In contrast to women with relatively asymptomatic endometriosis, women with endometriosis-associated chronic pelvic pain (CPP) exhibit nonpelvic hyperalgesia and decreased gray matter volume in key ...neural pain processing regions. Although these findings suggest central pain amplification in endometriosis-associated CPP, the underlying changes in brain chemistry and function associated with central pain amplification remain unknown. We performed proton spectroscopy and seed-based resting functional connectivity magnetic resonance imaging to determine whether women with endometriosis display differences in insula excitatory neurotransmitter concentrations or intrinsic brain connectivity to other pain-related brain regions. Relative to age-matched pain-free controls, women with endometriosis-associated CPP displayed increased levels of combined glutamine-glutamate (Glx) within the anterior insula and greater anterior insula connectivity to the medial prefrontal cortex (mPFC). Increased connectivity between these regions was positively correlated with anterior insula Glx concentrations (r = .87), as well as clinical anxiety (r = .61, P = .02), depression (r = .60, P = .03), and pain intensity (r = .55, P = .05). There were no significant differences in insula metabolite levels or resting-state connectivity in endometriosis patients without CPP versus controls. We conclude that enhanced anterior insula glutamatergic neurotransmission and connectivity with the mPFC, key regions of the salience and default mode networks, may play a role in the pathophysiology of CPP independent of the presence of endometriosis.
Similar to other chronic pain conditions, endometriosis-associated pelvic pain is associated with altered brain chemistry and function in pain processing regions. These findings support central pain amplification as a mechanism of chronic pelvic pain, and clinicians should consider the use of adjunctive therapies that target central pain dysfunction in these women.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Endometriosis-associated pelvic pain and subfertility may be managed medically in many cases; however, the surgical management of this insidious disease remains a necessary part of the treatment ...algorithm. Laparoscopy for diagnosis alone is rarely indicated with the advancements in preoperative imaging. When surgery is performed, the ideal goal would be a therapeutic and effective surgical intervention based on the preoperative evaluation. Surgery for women with pain due to endometriosis may be indicated in patients who cannot or do not wish to take medical therapies; acute surgical or pain events; deep endometriosis; during concomitant management of other gynecologic disorders; and patients seeking fertility with pain. The role of surgery for endometriosis-related subfertility may be considered in those with hydrosalpinges undergoing IVF; management of ovarian endometriomas in specific circumstances; and when a patient requests surgery as an alternative to assisted reproductive technology (ART). Surgery for ovarian endometriomas requires special attention due to the risk of potential harm on future fertility. Finally, a combined approach of surgery followed by postoperative medical therapy offers the best long-term outcomes for recurrence of disease and symptoms. A patient-centered approach and a goal-oriented approach are essential when determining the options for care in this population.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Chronic pelvic pain Steege, John F; Siedhoff, Matthew T
Obstetrics and gynecology (New York. 1953),
09/2014, Volume:
124, Issue:
3
Journal Article
Peer reviewed
As opposed to the satisfying solutions found in the management of acute pain, chronic pelvic pain can be a vexing problem for the patient and physician. Seldom is a single source or cause found, and ...nearly always the condition is influenced by the broader social and psychological context of the patient. In this article, we discuss the evaluation of chronic pelvic pain, often considering pain as the disease itself, and identify peripheral generators, which gynecologists can address to help reduce their contributions to symptoms.
Endometriosis can recur after either surgical or medical therapy. Long-term medical therapy is implemented to treat symptoms or prevent recurrence. Dienogest and gonadotropin-releasing hormone (GnRH) ...analogues with hormone add-back therapy seem to be equally effective for long-term treatment of pain symptoms associated with endometriosis. There is insufficient evidence to support the superiority of one therapy over the other. However, add-back hormone therapy (HT) is recommended for patients using GnRH agonists. The treatment selection depends on therapeutic effectiveness, tolerability, drug cost, the physician's experience, and expected patient compliance.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective
To assess the effects of non‐pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
Patients and Methods
We performed a comprehensive search using ...multiple databases, trial registries, grey literature and conference proceedings with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017. We included randomized controlled trials in men with a diagnosis of CP/CPPS. We included all available non‐pharmacological interventions. Two review authors independently classified studies and ed data from the included studies, performed statistical analyses and rated quality of evidence (QoE) according to the Grading of Recommendations Assessment, Development and Evaluation methods. The primary outcomes were prostatitis symptoms and adverse events. The secondary outcomes were sexual dysfunction, urinary symptoms, quality of life, anxiety and depression.
Results
We included 38 unique studies in 3290 men with CP/CPPS across 23 comparisons, reporting outcomes mostly at short‐term follow‐up. Our analysis showed that acupuncture probably leads to clinically meaningful reduction in prostatitis symptoms compared with a sham procedure (mean difference MD in total National Institutes of Health – Chronic Prostatitis Symptom Index NIH‐CPSI score −5.79, 95% confidence interval CI −7.32 to −4.26, moderate QoE). Acupuncture may result in little or no difference in adverse events (low QoE). Acupuncture may also lead to a clinically meaningful reduction in prostatitis symptoms compared with standard medical therapy (MD −6.05, 95% CI −7.87 to −4.24, two studies, 78 participants, low QoE). Lifestyle modifications may be associated with a reduction in prostatitis symptoms compared with control (risk ratio for improvement in NIH‐CPSI scores 3.90, 95% CI 2.20 to 6.92, very low QoE), but we found no information regarding adverse events. A physical activity programme may cause a small reduction in prostatitis symptoms compared with control (NIH‐CPSI score MD −2.50, 95% CI −4.69 to −0.31, low QoE), but we found no information regarding adverse events. It was uncertain whether prostatic massage reduces or increases prostatitis symptoms compared with control (very low QoE) and we found no information regarding adverse events. Extracorporeal shockwave therapy reduces prostatitis symptoms compared with control (NIH‐CPSI score MD −6.18, 95% CI −7.46 to −4.89, high QoE), but these results may not be sustained at medium‐term follow‐up (low QoE). This treatment may not be associated with a greater incidence of adverse events (low QoE). Transrectal thermotherapy, alone or in combination with medical therapy, may decrease prostatitis symptoms slightly when compared with medical therapy alone (NIH‐CPSI score MD −2.50, 95% CI −3.82 to −1.18, low QoE). One included study reported that participants may experience transient adverse events.
Conclusions
Based on the findings with moderate to high QoE, this review found that some non‐pharmacological interventions, such as acupuncture and extracorporeal shockwave therapy, are likely to result in a decrease in prostatitis symptoms and may not be associated with a greater incidence of adverse events. The QoE for most other comparisons was predominantly low. Future clinical trials should include a full report of their methods, including adequate masking, consistent assessment of all patient‐important outcomes including potential treatment‐related adverse events and appropriate sample sizes.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Female chronic pelvic pain (CPP) has multiple pain generators and significant psychosocial sequalae. Biopsychosocial-based phenotyping could help identify clinical heterogeneity that may inform ...tailored patient treatment. This study sought to identify distinct CPP profiles based on routinely collected clinical information and evaluate the validity of the profiles through associations with social histories and subsequent health care utilization.
Women (18-77 years, n = 200) seeking care for CPP in a tertiary gynecological pelvic pain clinic between 2017 and 2020 were included. Baseline data of pain intensity, interference, catastrophizing, acceptance, overlapping pelvic pain syndromes, and co-occurring psychiatric disorders were subject to a partition around medoids clustering to identify patient profiles. Profiles were compared across social history and subsequent treatment modality, prescribed medications, and surgeries performed.
Two profiles with equal proportion were identified. Profile 1 was vulvodynia and myofascial pelvic pain-dominant characterized by lower pain burden and better psychological functioning. Profile 2 was visceral pain-dominant featuring higher pain interference and catastrophizing, lower pain acceptance, and higher psychiatric comorbidity. Patients in Profile 2 had 2-4 times higher prevalence of childhood and adulthood abuse history (all P < .001), were more likely to subsequently receive behavioral therapy (46% vs 27%, P = .005) and hormonal treatments (34% vs 21%, P = .04), and were prescribed more classes of medications for pain management (P = .045) compared to patients in Profile 1.
Treatment-seeking women with CPP could be separated into two groups distinguished by pain clusters, pain burden, pain distress and coping, and co-occurring mental health disorders.
Objectives
To improve awareness and recognition of chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) among non‐specialists and patients. To provide ...guidance to healthcare professionals treating patients with CBP and CP/CPPS, in both non‐specialist and specialist settings. To promote efficient referral of care between non‐specialists and specialists and the involvement of the multidisciplinary team (MDT).
Patients and Methods
The guideline population were men with CBP or CP/CPPS (persistent or recurrent symptoms and no other urogenital pathology for ≥3 of the previous 6 months). Consensus recommendations for the guidelines were based on a search to identify literature on the diagnosis and management of CBP and CP/CPPS (published between 1999 and February 2014). A Delphi panel process was used where high‐quality, published evidence was lacking.
Results
CBP and CP/CPPS can present with a wide range of clinical manifestations. The four main symptom domains are urogenital pain, lower urinary tract symptoms (LUTS – voiding or storage symptoms), psychological issues and sexual dysfunction. Patients should be managed according to their individual symptom pattern. Options for first‐line treatment include antibiotics, α‐adrenergic antagonists (if voiding LUTS are present) and simple analgesics. Repeated use of antibiotics, such as quinolones, should be avoided if there is no obvious symptomatic benefit from infection control or cultures do not support an infectious cause. Early use of treatments targeting neuropathic pain and/or referral to specialist services should be considered for patients who do not respond to initial measures. An MDT approach (urologists, pain specialists, nurse specialists, specialist physiotherapists, general practitioners, cognitive behavioural therapists/psychologists, and sexual health specialists) is recommended. Patients should be fully informed about the possible underlying causes and treatment options, including an explanation of the chronic pain cycle.
Conclusion
Chronic prostatitis can present with a wide variety of signs and symptoms. Identification of individual symptom patterns and a symptom‐based treatment approach are recommended. Further research is required to evaluate management options for CBP and CP/CPPS.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
To identify metabolites in presurgical blood associated with risk of persistent postsurgical pelvic pain 1 year after endometriosis surgery in adolescent and young adult patients.
Prospective ...observational study within the Women’s Health Study: From Adolescence to Adulthood, a US-based longitudinal cohort of adolescents and women enrolled from 2012–2018.
Two tertiary care hospitals.
Laparoscopically confirmed endometriosis patients (n = 180) with blood collected before their endometriosis surgery. Of these, 77 patients additionally provided blood samples 5 weeks to 6 months after their surgery. We measured plasma metabolites using liquid chromatography tandem mass spectrometry, and a total of 390 known metabolites were included in our analysis.
None.
Persistent postsurgical pelvic pain, defined as severe, life-impacting pelvic pain 1 year after endometriosis surgery.
Most patients (>95%) were at stage I/II of the revised American Society for Reproductive Medicine classification. Their average age at diagnosis was 18.7 years, with 36% reporting persistent postsurgical pelvic pain. Of the 21 metabolites in presurgical blood that were associated with risk of persistent postsurgical pelvic pain, 19 metabolites, which were mainly lipid metabolites, were associated with increased risk. Only 2 metabolites—pregnenolone sulfate (odds ratio = 0.64, 95% confidence interval = 0.44–0.92) and fucose (odds ratio = 0.69, 95% confidence interval = 0.47–0.97)—were associated with decreased risk. Metabolite set enrichment analysis revealed that higher levels of lysophosphatidylethanolamines (false discovery rate = 0.01) and lysophosphatidylcholines (false discovery rate = 0.01) in presurgical blood were associated with increased risk of persistent postsurgical pelvic pain.
Our results suggest that dysregulation of multiple groups of lipid metabolites may play a role in the persistence of pelvic pain postsurgery among young endometriosis patients.
Metabolitos sanguíneos prequirúrgicos y riesgo de dolor pélvico posquirúrgico en pacientes jóvenes con endometriosis.
Identificar metabolitos en sangre prequirúrgica asociados con el riesgo de dolor pélvico posquirúrgico persistente 1 año después de la cirugía de endometriosis en pacientes adolescentes y adultas jóvenes.
estudio observacional prospectivo dentro del Estudio de salud de la mujer: de la adolescencia a la edad adulta, un estudio longitudinal basado en cohorte de adolescentes y mujeres reclutadas en EE. UU, entre 2012 y 2018.
dos hospitales de atención terciaria.
Pacientes con endometriosis confirmada por laparoscopia (n = 180) con sangre extraída antes de la cirugía de endometriosis. De estas, 77 pacientes adicionalmente proporcionaron muestras de sangre a las 5 semanas hasta los 6 meses después de su cirugía. Se han medido los metabolitos plasmáticos utilizando espectrometría de masas en tándem de cromatografía líquida, y un total de 390 metabolitos conocidos se incluyeron en nuestro análisis.
Ninguna.
dolor pélvico posquirúrgico persistente, definido como dolor pélvico intenso que afecta la vida 1 año después de la endometriosis cirugía.
La mayoría de los pacientes (>95 %) se encontraban en el estadio I/II de la clasificación revisada de la Sociedad Estadounidense de Medicina Reproductiva. La edad media en el momento del diagnóstico fue de 18,7 años, y el 36 % informó dolor pélvico posquirúrgico persistente. De los 21 metabolitos en sangre prequirúrgica que se asociaron con el riesgo de dolor pélvico posquirúrgico persistente, 19 metabolitos, que eran principalmente metabolitos lipídicos, se asociaron con un mayor riesgo. Solo 2 metabolitos: sulfato de pregnenolona (odds ratio = 0,64, intervalo de confianza del 95 % = 0,44–0,92) y fucosa (odds ratio= 0,69, intervalo de confianza del 95 % = 0,47–0,97) se asociaron con una disminución del riesgo. El análisis de enriquecimiento del conjunto de metabolitos reveló que los niveles más altos de lisofosfatidiletanolaminas (tasa de descubrimiento falso =0.01) y lisofosfatidilcolinas (tasa de descubrimiento falso= 0,01) en la sangre prequirúrgica se asociaron con un mayor riesgo de dolor pélvico posquirúrgico persistente.
Nuestros resultados sugieren que la desregulación de múltiples grupos de metabolitos de lípidos puede jugar un papel en la persistencia del dolor postoperatorio pélvico entre pacientes jóvenes con endometriosis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Of women with interstitial cystitis/bladder pain syndrome and men with chronic prostatitis/chronic pelvic pain syndrome 85% have concomitant pelvic floor muscle tenderness (PFT). The significance of ...this finding is incompletely understood. This study examines PFT among participants in the MAPP (Multidisciplinary Approach to the Study of Chronic Pelvic Pain) Research Network and its relationship with urologic chronic pelvic pain syndrome (UCPPS) symptom severity in order to determine whether this is a phenotypic predictor in UCPPS.
Participants in the MAPP Network Symptom Patterns Study underwent a standardized pelvic examination (PEX). Trained examiners palpated 6 locations evaluating the pelvic musculature for PFT. Participants were assigned a 0 to 6 PEX score based on the number of areas with tenderness on PEX. Using regression tree models, PEX scores were divided into low (0, 1), mid (2, 3, 4, 5) and high (6). The relationship between PFT and UCPPS symptoms was examined using several validated questionnaires.
The study cohort consisted of 562 UCCPS participants (375 females and 187 males) and 69 controls. Diagnoses included interstitial cystitis/bladder pain syndrome (397), chronic prostatitis/chronic pelvic pain syndrome (122), both (34) or no diagnosis (9). Of UCPPS participants 81% had PFT on PEX compared to 9% of controls: 107 (19%) low, 312 (56%) mid and 143 (25%) high. Participants with higher PFT scores had more severe disease burden (worse pelvic pain and urinary symptoms), worse quality of life and more widespread distribution of nonpelvic pain.
UCPPS patients with more widespread PFT have severe pain and urinary symptoms, worse quality of life and a more centralized pain phenotype.
OBJECTIVE:To compare adverse childhood experiences (ACEs) in women with chronic pelvic pain with a control group, and describe occurrence of specific ACEs in women with chronic pelvic pain.
...METHODS:This case-control study examined the relationship between history of ACEs, traumatic events occurring during childhood as defined by the Centers for Disease Control and Prevention (CDC), and chronic pelvic pain. Patients diagnosed with chronic pelvic pain (n=60) were age-matched to a control group of women without chronic pelvic pain (n=60). All participants completed validated measures to detect for presence of any of the 11 ACEs as identified by the CDCʼs Behavioral Risk Factor Surveillance System ACE Module.
RESULTS:Mean participant age was 40 (±11 years). Total numbers of ACEs were elevated in chronic pelvic pain participants compared with a control group (median 4 interquartile range 2–6 vs median 1 interquartile range 0–4, P<.001) and 53% of chronic pelvic pain participants had four or more ACEs, compared with 27% of the control group (odds ratio OR 3.14; 95% CI 1.46–6.75). All categories of abuse were more prevalent in chronic pelvic pain compared with the control groupphysical (43% vs 15%, OR 4.3; 95% CI 1.8–10.4; P=.001), sexual (55% vs 23%, OR 4.0; 95% CI 1.8–8.8; P<.001) and verbal or emotional (62% vs 33%, OR 3.2; 95% CI 1.5–6.8; P=.003). Regarding household challenges, the subcategory most prevalent in chronic pelvic pain participants compared with the control group was that of witnessed domestic violence (35% vs 8%, OR 5.9; 95% CI 2.1–17.1, P<.001).
CONCLUSION:Chronic pelvic pain participants had a greater than threefold odds of having a history of childhood abuse and having witnessed domestic violence during childhood compared with the control group. Women with chronic pelvic pain had increased numbers of ACEs and 53% had four or more ACEs, crossing a threshold that others have found to predict poor overall health outcomes.
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