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Interventional Approaches to pelvic pain in women

Interventional Approaches to pelvic pain in women. Geeta Nagpal , MD October 26, 2012. Chronic Pelvic Pain. …is a symptom, not a diagnosis Multifactorial. Case. 26 year old female referred for evaluation and treatment of chronic pelvic pain

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Interventional Approaches to pelvic pain in women

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  1. Interventional Approaches to pelvic pain in women GeetaNagpal, MD October 26, 2012

  2. Chronic Pelvic Pain • …is a symptom, not a diagnosis • Multifactorial

  3. Case • 26 year old female referred for evaluation and treatment of chronic pelvic pain • Constant pain in the pelvis and perineum for over one year. • Exacerbating factors include: • Sitting, standing, walking, Valsava maneuvers, sexual activity • Pain relieved by: • Norco and Valium • Prior Work-up • Gynecologic, Urologic, Gastroenterology

  4. Chronic Pelvic Pain (CPP) • Definition (by Royal College of OB and GYN) • Intermittent, or constant pain in lower abdomen or pelvis • Not occurring exclusively with menstruation, intercourse or ass’d with pregnancy • Duration > 6 months • Localized to: anatomic pelvis, anterior abdominal wall, lumbrosacral back or buttocks • Sufficient severity to cause functional disability or lead to medical care American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004

  5. CPP- Background • 15-20% of women between the ages of 15-73 years have pelvic pain lasting more than one year during their lifetime • Estimated prevalence 38/1000 For perspective: 37/1000 asthma prevalence, 41/1000 chronic back pain prevalence • Primary indication for: • 20% outpatient gynecology visits (most common reason for referral • 12% hysterectomy • 40% diagnostic laparoscopy BMJ. 2006 April 1; 332(7544): 749–755.

  6. CPP Background • Among women with CPP • Use 3x more medications • Have 4x more GYN surgeries • Are 5x more likely to have a hysterectomy In 2006, US spent $881.5 million on outpatient management of chronic pelvic pain BMJ. 2006 April 1; 332(7544): 749–755.

  7. Risk Factors • Dysmenorrhia: • Age (<30 yrs), weight (BMI <20), early menarche (<12 years), longer cycles/ duration of bleeding, PID, sterilization, ho sexual assault • Dyspareunia: • Ho circumcision, PID, anxiety, depression, sexual assault • Non-cyclic pelvic pain: • Abuse, psychologic morbidity (miscarriages), longer menstrual flow, endometrosis, PID, caesarian section scar, pelvic adhesions, sexual abuse, anxiety, depression BMJ. 2006 April 1; 332(7544): 749–755.

  8. The GU/GYN Differential • Painful Bladder Syndrome/Interstitial Cystitis • Endometriosis (cyclic pain) • Pelvic Floor Myalgia

  9. The Usual Work Up • H&P: cyclic, related to periods, related to intercourse, “chandelier sign” aka cervical motion tenderness • Labs/Studies: STD’s, HCG, WBC, Ultrasound for masses , CT Scan • Cystoscopy, Laparoscopy, Colonoscopy,

  10. Interventions • Ganglion Impar Block • Hypogastric Block • Sacral Neuromodulation • Trigger Point Injections • Lidocaine Infusion • Pudendal Nerve Block

  11. Ganglion Impar Block • Ganglion Impar is a solitary retroperitoneal structure at the level of the sacrococcygeal junction • First described by Plancarte in 1990 for the treatment of intractable perineal cancer pain of sympathetic etiology

  12. Ganglion Impar Block • Ganglion Impar receives afferent fibers from: • Perineum • Distal rectum • Anus • Distal urethra • Vulva • Distal third of the vagina

  13. Ganglion Impar Block • Approaches: • Transsacrococcygeal ligament • Transcoccygeal • Anococcygeal ligament • Paramedian approach

  14. Ganglion Impar Block • Therapy: • Local Anesthetic (diagnostic and possibly therapeutic) • Steroid • 6% phenol • Radiofrequency Ablation

  15. Ganglion Impar block • Is there evidence? • Plancarte et al. Anesthesiology 1990 • 16 pts with advanced cancer (cervical, colon, bladder, rectum, endometrial) with persistent pain • Localized perineal pain in all • 6% phenol using transanalcoccygeal approach: • 8 pts with complete relief • Remainder with significant pain reduction (60-90%)

  16. Ganglion Impar Block • Is there evidence? • Swofford et al. Reg Anesth Pain Med 1998 • 20 pts with perineal pain unresponsive to previous Rx • 18 bupivacaine/steroid • 5 had 100% relief, 10 >75% relief, 3 >50% relief • 2 with 6% phenol • Both with complete relief

  17. Ganglion Impar Block • Is there evidence? • Reig et al. Pain Practice 2005 • 13 patients with chronic perineal, non-cancer related pain • All had positive result with diagnostic local anesthetic block • Radiofrequency ablation of the GI produced 50% decrease in pain scores with an average duration of 2.2 months and no complications

  18. Ganglion Impar Block • Complications: • Risk is very low • In current published literature, there are no major complications reported • Due to anatomic variation, there is risk of ineffective block • Theoretical risks: • Bleeding into retroperitoneal space, nerve injury, discitis, puncture of surrounding organs (rectum)

  19. Superior Hypogastric block • The superior hypogastric plexus is also situated in the retroperitoneum • Extends from the lower third of the fifth lumbar vertebral body to the upper third of the first sacral vertebral body

  20. Superior Hypogastric block • The percutaneous approach to the SHP was also described by Plancarte et al. in 1990 • At that time, used for the treatment of pelvic cancer pain • Since that time, this block has been successfully used for the relief of both noncancer and cancerous conditions.

  21. Superior Hypogastric block • Superior hypogastric plexus receives afferent pain fibers from: • Bladder • Urethra • Uterus • Vagina • Vulva • Perineum • Rectum • Descending colon • (prostate, penis, testes)

  22. Superior hypogastric block • Approaches • Posterior • Anterior • Intradiscal • CT or Fluoro

  23. Superior hypogastric block

  24. Superior hypogastric block • Therapy • Local anesthestic • Steroid • Neurolysis with phenol (5-8 cc per side)

  25. Superior hypogastric block • Is there evidence? • Plancarte et al. Anesthesiology 1990 • Superior hypogastric block for pelvic CA pain • 28 patients with neoplastic involvement of pelvic viscera 2/2 cervical, prostate, testicular CA or radiation injury • Mean reduction in pain was 70% using VAS • de Leon-Casasola et al. Pain 1993 • 26 pts with extensive gyn, colorectal, genitourinary CA who suffered incapacitating pelvic pain • All had VAPS 10/10 prior to injection (10% phenol) • 69% had post injection VAPS <4, 31% VAPS 4-7 • Both groups had significant reduction in oral opioid use

  26. Superior hypogastric block • Is there evidence? • Plancarte et al. Reg Anesth 1997 • 227 pelvic pain pts with gyn, colorectal, genitourinary CA had bilateral diagnostic block with 0.25% bupi • 159 with positive response to the block • Of these, 72% with VAS <4 and mean opioid decrease by 40% • 28% with VAS 4-7 and mean opioid decrease by 26% • No additional block for those with good response for 3 mon th follow up • Rosenberg et al. Reg Anesth Pain Med, 1998 • Case report of SHB with bupi and methylprednisolone relieving pain for over 6 months in a man with chronic penile pain after TURP

  27. Superior hypogastric block • Is there evidence? • Pollitt et al. Int J Gynaecol Obstet. 2011 • Case report of chemical neurolysis or superior hypogastric plexus for non-cancerous pain • 21 year old student nurse with 4-year chronic pelvic pain (lower abdomen) thought 2/2 endometriosis • Medical management and laparoscopy x 2 • Diagnostic SHB with excellent relief of pain • Pulsed RF with no benefit • Phenol 6% (7cc in total) with complete pain relief immediately afterward and at 8 weeks, 6, 12, and 24 months

  28. Superior hypogastric block • Complications • There are no reports in the literature of neurologic complication as a result of this block • Neurologic complications could occur if retrograde spread of the neurolytic to the nerve roots • Discitis is a risk with transdiscal approach

  29. Sacral Nerve Stimulation • FDA approved sacral neuromodulation in 1997 as a treatment option for • Urge incontinence • Urgency/frequency • Non-obstructive urinary retention • In the past 10 years, sacral nerve stimulation has been studies in Rx of IC • More recently, this technique has been applied for the Rx of CPP

  30. Sacral nerve stimulation • How does it decrease pain • Common cause of pelvic pain is pelvic floor dysfunction caused by hypertonus • ? Maybe by re-establishing pelvic floor muscle awareness, and decreasing pelvic floor hypertonus • High-tone pelvic floor dysfunction present in 85% of patients with IC/PBS

  31. Sacral nerve stimulation • Approaches

  32. Sacral Nerve stimulation • Approaches

  33. Sacral Nerve Stimulation • Is there evidence? • Siegel et al. J Urol. 2001 • Measured the effectiveness of sacral nerve stimulation in 10 patients with chronic intractable pelvic pain • All had failed conservative measures • Leads placed in either the S3 or S4 foramen • 9/10 reported decrease in the severity of the worst pain compared to baseline at median 19-month follow up • Average decrease in rate of pain from 9.7 to 4.4 • Average decrease in daily duration of pain from 13.1 to 6.9 hours

  34. Sacral Nerve Stimulation • Is there evidence? • Everaert et al. Int Urogynecol J Pelvic Floor Dysfunct. 2001 • 111 patients with CPP (40 male, 70 female) • Underwent pelvic floor training, TENS, intrarectal or intravaginal electrostimulation applied • Sacral nerve stimulation for therapy-resistant pain • Test stim was effective in 16/26 patients • 11 patients were implanted successfully and followed for 36 months • 2 failed therapy soon after implantation • 9 experienced extended and significant reduction in pelvic pain

  35. Sacral nerve stimulation • Is there evidence? • Kapural et al. Pain Med 2006 • Case-series report of spinal cord stimulation for chronic intractable visceral pelvic pain • 6 females with CPP (ho endometriosis, multiple surgical explorations, dyspareunia) • All pts received repeated SHB (average 5.3 blocks) with significant pain relief from 1-6 weeks • 3 received neurolytic HSB with 3,8, and 12 months of relief respectively

  36. Sacral nerve stimulation • Is there evidence? • Kapural et al. Pain Med 2006 • All underwent SCS trial for 7-14 days and permanent dual lead implantation to T11-T12 • Median VAS decreased from 8 to 3, all pts had over 50% pain relief • Opiate use decreased from 22.5 mg to 6.6 mg morphine equivalents per day

  37. Pelvic Floor Myofascial Syndrome • Abdominal/pelvic pain associated with active trigger points in the pelvis, abdominal or low back muscles • Pelvic floor has three functions: support, contraction and relaxation • History • “heavy aching pelvic pressure, falling-out sensation,” often later in the day after prolonged sitting • dyspareunia (genital pain associated with intercourse: before, during, or after)

  38. Pelvic Floor Myofascial Syndrome Common Trigger Points: • Piriformis • Levator ani • Obturator internus

  39. LevatorAni • The levator ani is composed of two distinct muscles: pubococcygeus and iliococcygeus. • Innervation via pudendal plexus. • Function is to support and elevate the pelvic floor

  40. LevatorAni

  41. LevatorAni • Most widely recognized source of referred pain in the perineal region • Pain can be referred to sacrum, coccyx, rectum, pelvic floor, vagina, low back • Pt are uncomfortable with sitting, defection, or lying on the back.

  42. ObturatorInternus • Pain and a feeling of fullness in the rectum and some times back of ispilateral thigh, and vagina

  43. Pelvic Myofacial Pain Treatments • Physical therapy in the associated muscles. (Transvaginal pelvic floor message) • Botox • Combination of the two

  44. Pelvic Myofascial Pain Treatments • PT philosophy and goals: • Tender regions (trigger point) impedes blood flow to the area  pain • Goal is to place pressure, stretch the area, then release • The release is associated with pulsation (return of blood flow) • Decreased pain

  45. Pelvic Myofascial Pain Treatments • PT • Average 2-17 sessions • Improved pain, frequency, urgency • Case reports: 90+% improvement

  46. Pelvic Myofascial Pain Treatments • Botox type A • Abbott JA et al. Obstet Gynecol 2006 • Double-blinded, randomized, placebo controlled trial • All patients with CPP > 2 years and evidence of pelvic floor muscle spasm • 30 women had 80 U botulinum toxin type A injected into pelvic floor muscles • 30 women received saline • Dysmenorrhea, dyspareunia, dyschezia, and non menstrual pelvic pain were assessed by pre and post VAS monthly for 6 months

  47. Pelvic Myofascial Pain Treatments • Outcomes • 26 week follow-up • Pain scores were reduced for both groups in all parameters, no statistically significant intergroup differences • Improvements from pretreatment in both groups (dysparuenia) • Botox (VAS 66 v. 12 p <0.001), • placebo (VAS 64 v. 27, p < 0.05) • Significant reduction in pelvic floor pressure from baseline in Botox group • Complications • Transient incontinence

  48. Lidocaine Infusion • Lidocaine has been shown to reduce pain scores in painful diabetic neuropathy • Mexilitene for painful diabetic neuropathy and peripheral nerve injury • Tocainide for trigeminal neuralgia • Data for IV lidocaine infusion is sparse • Gupta A and Valovska A. EJP 2012 • 15 female patients with CPP through medications, pelvic PT, surgeries treated with IV lidocaine (ave 3-4 treatments) • Pts had 40-70% pain relief for 1-3 weeks • 5 pts d/c opioid regimen after 3 treatments

  49. Fin • References • American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004 • Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006 April 1; 332(7544): 749–755. • Fall M et al. EAU Guidelines on chronic pelvic pain. European Urology 57 (2010) 35-48. • Green I, et al. Interventional therapies for controlling pelvic pain: what is the evidence? Curr Pain Headache Rep (2010) 14: 22-32 • Fariello J et al. Sacral neuromodulation stimulation for IC/PBS, chronic pelvic pain, and sexual dysfunction. Int Urogynecol J (2010) 21: 1553-1558

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