shortening of right uterosacral ligament with nodularity, and right adnexal tenderness and fullness.

6

Test your knowledge

Prior to proceeding with surgery, you treat JD with 3 months of DepoLupron. Her pain improves. Does this establish the diagnosis of endometriosis?

A. yes

B. no

36

7

Does response to GnRHa diagnose endometriosis?

RCT, n=95, Lupron vs. PlaceboPain relief at 3 mo: p ≤ .001

81% of GnRHa treated group39% of placebo treated group, NNT 2.3

After 3 mo of Lupron treatment, pain relief in:82% of women with endometriosis73% of women without endometriosis

Ling FW. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group. Obstet Gynecol. 1999 Jan;93(1):51-8.

8

Test your knowledge

What are the indications for laparoscopy in a patient with dysmenorrhea or CPP?

A. Persistent complex adnexal mass

B. Pelvic pain refractory to medical therapy

C. Family history of endometriosis

D. A & B

E. All of the above

9

Indications for laparoscopic surgery in the evaluation of dysmenorrhea or CPP

To investigate an adnexal mass

To establish a diagnosis of endometriosis (and surgically treat endometriosis if present)

Decision Algorithm for dysmenorrhea or CPP with cyclic exacerbation

10

Actively trying for pregnancy

? Persistent adnexal mass

Laparoscopy

Comprehensive evaluation for all sources of pain

yes

Pain severe,Unresponsive to NSAIDs and

other eligible medical therapies

yes

no

Pain severe,Unresponsive to medical Rx

(including hormone suppression)

yesno

11

Endometriosis

Presence of endometrial stroma and glands outside of the endometrial cavity and musculature

UterusOvary

endometriosis

adhesions

12

Variable appearance of endometriosis

37

13

Misdiagnosed as endometriosis:

Hemangiomas

old suture

ovarian carcinoma

carbon deposits

adrenal rest

Walthard rest

carcinoma

breast

ovary

epithelial inclusions

Reaction of oil based HSG medium

inflammation with or without Psammoma bodies

splenosis

endosalpingiosis

submesothielial microbleeding

normal peritoneum

14

Characteristic PPV Sensitivity NPV Specificity Location

Anterior cul-de-sac 32 100 100 66 Posterior cul-de-sac 65 100 100 76 Uterosacral ligament (l) 61 100 100 77 All sites 45 97 99 77

Lesion appearance Any abnormality 62 100 100 33 Puckered-pigmented only 85 74 75 86

Walter AJ, et al. Endometriosis: correlation between histologic and visual findings at laparoscopy. Am J Obstet Gynecol. 2001 Jun;184(7):1407-11

Surgical biopsy is recommended because accuracy of visual inspection is poor

Accuracy of visual inspection for the diagnosis of endometriosis

Diagnosis requires histological confirmation

15

Test your knowledge

You identify endometriosis at the time of laparoscopy and perform biopsy to confirm the diagnosis and fulguration of the remaining lesions. What proportion of women report improved pain after this procedure?

A. 15-20%

B. 30-50%

C. 60-80%

D. >90%16

Laparoscopy for pelvic pain associated with endometriosis…RCT #1

Sutton et al. 1994Study design

RCT, double blindedN=63 ♀ stage I-III endometriosis[Laparoscopic laser ablation + LUNA] vs. expectant management

ResultsNo difference at 3 months (48% of expectant group with improved pain)Significant improvement with laser ablation at 6 months (63% vs. 23%, p<0.01)

0

1

2

3

4

5

6

7

8

9

10

Before 3 mo 6 mo

Expectant

Laser

VAS

pain

sco

re (0

-10)

Sutton et al. Fertil Steril 1994; 62(4):696-700.

*

* p=0.01, laser vs. expectant

17

83%

53%

32%

80%

N=196 mos 6 mos

N=20 6 mos 6 mos

83%

80%

Diagnostic L/S

Operative L/S

Abbot et al. Fertil Steril 2004; 82(4):878-884.

RCT, blinded, crossoverLaparoscopic excision more effective than placebo30% placebo rate20% not responsive to surgery

Laparoscopy for pelvic pain associated with endometriosis…RCT #2

18

Test your knowledge

At the time of laparoscopy, is it preferable to excise or ablate suspected endometriosis lesions?

A. excise

B. ablate

C. it depends on the location and depth of the lesion

D. it doesn’t matter

38

Excision vs. ablation?

Advantages:histological confirmation

may be more effective??

Disadvantages:Requires greater surgical skill

More bleeding

More operative time

Advantages:Surgeon comfort

Less bleeding

Less operative time

Disadvantages:increase risk of thermal damage

may be less complete

Excision Ablation

20

Excision vs. ablation: Is one superior for pain symptoms?

Wright 2005RCT, double-blinded

N=24

Stage 1-2 endo

Healy 2005RCT, double-blinded

N=103

Stage 1-4 endo

0

10

20

30

Before 6 month

Excision(n=12)

Ablation(n=12)

Wright J, Lotfallah H, Jones K, Lovell D. A randomized trial of excision versus ablation for mild endometriosis. FertilSteril. 2005 Jun;83(6):1830-6. Healey M, Ang WC, Cheng C. Surgical treatment of endometriosis: a prospective randomized double-blinded trial comparing excision and ablation. Fertil Steril. 2010 Dec;94(7):2536-40.

Mea

n Pa

in S

core

Mea

n Pa

in S

core

02468

Before 12 month

Excision(n=54)

Ablation(n=49)

P=0.94

21

Test your knowledge

JD reports that her pain is much improved at her postop visit. What is the likelihood that she will experience recurrent pelvic pain in the next year?

A. <5%B. 25%C. 75%D. 90%

22

Pain recurrence after 1st surgery

Vercellini et al. The effect of surgery for symptomatic endometriosis: the other side of the story. Hum Repro Update 2009; 15: 177-188.

Mean 25% (range 15-50%)

23

Time to recurrent pain after 1st surgery

Vercellini et al. The effect of surgery for symptomatic endometriosis: the other side of the story. Hum Repro Update 2009; 15: 177-188.

24

Test your knowledge

What if JD had a 6cm ovarian endometrioma. What is the best surgical approach?

A. drain the endometriomaB. drain and ablate the endometrioma wallC. excise the endometrioma cyst wallD. it doesn’t matter, all of the above are equivalent.

39

25

Endometriomas: excise or drain & ablate?

Outcome OR (95% CI)

Recurrence of Pain Symptoms:

Dysmenorrhea 0.15 (0.06, 0.38)

Non-menstrual pain 0.10 (0.02, 0.56)

Dyspareunia 0.08 (0.01, 0.51)

Recurrence of endometrioma 0.41 (0.18, 0.93)

1 10 1000.1OR

Favors excision Favors ablation

Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004992.

26

Test your knowledge

Following laparoscopic ovarian cystectomy of an endometrioma, JD wonders: will going back on OCPs prevent the development of another endometrioma?

A. No

B. Yes

27

Post cystectomy medical therapy reduces rate and size of recurrent endometrioma

In those with recurrent endometriomas, users of OCPs had smaller cysts.

Non-users

Cyclic

Continuous

Seracchioli R et al, Fertility and Sterility, 2010.

Recurrence free survival is higher in users vs. non-

users of OCPs.

Continuous

Cyclic

Non-users

RCT, n=239, 24 month follow-up.

28

Postop OCP: continuous or cyclic?

Outcome OR (95% CI)

Recurrence of Pain Symptoms:

Dysmenorrhea (n=287) 0.24 (0.06, 0.91)

Non-menstrual pain (n=209) 0.61 (0.36, 1.03)

Dyspareunia (n=180) 0.77 (0.52, 1.12)

Recurrence of endometrioma (n=154) 0.54 (0.28, 1.05)

1 2 50.5OR

Favors continuous Favors cyclicMuzii L, et al. Continuous versus cyclic oral contraceptives after laparoscopic excision of ovarian endometriomas: a systematic review and metaanalysis. Am J Obstet Gynecol. 2016 Feb;214(2):203-11.

0.2

29

Test your knowledge

Four years later, JD reports that she has recurrent dysmenorrhea and is unable to tolerate hormone suppression. She says she read about nerve ablation surgeries and wonders if it is an option for her. Is there evidence to support these procedure?

A. No

B. Yes

30

Presacral neurectomy & LUNA

1. Presacral neurectomy: surgical transection of presacral nerves

=superior hypogastric nerve in the interiliac triangle

2. Laparoscopic uterosacral nerve ablation (LUNA)

Sensory pain fibers from the midline pelvis

Do NOT receive input from ovaries or lateral structures

Indication for CENTRAL MIDLINE PAIN, especially dysmenorrhea

40

No evidence to support LUNA as a treatment for CPP or dysmenorrhea

Daniels 2009 (JAMA)• Double blind RCT

• N=487

• 69 month follow-up

• No difference in:• Worst pain

• Noncyclic pain

• Dysmenorrhea

• dyspareunia

31Daniels J, et al. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial. JAMA. 2009 Sep 2;302(9):955-61.

Presacral neurectomy associated with modest benefit and substantial risk

Zullo 2003• Single blinded RCT

• N=141

• 1 year follow-up

• 15x adverse events:• 15% constipation

• 5% urinary urgency

32

Zullo F, et al. Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a 1-year prospective randomized double-blind controlled trial. Am J Obstet Gynecol. 2003 Jul;189(1):5-10.

33

Test your knowledge

JD decides that nerve ablation surgery is not for her. But she is worried that “scar tissue around her uterus and ovaries” is causing her recurrent pain and requests surgery. Is there evidence to support lysis of adhesions as a therapy for CPP?

A. No

B. Yes

34

Pelvic & Abdominal Adhesions

~ 25% prevalence among CPP patients

80% of patients undergoing pain mapping reported pain when adhesions palpated

Nerves, sensory neuron markers found in adhesions of both pain & pain-free patients

Howard F, Ob Gyn Surv 1993; Sulaiman et al. Ann Surg 2001

35

Adhesiolysis is not an effective treatment for chronic abdominal pain

RCT of laparoscopic lysis of adhesions vs. diagnostic laparoscopy100 participants with chronic abdominal pain (> 6 months)

Participants, assessors maskedOutcome: overall improvement in pain, functionNo difference in groups at one year

Swank DJ, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial. Lancet. 2003 Apr 12;361(9365):1247-51.

Pain scores

hrQOL scores

36

Is adhesiolysis an effective treatment for women with CPP?

Cheong 2014• Double blind RCT• N=50• Study stopped early due to

lack of enrollment• Adhesiolysis group had

more adhesions and more pain at baseline

• Results suggest decreased pain and QOL in adhesiolysis group

Cheong YC, Reading I, Bailey S, Sadek K, Ledger W, Li TC. Should women with chronic pelvic pain have adhesiolysis? BMC Womens Health. 2014 Mar 4;14(1):36. doi: 10.1186/1472-6874-14-36.

41

37

Test your knowledge

Twenty years after her first surgery, JD returns and requests hysterectomy for definitive management. She reports persistent daily pelvic pain despite hormone suppression, physical therapy, and various treatments for interstitial cystitis. What should you recommend?

A. Total hysterectomyB. Total hysterectomy + BSOC. Supracervical hysterectomyD. Supracervical hysterectomy + BSOE. Hysterectomy is not likely to be helpful

78-86% of all women undergoing hysterectomy report improvement after surgery

50% report improvement in mental health, physical or social function

60% report improvement in dyspareunia

38Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol. 2004 Oct;104(4):701-9.

Hysterectomy:Most women are satisfied

Hysterectomy:Most women are satisfied, but there are risks

78-86% of all women undergoing hysterectomy report improvement after surgery

50% report improvement in mental health, physical or social function

60% report improvement in dyspareunia

39

Potential for serious morbidity

Regret over loss of fertility

and...significant risk of persistent pain

Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol. 2004 Oct;104(4):701-9.

Incidence of persistent pain after hysterectomy

40 Brandsborg B. Pain following hysterectomy: epidemiological and clinical aspects. Dan Med J 2012; 59(1):B4374.

Persistent postop pain = ~25% (6.7 – 31.9%)

New or increased postop pain = ~5% (1-15%)

Risk factors for persistent pain in large prospective observational study

1. Preoperative pelvic pain

2. Pain problems elsewhere

3. Pain is primary indication for hysterectomy

41 Brandsborg B. Pain following hysterectomy: epidemiological and clinical aspects. Dan Med J 2012; 59(1):B4374.

= 3x risk of persistent pelvic pain after hysterectomy

N=1135

Factors associated with persistent pelvic pain after hysterectomy

42

Pain elsewhere (Brandsborg 2007, VanDenKerkhof 2012)

Younger age (Shakiba 2008, MacDonald 1999, Hillis 1995)

Lack of private insurance (Hillis 1995)

Lack of pelvic pathology (Hillis 1995)

Depression (Kjerulff 2000, Hartmann 2004)

Pain catastrophizing (Martin 2011, Carey 2013)

42

Route of hysterectomy (Brandsborg 2009)

Preoperative dysmenorrhea (Stovall 1990)

Preoperative uterine tenderness (Stovall 1990)

Uterine fibroid symptom score (Brandsborg 2009)

Uterine weight (Stovall 1990, Brandsborg 2009)

Adenomyosis (Stovall 1990)

43

…i.e. clinical factors that often guide physicians to offer hysterectomy

Factors NOT associated with persistent pelvic pain after hysterectomy What about the ovaries?

Preserve ovaries

Unilateral oophorectomy

Bilateral oophorectomy

44

?

BSO should not be taken lightly

45

• Relief of pelvic pain

• Prevent recurrent ovarian cysts

• Prevent recurrent endometriosis

• Hot flashes• Vaginal

dryness• Osteoporosis• Cardiovascular

disease• Dementia• All cause

mortality

PROS CONS

BSO

46Parker WH, Feskanich D, Broder MS, Chang E, Shoupe D, Farquhar CM, Berek JS, Manson JE. Long-term mortality associated with oophorectomy compared with ovarian conservation in the nurses' health study. Obstet Gynecol. 2013 Apr;121(4):709-16.

Level II-2Large, prospective observation study

Summary

47

Effectiveness of Hysterectomy

KRISTEN H. KJERULFF, MS, PhD, PATRICIA W. LANGENBERG, PhD,

JULIA C. RHODES, MS, LYNN A. HARVEY, GAY M. GUZINSKI, MD, AND

PAUL D. STOLLEY, MD, MPH

A prospective study of 3 years of outcomes af terhysterectomy with and without oophorectomy

Cynthia M. Farquhar, MBChB, FRANZCOG, MD, CREI, MPH,a,b Sally A. Harvey, RN,RMidwife,a Yi Yu, MSc,a Lynn Sadler, MBChB, MRANZCOG, MPH,a,b

Alistair W. Stewart , BScb

1

2

3

4

5

6

Single site, retrospective, endo only Favors BSO

Single site, retrospective, any CPP No benefit of BSO

Multi site, prospective, any CPP Favors BSO

Multi site, prospective, any CPP BSO increases risk of CPP

Multi site, prospective, any CPP No benefit of BSO

Single site, survey, endo only No benefit of BSO in age<40 48

Likelihood of Success (no reoperation) depends on age and ovarian preservation

Hysterectomy only

Hysterectomy + BSO

Age 30-39 89.6 (76.0–100.0) 85.7 (70.7–100.0)

≥ 40 yrs old 64.3 (33.0–95.7) 96.0 (88.3–100.0)

=

<

Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstet Gynecol. 2008 Jun;111(6):1285-92

43

If ovaries are removed, what is the risk of recurrent pain and recurrent endometriosis with hormone replacement therapy?

49

Summary guidelines from Expert Reviews (2006, 2010)

Limited data, mostly expert opinion

Level of evidence: III

50

1. Benefits of HRT likely outweigh risk, in select populations

2. No reason to delay HRT after surgery, can start immediately

3. Consider combined estrogen-progestin methods in women with endometriosisUnopposed estrogen may stimulate recurrence of endometriosis and/or stimulate malignant transformation of residual endometriosis

51 52

So, before considering hysterectomy…

• Recognize that chronic pelvic pain is generally multifactorial, often with multiple organ systems involved

• Systematically treat all sources of pain before considering hysterectomy

If a patient fails medical therapy and chooses hysterectomy

She should be well informed regarding the risk of persistent pain (Grade B)

Retain the ovaries when possible (Grade B)Suggested when ovaries are visibly normal, superficial endometriosis, or ovarian endometrioma <5 cm (?)

If BSO is performed, patient should be fully counseled regarding risks associated with surgical menopause and persistent pain

53 54

Test your knowledge

JD undergoes TLH, BSO and was found to have extensive endometriosis and an obliterated posterior culdesac. She initially reported resolution of her pelvic pain, but then returns 3 years later with recurrent pelvic pain. Pelvic ultrasound demonstrates a 4 cm complex left ovarian mass. What do you recommend?

A. No interventionB. Hormone suppression and repeat ultrasoundC. LaparoscopyD. Laparotomy

44

55

Ovarian remnant syndrome

Definition:Histologically confirmed ovarian tissue in a women who has previously undergone bilateral salpingo-oophorectomy

PrevalenceUp to 18% of women with persistent pelvic pain, who previously underwent hysterectomy-BSO for endometriosis/pelvic pain

Abu-Rafeh, et al. J Am Assoc Gynecol Laparosc 2003. 10: 33-37 56

Ovarian remnant syndrome

Clinical presentation:Chronic pelvic pain: 84%Dyspareunia: 26%Cyclic pelvic pain: 9%Dysuria: 7%Pain with defecation: 6%

Risk factors are all related to history of difficult hysterectomy:

EndometriosisPelvic adhesive disease or h/o pelvic inflammatory diseaseMultiple prior abdominal or pelvic surgeries

57

Diagnosis of ovarian remnant

History of prior BSOPelvic pain and/or pelvic mass on exam or imaging

… not all remnants are hormonally active:~ 30% of patients with surgically documented remnants have postmenopausal values of serum estradiol (<35 pg/mL) and FSH (>30 IU/dL).

Magtibay PM, Magrina JF. Ovarian remnant syndrome. Clin Obstet Gynecol. 2006 Sep;49(3):526-34.\; Kho RM, Abrao MS. Ovarian remnant syndrome: etiology, diagnosis, treatment and impact of endometriosis. Curr Opin Obstet Gynecol. 2012 Aug;24(4):210-4.

58

Management of ovarian remnant

Asymptomatic, low risk of malignancy:Surveillance, expectant management

59


Asymptomatic, low risk of malignancy:

Surveillance, expectant management

Concern for malignancy (complex appearance, increasing size, etc)

Surgical excision with anticipation of extensive sidewall and retroperitoneal dissection

Laparoscopic approach is feasible, safe and associated with lower morbidity.

Zapardiel I, Zanagnolo V, Kho RM, Magrina JF, Magtibay PM. Ovarian remnant syndrome: comparison of laparotomy, laparoscopy and robotic surgery. Acta Obstet Gynecol Scand. 2012 Aug;91(8):965-9. 60


Asymptomatic, low risk of malignancy:Surveillance, expectant management

Concern for malignancy (complex appearance, increasing size, etc)

Chronic pelvic pain, low risk of malignancyConsider medical management with hormonal suppressionLook for other sources of painIf above fails, surgical excision with anticipation of extensive sidewall and retroperitoneal dissection

45

61

Surgical excision of ovarian remnant

Laparoscopic approach is feasible for the experienced surgeon

Significant improvement and/or resolution of pain in ~80%

Recurrence of remnant in 0-20%

Kho RM, Magrina JF, Magtibay PM. Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome. Fertil Steril. 2007 May;87(5):1005-9

Thank you

62“Wait, those weren’t lies. That was spin…”

References

63

References

64

References

65

Evaluation Question

Which of the following is NOT a risk factor for persistent pelvic pain after hysterectomy?

a) Pain elsewhere in the body prior to hysterectomy

b) Adenomyosis

c) Younger age

d) Normal uterine pathology

e) Depression

66

46

Pre‐operative, Post‐Operative and Chronic Pain Management

Georgine Lamvu, MD, MPH, CPE

Gynecologic Surgeon and Pelvic Pain Specialist, Orlando VA Medical Center

Associate Professor

University of Central Florida

Disclaimer

I have no financial relationships to disclose.

Objectives

• Briefly review pain physiology as it relates to surgical pain

• Describe the evidence available for pain management as it applies to surgical intervention

• Describe new guidelines for pain managmentWHY ARE WE DOING THIS LECTURE TODAY?

Challenges of Operative Pain Management

• 73 million surgeries done in the U.S. annually

– 80% experience acute pain and 20% experience severe pain

• 2001 US Congress “A decade of pain control”

• APS considers pain as the “fifth vital sign”

Hutchinson, Rob. Challenges in acute post-operative pain management, 2007.

Dolin SJ, et al. Effectiveness of acute post‐operative pain management I. Br J Anaesth 2002

• Meta‐analysis of 165 studies, nearly 20,000 patients

• Using VAS score for pain evaluation

– 11% experienced severe pain

– 30% experienced moderate to severe pain

0

10

20

30

40

50

60

70

80

% Severe Pain

% Moderate to Severe Pain

IM

IV PCA

Epidural

47

A History of Ineffective Pain Treatment

0

10

20

30

40

50

60

70

80

90

Any Pain Slight Pain Moderate Pain Severe Pain Extreme pain

% Patients With Acute Post Operative Pain: Hutchinson 2007

Hutchinson, Rob. Challenges in acute post-operative pain management, 2007.

Factors That Contribute to Inadequate Pain Management

Factors That Contribute to Inadequate Pain Management

Impact of Inadequate Pain Relief:

• Diminished patient functioning and increased risk for complications

– diminished immune response

– Avoidance of movement and ambulation increasing risk of DVT

– Anxiety, stress, demoralization, depression

• Extended lengths of stay, readmission, poor satisfaction

• Increased resource utilization and healthcare costs

• Development of chronic pain syndrome

Hutchinson, Rob. Challenges in acute post-operative pain management, 2007.Anesthesiology 2004; 100: 1573.Anesthesiology 2000; 93: 1123

Sinatra, Raymond. Surgeon’s Guide to Postsurgical Pain Management: Colorectal and Abdominal Surgery. First Edition, pp. 20. Professional Communications Inc. 2012.

Impact of Inadequate Pain Relief

• Over‐reliance on opioid therapy monotherapy

How Did We Contribute to the Opioid Epidemic?

• Heroin has been used for all types of ailments since 1900s

• In 2011 Oxycontin was the #1 most prescribed drug in the U.S.

• By 2010 Cochrane reported that 62 RCTs demonstrated that opioids are more effective than placebo for SHORT‐TERM acute pain control but the evidence is weak for its long‐term use

48

49

Monotherapy

Over‐reliance on single class analgesia commonly results in

• Limited efficacy

• Intolerable adverse events

• Diminished patient satisfaction

• Example of opioid monotherapy

– Nausea, vomiting, constipation, ileus, urinary retention

– Opioid induced hyperalgesia

– Long term‐side effects such as mood instability, insomnia, tolerance and withdrawal

Sinatra, Raymond , Larach S, Ramammorthy S. Surgeon’s Guide to Postsurgical Pain Management: Colorectal and Abdominal Surgery. First Edition, Professional Communications Inc. 2012.

Development of Chronic Pain Syndrome After Surgery

• 10‐50% of patients undergoing operations later develop persistent pain

– 14% of women after hysterectomy develop newonset pain after surgery

Kehlet H, et al. Persistent Postsurgical Pain: Risk Factors and Prevention. Lancet, 2006Pluijms, WA, et al. Chronic post-thoracotomy pain: A retrospective Study. Acta Anaesthsiol Scand, 2006Brandsborg B, Nikolajsen L, Hansen CT, Kehlet H, Jensen TSSO. Risk factors for chronic pain after hysterectomy: a nationwide questionnaire and database study. Anesthesiology. 2007.

What Should Surgeons Do?

Neurobiology of Pain

• Peripheral nociceptors

• Signal propagation and conduction to the spinal cord

• Cortical perception: identification and localization of pain

• Descending inhibition: suppression of pain transmission by descending contacts from the brainstem, midbrain and cerebral cortex

• Supraspinal reactions: cortical responses including fear, anxiety, depression

Sinatra, Raymond , Larach S, Ramammorthy Colorectal and Abdominal Surgery. First Edition, Professional Communications Inc. 2012.Julius and Basbaum Nature Sept, 2001;413 :203-210. Drysdaleosteopathy.wordpress.com

Predictive Factors of Postoperative Pain Intensity

Hui et al. Predictors of Postoperative Pan and Analgesic Consumption: A QualitativeSystemic Review. Anesthesiology 111; 657-77. 2009.

Predictive Factors of Postoperative Analgesic Consumption

Hui et al. Predictors of Postoperative Pan and Analgesic Consumption: A QualitativeSystemic Review. Anesthesiology 111; 657-77. 2009.

50

A Model to Identify Patients at Risk for Prescription Opioid Abuse,

Dependence and Misuse

• Pain Med 2012; (13)9:1162

Guide to Pain Managment

• These recommendations are based on CDC, Va/DoD and APS pain management guidelines

• Evidence about opioid therapy– Benefits of long‐term opioid therapy for chronic pain not well

supported by evidence– Short term benefits small to moderate for pain; inconsistent for

function– Insufficient evidence for long‐term benefits in low back pain,

headache and fibromyalgia

• Non‐opioid therapies– May be used alone or in combination– Non‐opioid medication, e.g. NSAIDS, TCA, SNRIs, anti‐convulsants– Topical analgesics, injections (e.g. steroids) and blocks– Physical treatments, e.g. physical therapy, exercise– Behavioral therapy, e.g. counseling, CBT

Four Steps to Pain Management*

1. Assess: History, Exam and Risk Assessment

2. Check: what other medications are being taken, possible interactions, opioids, benzodiazepines, high doses, obtaining medications from multiple providers

3. Discuss: Expectations, potential risks

4. Observe: Look for clinical improvement, overuse and misuse, go slow with dose increases, consult support pain management teams if needed

* A must before surgery

Risk Assessment for Pain Chronicity*

• Poorly controlled pain

• Psychiatric co‐morbidities

• Pre‐operative anxiety

• Having surgery

• Poorly controlled post operative pain

• If the patient has multiple pain co‐morbidities


Risk Assessment*

• Urine Drug Screen

– Check to confirm presence of prescribed substances or for undisclosed prescription drug or illicit substances

• Prescription drug monitoring program

– Check for opioids or benzodiazepines from other sources


Patient Education*

• Opioids are not first‐line or routine therapy for chronic pain and for acute pain they are used only in severe pain and in short amounts

• Establish realistic goals for improvements in pain and function

• Discuss benefits and risks and availability of non‐opioid therapies with patients


51

Key Points For Patient / Family Education*

• Analgesics will not make you pain free, they only help alleviate some pain, most pain medications take 1‐2 hours to take effect; the goal is not to cure pain but rather to improve function

• We expect about a 30% improvement in pain and function for most therapies• Recovery from surgical or acute traumatic injury is expected to take 2‐4 weeks, it is not immediate• Don’t take extra doses beyond what is prescribed, tell all you providers what medications you are

taking• Don’t stop opioids suddenly, instead taper slowly as instructed by your provider• Do not drive or operate heavy machinery, don’t drink alcohol or take other street drugs with you

pain medications• Protect your pain medications from damage, loss or theft• Report any side effects such as sleepiness, confusion, constipation, itching, nausea and vomiting,

difficulty breathing to your provider• Your prescriptions are registered in a state monitoring program that is accessible to all of your

providers• To monitor your medication intake, your provider may recommend a urine drug screen when you

are evaluated


Surgical Pain Management

Multimodal Analgesia

• Defined as the simultaneous use of different analgesic agents or forms of analgesic delivery to suppress pain transmission in the peripheral and Central Nervous System (CNS). Regimens can be designed to:

– Inhibit release of noxious mediators

– Block conduction in sensory nerves

– Suppress pain perception in the CNS


Multimodal Analgesia

Advantages• Addresses multiple mechanisms of pain

• Allows for use of lower nontoxic does of medications

• It can be used in acute and chronic pain management

• In some cases can avoid use of opioids completely

• 52 RCTs vs. opioid monotherapy show

– Improved mobilization and rehabilitation

– Better pain control

– Improved patient satisfaction

– Less 15‐55% decrease in opioid dosing

Disadvantages

• Requires knowledge of multiple drugs and pain mechanisms

• Potential for interaction

• Requires skills in regional and neuraxial analgesia

• Possible post discharge patient confusion and compliance issues


Pain Management

American Society for Anesthesiology Postsurgical Pain Practice Guidelines

and Recommendations

Perioperative Techniques for Pain Management Guidelines

• The literature supports the use of epidural or intrathecal opioid analgesia, PCA with systemic opioids, regional anesthetic blocks ( intercostal, plexus) and peripheral anesthetic blocks (intercostal, ilioinguinal, interpleural, femoral)

• The literature supports post‐incisional infiltration with local anesthetics

• The literature is equivocal on benefits of pre‐incisional infiltration


52

• The literature supports the administration of two analgesic agents that act by two different mechanisms. Examples include:

– Epidural opioids combined with epidural local anesthetics or clonidine

– IV opioids combined with Ketorolac or Ketamine

– Unless contraindicated, all patients should receive an around –the‐clock regimen of NSAIDS, COXIBs or acetominophen, in addition regional blockade with local anesthetics should be considered

Perioperative Techniques for Pain Management Guidelines


Non‐Opioid Treatments for Pain

Medication Harms Comments

Acetominophen Hepatotoxic

NSAIDS Cardiac, GI, Renal

Gabapentin/pregabalin

Sedation, dizziness, ataxia

Neuropathic pain, fibromyalgia

TCAs and SNRIs TCAs anticholinergic and cardiac

Neuropathy, fibromyalgia, headaches

Topical agents (Lidocaine, Capsaicin, NSAIDs)

Capsaicin burning Lidocaine for neuropathic pain, NSAIDS for arthritis

Muscle Relaxants

Steroids

Opioid : Higher Dose=Higher Risk• Start with immediate release instead of extended‐release• Increase slowly and keep dose below 50MME/day. What is

50MME/d?– 50mg of hydrocodone (10 tabs of 5/300)– 33mg of oxycodone (2 tabs of oxycodone sustained release, 15mg)– 12 mg methadone (<3 tabs of 5mg)

• Start with 3‐7 days with a taper (by about 30% at a time)• Prescribe exact doses and instructions, avoid “PRN”• Avoid concurrent benzodiazepine use• Prescribe naloxone when concerned about risk of overdose• Have an explicit (and document it) conversation with the patient

about risks, benefits and expectations for pain relief Opioid Morphine Equivalent

1mg Codeine 0.1mg Morphine

1mg Hydrocodone 1mg Morphine

1mg Hydromorphone 4mgMorphine

1mg Methadone 4mg‐12 mgMorphine

1mg Oxycodone 1.5mgMorphine

1mg Oxymorphone 3mgMorphine

1 mcg Fentanyl 2.4 mg Morphine

=

Keys to Opioid Start, Continuation and Discontinuation

• Repeated or long‐term use of opioids requires

– Periodic re‐assessment– Urine drug screen– Checking the prescription drug

monitoring program

• Start low and increase dose slow by 10%

• Decrease slow by 10‐30%, patients can have severe withdrawal

• Document the dose, total # of pills given and the instructions for use every time

Recommendations for Post‐Surgical Pain

• Acetaminophen, NSAIDS first (PO or IV)

• Preferably use oral vs. IV opioids if patients can take PO, avoid IM

• Use anesthetic epidurals or spinals for thoracic and abdominal surgery

• Use PCA without basal rate• Pre‐operative celecoxcib• Pre or Post‐operative

gabapentin• Infiltrate surgical sites with

anesthetic, nerve blocks or topical anesthetics

• Physical Therapy / Occupational Therapy

• Heat or cold therapy• Acupuncture• Chiropractic• TENS‐ Nerve stimulation• Relaxation • Cognitive behavioral therapy

Preemptive Analgesia

• Benefits associated with preemptive analgesia are gained only when:

– Pre‐operative dosing occurs prior to surgical incision

– There is continued dosing during anesthesia

– Post‐surgical maintenance of therapy is maintained for 24‐48 hours for outpatient surgery and 96 hours for longer more invasive procedures

• I.e. preemptive analgesia does not work without post‐operative pain control


53

In Patients With Difficult‐to‐Manage Pain Consider

• Skeletal muscle spasm

• Visceral muscle spasm

• Inflammation

• Neuropathic pain

• Opioid induced hyperalgesia

• Anxiety

• Insomnia


For Patients With Difficult‐to‐Manage Post Surgical or Chronic Pain

• Start with NSAIDS, Acetominophen unless contraindicated, then add one or more of the following:

– Local anesthetics: lidocaine, marcaine, bipuvacaine via local injection, transdermal or long acting local injection

– Alpha 2 agonists: clonidine provides sedation, anxiolysis and analgesia, via oral, transdermal or IV or epidural, most effective when combined with opioids


– Anticonvulsants: Neurontin and Pregabalin oral approved for long term treatment neuralgias and also recommended for acute surgical pain management

• Gabapentin 600mg‐900mg pre‐op and 600‐900mg tid for 24‐72 hours post op

• Pregabalin 75‐100mg preoperatively followed by 75‐100mg bid for 24‐72 hours


– NMDA receptor antagonists: Ketamine potentiates opioid‐mediated analgesia and provides opioid‐sparing effect. IV, PCA

– Muscle relaxants: Methocarbamol, cyclobenzaprine, tizanidine, benzodiazepines such as diazepam and lorazepam

• Carisoprodol ranked 14th or the 20 most abused mood‐altering drugs in the US

– Corticosteroids: anti‐inflammatory actions useful in post‐surgical pain relief, comparable to NSAIDS and acetominophen, may be useful in patients who cannot tolerate NSAIDS

– TCAs: unclear mechanisms of pain relief, used for management of depression and chronic pain (neuropathic, fibromyalgia, neck and low back pain)

• Lower doses needed for pain control than for management of depression


54

You Want Me to Do What? Physiotherapy Treatments for

Chronic Pelvic Pain




Email: [email protected]

www.pelvicguru.com

www.sherpelvic.com


Financial DisclosuresI have no financial relationships to disclose.





Objective

Discuss physical therapy for the treatment of chronic pelvic pain.


So WHAT IS Pelvic Physical Therapy?


What My Mom Thinks We Do


55

What Patients Think We Do


What Potential Dates Think We Do


Pelvic Physical Therapy / Physiotherapy

What We Actually Do * we have time

Property of Tracy Sher, MPT, CSCS. All rights reservedhttp://personcentredcare.health.org.uk/overview‐of‐person‐centred‐care/overview‐of‐person‐centred‐care/overview‐of‐person‐centred‐care/se‐0

Treating the Whole PersonOverlapping Conditions with Pelvic Pain


2015 Report: Impact of Chronic Overlapping Pain Conditions on Public Health and the Urgent Need for Safe and Effective Treatment 2015 Analysis and Policy Recommendations

Somatic NEURAL Visceral



Treatment Umbrella- Key Points

Brain and Pain – Neural Education

Manual Therapy

Therapeutic Exercise

Integrating Downtraining / Desensitization

sEMG Biofeedback

Lifestyle Modifications – Bladder, Bowel, Hygiene, Cushions

Modalities


56

Motivational Interviewing, Neural Education, and “Cheerleading.” Biopsychosocial


Neuro Education- Pain Management

Conclusions: For chronic musculoskeletal disorders there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophizing, and physical performance.

Property of Tracy Sher, MPT, CSCS and Loretta J. Robertson, PT, MS. Permission required to reproduce or share. 14

Louw, Adriaan. The effect of neuroscience education on pain disability, anxiety, and stress in chronic musculoskeletal pain. 2011; 92. (12)


Manual Therapy

Myofascial release /

Soft tissue mobiization

Trigger point release

(Dry Needling TrP)

Connective tissue manipulation

Visceral mobilization

Joint mobilization / Manipulation

Muscle energy techniques

Strain‐Counterstrain

Pelvic Physical Therapy Treatment


Manual Therapy Local and Central:

• “direct effect on tissue dysfunction…muscles, fascia, and neural tissue “

• “…may also directly impact the state of the autonomic nervous system, specifically by interrupting the viscera‐somatic reflex arc, which is an autonomic reflex.”

• So, “treatment may have an important effect not only on local tissue dysfunction but also on the sensitized nervous system”

CMT Connective Tissue Mobilization:


(Hilton and Vandyken 2012)

57

Manual Therapy

• “Manual therapy techniques may unload the peripheral nerve by increasing the space or fluid motion in the tissues around the nerve.”

• the nerve has a better chance of moving well within the space surrounding it.

Local Tissue and Peripheral Nerve:


(Hilton and Vandyken 2012)

Therapeutic ExerciseKey Findings:

• Exercise therapy improved post‐treatment pain intensity and disability

• There is no evidence that one particular type of exercise therapy is clearly more effective than others.

LBP (van Middlekoop 2010)

• “The value of supervised active therapy programs…not…specific muscular deficiencies, but rather…encouragement for the patient, that movement is not harmful…

• Decreased catastrophizing had positive effect.

• Authors ask‐ do stabilization exercises have some sort of "central" effect, unrelated to abdominal muscle function per se?

Spine Stab/ LBP (Mannion 2012)


Muscles – “CORE” Pressure System


Understand Your Back & Pelvic Girdle Pain Written by Diane Lee Physiotherapist

Lee, D. The Pelvic Girdle, 3rd and 4th Elsevier 2011

Self-Care and Lifestyle Modifications


If Patients Have MSK Findings as the Source or a Part of Their Pelvic Pain…

Do NOT start on Kegels and send them away

Do NOT suggest surgery will fix all of the issues

Do NOT tell them Barry White, wine or “just relaxing” will cure them

Refer to Pelvic Physical Therapy if possible Will screen to rule out Back/Hip and other differentialsRestore Tissue mobility and improved movement (decrease kineseophobia)Train patient in toileting postures, muscle re‐education, self help strategies Help ”downregulate” nervous system


If Patients Have MSK Findings as the Source or a Part of Their Pelvic Pain…

If You Have to Do This Alone

Start patient on deep breathing, Yoga, relaxation, meditation to help relax

Toilet posture – feet supported Self massage for abdomen Don’t just tell them to get dilators. They need more guidance (do follow‐up)

Get an Ortho PT to rule out hip/back involvement if you suspect that


58

Find a Pelvic PT (and Other Pelvic Pain Professionals)

International Pelvic Pain Society www.pelvicpain.org

Women’s Health APTA/SOWHwww.womenshealthapta.org

Pelvic Guru:https://pelvicguru.com/2016/02/13/find‐a‐pelvic‐health‐professional/


Pelvic PT – Part of a Team Approach• Best approach is a team approach. Multimodal!

• Lots of hope. Even if past failure, were they having a multimodal approach at same time?

• At the point that it is chronic, there’s likely local, central and psychological impact.


THANK YOU!!


www.pelvicguru.com www.sherpelvic.com

[email protected]

References

Alvarez, DJ, Rockwell, PG. Trigger Points: Diagnosis and Management. Am FamPhysician. 2002 Feb 15;65(4):653‐661

Butler and Mosely, Explain Pain, 2003

FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for treatment of urologic chronic pelvic pain syndrome. J Urol. 2009;182:570–580.FitzGerald MP, Kotarinos, ER. Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J (2003) 14: 261–268

Hilton S, Vandyken C. Clinical Commentary. The puzzle of pelvic pain – a rehabilitation framework for balancing tissue dysfunction and central sensitization, I: Pain physiology and evaluation for the physical therapist J Women’s Health PT. 2011;35(3):103‐113

Lee, D. The Pelvic Girdle, 3rd and 4th Elsevier, 2004/ 2011.

Louw A, et al. The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Arch. Phys. Med. and Rehab 2011; 92(12):2041‐2056

Mannion AF, et al. [Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance] Schmerz 2001;15(6): 468‐73.


References

Takada T, Ikusaka M, Ohira Y, Noda K, & Tsukamoto T (2011). Diagnostic usefulness of Carnett’s test in psychogenic abdominal pain. Internal medicine (Tokyo, Japan), 50 (3), 213‐7 PMID: 21297322

Tu, FF. Physical therapy evaluation of patients with chronic pelvic pain: a controlled study. American Journal of Obstetrics & Gynecology Volume 198, Issue 3 , Pages 272.e1‐272.e7, March 2008

Travell, and Simon. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2, 1992

•vanMiddelkoop M, et al. Exercise therapy for chronic nonspecific low‐back pain. Best Pract Res ClinRheumatol 2010;24(2):193‐204

Vandyken C, Hilton S. The puzzle of pelvic pain‐a rehabilitation framework for balancing tissue dysfunction and central sensitization, II: A review of treatment considerations. J Women's Health PT. 2012;36(1):44‐54

Wall LL. The muscles of the pelvic floor. Clin Obstet Gynecol 1993;36:910‐25

Weiss J.Chronic pelvic pain and myofascial trigger points. Complim Med and Pain. 2000 Dec:13‐18

Weiss JM, Prendergast SA. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol. 2003;46(4):773‐82

Hip References• Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of Sacroiliac Joint Pain: Validity of Individual Tests and Composites of Tests. Manual Therapy. 2005: 10; 207‐18.

• van der Wurff P, Hagmeijer RH, Meyne W. Clinical tests of the sacroiliac joint: A systematic methodological review. Part 1: Reliability. Man Ther. 2000;5:30–36.

• Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of selected motion and pain provocation tests for the sacroiliac joint. Man Ther. 2007;12:72–79.


59

Website References




http://medicfrom.com

2015 Report: Impact of Chronic Overlapping Pain Conditions on Public Health and theUrgent Need for Safe and Effective Treatment 2015 Analysis and Policy Recommendations http://www.chronicpainresearch.org/public/CPRA_WhitePaper_2015‐FINAL‐Digital.pdf

www.visiblebody.com

60

Michael Hibner, MD, PhD, FACOG, FACS

Director, Division of Surgery and Pelvic Pain

St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Professor of Obstetrics and Gynecology

Creighton University School of Medicine

I have no financial relationships to disclose. Diagnosis and treatment of neuropathic pain.

Annual cost to US economy for treating chronic

pain conditions is 600 billion dollars/year

Greater than combined treatment for diabetes,

cancer and heart disease

Neuropathic pain 0.9% to 17.9% of pain patients

61

Pain caused by a lesion or disease of

somatosensory system

Affects 8% of population

Compression

Transection

Contusion

Stretch

Crush

Blunt Trauma

• Falls

• Accidents

• Pelvic fractures

Obstetrical

• Prolonged second stage of

labor

• Positioning

• Traumatic Delivery

Surgery

• Incisions

• Compression from

retractors

• Stretching from positioning

• Mesh

Radiation Therapy

• Fibrosis

Medical conditions

Tingling (“pins and needles” or “prickling”)

Burning (“hot”)

Shooting (“electrical shocks”)

If motor nerve – numbness, weakness, loss of

reflexes

Hypoesthesia (abnormally reduced sensation to touch

or cold)

Hypoalgesia (abnormally reduced pain sensation to

noxious stimulus)

Hyperalgesia (abnormally increased sensation to

noxious stimulus)

Allodynia (pain sensation to a nonnoxious stimulus)

Diagnosis and treatment of neuropathic pain

has to be done in timely fashion to minimize

central and peripheral sensitization

62

Description of injury

Description of distribution of motor, sensory and

autonomic changes

Pain quality

Additional pain generators

Palliative and provocative positions

Neurological exam testing sensory, motor and

autonomic fibers

Hypo and hyper sensitivity, allodynia

Tinel’s sign – percussion tenderness over

affected nerve – distal migration of axonal

cone

Guided nerve blocks

MRI

EMG

Nerve conduction studies/PNMTL

Pain must be present

• Patients must have pain at the time of the injection

Evaluate for technical success

• Anatomical position, diffusion of solution, and achieved

analgesia

Interpretation

• Relief of symptoms, the specificity of the block, and the

possibility of placebo effect

Local anesthetic

• Lidocaine 1 – 2% with epinephrine

• Bupivacaine 0.5% with epinephrine

Sodium Bicarbonate 8.4% (10:1 ratio)

Three to five milliliters, to minimize spread

Image guidance (ultrasound, CT, etc…)

63

Multidisciplinary approach

Avoidance of offending factors

Pharmacotherapy

Physical therapy

Holistic treatments – acupuncture

Psychological – counseling, biofeedback

Botox and steroid injections

Antidepressants

Anticonvulsants

Local anesthetics

NMDA receptor

antagonists

Opioids

Cannabinoids

Botulinum toxin

Topical capsacin

64

Neurolysis

Neurectomy

Nerve repair/reconstruction

Static

• Within rigid fibro‐osseus tunnel

• Between ligaments

• Scarring in or apart of the tunnel

Dynamic

• Narrowing of the nerve from muscle contractions

• Angulation during positioning

Freeing the nerve from:

• Scar tissue

• Ligaments

• Surgical material

Transposition of the nerve

Prevention of re‐scarring

For purely sensory nerves

Permanent numbness ‐ diminishes over one year

as surrounding nerves take over

Risk of stump neuroma (tangle of regenerating

axons and Schwann cells without end destination

• Implantation into the muscle may diminish the risk

Neurolysis – 70‐88%

Neurectomy – 64‐75%Inferior rectal nerve

Cutaneous branch of obturator nerve

Lateral cutaneous branch of iliohypogastric nerve

Femoral branch of genitofemoral nerve

Posterior femoral cutaneous nerve

Lateral femoral cutaneous nerve

Iliohypogastricnerve

Clitoral/perinealnerves

Femoral nerve

Genital branch of genitofemoral nerve

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Overall any neuropathy – 1.9%

Obturator – 39%,

Ilioinguinal/iliohypogastric – 21%

Genitofemoral – 17%

Femoral ‐ 7.5%

Lumbosacral plexus – 0.2%

Overall recovery rate – 73%

Honig, 2002

Originates from S2‐S4

Sensory

• Rectum

• Perineum

• Scrotum / Vulva

• Penis / Clitoris

Motor

• Sphincters (anal, urethral)

• Muscles of the urogenital triangle

Autonomic

Pain in the area of innervation of the pudendal nerve

Pain is neuropathic in nature

• Paresthesia – burning, tingling, prickling, numbness sensation

• Allodynia – pain in response to non painful stimulus

• Hyperalgesia – pain out of proportion to the stimulus

Pain is more severe with sitting

Pain absent or significantly less when lying down

Pain less when sitting on the toilet vs. chair

Sensation of foreign body in the rectum or vagina (allotriesthesia)*

Urinary symptoms – frequency, urgency, hesitancy

Dyschesia

Dyspareunia

Pain with orgasm

Pain with sexual arousal

Persistent sexual arousal

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Surgery

• Direct mesh injury

• Indirect – hysterectomy, cystocele repair, prolapse repair

Vaginal childbirth

Trauma

• Falls

• Cycling

• Intense lower extremity exercise

(abductor machine)

• Excessive masturbation

• Excessive use of anal vibrators

100 patients – 8 lost to follow up

Cured – 13/91 (14%)

Better – 45/91 (49%)

Same – 28/91 (31%)

Worse – 6/91 (6%)

63%

37%

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Originates from L1

Sensory:

• Posterior lateral glute

• Suprapubic skin

Motor:

• Transverse abd.

• Internal oblique

Burning numbing pain in the lower abdomen

radiating to the labia (scrotum)

Worsened by lumbar extension

Transection, entrapment, crush injury, neuroma formation

Ilioinguinal nerve

• to ASIS

• 3.1 cm medial

• 3.7 cm inferior

• to symphisis pubis

• 2.7 cm lateral

• 1.7 cm superior

Iliohypogastric nerve

• to ASIS

• 2.1 cm medial

• 0.9 cm inferior

• to symphysis pubis

• 3.7 cm lateral

• 5.2 cm superior

Whiteside et al., 2003

Sensory sparing

• Nerve Blocks – 25%

Sensory non sparing

• Alcohol Ablation – 70%

• Neurectomy – 87%

Loos et al. 2008

Originates from L1‐L2

Divides into genital and femoral branches

Sensory:

• Labium majus

• Anteromedial thigh

Motor:

• Cremaster

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Compression from self retaining retractor

Genitofemoral n.

IVC

Genitofemoral Nerve

67 to 100% resolution of pain

Chen DC, Hiatt JR, Amid PK. Operative management of refractory neuropathic inguinodynia by a laparoscopic retroperitoneal approach. JAMA Surg. 2013;148(10):962‐7.

Emerges from S1‐4

Sensory:

• Inferior buttocks

• Lateral perineum

• Proximal medial thigh

• Labia majora

• Clitoris

Often confused with the

pudendal nerve

Darnis B, Robert R, Labat JJ, et al. Perineal pain and inferior cluneal nerves: anatomy and surgery. SurgRadiol Anat. 2008;30(3):177‐83.

69

Emerges form L2‐4

Sensory

• Medial thigh

Motor

• Pectineus

• Abductor longus/brevis

• Gracillis

87% improvement

50% complete resolution of pain

Rigaud J, Labat J‐J, Riant T, Hamel O, Bouchot O, Robert R. Treatment of obturator neuralgia with laparoscopic neurolysis. J Urol. 2008;179(2):590‐4; discussion 594‐5.

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

71

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

Documents

Didactic: Chronic Pelvic Pain 2.0: Decoding Peripheral and ... · mechanism contributes to the transparency and accountability of CME. Table ... physiology and neurobiology of acute