Clinical Management of Chronic Pelvic Pain in Endometriosis Unresponsive to Conventional Therapy

Background: Although several treatments are currently available for chronic pelvic pain, 30–60% of patients do not respond to them. Therefore, these therapeutic options require a better understanding of the mechanisms underlying endometriosis-induced pain. This study focuses on pain management after failure of conventional therapy. Methods: We reviewed clinical data from 46 patients with endometriosis and chronic pelvic pain unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain from 2018 to 2021. Demographic data, clinical and exploratory findings, treatment received, and outcomes were collected. Results: Median age was 41.5 years, and median pain intensity was VAS: 7.8/10. Nociceptive pain and neuropathic pain were identified in 98% and 70% of patients, respectively. The most common symptom was abdominal pain (78.2%) followed by pain with sexual intercourse (65.2%), rectal pain (52.1%), and urologic pain (36.9%). A total of 43% of patients responded to treatment with neuromodulators. Combined therapies for myofascial pain syndrome, as well as treatment of visceral pain with inferior or superior hypogastric plexus blocks, proved to be very beneficial. S3 pulsed radiofrequency (PRF) plus inferior hypogastric plexus block or botulinum toxin enabled us to prolong response time by more than 3.5 months. Conclusion: Treatment of the unresponsive patient should be interdisciplinary. Depending on the history and exploratory findings, therapy should preferably be combined with neuromodulators, myofascial pain therapies, and S3 PRF plus inferior hypogastric plexus blockade.

Management of a patient with myofascial pain syndrome (piriformis syndrome): clinical follow-up

The article considers a clinical case of treatment of one of the variants of myofascial pain syndrome – piriformis syndrome without signs of sciatic nerve neuropathy. The peculiarity of the case is the comorbidity of the opioid syndrome with diabetic sensorimotor polyneuropathy and osteoporosis, which required the appointment of complex therapy. The diagnosis was confirmed by additional research methods: spondylography, MRI of the lumbosacral spine, ultrasound of the piriformis muscle, electroneuromyography. A patient management tactic was chosen based on federal clinical guidelines for the treatment of patients with nonspecific back pain. Treatment included non-medicinal and medicinal methods. In order to relieve pain, dexketoprofen was prescribed 2 ml intramuscularly per 2 ml of 0.5% lidocaine solution – 1 time а day No. 2 – under navigation by ultrasound. Subsequently, the transfer was made to oral administration of 25 mg 3 times а day for 3 days. A step-by-step scheme of prescribing dexketoprofen: its introduction into the piriformis muscle with subsequent transfer to oral administration allowed to significantly reduce the severity of pain after 5 days of treatment. The complex effect on the spasmodic piriformis muscle with the help of a tableted muscle relaxant in combination with postisometric relaxation made it possible to quickly stop the pain syndrome and prevent its chronization. The administration of the preparation of thioctic acid pursued two goals: to improve the metabolism of the spasmodic muscle and restore the energy metabolism of peripheral nerves. As a result of the use of complex, pathogenetically based therapy, a positive effect was achieved.

Pelvic Floor Myofascial Pain Might Influence Treatment Outcome of Interstitial Cystitis/bladder Pain Syndrome

IntroductionIn patients with interstitial cystitis or bladder pain syndrome (IC/BPS), 85% were found to have pelvic floor myofascial pain (PFMP) and hypertonicity (PFH). However, they are not typically trained to consider or assess PFMP as a contributing factor to patients’ IC/BPS symptoms. This study aimed to explore the relationship between PFMP and treatment outcomes in women with IC/BPS.MethodsPatients with IC/BPS who received any type of treatment were prospectively enrolled. They underwent vaginal digital examination at baseline. PFMP severity was quantified on the visual analog scale (VAS). Subject assessment items included O’Leary-Sant symptom score (OSS), Global Response Assessment (GRA), and Beck’s anxiety inventory. Object assessment items included bladder computed tomography (CT), urodynamic parameters, maximum bladder capacity, and grade of glomerulation.ResultsA total of 65 women with IC/BPS (mean age, 57.1 ± 11.3 years) were enrolled in the study. Patients with more severe PFMP had significantly higher rate of dyspareunia (p = .031); more comorbidities (p = .010); higher number of PFMP sites (p < .001); and higher OSS (p = .012). PFMP severity was not significantly correlated with bladder conditions, whether subjective or objective. Moreover, PFMP severity (VAS) was significantly negatively associated with GRA score.ConclusionPFMP might affect the subjective results of IC/BPS treatment but not the bladder condition. Therefore, in the future treatment of patients with IC/BPS, digital vaginal examinations of pelvic floor muscles should be performed and focused more on the PFM-related conditions, and necessary PFM treatments, such as the vaginal pelvic floor muscle message, should be scheduled.