1. health and fitness
2. disease

ABSTRACTS
1
Secondary provoked localized vulvodynia is associated with interleukin-4 polymorphisms linked to
interstitial cystitis and atopy
Terry K. Morgan, MD, PhD
Departments of Obstetrics & Gynecology and Pathology; Oregon Health & Science University, Portland,
Oregon, USA
Introduction: Chronic vestibulitis, also known as provoked localized vulvodynia (PLV), occurs in the rim of
mucosa between the labia minora and hymen. This common disease affects approximately 15% of women
during their lifetime and is the leading cause of painful intercourse. The cause is unknown, but neurogenic
inflammation appears to play a key role. Neurogenic inflammation is also a shared feature with interstitial
cystitis, which is present in 20% of women with PLV. Many investigators suspect a genetic basis for interstitial
cystitis. However, testing for a genetic predisposition for PLV is only in the early stages of discovery. We
hypothesized that PLV would be associated with the IL-4 promoter (rs22432250) and intron 2 (rs2227284)
variants commonly seen in patients with interstitial cystitis and atopy.
Methods: Retrospective analysis of 212 clinically confirmed cases of PLV diagnosed from 2002-2012 at Oregon
Health & Science University. Subjects were classified into primary PLV (pain with first introital touch) and
secondary PLV (de novo pain usually after childbirth or menopause). Clinical charts were reviewed to confirm
diagnoses and screen for a history of interstitial cystitis and allergies. Since patient race may significantly
affect allele frequencies, only data from non-hispanic Caucasian women were included for genetic analysis
(205/212). Subject DNA was available for 195 cases (91 primary and 104 secondary). IL-4 genotypes were
determined using real-time PCR-based Taqman Allelic Discrimination (ABI). Data were analyzed by X2 analysis.
Results: Secondary PLV was associated with both IL-4 variants (p<0.01) known to increase IL-4 activity and
lead to elevated serum IgE levels. The allele frequency of the T-allele at -589 (promoter) was 0.20 (Caucasian
controls 0.14); the allele frequency of the T-allele at 3017 (intron 2) was 0.31 (controls 0.25). IL-4 allele
frequencies in primary PLV were not significantly different than controls. The prevalence of interstitial cystitis
was increased in both primary and secondary PLV (32%, 27%, respectively) compared with controls (6%).
Atopy was more common in secondary (2.34 [1.3-4.4] (p<0.01), but not primary PLV.
Conclusions: We show for the first time that IL-4 genetic variants associated with interstitial cystitis and atopy
may also play a role in secondary PLV. We have recently demonstrated that primary and secondary PLV may
have different underlying causes. Our data support this working hypothesis and suggest drugs targeting the IL4 pathway may provide a potential treatment for secondary PLV.
2
Correlation between bladder pain syndrome and histopathological findings, urinary bladder wall visceral
nerve axonopathy, beta-HCG expression in urothelium and microbial findings in biopsy – pilot study
Valová, Z., Zámečník, L., Hanuš, T., Povýšil, C., Dundr, P., Adámková, V., Doubková, Z.
1st Medical Faculty, Charles University, General Faculty Hospital, Dept. of Urology, Prague, Czech Republic
Introduction & objectives: The etiology of bladder pain syndrome (BPS) still remains poorly understood. A role
of mast cells, a failure of protective function of urothelium as well as neurogenic causes has been considered.
Furthermore, factors inducing long-term fixation of pelvic and bladder pain and urologic symptoms have
remained unexplained.
The aim of our pilot study is to analyze correlation between endoscopy, histopathological assessment and
electron microscopy, correlation between beta-HCG expression in the urothelium and pelvic pain. A secondary
objective is to assess sexually transmitted infection in bladder wall biopsy (chlamydia, ureaplasma and
mycoplasma).
Material & methods: Between April 2011 and December 2012 was performed clinical evaluation (O´Leary Sant
Questionaire), endoscopy and biopsies of urinary bladder wall in 15 patients with bladder pain syndrome
(according to the ESSIC - International Society for the Study of BPS) classification of endoscopic findings.
Specimens fixed in paraformaldehyd and semithin and ultrathin sections for electronmicroscopic examination
were analyzed for ultrastructural changes of axons and myelin sheaths of nerve fibers in urinary bladder
mucosa. Morphometric analyses of fibers were performed and the results were compared to the findings in
samples in control group. Imunohistochemistry (cytokeratins, HCG, estrogens, progesterone, p63, p16, CD56,
etc.) and STD infection assessment was performed as well.
Results: In 11 of the 15 studied samples of BPS patients, presence of ultrastructural morphologic changes of
visceral nerve fibers - particularly signs of axonal neuropathy and signs of mild chronic demyelinisation in
myelinated fibers were observed. There was positive correlation between beta-HCG expression in the
urothelium and pelvic pain changes. Only in 1 of the 15 patients was positive STD findings in bladder wall
biopsy.
Conclusions: Based on our findings we consider that chronic neuropathic changes occur in visceral nerve
endings of urinary bladder in interstitial cystitis patients. They might represent one of etiologic factors
inducing the fixation of chronic pain and urologic disorders in these cases. There is a positive correlation
between beta-HCG expression in the urothelium and pelvic pain changes (symptom score, analogue pain
score). The presence of STD is not specific for BPS. The role of immunohistochemistry as a marker for the BPS
is still unclear and requires further studies continue.
3
Dynamic Weight Bearing (DWB) employed as a new concept for quantification of pelvic pain in a pre-clinical
model
Nagel J. , Gruen M. & Zollner T.M.
Bayer Healthcare, TRG Oncology/Gynecological Therapies, Berlin, Germany
Introduction & objectives: Chronic pelvic pain (CPP) is defined as long-lasting and severe pelvic pain persisting
over 6 months in cyclic, intermittent, or non-cyclic chronic manner. It is related to a pronounced decrease of
quality of life (1). Various pathologic conditions like endometriosis, abdominal infections, intra-peritoneal
adhesions ensuing from surgery or infection etc. underlie CPP which is often the leading symptom of the
associated diseases. Pharmacological approaches addressing CPP are hampered by the fact that no specific,
validated animal model for pelvic pain is available. Earlier developed approaches like writhing assay in rodent
lack of construct and face validity and deliver just a sparse predictive validity related to the clinical setting. In
the presented study, the newly developed dynamic weight bearing system (Bioseb, France) was employed for
quantification of pelvic pain in a rat model for peritonitis.
Materials & methods: Dynamic weight bearing analyses the weight distribution of an animal on the 4 paws
and is therefore able to give evidence for pain-related relief posture. Han-Wistar rats (N=8 per group) were
treated with rofecoxib 10 mg/kg or vehicle and received 30 min later an i.p. application of LPS (500 µg/kg).
Dynamic weight bearing was performed 5 hours after first application. Peritoneal lavage sampling followed 1
hour later (post mortem).
Results: DWB analysis revealed, that rats treated with LPS i.p. showed 5 hours after application a significantly
increased weight distribution to the front from the hind paws when compared to vehicle-treated animals. This
is indicative of a relief posture associated with pelvic pain by LPS treatment. Pretreatment with the COX2
inhibitor rofecoxib abolished the development of relief posture indicating the sensitivity of the model for
pelvic pain related to peritonitis. Post mortem analysis of the peritoneal fluid of the animals revealed
increased PGE2 levels after LPS treatments which were significantly lower in the rofecoxib group.
Conclusion: Taken together, we were able to show that DWB combined with LPS-induced peritonitis may
deliver a new animal model addressing pelvic pain with high construct validity (peritoneal inflammation),
predictive validity (effect of COX inhibitor in relevant dose), and face validity (pain related relief posture).
4
Upregulation of the cannabinoid receptor 1 in neural tissue seems to be involved in endometriosis induced
hyperalgesia
Barcena de Arellano, M.L., Pauly, N., Schneider, A., Mechsner, S.
Endometriosis Research Centre, Clinic for Gynecology, Charité-Universitätsmedizin Berlin, Berlin Germany
Introduction & objectives: About 40% of women with pelvic pain (PP) have endometriosis (EM). EM is a
chronic inflammatory estrogen dependent disease, affecting 15-20% of women in reproductive age. The main
symptom is chronic cyclic and non cyclic PP with a prevalence of up to 80%. An imbalance of sensory and
sympathetic nerve fibers (NF) close to the lesions is involved in the chronic inflammatory condition of EM,
generating a preponderance of proinflammatory and a depletion of antiinflammatory neurotransmitters.
However the pain severity does not correlate with the chronic inflammatory stage, suggesting the involvement
of other mediators in the pain mediation in EM.
The cannabinoid receptor type 1 (CB1) is a G protein-coupled receptor, which is mostly expressed in the
nervous system. CB1 seems to be involved in the reduction of pain and inflammation. The aim of this study
was to analyse dysfunctions in the expression of the CB1 in neural cells after incubation with peritoneal fluid
(PF) of women with EM.
Materials & methods: Neural PC12 or F11 cells were incubated with 20 PF of women with EM and 20 PF of
women without EM (CG). After 120 hours, the cells were lysated and RNA was extracted. The relative CB1
RNA-expression was analysed in the different groups using quantitative real time PCR.
Results: PC12 cells incubated with PF from the CG did not show any differences between the symptomatic and
the asymptomatic group (p>.05). However, CB1 expression in F11 cells was in trend decreased in the
symptomatic CG. Interestingly, the CB1 expression was upregulated in PC12 and F11 cells after incubation with
PF of women with EM in comparison to the CG. PC12 and F11 cells incubated with PF of women with severe PP
showed a significant upregulation of CB1 compared to the PF of women with EM and no to minimal pain
(p<.05).
Conclusion: The imbalance between sensory and sympathetic nerve fibers promotes the chronic inflammatory
condition in EM, however, the inflammatory stage does not correlate with the pain severity, suggesting that
other factors/receptors are involved in the pain mediation of the EM. The cannabinoid system plays a crucial
role in inflammation, promoting anti-inflammatory and antinociceptive effects in the peripheral and in the
central nervous system.
In this study, the presence of the CB1 in two neural cell lines was demonstrated; the expression of CB1 was
upregulated in the cells incubated with PF of women with EM. The PF of symptomatic women with EM evoked
a pronounced upregulation. The upregulation of CB1 in these cells suggests a disturbed cannabinoid system in
the EM, which can contribute to the proinflammatory stage of the EM.
5
Alleviation of symptoms of chronic pain syndrome by pregabalin
Drasa K.¹ , Xhixha A.² ,Krasniqi M.³ ,Haruni A.⁴
¹Central Polyclinic,Dept of Urology ,Tirana, Albania ,²DSHP Tirana, ³Dept Health Care Elbasan, ⁴Central
Polyclinic, Dept of Neurology, Tirana, Albania
Introduction & objectives: Male chronic prostatitis /chronic pelvic pain syndrome( CP/CPPS) is a condition of
uncertain etiology. My evidence suggested me that urogenital pain of CP/CPPS may be neuropathic in origin.
Pregabalin (PGB) is used off-label for the treatment of chronic pain, neuropathic pain. The object of this study
was to evaluate the efficacy and safety of PGB in the alleviation of CPPS symptoms.
Materials & methods: 110 man, were enrolled in this randomized, double – blind placebo - controlled trial.
They were with pelvic pain for at least 3 of the previous 6 months , a National Institutes of Health Chronic
Prostatitis Symptom Index(NIH-CPSI) score of >15 and a non zero pain domain score were randomly assigned
to either PGB or matching placebo (PLA) in a 2:1 ratio for 6 weeks(wks), respectively. Daily PGB dose was
increased at two wks intervals beginning with 75 mg to 150 mg and finally 300mg.The primary endpoint was
alleviation of pain at 6 wks based on the NIH-CPSI pain domain scale. Secondary endpoints were the Global
Response Assessment (GRA),sub-scores of the NIH - CPSI( voiding and quality of life(QoL)) and Depression
Scale( DS) and the Sexual Health Inventory for Men (SHIM).
Results: At 6 wks patients in PGB group, reported significant improvement in pain. Among men assigned to
PGB 60/76( 79.8 % )reported a 6-point decrease in total NIH-CPSI score at 6 wks compared to 10/34 ( 29.4%)
of man assigned to PLA (p=0,073). GRA and QoL as compared with pts in PGB and PLA group were 77% vs
16%, respectively (p<0.001). No difference was noted between treatment vs PLA group in the voiding subscale
of the NIH-CPSI.Results for the DS were more alleviation in the PGA group than PLA group and for SHIM were
not different between treatment groups. Adverse events were minimal and included dizziness (5%)
headache(3%) and tiredness( 1%).
Conclusion: Treatment with Pregabalin appears safe and effective in the alleviation of symptoms of chronic
pelvic pain syndrome in man. Impressive differences in secondary endpoints suggest that Pregabalin may
prove effective in some man with long –standing CP/CPPS. Don’t forget that PGB should be reduced gradually
when finishing treatment.
6
Pulsed dose radiofrequency to treat chronic pudendal neuralgia: A new therapeutic option
Canzoneri L., Maniscalco G., Morra I.1,Cena T., Castellano M.
Pain Medicine and Therapy Center, 1Department of Urology, AOU San Luigi Hospital, Orbassano, Turin, Italy
Introduction & objectives: Patients with pudendal neuralgia (PN) complain pain in the external
genitalia, perineum, buttock and anus. Treatment guidelines for PN has not been defined. Therapies include
lifestyle changes, medication management, pudendal nerve blocks, decompressive surgery, botulin toxin
injections, intrathecal drug delivery and neuromodulation. Another interesting option is pulsed dose
radiofrequency (PDRF)(1). PDRF is a minimally invasive percutaneus procedure that involves placement of an
insulated needle with an active tip close to the nerve.
PDRF provides the analgesic effect inducing a long-lasting “stunning” of the nerve without a thermal
destruction of nervous tissue.
A prospectic trial has been planned in order to verify the safety and the analgesic effect of this procedure. The
preliminar results are described.
Materials & methods: 8 patients were treated with PDRF during a period of 7 months. All of them met the
Nantes criteria proposed by JJ Labat et al(2).Secondary aetiologies were excluded by a multidisciplinary
urogynecologycal team.
If the patients responded to anesthetic nerve block they were selected to be treated with PDRF.The needle
was placed with a trans perineal access and the correct position of the needle was confirmed with sensory
stimulation at 50Hz. It was accepted paresthesia in the pain area with stimulation inferior to 0,5 mV.
The parameters standard were:1200 doses, 45 volts (fixed value), 20 msec, temperature always inferior to
42°C.
The pain was evaluated before the procedure and after 1, 3, 6 and 9 month using the numeric rating pain scale
(NRS) and the global pain relief.
Results: Demographics data: the average age was.52,5. The average durability of the pain was 1 years and 6
months.
Mean NRS control:
Controls:
Time 0
1 months
3 months
6 months
9 months
Pt1 (M)
7
1, 5
1, 8
2
2, 8
Pt2 (F)
8,2
3
2,6
2,8
3,5
Pt3 (F)
8
4, 4
5
5,5
5,6
Pt4 (M)
6,4
2,2
2
2,3
3,6
Pt5 (F)
8,3
3
3
3
3,4
Pt6 (F)
6,9
3,7
3,8
3,9
4,5
Pt7 (F)
7,4
3,4
3,5
3,8
3,8
Pt8 (F)
8,2
2,3
3
3
3,3
Mean global pain relief was 82% at 1 month, 79% at 3 months, 76% at 6 months, 60% at 9 mouth.
The average time of procedure was 30 minutes (range 20-45mins)
No complications were recorded.
5 patients gradually interrupted analgesic therapy (opioids, antidepressants e anticonvulsivants), whereas the
others reduced the consumption.
Conclusion: In this preliminary results it seems that PDRF is safe and repeatable option to treat PN.
Bibliografy
(1) Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency.
Rhame EE et Al. Pain Physician. 2009 May-Jun;12(3):633-8
2) Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Labat JJ et al.
Neurourol Urodyn. 2008;27(4):306-10
7
The value of MRI in the investigation of pudendal nerve entrapment
Chow J.S.W.1, Sachinwalla T.1,2, Jarvis S.K.1, Vancaillie T.G.1
1
Women’s Health & Research Institute of Australia (WHRIA), Sydney, Australia
2
Northside Medical Imaging, Sydney, Australia
Introduction & objectives: Magnetic resonance imaging of the sacral spine and pudendal nerves has been part
of the investigations for perineal and pelvic pain at our unit since 2008. This retrospective study examines the
correlation of MRI findings of suspected pudendal nerve compression with outcomes of pudendal nerve
blocks.
Materials & methods: The radiology protocol went through a number of iterations as expertise was acquired.
From January 2012 MRI was performed on a Philips 3 Tesla Achieva System using a 16 channel Torso coil.
Anatomical detail was obtained from an Axial PD weighted 3mm sequence and a volume THRIVE T1 weighted
sequence aquired in the coronal plane. Supplementary coronal T2 fat supressed and sagittal T2 weighted
images were also obtained.
MRI studies were evaluated for dimensions of the pudendal nerve canal above and below the level of the
ischial spine. Positive studies demonstrated narrowing of the interligamentous space less than 3mm when
superior to the ischial spine and focal reduction in perineural fat when below the ischial spine. Positive studies
distal to Alcock's canal demonstrated focal changes consistent with scarring around distal pudendal nerve
branches.
Patients also underwent a pudendal nerve block as a diagnostic test for pudendal nerve entrapment according
to the criteria of Nantes. The block was performed under image intensifier control with Urografin 30 as
contrast medium. A standard amount of 5cc of Chirocaine 0.5% was injected. A positive block is defined as the
occurrence of numbness in the distribution of the pudendal nerve and resolution of the perineal pain. A block
is considered negative if the pain is not or only partly resolved.
Results: 124 patients underwent an MRI between January and November 2012 and 59 patients underwent a
pudendal nerve block with the above protocols. 64.4% patients had a positive block. Of the patients with a
positive block, 68.4% had MRI indicating possible pudendal nerve compression. Of the patients with a
negative block, 47.6% had MRI demonstrating possible pudendal nerve compression.
Conclusion: Patients with a positive pudendal nerve block did not have findings on MRI different from patients
with a negative pudendal nerve block.
8
Female chronic pelvic pain is highly prevalent in Denmark. A randomly selected cross-sectional population
study
S. Loving1, T. Thomsen2, P. Jaszczak3, J. Nordling4
1
Multidisciplinary Pain Centre, Department of Anaesthesiology, Herlev Hospital, University of Copenhagen,
Denmark
2
Abdominal Centre, University of Copenhagen, Rigshospitalet, Denmark
3
Department of Gynaecology, Herlev Hospital, University of Copenhagen, Denmark
4
Department of Urology, Herlev Hospital, University of Copenhagen, Denmark
Background and aim: Chronic pelvic pain in women is a debilitating condition with a major impact on healthrelated quality of life, work productivity and health care utilisation. The exact prevalence remains unknown,
but 3.8% is commonly suggested. A recent WHO review reports worldwide prevalence rates for non-cyclic
chronic pelvic pain ranging from 2.1% to 24.0%. Our aim was to assess prevalence, characteristics, impact on
daily life and risk factors for chronic pelvic pain in Danish women, and to compare these findings with a
healthy reference group.
Methods: A cross-sectional postal survey of the prevalence of chronic pelvic pain was undertaken in a
randomly selected general female population in Denmark (N=2500). Initially, we developed and validated a
self-reported, paper-and pencil based questionnaire on experiences of chronic pelvic pain. The questionnaire
consisted of 18 questions, and was mailed to potential participants between November 2010 and April 2011.
Inclusion criteria were: a. female, b.≥ 18 years of age. Statistical analyses included prevalence percentage
rates, chi-square tests, Mann-Whitney tests, unpaired T- tests, and multiple regression analyses.
Results: 1179 women living in representative areas of Denmark responded. 130 (11.0%) women reported
chronic pelvic pain in the preceding 6 months; of these 65 (5.5%) had chronic pelvic pain ≥ 2 days weekly. The
highest prevalence was observed in women aged ≤ 25 years (17.1%) and between 46-55 years (16.8%).
Average pain intensity reported was 4 [inter-quartile range 2-6] on a Numerical Rating Scale [NRS]. 61 (5.2%)
women experienced at least moderate average pain intensity (NRS ≥ 4). Among those with chronic pelvic pain,
experiences of pain interfered with daily life “all the time” in 5.0%, “sometimes” in 72.3%, and “not at all” in
22.7%. Moreover, women with chronic pelvic pain more frequently reported pain during intercourse than
pain-free controls (p = 0.00). Potential risk factors for chronic pelvic pain were age, country of birth, selfreported pelvic diseases, and former pelvic trauma or surgery (p < 0.05). No association was found between
chronic pelvic pain and selected socioeconomic factors (residence, education, occupation, and cohabitation).
Subgroup analyses excluding cases with only mild pain (≤ 3 NRS) resulted in similar pain characteristics and
associated risk factors for chronic pelvic pain.
Discussion and conclusion: Female chronic pelvic pain appears highly prevalent in Denmark. Although the
reported prevalence is based on 48% of the invited sample, drop-out analyses found that respondents did not
deviate from non-respondents. Therefore, we considered the reported 11% prevalence rate representative for
the total sample and generalisable to the general female population in Denmark.
9
Combination of pelvic floor biofeedback with electric stimulation can improve chronic pelvic pain, lower
urinary tract symptoms and sexual dysfunction in patients with Interstitial Cystitis/Bladder Pain Syndrome
(IC/BPS) – 1 year follow-up
Ming-Huei Lee1, 2, Wei Chih Chen 1, Chiu-De Chiu3, 4, Huei-Ching Wu1, 2, Hsiu-Ming Lin 1
1
Department of Urology, Feng-Yuan Hospital, Department of Health, Taichung, Taiwan
2
Central Taiwan University of Science and Technology, Taichung, Taiwan
3
Department of Psychology, National Taiwan University, Taipei, Taiwan
4
Unit of Clinical, Health, and Neuro Psychology, Institute of Psychology, Leiden University, Netherlands
Introduction & objectives: In recent years, female sexual dysfunction (FSD) has become a popular research
area because of the importance of sexual function in determining quality of life. Recent research showed that
75% of patients with IC/BPS reported exacerbation of their urinary and pain symptoms following sexual
activity. Moreover, most of IC/BPS patients have hypertonic pelvic floor muscle dysfunction (HTPFD) which can
be closely associated with sexual dysfunction. Other studies suggested that transvaginal biofeedback (TVBF)
and transcutaneous electric nerve stimulation (TENS) reported a short-term effect on the patients with urinary
urgency with frequency and pelvic floor muscle spasm. The aim of this study was to investigate the
effectiveness and different regimen of combination of TVBF plus TENS for a follow-up of 12 months in patients
with IC/BPS.
Material & methods: A total of 56 IC/BPS female patients compatible with the NIDDK criteria were included in
this study. Among the patients, 28 were assigned to TVBF plus TENS for one month group (Group-1), 12 were
assigned to TVBF plus TENS for 2 months group (Group -2), and 16 were assigned to TVBF plus TENS for 3
months group (Group-3). All patients were treated by TVBF 2 times daily and TENS 2 times a week. After the
treatment, all patients were followed up for one year and O'Leary-Sant Symptom (ICSI) and Problem Index
(ICPI), bladder pain visual analogue scale (VAS), bladder urgent score, Global response assessment (GRA), and
self-report sexual activity were collected at baseline, 3rd month, 6th month, 9th month, and 12th month. We
compare the clinical results and response at different follow-up time in each three groups.
Results: Patient demographics showed the average age of Group-1, Group-2, and Group-3 was 35.1(20-60),
36.6(23-53), 40.1(21-63) year-old respectively. Subjective symptoms including ICSI, ICPI, VAS, and urgency
score all decreased significantly after TVBF plus TENS therapy in each three groups at 3rd month, 6th month,
9th month, 12th month compare to baseline (p<0.05). GRA rate in each three groups was 71%, 70%, 40% at
12th month respectively. Statistically significant increase of self-report sexual activity was noted at 12th month
compare to 3rd month (84% v 77%, 75% v 70%, 83% v 40%). However, there was little adverse effect including
intravaginal discomfort (n=8) and urinary tract infection (n=5).
Conclusions: The combination of TVBF plus TENS provided a benefit effect on irritative symptoms, pelvic pain,
and sexual activity with little adverse effect. Because there was no difference in each three groups, therapy
with TVBF plus TENS for 1-2 months is safe and effective in the improvement of clinical symptoms except for 3
months due to lower GRA score. The therapeutic effect could last for 12 months and it seems to be one good
choice of conservative treatment.
10
Outcomes of pelvic muscle training under biofeedback control in non-inflammatory chronic pelvic pain
syndrome in males
P.V. Glybochko, Yu.G. Alyaev, A.Z. Vinarov, Yu.L. Demidko, S.A. Myannik, L.S. Demidko, M.V. Epifanova
First Moscow Medical State University I. M. Sechenov, Research institute of Uronephrology and Reproductive
Health, Moscow, Russia
Introduction & objectives: The use of pelvic muscle training pertains largely to treatment recommendations
for chronic pelvic pain syndrome. The close proximity of pelvic organs and muscles to each other, the common
sources of nervous input, blood supply and the presence of reflex connections allow one to impact on the
source of pain. All the more so as not infrequently the pain may emanate from the involuntarily controlled
pelvic floor muscles.
Real-time biofeedback enables better control to be exercised over the pelvic muscles while boosting the
effectiveness of training sessions. The authors have studied the efficacy of pelvic muscle training under
biofeedback control in non-inflammatory chronic pelvic pain syndrome.
Materials & methods: Between 2008 and 2012 we have employed the pelvic muscle training system under
EMG biofeedback control in 15 patients who were diagnosed with non-infammatory chronic pelvic pain .The
median age of patients was 27 (range: 21-69) 1 years. Duration of complaints -3 (1-7) years. Causes of pain due
to infection, tumors or neurological conditions in this group of patients were ruled out. All patients answered
the NIH- CPSI questionnaire before commencing treatment and three months after therapy. As supportive
care all patients were recommended to have their pelvic floor muscles trained under biofeedback control. The
effectiveness of pelvic floor muscle exercises and the state of pelvic muscles were monitored using a rectal
EMG sensor.
Results: Initially the NIH-CPSI scale score in the group was 25 (15-33). All patients exhibited instability of pelvic
floor muscles. According to total EMG data, fluctuations in the amplitude of the EMG signal (deviation) were
in excess of 15 percent. In 7 patients (46.7%) higher deviation was observed during both contraction and
relaxation, in 5 patients (33.3%) during relaxation and in 3 patients (20%) during contraction. The duration of
pelvic floor muscle training with biofeedback control was 3 months. After completion of treatment the NIHCPSI score totaled 16 (11-22). A significant decrease was observed in the severity of symptoms (р=0,001) 2.
Moreover, deviation of the EMG signal produced by the pelvic floor muscles tended to decrease both in
contraction (р=0.240) and relaxation (р=0.277).
Conclusion: Training pelvic muscles with biofeedback control offers the possibility of reducing the intensity of
symptoms in non-inflammatory chronic pelvic pain syndrome. There is also observed a reduction in pelvic floor
instability as evidenced by total EMG data. The present method provides a means to increase the effectiveness
of treatment of chronic pelvic pain syndrome and also to ascertain one of its underlying causes – pelvic floor
muscle instability.
1
2
The median, 5th, and 95 th percentiles are shown
The Mann-Whitney test was applied
11
Women with chronic pelvic pain secondary to myofascial abdominal pain syndrome present
electromyographic signals at trigger points that could predict clinical response to treatment with injection of
local anesthetic
Chamochumbi C.C.M.1, Pitanguy M. 1, Máximo M. 1, Toscano P.2, Marques Junior W. 2, Rosa-e-Silva J.C.1,
Francisco José Candido-dos-Reis F.J.1, Nogueira A.A.1, Poli-Neto O.B.3
1
Department of Gynecology and Obstetrics, Faculty of Medicine of Ribeirão Preto, University of São Paulo,
Ribeirão Preto, Brazil
2
Department of Neurology, Psychiatry and Medical Psycology, Faculty of Medicine of Ribeirão Preto, University
of São Paulo, Ribeirão Preto, Brazil
3
3Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão
Preto, Brazil
Introduction & objectives: Chronic pelvic pain (CPP) is a highly prevalent condition with negative impact on
the quality of life and productivity of women. The aim of this study was to investigate the pattern of needle
electromyography at trigger points in the rectus abdominis muscle in women with CPP secondary to
abdominal myofascial pain syndrome (AMPS) and to verify any association pattern obtained with response to
treatment with local injection of anesthetic.
Materials & methods: The study included 26 women with CPP secondary to AMPS exclusively to the
examination of needle electromyography at abdominal trigger points. All women underwent local anesthetic
injection at the first consultation, and clinical improvement was considered standard to confirm the origin of
somatic pain. We performed needle electromyography for capturing the electrical activity of the lower rectus
abdominal muscle, collected both in the trigger point and in a normal contralateral region the week after the
first injection with anesthetic and immediately before the next injection. The electromyographic examination
was performed during the resting phase and during voluntary muscle contraction of the muscle. All women
underwent the same clinical protocol of local injection of 2 mL of 2% lidocaine without vasoconstrictor for 4
consecutive weeks and were reassessed a week after the end of the sessions. The study was approved by the
local Research Ethics.
Results: We observed two main patterns of electromyography to record the trigger points. One group (A) with
electromyographic changes was composed of 14 women with a mean age of 41.8 ± 10.1 years and a group (B)
with normal electromyography composed of 12 women with a mean age 37.1 ± 10.9 years. Thirteen women in
group A responded very well to treatment (complete or significant improvement of pain), while only six
women in group B responded satisfactorily (p = 0.02*). The mean visual analogical scale (VAS) pre-treatment
for Group A was 70.6 and 1 week after the end of treatment was 32.8, with a decrease of 53.5% in pain score
compared to pre-treatment, whereas for the average VAS pre-treatment for Group B was 59.2 and 47.3 a
week after completion of treatment, a reduction of 20.1% in the pain score relative the pre-treatment value.
Conclusion: Electromyography can be a useful auxiliary tool in objective identification of distinct
pathophysiological events within a clinically similar group of women, besides providing useful information in
predicting clinical response to treatment with local anesthetic injection in this clinical condition. More studies
on the pathophysiology of AMPS are needed to ensure that appropriate workup in this heterogeneous group
of women.
12
Pelvic floor complaints, gynaecologic problem, orthopaedic problem or both?
JP. Van Wingerden, S. Siegers, I. Ronchetti
Spine & Joint Centre, Rotterdam, The Netherlands
Introduction: The medical world is subdivided in specialisms, allowing to develop in-depth knowledge on
specific pathology and/or areas of the human body. However structures, organs and tissues of the human
body usually have multiple functions which often transcend one single specialism. The pelvic floor preeminently is such structure. Besides the uro-genital functions this complex part of the body also has an
important task in contributing to the integrity and stability of the pelvic joints (Apte 2012). While pelvic floor
complaints mostly are attributed to gynaecological problems the orthopaedic options are underexposed or
even ignored (Stuge 2012).
Objectives: The objective of this study is to demonstrate that the cause of pelvic floor complains not
necessarily has to lie in the gynaecological field.
Material and methods: From the regular patient population of a Dutch outpatient rehabilitation clinic,
specialized in chronic low back and pelvic pain, a sample of 1636 patients was taken from a random period.
Patients with low back, pelvic girdle pain and combined pain were selected as follows:
Pelvic pain: Active straight Leg raise(ASLR)> 3, Posterior pelvic pain provocation (PPPP) >1 and pain located
only in the pelvic area.
Back pain: ASLR<= 3, Posterior pelvic pain provocation (PPPP) <=1 and pain located low back area.
Combined: ASLR> 3, PPPP >1 and pain located in both the pelvic and low back area.
Groups were compared on the occurrence of pelvic floor complaints, without specification.
Results: Final analysis was performed on 1255 patients (348 male, 907 female). 381 patients were omitted
because they did not meet the criteria or had incomplete data.
Pelvic floor %
Females(n)
Ø
+
Pelvic
177
37
63
Low back
387
61
39
Combined
343
43
57
Ø = no pelvic floor complaints, + = pelvic floor complaints
Males(n)
2
279
67
Pelvic floor %
Ø
+
50
50
76
24
64
26
Discussion and conclusion: The results of this inventory show that in low back and pelvic pain patients, not
only woman, but also men significantly suffer from pelvic floor problems. In woman the incidence is higher
than in woman without low back or pelvic complaints (Weijenborg 2009). Another finding is that pelvic floor
problems not only occur in pelvic girdle pain but also in back pain patients. A limitation of this study is that we
were not able to determine any cause-effect relationship. This will be the focus of next studies.
This study underpins that to comprehend the etiology of pelvic floor problems it is inevitable that we look
beyond the boundaries of medical specialisms. Pelvic floor problems can be caused by gynaecological factors,
but just as well by orthopaedic problems. In addition, altered pelvic floor function as a result of pathology in
one area, may secondary cause problems in another area. For example, a hyperactive pelvic floor as a result of
diminished control over the sacroiliac joints may trigger urinary duct infections. From this perspective there
lies a huge field of knowledge to be explored.
13
Impact of partner responses on pain intensity in women with provoked vestibulodynia and their partners: A
dyadic daily experience study
Rosen, N. O.1,2, Bergeron, S.,3 Sadikaj, G.4, Glowacka, M.1, Delisle, I.2, & Baxter, ML.5
1
Dalhousie University, Department of Psychology and Neuroscience, Halifax, Canada; 2IWK Health Centre,
Department of Obstetrics and Gynecology, Halifax, Canada; 3Université de Montréal, Department of
Psychology, Montréal, Canada; 4McGill University, Department of Psychology, Montréal, Canada; 5QEII Health
Sciences Centre, Department of Dermatology, Halifax, Canada
Introduction & objectives: There is a paucity of research investigating the role of interpersonal variables in
provoked vestibulodynia (PVD) – a prevalent, recurrent, vulvo-vaginal pain condition elicited via pressure to
the area. PVD negatively affects all aspects of women’s sexual health, including sexual desire, arousal, orgasm,
and satisfaction, as well as their emotional well-being and intimate relationships. Cross-sectional studies to
date have shown that partner responses to painful intercourse are associated with the pain experienced by
women with PVD. Partner responses can be solicitous (demonstrations of attention and sympathy), negative
(demonstrations of hostility and frustration), and facilitative (expressing encouragement of adaptive coping).
Higher solicitous partner responses have been found to be associated with higher levels of vulvo-vaginal pain
intensity, whereas higher facilitative partner responses are associated with lower pain intensity (Rosen et al.,
2010; 2012). It is likely that partner responses and pain experiences vary considerably across interpersonal
interactions. No studies have established the influence of partner responses in the daily lives of women with
PVD and their partners, in order to better capture the complexity of these interactions, and reduce recall
biases. The objective of this study was to examine the within-person associations between partner responses –
assessed from the perspective of both the woman and her partner – and women’s pain during intercourse.
Materials & methods: Using daily diaries, 69 women (M age = 27.91, SD = 5.94) diagnosed with PVD and their
cohabiting partners (M age = 30.00, SD = 8.33) reported on solicitous, negative, and facilitative partner
responses on days when sexual intercourse occurred (M = 5.85, SD = 5.60) over eight weeks. Women also
reported their vulvo-vaginal pain intensity on a horizontal analog scale assessing the intensity of their pain
during intercourse. Drawing on the Actor-Partner Interdependence model (APIM), a multivariate multilevel
modeling approach was adopted.
Results: A woman’s pain during intercourse increased when she perceived greater solicitous (β = .06, t(797) =
3.26, p < .01) and negative (β =.22, t(797) = 4.23, p < .0001) partner responses, and when her male partner
reported greater solicitous (β =.09, t(797) = 4.34, p < .0001) and lower facilitative (β = -.04, t(797) = -2.51, p <
.05) partner responses.
Conclusion: Findings suggest that facilitative partner responses may reduce pain whereas solicitous and
negative responses may increase it in the everyday sexual interactions of women with PVD and their partners.
Targeting partner responses may enhance the quality and efficacy of interventions aimed at reducing the pain
experienced by women with PVD.
14
Childhood abuse among women with chronic pelvic pain
Tawasha K.A.S., Silva A.P.M., Pazin C., Moriyama A., Hisano M.K., Rosa-e-Silva J.C., Reis F.J.C., Nogueira A.A.,
Romão A.P.S., Poli-Neto O.B.
University of São Paulo, School of Medicine of Ribeirão Preto, Dept. of Obstetrics and Gynecology, Ribeirão
Preto, Brazil
Introduction & objectives: Chronic pelvic pain (CPP) is a clinical condition with high prevalence rate, which is
associated to several comorbidity conditions and unfavorable marital, social and economical impact. There are
evidences that painful chronic syndromes may be related to history of sexual and/or physical violence and
abuse. The objective of this study was to assess childhood abuse and maltreatment histories in women who
suffer from CPP and to verify the association with mood disorders.
Materials & methods: Cross-sectional study including 57 women complaining of CPP who were assisted
consecutively at the University Hospital in Ribeirão Preto, and 58 healthy women assisted at the Community
Medical Center in Ribeirão Preto, Brazil. The analysis instruments were: Epidemiological and clinical data
protocol, Rating Scale for Hospital Anxiety and Depression (HAD) and Childhood Trauma Questionnaire (CTQ).
The statistical analysis was performed at JMP-10 software. The Wilcoxon rank sum test was performed to
evaluate the media differences, considering non-parametric distribution by Kolmogorov-Smirnov. The Fisher’s
exact test or the X2 test was used to perform the comparative analysis of the qualitative variables. The
Spearman’s rank correlation coefficient was used to correlate CTQ domains and HAD scores, being alpha of .05
as significant.
Results: We did observed differences in scores of childhood abuse and maltreatment hystories among women
suffering from CPP and healthy subjects (Table 1). However, there was a direct correlation between the CTQ
and HAD scores (Table 2).
Table 1. Clinical characteristics of the subjects.
Age
Healthy
CPP
P
33.8±7.6
37.2±7.7
.02*
Parity
1 (0-9)
1 (0-5)
NS
BMI
26.0±5.6
27.1±5.2
NS
Age of first intercourse
17.5±2.2
17.4±3.7
NS
Number of partners
1.5 (1-10)
2.0 (1-15)
NS
CTQ total
39.8±16.1
43.8±18.0
NS
CTQ PN
7.7±3.5
8.4±3.4
NS
CTQ EN
9.6±4.9
11.2±5.8
NS
CTQ SA
6.2±2.7
6.3±3.5
NS
CTQ PA
7.7±4.4
8.2±4.3
NS
CTQ EA
8.7±4.4
9.7±5.2
NS
HAD-depression
5.9±4.3
7.9±4.6
.02*
HAD-anxiety
7.3±4.6
8.9±4.9
NS
Notes: CPP: chronic pelvic pain; BMI: Body Mass Index; CTQ:
Childhood Trauma Questionnaire; PN: Physical Neglect; EN: Emotional
Neglect; SA: Sexual Abuse; PA: Physical Abuse; EA: Emotional Abuse;
HAD: Scale for Hospital Anxiety and Depression; *P<.005
Table 2. Correlation between childhood abuse and mood disorders.
Healthy
HAD anxiety x
HAD depression x
CTQ total
CTQ PN
CTQ EN
CTQ SA
CTQ PA
CTQ EA
CTQ total
CTQ PN
CTQ EN
CTQ SA
CTQ PA
CTQ EA
CPP
Spearman’s
ρ
P
Spearman’s
ρ
P
.41
.13
.41
.31
.33
.33
.51
.35
.50
.27
.45
.32
.0016*
NS
.0015*
.0195*
.0107*
.0121*
<.0001*
.0067*
<.0001*
.0390*
.0004*
.0133*
.52
.41
.42
.24
.42
.55
.48
.41
.32
.34
.47
.44
<.0001*
.0014*
.0011*
NS
.0012*
<.0001*
.0001*
.0014*
.0139*
.0002*
.0006*
<.0001*
Notes: CPP: chronic pelvic pain; HAD: Scale for Hospital Anxiety and Depression; CTQ:
Childhoood Trauma Questionnaire; PN: Physical Neglect; EN: Emotional Neglect; SA: Sexual
Abuse; PA: Physical Abuse; EA: Emotional Abuse; *P<.005.
Conclusion: The history of childhood abuse alone does not appear to be an independent risk factor for
development of CPP. However, the association with mood disorders and how the subjects deal with this
condition seems to be more important. More studies should be directed to clarify this point.
Keywords: chronic pelvic pain, sexual abuse, child neglect and mood disorders.
15
The need of holistic care in women with Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) who have
child abuse experience and psychiatric troubles
Wei Chih Chen 1, Ming-Huei Lee1, 2, Chiu-De Chiu3, 4, Huei-Ching Wu1, 2, Hsiu-Ming Lin 1
1
Department of Urology, Feng-Yuan Hospital, Department of Health, Taichung, Taiwan
2
Central Taiwan University of Science and Technology, Taichung, Taiwan
3
Department of Psychology, National Taiwan University, Taipei, Taiwan
4
Unit of Clinical, Health, and Neuro Psychology, Institute of Psychology, Leiden University, Netherlands
Introduction & objectives: IC/PBS is a chronic disease of uncertain etiology that is characterized by urgency,
frequency, and suprapubic pain related to bladder filling. Early stressful experience, such as childhood sexual
maltreatment, has been considered as an environment risk factor for IC/PBS. However, some reported higher
incidence of child sexual abuse; Still others observed higher incidence of physical and emotional abuse. The
measurement issue may affect the prevalence rates estimated. It also hampers the evaluation of the role of
this environmental factor in IC/BPS and its impacts on the symptoms manifestation and psychiatric functions.
Applying a standardized instrument, we reexamine the prevalence of a broad range of potentially traumatizing
events in women with IC/BPS. Furthermore, we investigate their effects on the symptoms severity of IC/BPS
and psychiatric symptoms including negative affects (i.e., anxiety and depression) and trauma-related
symptoms (i.e., dissociation).
Material & methods: This was a prospective case control study. Of 74 female patients who were compatible
with the NIDDK criteria were included and 201 Taiwanese college students who was selected randomly served
as controls. Standardized self-report instruments, Chinese Brief Betrayal-Trauma Survey (BBTS) questionnaire
was used to measure the prevalence of diverse potentially traumatic experiences in childhood. The BBTS
differentiates the high and low levels of social impacts, in terms of betrayal, of those interpersonal traumas.
Three self-report instruments, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Somatoform
Dissociation Questionnaire (SDQ) were administered for the psychiatric functions. These data were analysed
using simple and multiple regression analyses.
Results: Patient demographics show the average age being 40.34 years (+/- 9.6). The prevalence of physical
attack and emotional maltreatment by someone close to the patients showed 17% and 26% compared to
control groups, 9% and 12% respectively. A higher proportion of patients with IC/PBS reported a history of
emotional and physical abuse than controls (P<0.001) (Table 1). Correlation analysis with simple and multiple
regression coefficients and t value showed positive correlation between depression and high betrayal trauma,
4.01 (+/-4.45). There was no association between traumatic experience and anxiety and somatoform
dissociation.
Conclusions: Our result showed that women with IC/PBS endorsed higher incidences on various traumatic
experiences except for sexual maltreatment in childhood. Moreover, positive correlation between female
patients with interstitial cystitis with a history of abuse and depression was also noted. Our results imply us
that single treatment could not achieved expectation of patients due to complicated psychological troubles.
Mutidisciplinary approach and multimodal therapy should be considered for holistic care in IC/PBS patients.
Table 1
The prevalence of potentially traumatizing events in Taiwanese patients with IC and Taiwanese
undergraduates
Women
Female
with IC/PBS
Undergraduates
(N = 74)
(N = 201)
High betrayal Trauma
Witnessing people being attacked
Witnessing people attacking others
15%
06%
17%
07%
Physical maltreatment
17%
09%
Sexual maltreatment
08%
05%
Emotional/psychological maltreatment
26%
12%
21%
11%
Traffic accident
21%
12%
Witnessing people being attacked
13%
12%
Physical attack
10%
12%
Sexual maltreatment
07%
06%
Low betrayal trauma
Natural disaster
16
Adaptation of instrument Patient Satisfaction Questionnaire (PSQ) for women with chronic pelvic pain
Souza P.P.1, Romão A.S. 1, Rosa-e-Silva J.C.1, Candido-dos-Reis F. 1, Nogueira A.A. 1, Poli-Neto O.B.2
1
Department of Gynecology and Obstetrics, Faculty of Medicine of Ribeirão Preto, University of São Paulo,
Ribeirão Preto, Brazil
2
Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão
Preto, Brazil
Introduction & objectives: Chronic pelvic pain (CPP) is a clinical condition whose pathophysiology is not
completely understood and, consequently, the treatment options are unsatisfactory, causing dissatisfaction of
women with their own and her medical team. Elements of doctor-patient interaction influence on the
satisfaction of both and, consequently, on the response to therapy, including pain levels. Thus, it is essential to
use a tool that explores the professional and user satisfaction in relation to health care. In the absence of a
validated tool for the Portuguese this study aims to adapt and validate the instrument Patient Satisfaction
Questionnaire (PSQ) from English to Portuguese in a population of women with DPC. The study was approved
by the local Research Ethics.
Materials & methods: The study included 50 women with CPP in the outpatient clinic and 50 physicians
responsible for their care, who fill separately the instrument in rooms of the clinic after medical consultation
and 20 days after it was applied again for the women. The methodological procedure involved two steps:
translation and semantic analysis followed by analysis of the psychometric properties of the instrument
through the validity of the construct correlate; discriminative validity, reliability and exploratory factor
analysis.
Results: The Cronbach's alpha shows good internal reliability with α=0.72 in groups of women and doctors. In
exploratory factor analysis the results showed no allocation or rotation allocation of items in both groups,
indicating a single factor-structure to the instrument. In the test-retest was used the correlation coefficient
intra-class and the Pearson correlation coefficient, with confidence interval (ICC) [0.53 to 0.82] and r=0.71. On
checking the validity of the construct correlate used the Pearson correlation coefficient, with significant
negative correlation of low intensity for PHQ-9 (r=-0.34 p=0.02*) and negative correlation of reasonable
intensity for IDATE-E (r=-0.47 p=0.001*). In the discriminative validity for IDATE t=1.82 p=0.08* and for PHQ-9
t=1.93 p=0.06*, these results showed a strong tendency to the groups without anxiety and without depression
have higher values of QSP. The discriminative validity for sociodemographic variables was significant for race
(t=2.16 p=0.04*) and education (t=2.87 p=0.006*) in which Caucasians person and who completed education
high school have higher values of QSP.
Conclusion: The Portuguese version of the PSQ shows good levels of reliability and validity. The fact that
higher levels of education are associated with greater satisfaction between women is relevant and shows that
a better understanding of the disease provides individuals more satisfied and can generate positive results in
the interaction physician-patient, and, consequently, to the treatment of these women.
17
Psychological mechanisms contributing to the etiology and maintenance of Chronic Pelvic Pain Syndrome
(CPPS) in men
Riegel B., Brünahl, C., Löwe, B.
University Medical Center Hamburg-Eppendorf, Dept. of Psychosomatic Medicine and Psychotherapy,
Hamburg, Germany
Introduction & objectives: Chronic Pelvic Pain Syndrome (CPPS) is a disease that causes severe morbidity.
Despite the high prevalence of CPPS, the etiology and maintenance of CPPS is not yet well understood. In
recent years research has focused on the somatic causes of the disease, while psychological factors have
received marginal attention. Such a focus on somatic causes is also reflected in the existing therapeutic
approaches. Despite intensified research efforts in the last two decades, there are no successful sustained
treatment strategies which have been confirmed in the literature.
Materials & methods: We conducted a literature search in several databases (medline, psychindex, psychinfo)
to identify experimental, psychotherapy, case-control and epidemiological studies which include psychological
aspects as outcome data. PRISMA criteria were used as guidelines and the review was also registered in
PROSPERO (registration number: CRD42013003160).
A total of 1083 publications were found and were reduced to 71 after abstract-screening for psychological
factors. The full-text-analysis reduced the number of studies to 41.
Results: Overall results suggest an apparent lack of research into the psychological aspects of CPPS in men. In
the studies that do address psychological factors, diagnosis and underlying factors were collected using
inappropriate instruments or data collection involved only screening procedures.
We found some psychological co-morbidities (e.g. depression, anxiety disorders and sexual disorders) as well
as further psychological factors (e.g. pain catastrophizing, self-efficacy, social interaction and quality of life) are
associated with CPPS in men.
Conclusion: There is an apparent lack of scientific research in the psychological contributions to the etiology
and maintenance of CPPS in men. Studies which address such factors show that psychological factors seem to
play an important role for the understanding of CPPS. More research is necessary to further improve
understanding and to tailor interventions to this patient group.
18
Movement methods in dysmenorrhea
Jachacz-Lopata M.1, Milka D.2, Gazdzik T.3, Bajor G.2
1
Department of Physiotherapy, Medical University of Silesia, Katowice, Poland
2
Department and Institute of Human Anatomy, Medical University of Silesia, Katowice,
Poland
3
Department of Orthopaedics and Traumatology, Jagiellonian University, Medical College,
Cracow, Poland
Introduction and objectives: Menstrual pain is a common problem among women that affect their activities,
such as work or studying. Beyond conventional dysmenorrhea non-steroid anti-inflammatory therapy or soft
tissue therapy (for instance osteopathy or manual therapy) the simple and accessible methods are still
underestimated. To manage primary dysmenorrhea selected exercises from pilates, yoga and Feldenkreis
method have been used. Exercise program was conducted by physiotherapist and based on fascial release,
improving pelvic blood supply and relaxing the abdominal. The objective of this research is to study the effects
of movement program conducted before and during menstruation.
Material and methods: The study included 70 women aged 23-35 (x=29 ± 2,4) who were randomly assigned in
two groups. Active group (n=35) implemented adjusted to current menstrual phase exercises in their daily
activity. Program differed especially during luteal and premenstrual phase. During menstruation relaxation and
analgesic poses have been done. Program was realized once a day for the three following cycles.
Questionnaire contained Visual Analogue Scale and was based on McGill Pain Questionnaire. Pain was
measured in the first, second and third day of each cycle. Control group (n=35), completed questionnaire on
the same days. Data were analyzed using Statistica StatSoft software and tested using chi-square and student’s
t-test.
Results: The results showed that exercise program had significant impact on pain relief in the second and third
cycle (p less than 0.01) in the active group. Results in the first cycle were similar in both groups. The average
level of pain before starting the program was approximately 6,8 in both groups. After following cycles results
started to differ slightly with final pain evaluation in active group about 3 (x=3,1) and in the control group
without significant difference (x=6,7).
Conclusions: Women who included daily exercises focused on releasing abdominal and pelvic tension, noticed
substantial pain ailments relief in premenstrual period and lower level of menstrual pain. The effects should be
observed for the next months to assess long-term results. The pain relief achieved after second cycle and held
up during third cycle suggests that moderate release exercises are useful in treating dysmenorrhea.
19
Effectiveness of ultrasound therapy in combination with manual therapy and lower back exercises for
sacroiliac joint pain
R.A.D.W.U. Jayawardana 1, A.A.J.R. Rajarathne2
1
Department of Physiotherapy, Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka,
2
Department of Physiology, Faculty of Medicine, University of Peradeniya, Sri Lanka
Introduction and objectives: Sacroiliac joints (SI joints) are formed by the connection of sacrum and two iliac
bones. There is relatively less motion at the sacroiliac joints. These joints support the entire weight of the
upper body causing large amount of stress across them. Many causes like degenerative arthritis, pregnancy,
rheumatoid arthritis, ankylosing spondylitis and pathological gait patterns can create sacroiliac joint pain.
Ultrasound is a commonly used electrotherapeutic modality for sacroiliac joint pain.
The aim of this study was to find out whether ultrasound therapy has an added effect when combined with
manual therapy and lower back exercises in the physiotherapy management of patients with SI joint pain to
increase range of motion and reduce pain.
Materials and methods: Patients with sacroiliac join pain in the acute and sub-acute stages were recruited to
the study. They were divided into two groups. Both the groups received manual therapy and lower back
exercises, whereas only the intervention group received ultrasound therapy in addition. Patients were treated
for three weeks and the outcome measures were VAS for pain, and lumbar ROM.
Results: 13 participants from the control group and 13 participants from the intervention group completed the
study. Both groups show significant improvement after treatment. Intergroup comparisons for VAS, and ROM
show no significant difference before and after the treatments.
Conclusion: Ultrasound therapy has no added effect when combined with manual therapy and lower back
exercises for SI joint pain.
KEY WORDS; Sacroiliac joint, manual therapy, ultrasound therapy, lower back exercises, visual analogue scale
(VAS), lumbar range of motion (ROM).
20
Sexual and relationship intimacy in women with persistent genito-pelvic pain and their partners:
Associations with sexual satisfaction, sexual function, anxiety and pain self-efficacy
Bois, K. ¹, Bergeron, S. ¹, Rosen, N.O. ², Hainault, V-A¹
¹ Department of Psychology, Université de Montréal, Montréal, Qc, Canada
²Department of Psychology, Dalhousie University, Halifax, Nova Scotia, Canada
Introduction & objectives: Provoked vestibulodynia (PVD) is the most frequent subtype of dyspareunia,
affecting 12% of premenopausal women (Harlow, & Stewart, 2003) and negatively impacting their romantic
and sexual relationships. Recent research has highlighted the importance of examining interpersonal factors
such as intimacy, and of including both women and their partner in study designs (Bergeron, Rosen & Morin,
2011; Cano & Williams, 2010). However, most studies in the area of pelvic pain have investigated intraindividual variables and neglected the interpersonal component of this pain problem. Also, the few studies to
date adopting a dyadic perspective have excluded the affective dimension by focusing primarily on the
cognitive-behavioral aspects of relationships. Nevertheless, findings show that partners’ responses to the pain
are associated with sexual satisfaction and pain intensity among women with PVD (Rosen, Bergeron, Leclerc,
Lambert, & Steben, 2010) and suggest that the partner may play an important role in the modulation of pain
and associated sexual difficulties. The present study aimed to investigate sexual and relationship intimacy
using The Interpersonal Process Model of Intimacy (Reis & Shaver, 1988) in women with PVD and their
partner.
Materials & methods: Couples (N = 91) completed self-report questionnaires about sexual intimacy,
relationship intimacy, sexual satisfaction, sexual function, anxiety, pain self-efficacy and pain intensity.
Dependent measures were the 1) Global Measure of Sexual Satisfaction Scale, 2) Female Sexual Function
Index, 3) State-Trait Anxiety Inventory, 4) Painful Intercourse Self-Efficacy Scale, 5) Visual Analog Scale.
Results: Hierarchical regression analyses were conducted. After controlling for women’s age, results showed
that 1) higher women’ sexual (ß = 0.24, p = 0.05) and relationship intimacy (ß = 0.54, p = 0.003) were
associated with higher sexual function among women and 2) higher women’s sexual intimacy was associated
with her higher sexual satisfaction (ß = 0.49, p < 0.001), higher pain self-efficacy (ß = 0.39, p = 0.001) and lower
anxiety (ß = 0.44, p = 0.001), above and beyond the effects of partners’ sexual and relationship intimacy.
Women and partners’ sexual and relationship intimacy were not associated with pain.
Conclusion: Findings were in line with our hypothesis and indicate that promoting sexual and relationship
intimacy in interventions is potentially beneficial to decreasing the negative consequences associated with
persistent genito-pelvic pain and foster the sexual well-being of women with PVD. On a theoretical level, it
may be relevant to move beyond a behavioural perspective to incorporate affective aspects of romantic
relationships such as intimacy in the study of pelvic pain.
21
An interdisciplinary framework for the management of women with vaginismus
Claudia Brown, PT, B.Sc.1,2, Nicol Korner-Bitensky, OT, Ph.D.1,2, Yitzchak M. Binik, Ph.D.3,4,5, Samir Khalifé,
M.D.3,5,6, Marie-Andrée Lahaie, Ph.D.3, Talli Y. Rosenbaum, PT, M.Sc.7
1
School of Physical and Occupational Therapy, McGill University; Montreal, Canada
2
Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR); Montreal, Canada
3
Laboratory for the Biopsychosocial Study of Sexuality; Montreal, Canada
4
Department of Psychology, McGill University; Montreal, Canada
5
MUHC – Royal Victoria Hospital; Montreal, Canada
6
Jewish General Hospital; Montreal, Canada
7
Private Practice, Jerusalem, Israël
Introduction & objectives: In 2012, much discussion evolved around the conceptualisation of vaginismus as a
genito-pelvic pain/penetration disorder. Vaginismus is characterised by persistent or recurrent difficulty in
allowing vaginal penetration, in spite of an expressed desire to do so. The estimated prevalence of vaginismus
is 0.5-1% in the general community, and 5-17% of referrals for female sexual dysfunction. Current
recommendations for the management of vaginismus encourage the use of a multi-modal, multidisciplinary
approach. The benefits of collaborative practice have been proven in the management of many health
conditions, and the advantages of interdisciplinary management are believed to outweigh those of
multidisciplinary management. Almost no literature is available on the collaborative approach to vaginismus
nor on the operationalization of such an approach. The objective of this study was to establish preliminary
international recommendations for best-practice interdisciplinary management of women with vaginismus.
Materials & methods: A 2-fold methodological approach was used. First, an international multidisciplinary
meeting of expert health professionals was held, to establish initial recommendations for the interdisciplinary
management of women with vaginismus. Next, a two-round Delphi electronic survey of expert health
professionals (who had not been involved in the expert meeting) was undertaken, to validate these
recommendations and gather more information on the topic. Each participant had to be recognised by his
peers as a knowledgeable source on the topic of vaginismus, and have at least one of the following: a) clinical
experience in the treatment of at least 10 cases of vaginismus in the past 2 years; b) published professional
papers on the topic area; c) initiated research on the topic area with publication expected in the near future.
15 experts participated in the group meeting, 18 in the Delphi survey.
Results: Qualitative and quantitative analysis led to a list of recommendations for best-practice
interdisciplinary management of women with vaginismus, to include team make-up and coordination, goals of
interdisciplinary collaboration and team functioning, elements in a comprehensive patient assessment,
intervention availability, and patient involvement.
Conclusion: Because vaginismus involves significant physical and psychological components, it follows that the
approach to management would require more than one discipline. Interdisciplinarity would optimize this
approach. Education of the medical health professional on the psychological approach and of the mental
health professional on the physical approach may facilitate more integrated management. Interdisciplinary
intervention studies are needed to address the multi-faceted approach to vaginismus.
References:
 Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database of Systematic Reviews
2012, Issue 12. Art. No.: CD001760. DOI: 10.1002/14651858.CD001760.pub2.
 Lahaie MA, Boyer S, Amsel R, Khalife S, Binik Y (2010) Vaginismus: a review of the literature on the
classification/diagnosis, etiology and treatment. Women’s Health 6(5)
 Enhancing Interdisciplinary Collaboration in Primary Health Care Initiative www.eicp-acis.ca, March 10,
2006
22
Sexual dysfunction is associated with chronic pelvic pain in patients with Interstitial Cystitis/Bladder Pain
Syndrome (IC/BPS)
Ming-Huei Lee1, 2, Wei Chih Chen 1, Chiu-De Chiu3, 4, Huei-Ching Wu1, 2, Hsiu-Ming Lin 1
1
Department of Urology, Feng-Yuan Hospital, Department of Health, Taichung, Taiwan
2
Central Taiwan University of Science and Technology, Taichung, Taiwan
3
Department of Psychology, National Taiwan University, Taipei, Taiwan
4
Unit of Clinical, Health, and Neuro Psychology, Institute of Psychology, Leiden University, Netherlands
Introduction & objectives: Previous study established a strong association between urinary tract symptoms
and arousal disorders and sexual pain disorders in lower urinary tract dysfunction (LUTD). Other sources
suggested that IC/BPS patients had significantly more dyspareunia and more fear of pain, compared with
healthy controls. The aim of our study is to investigate the differences in the subjective symptoms, urodynamic
parameters and anesthetic bladder capacity of IC/BPS in women with or without sexual pain.
Material & methods: A total of 89 IC/BPS female patients compatible with the NIDDK criteria were included in
this study. All subjects were asked if they had a history of sexual pain in recent two weeks and were assessed
by validated questionnaire including O'Leary-Sant Symptom (ICSI) and Problem Index (ICPI). Pelvic Pain and
Urgency/Frequency (PUF) questionnaire was also completed. Standardized consecutive filling cystometry and
volume at first desire to void (FDV), normal desire to void (NDV), strong desire to void (SDV) and maximum
cystometric capacity (MCC) were performed. Hydrodistension and cystoscopic anesthetic maximal bladder
capacity (MBC) was also measured. We compared subjects with and without a history of sexual pain disorder
using unpaired 2-tailed t tests.
Results: The occurrence of IC/BPS patients with sexual pain disorder was 65/89 (73%). (Figure 1) Patient
demographics with or without sexual pain disorder showed the average age being 39.98 years (± 11.8) and
41.17 years (± 10.2), respectively. The ICSI and ICPI scores were equivalent between the two groups but
patients with sexual pain had a statistically significant higher PUF scores than those without sexual pain
(21.5±5.4 v 16.2±4.6, p< 0.01). In IC/BPS patients with sexual pain, the values for FDV, NDV, SDV, and MCC
were lower than those without sexual pain but were not statistically significant (67.8±35.9 v 86.1±52.5,
93.3±38.2 v 115.1±56.4, 138.7±65.8 v 158.1±110.2, 195.4±69.9 v 225.7±149.8l). Similarly, patients with sexual
pain had lower anesthetic MBC than those without sexual pain (596.1±210.1 v 646.2± 156.7, p=0.2). (Table 1)
Conclusions: Sexual pain in IC/BPS patients is indeed a bother symptom accompanied with chronic pelvic pain
and decrease of bladder capacity in urodynamic examination and hydrodistension. PUF score was higher in
patients with sexual pain disorder group because ICSI and ICPI did not particularly evaluate sexual pain score
but PUF did. This suggests that physicians should consider sexual pain disorder in the management of patients
with IC/PBS and use PUF score to evaluate not only irritative lower urinary tract symptoms (LUTS) but also
sexual pain disorder.
Table 1
Difference in IC/PBS with or without sexual pain
Without sexual pain
(n=24)
Age: 41.17±10.2
With sexual pain
(n=65)
Age: 39.98±11.8
Mean ± SD
Mean ± SD
T value
P value
3.52 ± 3.37
5.36 ± 3.01
-3.48
< 0.01
Testing
Symptom Score
Pain score
Urgent score
6.13 ± 2.62
6.78 ± 2.68
-1.40
0.16
ICSI
11.36 ± 2.8
12.55 ± 3.2
-1.54
0.13
ICPI
10.55 ± 2.6
11.22 ± 3.3
-0.86
0.39
PUF
16.21 ± 4.6
21.52 ± 5.4
-3.17
< 0.01
FDV
86.13 ± 52.52
67.89 ± 35.96
1.47
0.15
NDV
115.13 ± 56.41
93.31 ± 38.25
1.61
0.11
SDV
158.19 ± 110.28
138.78 ± 65.84
0.79
0.43
MCC
225.75 ± 149.86
195.43 ± 69.90
1.01
0.32
0.2M KCL-FDV
73.56 ± 45.31
81.52 ± 61.27
-0.46
0.65
0.2M KCL-NDV
107.75 ± 65.43
112.16 ± 71.71
-0.21
0.84
0.2M KCL-SDV
162.75 ± 102.10
149.25 ± 82.71
0.49
0.62
0.2M KCL-MCC
198.63 ± 121.17
187.67 ± 96.64
0.34
0.73
Urodynamic study
Urodynamic study
23
Sexual dysfunction in women with chronic pelvic pain and infertility for endometriosis
Stenyaeva N.N.1, Chritinin D.F.2
1Federal State Budget Institution "Research Center for Obstetrics, Gynecology and Perinatology" Ministry of
Healthcare of the Russian Federation, 2- I.M. Sechenov First Moscow State Medical University
Objectives: To study the clinical types of sexual dysfunction, feature of sexual functioning in a pair of women
with different clinical courses of endometriosis.
Materials: A cross-sectional study was conducted of mental and sexual health in the 34 women with
endometriosis. The inclusion criteria were the presence of sexually partner. The 1 group included 15 patients
with manifestations of chronic pelvic pain (CPP) at the age of 32.6 ± 4.7 years. The 2 group included 19
patients with infertility at the age of 36.3 ± 6.2 years. They were assessed a semi-structured interview for
demographic and clinical variables; Russian version of the Female Sexual Functioning Index (FSFI), Hamilton
Depression Rating Scale (HDRS); Hamilton Anxiety Rating Scale (HARS); and a questionnaire for quality of life
(the 36-Item Short Form Health Survey [SF-36]). Sexual function of their partners was assessed using the
International Index of Erectile Function (IIEF). P values of less than 0.05 were significantly considered.
Results: In the group 1 was identified sexual dysfunction in all patients. In the structure of sexual dysfunctions
were prevailed deep dyspareunia (86.7%), coital anorgasmia (80.0%), accompanied of violation by sexual
adaptation of pair (93.3%). All patients were identified of depression and anxiety. Their severity was correlated
with the severity of pain. The patients avoided from the genital and extragenital forms of sexual activity in the
pair. The partners of patients were observed reduction in the election of sexual desire, makes less frequent
attempts to intimacy. In the group 2 was dominated in the structure of sexual disorders decreased libido
(84.2%), and coital anorgasmia (63.1%), manifested in the background of anxiety and depressive states.
Patients detected displacement of motivation of sexual activity with a recreational component of sexuality to
the reproduction, which led to a violation of sexual relations in a pair and decreased in quality of life. At the
same time, the partners of patients were to share the idea of the need of pregnancy. They were included in
the diagnostic and therapeutic measures to restore fertility, provided the necessary support to patients that
preserved interpersonal relationships and marriage.
Conclusion: Сlinical manifestations of endometriosis leads to a significant violation of the sexual health of
women, disruption marital relations, reduced the quality of life for both partners.
24
Transcutaneous electrical stimulation of the posterior tibial nerve (TENS) in the treatment of chronic pelvic
pain / chronic prostatitis (DPC / PC): A prospective monocentric study
Y. El Abiad, A. Ameur, A. Janane, M. Abbar
Department of Urology, Military Hospital of Instruction Mohammed V. Rabat
Objectives: Posterior tibial nerve stimulation is a neuromodulmative therapy that has demonstrated success in
the treatment of various dysfunctions of the lower urinary tract. The purpose of this study was to evaluate the
therapeutic efficacy of this technique in the management of chronic pelvic pain / chronic prostatitis rebels to
medical therapy.
Participants and Methods: prospective monocentric study including 28 patients followed for DPC / PC
category IIIa and IIIb of classification NIH (national institute of health), and who failed with other usual
treatments (NSAIDs, analgesics, antibiotics and prostatic massage ...)
The pre and post treatment evaluation was based on a questionnaire score of the Genito-Urinary Male NIH
Pain Index, which includes a pain scale (0-23), urinary symptoms scale (0-10) and scale of quality of life (0-12).
All patients received the same treatment scheme: 1séance of 15 minutes per day for 12 weeks as an
outpatient.
The subjective responses (need to continue treatment to keep the effect obtained) and objective (improving
scores over 50%) were evaluated after 12 weeks of treatment.
Results: a subjective response to pain was achieved in 46% of patients, whereas objective response in 28%.
After 12 weeks, 8 patients have ended up with a pain score of NIH <10, and in all patients there was a
significant improvement in urinary symptoms score and quality of life.
Conclusions: Despite its modest results, TENS is a promising non-invasive therapeutic alternative in support of
DPC / PC, especially after failure of other treatment modalities. Randomized controlled trials with long-term
effect assessment are needed.
Keywords: Chronic pelvic pain, chronic prostatitis, electrical stimulation of posterior tibial nerve.
Topic: abdomino-pelvic pain in men.
25
Urological chronic pelvic pain syndromes in the pediatric population – a review
J.W.O. van Till; J.G.A. Houbiers
Astellas Global Medical Science, Leiden, The Netherlands
Introduction & objectives: CP/CPPS and BPS/IC are elusive syndromes with unknown etiologies. The burden of
disease is very high in adults. However, these conditions have been seldom described in the pediatric
population and the scarce reports are ambiguous. The objective of this review is to describe the pediatric
populations using reports from literature on pediatric CP/CPPS and BPS/IC as defined by current criteria.
Materials & methods: Literature was searched for articles in English in peer reviewed journals on CP/CPPS and
BPS/IC that included patients aged 18 years and younger. Disease and diagnostic characteristics were
reviewed.
Results: Since 1941 in total 52 articles were published (12 on CP/CPPS and 40 on BPS/IC). However, only 11
described BPS/IC by current criteria. The diagnostic criteria for both conditions are identical in children and
adults. The prevalence of CP/CPPS as well as BPS/IC in pediatric population was not described. Of the total
population with CP/CPPS and BPS/IC possibly less than 1% is below 18 years of age. The most applicable age
range for pediatric CP/CPPS patients is possibly 15-18 years of age (i.e., adolescence). The age range of
pediatric BPS/IC was broader (4-18), but the vast majority of described patients were adolescent (14-18).
Treatment varied but was regarded to be similar to therapy in adults. No data on disease burden were
available.
Conclusion: CP/CPPS as well as BPS/IC exists in the pediatric population, but is rare and mainly occurs in
adolescents. Data on prevalence, efficacy of treatment and disease burden are needed to define the issue
correctly.
26
Comparison of disease characteristics in BPS/IC and CP/CPPS
J.W.O. van Till1, F.M.E. Wagenlehner2, J. Nordling3, J.C. Nickel4, G. Perletti5, V. Magri6, M. Boorsma 1, A.S.
Salami1, J.H.J.M. Melis1, J.G.A. Houbiers1
1
Astellas Global Medical Science and Clinical Development, Leiden, the Netherlands
2
Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University, Giessen, Germany
3
Department of Urology, University of Copenhagen, Herlev, Denmark
4
Department of Urology, Queen’s University, Kingston, ON, Canada
5
Biomedical Research Division, Department of Theoretical and Applied Sciences, Università degli Studi
dell’Insubria, Busto A./Varese, Italy.
6
Urology and Sonography Outpatient Clinic, Azienda Ospedaliera Istituti Clinici di Perfezionamento, Milan, Italy
Introduction & objectives: CP/CPPS and BPS/IC are chronic pelvic pain syndromes with unidentified etiologies.
CP/CPPS occurs in men and BPS/IC predominantly in women. The medical treatment of both conditions is
symptomatic and quite similar, but currently insufficiently effective. Although the pathophysiology and
prognosis may be different, there are various similarities between both syndromes. The objective of this study
was to explore and compare disease characteristics in these two conditions.
Materials & methods: This study included anonymous data of patients who were screened for two
interventional placebo-controlled randomized trials (one completed trial in men with CP/CPPS and one
ongoing trial in women with BPS/IC). In both study groups, adult patients were selected on similar criteria:
moderate to severe pain (i.e., a score of 4 or higher on a NRS for pain), matching the current disease
definition, no other major medical illness and no UTIs. Disease characteristics (pain, depression, QoL) in the
study groups were compared, and were measured by specific questionnaires: 0-10 average pain NRS, the
Center of Epidemiological Studies – Depression scale (CES-D, scale 0-60) and the QoL Impact domain of
comparable disease specific symptoms scores (scale 0-12). Additionally, a comparison was made with 1/ those
patients meeting strict selection criteria (i.e., randomized into the two clinical trials), and 2/ a cohort of
unselected CP/CPPS patients from clinical practices.
Results: Median scores of pain NRS, CES-D and QoL Impact were significantly higher in the screened BPS/IC
(n=98) vs. the CP/CPPS study group (n=342): 7 vs. 6 (p<0.0001); 11 vs. 9 (p=0.0006); 11 vs. 8, (p<0.0001),
respectively. The median age of the BPS/IC study group was higher than in CP/CPPS study group (55 vs. 44;
p=0.0015). Difference in age could not explain the observed differences between the study groups because
age did not correlate to any of the outcomes (linear regression, all R<0.5). Sixty (61%) and 239 (70%) of the
patients were randomized into the BPS/IC and CP/CPPS clinical trials, respectively. The CES-D score of these
trial populations was significantly lower (patients with major depressive symptoms were excluded) than the
screened population; the other symptoms scores were similar. No significant differences in pain and QoL
scores were found between the unselected clinical CP/CPPS cohort (n=860) and the CP/CPPS screened and
randomized populations; CES-D was not measured in the clinical cohort.
Conclusion: Measures of pain, depression as well as QoL Impact were higher in patients with BPS/IC (female)
compared to CP/CPPS (male). In patients with moderate to severe symptoms BPS/IC may have a higher disease
burden than CP/CPPS. Pain and QoL outcomes in the examined CP/CPPS study populations may represent
those in clinical practice.
27
Multidisciplinary approach to chronic pelvic pain in women
Angela Chia, The Royal Women’s Hospital, Melbourne, Australia
complex and difficult to treat. Most women received heterogeneous treatments before they were referred to
a multidisciplinary pain clinic. Needless to say, psychosocial co-morbidities are very common amongst them.
We conducted questionnaires and phone follow up interviews for women who had persistent pain despite
usual cares from GP and Gynecologists. Our objective is to demonstrate the efficacy of multidisciplinary care
(MDC) and how it can improve patient’s quality of life.
Materials and methods: Ninety-five questionnaires were collected prior to clinic assessment. Information on
demographic data, Brief Pain Inventory (BPI), Hospital Anxiety and Depression scores (HADS) and Self Coping
Strategies Questionnaire ( CSQ) were recorded. Sexual function and bladder function were recorded using
standardized validated questionnaires.
After initial treatment by the Chronic Pelvic Pain Clinic (CPPC), we monitored patients progress from phone
follow up.
Results: The Royal Womens’ Hospital CPPC’ s cohort are mainly young women in their reproductive age. 56%
are nulliparous and 68% had documented or history of endometriosis. 11% of the patients had hysterectomy
yet requiring ongoing pain management.
From the entry questionnaire, patients reported initial high pain score with mean BPI =6.1. They are more
Anxious than depressed with HADS Anxiety score =10.8, Depression=8. They demonstrated poor coping skills
with CSQ=20 and high prevalence of sexual trauma (58%). It is common to have concurrent gastrointestinal,
gastrourinary or sexual dysfunction among such cohort (Table 1).
Forty patients were interviewed in the phone follow up regarding their pain after the CPPC intervention. They
reported a drop in pain intensity from BPI 7.8 to 4.8 (Figure 1)
reduce activity interference from 8.1 to 5.5 (Figure 2)
Overall speaking, 50% of patients reported improvement in general wellbeing (Figure 3) and 55% (Figure 4) of
them attributed this to having learned some strategies to cope or manage their pain.
Conclusion: Women with chronic pelvic pain improve after MDC. Further research focusing on how to conduct
MDC in a timely and effective fashion can guide pain management to help this challenging cohort.
28
Dynamometric assessment of the pelvic floor muscles in women with genito-pelvic pain and psychological
correlates
Mélanie Morin1, Sophie Bergeron2, Samir Khalifé3, Yitzchak M. Binik4, Stéphane Ouellet5
1
School of Rehabilitation, University of Sherbrooke, Canada
2
Department of Psychology, University of Montreal, Canada
3
Jewish General Hospital and McGill University Health Center (Royal Victoria Hospital), Canada
4
Department of Psychology, McGill University, Canada
5
Department of Obstetrics and Gynecology, University of Montreal, Canada
Introduction & objectives: Pelvic floor muscles (PFM) and psychological factors have been suggested to play
an important role in the pathophysiology of provoked vestibulodynia (PVD). Although potential associations
between these sets of factors have been proposed, the current PFM assessment tools have several flaws
preventing a complete understanding. Therefore, the dynamometric speculum was developed. This study
aimed to: 1) compare PFM function in women with PVD to controls and 2) examine associations between PFM
function and pain, fear of pain, sexual function, depression and anxiety.
Materials & methods: Fifty-five controls and 55 women with PVD participated. Validated questionnaires were
used to assess pain during intercourse (McGill pain questionnaire), fear of pain (Pain anxiety symptoms scale
(PASS-20)), sexual function (Female sexual function index), depression (Beck depression inventory) and anxiety
(State anxiety inventory). Using the dynamometric speculum, maximal strength was assessed in a 10s
contraction. To evaluate speed of contraction, women performed fast contractions for 15s and the first
contraction slope was calculated. To measure passive forces, the speculum was opened to maximal tolerated
vaginal aperture and then closed for five cycles. Mean passive forces were calculated at minimal, 15mm and
maximal vaginal apertures. Independent t-tests were used to compare both groups and correlations were
calculated using Spearman rho coefficients.
Results: Women with PVD had significantly lower strength and speed of contraction and demonstrated higher
passive forces at minimal and 15mm aperture (p<0.035). In all participants, better sexual function was
correlated with higher strength (r=0.272, p=0.004), superior contraction speed (r=0.371, p<0.001) and lower
passive forces at minimal and 15mm aperture (r=-0.294 and -0.363, p<0.003). Depression and higher state
anxiety were significantly correlated with lower speed of contraction (r=-0.207 and -0.237, p=0.036) and lower
tolerated aperture (r=-0.231 and -0.303, p=0.017). State anxiety was also related to passive forces at minimal
aperture (r=0.221, p=0.025). In women with PVD, pain reported during intercourse was related to lower
strength (r=-0.298, p=0.007) and lower speed of contraction (r=-0.426, p=0.002). Fear of pain was correlated
with a lower tolerated aperture (r=-0.312, p=0.021). Moreover, the fear subscale of the PASS-20 was related to
higher passive forces at 15mm aperture (r=-0.363, p=0.007).
Conclusion: This research provides evidence that PFM is impaired in women with PVD showing that these
women present increases in passive forces, lack of strength and decrease in speed of contraction. Associations
between PFM function and sexual function, pain, fear of pain, depression and anxiety support the rationale for
multidimensional approaches to treat PVD.
29
Evaluation of pain severity, catastrophic thoughts and quality of life in women with chronic pelvic pain in a
multiprofessional center for pain treatment
Minson F.P. 1; Morete M.C.2; Silva A.P. 3; Podgaec S. 4; Abrão M.S. 5
1
Physician, Team coordinator of the Centro Integrado de Tratamento da Dor in São Paulo, Brazil. 2,3 Nurses of
the Centro Integrado de Tratamento da Dor in São Paulo, Brazil.
4,5
Gynecologists of the Clinica Medicina da Mulher in São Paulo, Brazil
Introduction: Chronic pelvic pain (CPP) is a common condition among women at child-bearing age, which may
be associated to reduced work productivity, restricted mobility, as well as emotional, sleep and sexual
disorders. CPP is defined as continuous or intermittent pain in the region pelvic, lasting for at least six months,
not exclusively associated to menses or sexual intercourse. Catastrophic thoughts can be defined as mental
processes directed to an exaggerated negative orientation related to a noxious stimulus. Women suffering
from CPP may present anxiety and depression. These alterations contribute to decreased quality of life (QoL).
Objective: to assess severity of pain, presence of catastrophic thoughts and quality of life in chronic pelvic pain
patients seen at a multiprofessional pain center.
Methods: The sample comprised 25 women, mean age of 35 years, with pelvic pain for over one year, treated
in a Multiprofessional Pain Center in the city Sao Paulo, Brazil. The following tools were employed: the
Catastrophic Thought questionnaire of the Pain-Related Self-Statements Scale, the Verbal Numeric Scale (VNS)
to assess severity of pain, the Quality of Life questionnaire (SF-36) and the Brief Pain Inventory (BPI).
Results: The data on pain severity showed that 20% of patients had mild pain (VNS=0-3), 64% had moderate
pain (VNS=4-7) and 16% had severe pain (VNS= 8-10). Concerning evaluation of catastrophic thoughts, 44%
had a positive result and 66% a negative result. As regards to quality of life, the following domains stood out:
60% of patients referred decrease in physical function, 48% in role physical, social and role emotional
functions, and 44% in mental health function due to chronic pain. As to analysis of BPI results, 52% of patients
reported that pain fully interfered in their mood, 48% in their work activities, 44% in interpersonal relationship
and in 40% pain impacted on sleep.
Conclusion: Chronic pelvic pain interferes in activities of daily life of women who are active in the job market,
besides effectively impacting on their quality of life. This study enabled the multiprofessional team to develop
projects aiming to give support to this population, so that the individuals can actively participate in treatment
and manage their pain.
30
Female chronic pelvic pain is associated with pelvic floor muscle dysfunction examined by a standardised set
of intravaginal examination manoeuvres. A population-based, randomised single-blinded case-control study
S. Lovinga, T. Thomsenb, P. Jaszczakc, J. Nordlingd
a
Multidisciplinary Pain Centre, Department of Anaesthesiology, Herlev Hospital, University of Copenhagen,
Denmark
b
Abdominal Centre, Rigshospitalet, University of Copenhagen, Denmark
c
Department of Gynaecology, Herlev Hospital, University of Copenhagen, Denmark
d
Department of Urology, Herlev Hospital, University of Copenhagen, Denmark
Background: Evidence indicates that physiotherapy can reduce pain in female chronic pelvic pain caused or
influenced by pelvic floor muscle dysfunction. The objective was (a) to determine whether women with or
without chronic pelvic pain demonstrate different results using a set of standardised physical examination
measures of pelvic floor muscle function, and (b) to assess whether experiences of chronic pelvic pain were
associated with general well-being, dyspareunia, bladder pain symptoms, and constipation.
Methods: In this population based case-control study, we reported blinded findings from a set of standardised
vaginal physical pelvic floor muscle examination manoeuvres on 50 female participants (24 with chronic pelvic
pain, 26 pain-free). Pelvic floor muscle dysfunction outcomes were: resting tone, strength, relaxation capacity,
surface electromyographic activity, and pressure pain detection thresholds. Bivariate analysis was performed
to test the association of each variable with experiences of chronic pelvic pain. Unpaired T- tests, Fishers exact
tests, and Mann-Whitney tests were used.
Results: Women with chronic pelvic pain had higher pelvic floor muscle resting tone, decreased pelvic floor
muscle strength and relaxation capacity compared with controls as well as enhanced pelvic floor muscle
pressure-pain sensitivity (p < 0.05). Women with chronic pelvic pain reported reduced general well-being
(higher risk of stress and depression) and more severe dysfunction of sexual life than pain-free controls.
Conclusion: Women with chronic pelvic pain demonstrated altered pelvic floor muscle function when
compared with controls, providing empirical evidence of pelvic floor muscle dysfunction in women with
chronic pelvic pain measured by a set of standardised and commonly used vaginal examination manoeuvres.
Thus, these examination manoeuvres might guide intervention decisions in a muskuloskeletal direction
(physiotherapy) resulting in improved treatment outcomes.
31
Bladder pain syndrome and endometriosis: Multidisciplinary diagnostic approach
Zaytsev A.V.1, Khashukoeva A.Z.2, Comaeva E.A.2, Gumin L.M.3
1
Moscow State Medical Stomatological University named after A.I. Evdokimov, Dept. of Urology, Moscow,
Russian Federation, 2 The Russian National Research Medical University named after N.I. Pirogov, Dept. of
Gynecology and Obstetrics, Moscow, Russian Federation, 3 Moscow City Hospital 50, Dept. of Urology,
Moscow, Russian Federation
Introduction & objectives: Chronic pelvic pain (CPP) is a common disorder affecting gynecological patients
with pelvic adhesions, ovarian cysts, endometriosis, pelvic congestion syndrome, pelvic inflammatory disease,
adenomyosis, and uterine leiomyoma. Endometriosis is one of the most prevalent diagnoses among women
with recurrent and progressive CPP. Until recently, the urinary bladder was not recognized as an important
generator of pelvic pain, and bladder pain syndrome/interstitial cystitis (BPS/IC) was not often considered in
the differential diagnosis of CPP.
Materials & methods: We examined 52 patients (mean age 34 + 4.7) with CPP and presumptive diagnosis of
endometriosis. Pain level was evaluated by visual analog scales (VAS). Symptoms’ severity and voiding
problems were assessed using O’Leary-Sant IC Symptom and Problem Index. Participants reported an average
pelvic-pain score of 8 on a VAS and 22 of them (46.8%) had scored >12 (a median 18.3 + 3.5) on the IC
Symptom and Problem Index. Cystoscopy with bladder hydrodistention and targeted biopsy were performed
under anesthesia at the time of diagnostic laparoscopy.
Results: Endometriosis was confirmed in 44 (84.6%) patients. Affection of the bladder was detected in 7
(15.9%) cases. In 22 patients (44.6%) BPS/IC was diagnosed by cystoscopic evidence. Those patients with CPP
with or without urologic symptoms of urgency/frequency may in fact have BPS/IC as a component of their
pelvic pain. If cystoscopy had been performed only in patients with irritative voiding symptoms a diagnosis of
BPS/IC would have been missed because BPS/IC would be diagnosed on the basis of a chronic unpleasant
sensation (e.g. pelvic pain, pressure or discomfort) perceived to be related to the urinary bladder, generally
accompanied by lower urinary tract symptoms. This finding will lead to better results in treatment these
patients.
Conclusion: This study has demonstrated that in a group of women undergoing a comprehensive work-up for
CPP, the bladder was the predominant pain generator and underscores the point that endometriosis may not
be the only cause of the pain symptoms. Laparoscopic confirmation of endometriosis does not exclude BPS/IC.
Cystoscopy/hydrodistention is often performed only in patients with a negative laparoscopic evaluation.
Cystoscopy/hydrodistention should be considered as an integral part of surgical evaluation of patients with
CPP. For women with chronic pelvic pain, screening for BPS/IC should be performed.
32
Difference of apoptosis in eutopic endometrium and ectopic endometriotic tissue according to proliferative
and secretory phase of menstrual cycle
1
Suk Bong Koh, 2Sung Tack Oh, 3 Sam Hyun Cho, 4Hoon Choi, 5 Kyung Jin Hwang, 6Jong Sun Choi, 7Dong Han Bae
1
Dept. of Ob/Gyn, School of Medicine, Catholic University, Daegu, Korea, 2Dept. of Ob/Gyn, School of
Medicine, Chonnam National University, Gwangju, Korea, 3Dept. of Ob/Gyn, School of Medicine, Hanyang
University, Seoul, Korea, 4Dept. of Ob/Gyn, School of Medicine, Inje University, Seoul, Korea, 5Dept. of Ob/Gyn,
School of Medicine, Grace Women's Hospital, 6Dept. of Family Medicine,, School of Medicine, Kosin university,
Busan, korea, 7Dept. of Ob/Gy, School of Medicine, Soonchunhyang University, Chunan, Korea
Introduction and objectives: To evaluate the difference of apoptosis in eutopic normal endometrium and
ectopic endometriotic tissue according to proliferative and secretory phase of menstrual cycle.
Material and methods: Eutopic normal endometriums were obtained from fertile women during laparoscopic
tubal ligation. Ectopic endometriotic tissues were obtained from rectal, tubal and peritoneal lesions of
endometriosis patients.
Eutopic normal endometriums and ectopic peritoneal endometriotic tissues were obtained at proliferative
phase and secretory phase. All samples were obtained after permission of patients. Apoptotic cells were
detected using the d-UTP nick-end labeling assay for DNA fragmentation by in situ end-labeling.
Results: In normal eutopic endometrium, apoptosis during secretory phase was significantly higher than
apoptosis during proliferative phase (P<0.01).
In peritoneal ectopic endometriual tissue, apoptosis of proliferative phase was not significantly different from
apoptosis of normal eutopic endometrium on proiferative phase.
However in secretory phase, apoptosis of peritoneal ectopic endometriuotic tissue was significantly lower than
apoptosis of normal eutopic endometrium (P<0.01).
In tubal and rectal endometriotic tissues, apoptosis were significantly lower than normal eutopic endometrium
although they were tissues at secretory phase (P<0.01).
Conclusion: The alternation of apoptosis change according to menstrual cycles on ectopic endometriotic
tissue seems to be cause of progressive proliferation of ectopic endometriotic tissue.
33
The effect of combined treatment of LNG-IUS and MPA for chronic pelvic pain of endometriosis
1
A Ri Kim, 2Heung Yeol Kim, 3Sung Tack Oh, 4 Ho Yeun Chang, 5 Sam Hyun Cho, 6 Kyung Jin Hwang
1
Dept. of Ob/Gyn, School of Medicine, Wonkwang University, Iksan, Korea, 2Dept. of Ob/Gyn, School of
Medicine, Kosin University, Busan, Korea, 3Dept. of Ob/Gyn, School of Medicine, Chonnam National University,
Gwangju, Korea, 4Dept. of Orthopedics, Taereung Sungsim Hospital, 5Dept. of Ob/Gyn, School of Medicine,
Hanyang University, Seoul, Korea, 6Dept. of Ob/Gyn, School of Medicine, Grace Women's Hospital. Ilsan, Korea
Introduction & objectives: High-dose (30-50 mg) Medroxy-progesterone Acetate (MPA) is highly effective for
pain of endometriosis, but it has the side-effects such as genital spotting, weight gain, breast engorgement
and depression. Levonorgestrel-releasing intrauterine system (LNG-IUS) has been used for pain of
endometriosis recently although it was originally developed for contraceptive purpose. However its
effectiveness for pain of endometriosis is far lower than high-dose MPA even although its side-effects are
lower than high-dose MPA. Therefore the object of this study is to evaluate the effect on pain of endometriosis
and the low side-effects of LNG-IUS plus relatively low-dose (20 mg) MPA combined treatment compared to
LNG-IUS only or high-dose MPA (30-50 mg) only treatment.
Material and methods: The study was performed in 84 patients of LNG-IUS only group (Group A, 23 patients),
LNG-IUS plus relatively low-dose 20mg MPA group (Group B, 34 patients) and high-dose 30-50mg MPA only
group (Group C, 27 patients).
The degree of pain was estimated by visual analog scale (VAS). The number of decreased pain (more than VAS
3) after treatments, the frequency of irregular bleeding during treatment, the frequency of weight gain and
the frequency of breast engorgement were compared among three groups.
Statistical analysis was done by X2 with Yates’ correction and Fisher’s exact test.
Results: The number of patients with decreased pains after treatment in Group B was significantly more than
in Group A (p<0.05), and the significant difference of numbers of patients with decreased pain after
treatments was not found between Group B and Group C. The frequency of irregular bleeding in Group B was
significantly lower than Group A (p<0.05), but not than Group C.
The frequency of weight gain in Group B was significantly lower than Group C (p<0.05), but it was still
significantly higher than Group A (p<0.01).
The frequency of breast engorgement in Group B was significantly higher than Group A (p<0.01), but not than
Group C.
Conclusions: Therefore, LNG-IUS plus low-dose MPA combined treatment is very effective treatment method
same as high-dose MPA treatment with the lower side-effects compared to high-dose MPA or LNG-IUS alone
treatment.
34
The usefulness of mini-laparoscopic cystectomy for small endometrioma in adolescent women
1
WonYoung Paik, 2Jung Hoi Goo, 3 Sam Hyun Cho, 4Heung Yeol Kim, 5Sung Tack Oh, 6 Chu Yeop Huh,
1
Dept. of Ob/Gyn, School of Medicine, GyeongSang National University, Jinju, Korea, 2Dept. of Ob/Gyn, Good
Gang-An Hospital, 3Dept. of Ob/Gyn, School of Medicine, HanYang University, Seuol, Korea, 4Dept. of Ob/Gyn,
School of Medicine, Kosin University, Busan, Korea, 5Dept. of Ob/Gyn, School of Medicine, Chonnam National
University, Gwangju, Korea, 6Dept. of Ob/Gyn,, School of Medicine Kyung Hee university, Seoul, Korea
Introduction & objectives: Mini-laparoscopy is lesser invasive and more cosmetic than conventional
laparoscopy, and simple surgical procedure is possible by development of instrument. It is very important
point in adolescent women. This study was done to evaluate the usefulness of mini-laparoscopic cystectomy
for treatment for small endometrioma in adolescence.
Methods: The prospective, randomized study was done in 54 adolescence patients with for small
endometrioma of lesser than 2 cm diameter. The mini-laparoscopic cystectomy with 3 mm telescope and 3
mm instruments was performed in 18 patients (Group A), and conventional laparoscopic cystectomy with 10
mm telescope and 5 mm instruments was performed in 20 patients (Group B). The Anesthesia of laparoscopy
was general anesthesia in all 38 cases. The operating time, average operating room costs, average ancillary
department costs, instrument and supply costs, and length of hospital stay were compared. Postoperative pain
score of each patient was estimated by visual analog scale (VAS). The recurrence was observed for 2 years. The
statistical analysis was done by student's t-test and Fisher's exact test.
Results: The procedures were performed satisfactorily in all patients of both groups without any difficulty.
However in 8 patients (44.4%) of Group A, skillful doctor was necessary due to weak illumination of scope.
There was no significant difference in operating time, average operating room costs, average ancillary
department costs, instrument and supply costs, or length of hospital stay. Postoperative pain was significantly
lesser in Group A than B (VAS 1.3 +/- 1.1 vs. 5.8 +/- 2.1; P <0.01), and patients requiring analgesia were lesser
in Group A than B (2/18 vs. 20/20; P <0.01). The satisfaction of operation scar was higher in Group A than B
(18/18 vs. 5/20; P <0.01). There was no postoperative complication and no recurrence of cyst for 2 years in
both groups.
Conclusions: The success rate of mini-laparoscopic cystectomy of cyst wall does not differ from conventional
laparoscopy, but acceptability and satisfaction of patients are more and postoperative pain is lesser. Therefore
mini-laparoscopy seems to be better than conventional laparoscopy for the management of adolescence
patients with small endometrioma of lesser than 2 cm diameter.
35
Chronic endometritis as a cause of recurrent cystitis in women of reproductive age
N. Shelkovnikova, A. Neimark
Altai State Medical University, Department of Urology and Nephrology, Barnaul, Russia
Introduction and objectives: Doing chronic endometritis is one of the causes of chronic recurrent cystitis in
young women. The reason for such cystitis usually is urogenital infection, retrograde falls within the urethra
and bladder of the vestibule. Long-term persistence of the infectious agent in the uterus and bladder and
reinfection, a significant change in the parameters of the general and local immunity in these patients causes
chronization and duration of the disease in the abortive form, with the formation of chronic pelvic pain
syndrome.
The aim of our research: to justify the need of complex simultaneous treatment of chronic endometritis and
chronic cystitis, complicated by chronic pelvic pain syndrome.
Materials and Methods: Conducted a combined survey and treatment for 100 women of reproductive age
(25-35 years) with chronic endometritis, and chronic cystitis, complicated pelvic pain syndrome. For the
diagnosis of the following methods were used: Evaluation of symptoms and quality of life, Diary of urination,
physical examination, examination of the external genitalia, vaginal examination, ultrasonography (USG) of the
pelvic organs, the study vaginal flora, cervical and urethral PCR, Microcirculation the uterus and the bladder
was assessed by laser Doppler flowmetry (LDF). Performed Urethrocystoscopy and hysteroscopy, followed by
morphological study of the material. Patients received antibiotic therapy with the sensitivity of the vaginal
flora and bacterial urine culture, a combination drug safotsid. The active ingredient is atsitromitsin 1 g, g
seknidzol1 and fluconazole 150 mg. The choice of the drug due to the simultaneous action of various
microorganisms, which are composed of microbial associations influence the development and course of
chronic inflammatory process at the same time in the genitals and lower urinary tract. The drug is used in 1, 7,
14 days of treatment.
Results: At 1 year follow-up after combined treatment of recurrent inflammatory endometritis and cystitis
occurred in 24 patients. With the ineffectiveness of re-treatment began searching for other reasons supporting
the pain in the pelvic area. The remaining 76 patients were completely satisfied with the quality of treatment.
When the control PCR assays microflora urogenital infection pathogens have been identified, acute
exacerbations of chronic cystitis, endometritis and pelvic pain were noted.
Conclusion: Relationship of chronic endometritis with recurrent cystitis, complicated pelvic pain syndrome
necessitates complex treatment - the use of combined antibiotics for the treatment of inflammatory genital
and urinary bladder, with subsequent courses of immune, vitamin and possibly sanatorium rehabilitation.
36
Vaginal stenosis after radiotherapy in cervical cancer
Montes Posada I1; Aranda Rodríguez C2; Betancor Santos M.A3; Gómez García A4.
1,2,3
Dr Negrin Gran Canaria University Hospital, Dept. of Physical Medicine and Rehabilitation, Las Palmas de
GC, Spain
4
Dr Negrin Gran Canaria University Hospital, Head of the Dept. of Physical Medicine and Rehabilitation, Las
Palmas de GC, Spain
Introduction and objectives: As part of the treatment for cervical carcinoma, patients may receive external
beam radiotherapy and intracavitary irradiation. Brachytherapy is an essential part of definitive radiotherapy,
which has the advantage of delivering high dose to the tumor while sparing the surrounding normal tissues.
However, brachytherapy is associated with late complications arising in organs adjacent to the cervix such as
rectum and bladder.
The assessment of patients following intracavitary irradiation reveals vaginal stenosis in the majority. It occurs
as a result of the formation of adhesions, together with circumferential fibrosis of upper vaginal tissue. Vaginal
stenosis can lead to long-term effects on sexual activity, including vaginal dryness, pain, and dyspareunia.
Nunns et al describe vaginal stenosis as the inability to pass two fingers into the vagina. Other authors have
defined it according to vaginal length, with stenosis defined as length < 8 or 9 cm. In cervical cancer treatment,
the stenosis is most often thought to be associated with brachytherapy, and therefore the upper vagina is the
most affected.
We aimed to determine the prevalence of pelvic and perineal pain, urinary and faecal incontinence,
dyspareunia, vaginal stenosis and shortening after radiotherapy due to cervical cancer.
Materials and methods: A retrospective study of patients sent to our rehabilitation consulting before and
after pelvic radiotherapy from January 2007 until January 2013. We analyzed the results with the SPSS System.
Among this period we evaluated 2280 patients (1888 women (82’8%)). A total of 29 carcinoma cervix patients
were examined previous rehabilitation to assess whether they experienced any of the following side effects:
urinary and faecal incontinence, telangiectasia, vaginal shortening, stricture, ulceration, atrophy, and necrosis
and actinic cystitis or proctitis.
Results: Average age was 50 years (range 30-77). Urinary incontinence previous to the radiotherapy treatment
was presented in 5 patients (17%), after the treatment, it appeared in 21 (72%). Faecal incontinence was
absent previous the treatment and when finished it in 9 (31%). Perineal pain referred as dyspareunia was
presented in 20 patients (69%). Vaginal stenosis in 23 (79%) and shortening in 15 (52%). Actinic cystitis in 5
patiens (17%) and proctitis in 4 patients (14%)
Conclusion: To minimize the consequences of vaginal stenosis, it’s essential that clinicians have a thorough
discussion with patients about the potential for this side effect, and ways to treat it before, during, and after
radiation therapy. The incidence of vaginal stenosis reported in the literature after treatment for cervical
cancer ranges from 12% to 88% and in our serie was 79%. Some pretreatment assessment of sexual function
and activity should be made. This should include pretreatment measurement of vaginal length and width and
the correlation with dyspareunia.
Pain after pelvic radiotherapy may negatively affect rehabilitation, increase suffering, and negatively influence
QOL. Physicians can do much for the welfare of patients with simple measures that should be encouraged,
such as asking and informing. Chronic pelviperineal pain is a frequent complication of cancer and its
treatment, and is often underreported and poorly described.
37
Relation of late side effects on pelvic floor in the treatment of endometrial carcinoma
Aranda Rodríguez C1; Montes Posada I2, Betancor Santos, M.A3.; Gómez García A4.
1,2,3
Dr Negrin Gran Canaria University Hospital, Dept. of Physical Medicine and Rehabilitation, Las Palmas de
GC, Spain
4
Dr Negrin Gran Canaria University Hospital, Head of the Dept. of Physical Medicine and Rehabilitation, Las
Palmas de GC, Spain
Introduction and objectives: Treatment for endometrial cancer usually includes surgical removal of the uterus,
cervix, ovaries, and fallopian tubes; it may also involve sampling or removal of the surrounding lymph nodes.
Adjuvant radiotherapy is the standard treatment for endometrial carcinoma. Radiotherapy is associated with
late complications arising in organs adjacent to the uterus such as rectum and bladder. The side effects long
term most often described in literature are diarrhea, chronic cystitis and vaginal stenosis. Not so frequent are
rectal ulcus, rectovaginal fistula and sigmastenosis.
We have made a review of our patients to assess the pathologies associated with the treatment of
endometrial cancer, and compare them with those described in the current literature.
Materials and methods: A retrospective study of patients sent to our rehabilitation consulting after pelvic
radiotherapy from January 2007 until January 2013. We analyzed the results with the SPSS System.
Among this period we evaluated 2280 patients (1888 women (82’8%)). A total of 11 endometrial cancer
patients were examined to assess whether they experienced any of the following side effects: urinary and
faecal urgency and incontinence, vaginal stenosis and actinic cystitis or proctitis.
Results: Average age was 69 years (range 59-81). All patients received surgical treatment and were irradiated.
Only one patient received chemotherapy treatment. Mixed urinary incontinence previous to the radiotherapy
treatment was presented in 3 patients (27%), after the treatment, it appeared in 6 (54%), from them, 4 effort
urinary incontinence (36%), and 2 urge urinary incontinence (18%). Urge faecal incontinence was absent
previous the treatment and appeared on 8 patients when finished (73%). Perineal pain referred as dyspareunia
was presented in 1 patients (9%). Vaginal stenosis in 2 (18%), vaginal shortening in 2 (18%), and vaginal
stenosis and shortening in 3 patients (27%). Actinic proctitis appeared on 1 patiens (17%).
Conclusion: The most frequently appeared side effect was the urge faecal incontinence. Literature describes
the chronic diarrhea as one of the most frequent side effects in long term, but nothing about the urge
defecation. Another side effect that is frequently found in the vagina is the pain, shortening and stenosis,
which leads to a limitation in the sex life of the woman. Urinary incontinence after treatment, mixed urinary
incontinence and urinary urgency without incontinence are the most frequent.
38
Visceral osteopathic techniques in severe menstrual pain
Milka D.1, Jachacz-Lopata M.2, Kmita B.1 , Bajor G.1, Gazdzik T.3
1
Department and Institute of Human Anatomy, Medical University of Silesia, Katowice,
Poland
2
Department of Physiotherapy, Medical University of Silesia, Katowice, Poland
3
Department of Orthopaedics and Traumatology, Jagiellonian University, Medical College,
Cracow, Poland
Introduction and objectives: Visceral osteopathic techniques treat internal organs which have got restrictions
of movement towards other organs or restricted mobility. Aforementioned restrictions cause impaired blood
circulation, tissue nutrition and referred pain or additional symptoms, such as for instance irregular period,
acute menstrual pain, low back pain or pain syndromes in other areas, not explicitly connected with the
primary cause of the pain. Severe menstrual pain impedes women daily activity and significantly decreases
their quality of life evaluation. Internal organs are affected by the same mechanisms or factors as motor
system, however the influence of the parasympathetic nervous system is more significant. Beyond the
medication and treatment based on simple relaxation (warming compresses, relieving position) during
menstruation and classical manual therapy techniques (mostly based on low back mobilization and soft tissue
techniques) before period, there are not so many alternatives, beyond Osteopathy, for directed visceral
therapy. The aim of the study was to present effects of simple and useful visceral techniques for uterus and
neighboring organs in women with severe menstrual pain.
Material and methods: The sample was constituted from 30 women aged 25-38 (x= 29,2 ±2,7) and affected by
severe menstrual pain that were subjected to questionnaire, gynecological examination qualifying to the
research and four osteopathy sessions made by certified ostheopatist (D.O.). Women assessed their health
state and pain sensations during three menstruations before therapy, then four-week-long program were
conducted. During three consecutive menstrual periods after treatment women assessed their pain
sensations. On the basis of the subjective pain evaluation before and after therapy results were correlated.
Results: Women stated that pain symptoms were decreased during three following periods. The average level
of pain before therapy was 7, women described it mostly as dull (n=21), wrenching(n=12), pulling(n=9) and
radiating(n=6). Pain level after therapy was decreased and was approximately about 4,2 during the first period,
4,8 during second period and 4,0 in third menstrual period. The correlation ratio between average pain level
during menstrual cycles before and after therapy was significant (X2=13,005, df=6, a=0,05) and contingency
coefficient was C=0,437.
Conclusions: Visceral techniques used in the treatment cause pain relief for next few months after treatment.
The results are constantly collected so the long-term results will be clearly visible in at least next six months.
The project will include more women, presented results should be treated as a pilot study. It is worth to
include post-osteopathy treatment, such as exercises and assess results of the combined therapy.
39
Resting scan alterations in female patients with Interstitial Cystitis/Painful Bladder Syndrome: Preliminary
data from the Multi-disciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Network
Lisa Kilpatrick1, Kirsten Tillisch1, Bruce Naliboff1, Jennifer Labus1, Zhiguo Jiang1, Emeran Mayer1, Melissa
Farmer2, A. Vania Apkarian2, Sean Mackey3, Kevin Johnson 3, Dan Clauw4, Richard Harris4, Georg Deutsch5,
Timothy Ness5, Claire Yang6, Chris Mullins7
1
Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, David Geffen School of Medicine at
UCLA, 2Northwestern University, Chicago, 3Stanford University, Stanford, 4University of Michigan, Ann Arbor,
5
University of Alabama, Birmingham, 6University of Washington, Seattle, 7NIDDK, Bethesda, United States
Introduction: The Multi-disciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Network is a multisite endeavor to identify epidemiological and neuroimaging parameters to advance clinical phenotyping and
treatment efforts for urological chronic pelvic pain, including interstitial cystitis/painful bladder syndrome
(IC/PBS). The current study consists of pooled resting scan data collected between Fall 2010 – Fall 2011.
Methods: We examined oscillation dynamics of intrinsic brain activity in female IC/PBS patients without
comorbidities (n=27) and female healthy controls (HCs; n=45) collected during a 10-minute resting fMRI scan.
The BOLD signal was transformed to the frequency domain and relative power was computed for low (0.010.05 Hz), mid (0.05-0.12 Hz), and high (0.12-0.25 Hz) frequency bands.
Results: Sensorimotor-related regions (primary somatosensory, paracentral lobule, superior parietal, and
supplementary motor area) demonstrated significantly less high frequency power and greater low/medium
frequency power in patients compared to HCs. In addition, several regions with both sensorimotor and limbicrelated connections (insula, middle frontal gyrus, precuneus/retrospenial cortex) demonstrated significantly
greater high frequency power and less low/medium frequency power in the patient group. An independent
component analysis (ICA) confirmed that all of the regions demonstrating altered oscillation frequency were
contained within a sensorimotor network (SN), previously reported (Smith et al, 2009).
Conclusions: Interregional correlations in frequency power suggest altered relationships between lateral and
medial SN regions as well as altered relationships between primary somatosensory cortex, insula, and mid
frontal gyrus in patients. These findings suggest the presence of alterations not only in the insular cortex, but
in the extended sensorimotor network of female IC/PBS patients. These findings are consistent with a previous
report demonstrating reduced sensorimotor gating in female IC/PBS patients reflecting a decreased ability to
adequately filter incoming information (Kilpatrick et al, 2010). Thus, a possible mechanism contributing to
altered interoceptive information processing in IC/PBS may be the presence of a generalized alteration in
sensorimotor gating/pre-attentive processing.
40
First results of urine and bladder wall study for the presence with pelvic pain/bladder pain syndrome
Sinyakova LA, Vinarova NA, A. Seregin, Jr, Russia
Objectives: Bladder pain syndrome is one of the leading causes of the pelvic pain. The cause of BPS/IC remains
a mystery. There is a growing data of possible role of biofilm-forming agents in the pathogenesis of this
disease.
The aim of our study was to elucidate the frequency of biofilm-forming agents presence in the bladder tissue
of patients with BPS/IC using new cultural and PCR methods.
Methods: From 2009 to 2012 in our clinic we examined 186 patients with Pelvic Pain and 24 patients of them
had cystoscopycally proven PBS/IC. 13 of these 24 patients had ulcerative changes and others had
glomerulationes. In addition to the standard approach to screening patients, which included a urine culture to
determine the growth of microorganisms, we also performed a biopsy of the bladder mucosa, followed by the
culture and pathology of the biopsy specimens.
The sample of the bladder mucosa was cultured using an extended method in order to isolate a pure culture
and to assess antibiotic resistance.
We evaluated the isolated cultures ability to biofilm formation on the abiogenic media bacteriologically
(analyzer "BioTrac 4250").
From 2012 the PCR test for the presence of S16 rRNA was performed in 5 BPS/IC patients.
Results: The urine culture was negative in all patients. Biopsy samples showed the growth of microorganisms
in bladder tissue at counts of 103 – 105 CFU/ml in 14 BPS/IC patients with the background of inflammatory and
proliferative changes detected by morphology.
We revealed the presence of members of the family Micrococcaceae: Staphylococcus spp., Enterococcus spp.,
Kocuria spp. and nonfermentative Gram-negative bacteria: Burkholderia, Flavimonas, Brevundimonas,
Acinetobacter, Pseudomonas, Proteus mirabilis, Klebsiella pneumoniae.
All strains isolated from patients with BPS/IC cases demonstrated the ability to form biofilms in vitro.
PCR analysis in 5 patients with BPS/IC showed the presence of S16 rRNA. The DNA sequence unique to
Corynebacterium sp. was identified in all 5 patients. All of these patients had ulcerative cystitis.
Conclusion: Our results raise again the possibility of biofilm forming bacteria Corynebacterium sp. involvement
in the pathogenesis of IC, and specifically in ulcerative cystitis.
The BPS/IC investigation trials including antibiotic therapy should consider the presence of biofilm forming and
intracellular pathogens and thus the biofilm penetrating antibiotics should be preferred.
41
Bladder pain syndrome – assessing the information available to patients on the internet
Tirlapur S.A., Lieu C., Khan K.S.
Women’s health research unit, Queen Mary, University of London, United Kingdom
Introduction: Bladder pain syndrome, formerly known as interstitial cystitis, often presents with chronic pelvic
pain and urinary symptoms. It has an estimated prevalence of 61% amongst women presenting with chronic
pelvic pain. The unknown aetiology and complex clinical characterisation of the condition often leads to delays
in diagnosis, causing a huge impact on patient’s quality of life.
Objectives: To assess the quality of medical information on the internet available to patients related to
bladder pain syndrome.
Methods: A search was performed using the meta-search engine Copernic agent on a pre-specified date and
time, using the search terms ‘bladder pain syndrome, interstitial cystitis, painful bladder syndrome, pelvic
pain’. Two reviewers independently assessed websites to assess their credibility, quality, accuracy and
readability. Only websites in the English language that were open-access were included.
Results: Eighteen suitable websites were identified in the search performed on 15th November 2012. 12 (67%)
websites were based in America and eight (44%) websites were specific to BPS. Most websites performed well
in readability. Quality, accuracy and credibility are necessary to provide high quality information for patients.
We found the best information was provided by the following websites: www.ic-network.com,
www.ichelp.org, www.painful-bladder.org, www.niddk.nih.gov. Two of them were linked to patient forums
and social media.
Conclusion: There is variable information provided on the internet about bladder pain syndrome. At a time
when digital communication is used by many patients as a source of information and as a means of sharing
experiences, good quality websites can act as a valuable tool during clinician’s consultations and provide useful
practical advice to patients. This is especially important in chronic conditions where treatments may only offer
temporary symptomatic relief.
Funding: None
42
Struggling to construct chronic pelvic pain as real - a qualitative synthesis of patients’ experience
Toye F.1, Seers K2., Barker K1.
Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
Royal College of Nursing Research Institute, School of Health & Social Studies, University of Warwick
Introduction & objectives: Chronic pelvic pain (CPP) is a prevalent chronic pain condition with a high disease
burden. Its multifactorial nature makes it extremely challenging for both clinicians and patients. Qualitative
research aims to help us understand the experience of illness, and make sense of the complex processes
involved. However, it can be difficult to incorporate qualitative knowledge into practice and policy. Metaethnography is a conceptual approach to research synthesis that is useful in healthcare.
Materials & methods: We used the methods of meta-ethnography to systematically review and integrate the
findings of qualitative research exploring patients’ perceptions of chronic pelvic pain.
Results: We included 29 papers in the meta-ethnography. Nine studies explored the experience of women
with CPP, 2 explored CPP in men and 20 studies explored the experience of endometriosis. Our conceptual
model highlights that CPP is physically and emotionally relentless, disrupting a person’s sense of self and
biography. Central to this experience is a struggle to explain pain, in particular to determine whether pain is
normal (not pathological/not real) or not-normal (pathological/real). In the absence of diagnosis, pain is
constructed as ‘not pathological’, and patients do not feel believed or valued as a person by health care
professionals. For some women, experiential knowledge overrides the voice of medicine in their attempts to
construct pain as pathological and ‘real’. Entry into a community of other people with CPP plays an important
role in constructing pain as ‘real’ and allowing women to feel valued and believed. More research is needed to
explore men’s’ experience of CPP.
Conclusion: The struggle to construct ‘pathological’ or ‘not pathological’ reflects associated cultural polarities
which make it very difficult for people with conditions that remain undiagnosed. This meta-ethnography
supports findings that the medical model, and its inherent dichotomies, does not fit the experience of CPP.
This finding is likely to be transferable to other health conditions, and calls for change in the cultural models
that are currently used in health care. It also has clear implications for clinical practise and education.
44
Developing specialist physiotherapy for urogenital pain patients
Wilkin A1, Hughes J2, Hughes E3.
1
Physiotherapy, The James Cook University Hospital, Middlesbrough, UK
2
Pain Management Unit, The James Cook University Hospital, Middlesbrough, UK
3
Physiotherapy student, Teesside University, Middlesbrough, UK
Introduction: Physiotherapy is an integral part in the management of patients with urogenital pain1. There are
relatively few physiotherapists that express an interest in this area of practice and often reside in woman’s
health. The pain clinic in Middlesbrough has had an interest and expertise in managing pelvic pain patients for
over a decade but with no specific physiotherapist with an interest. Over the last 12 to 18 months a
physiotherapist has developed an interest and informal links have been made.
Method: Patients referred to physiotherapy have had their outcomes and interventions reviewed. From this
comments are made with regard to the future aspirations for the clinic.
Results: To date 17 patients have been referred for physiotherapy, Three were seen immediately and a further
8 within 6 months. All but one was female. The patients tend to be complex with 12 being tertiary referrals
from within secondary care, 10 patients had significant psychological comorbidites as part of the presentation.
Outcomes to date have 4 improvement (3 discharged), 6 remain the same (3 discharged with agreement), 5
are under ongoing management and not been assessed for change. Two patients failed to attend
appointments and were discharged. Improvements have included increased levels of daily activity, more
relaxed and self aware, improved understanding of pain and its perception, some reduction in pain and
increased sexual activity. The numbers are too small to do any analysis but do demonstrate that the
interventions are having an effect.
Interventions have included both hands on and hands off techniques; advice, education, relaxation work,
trigger point release, internal and external work along with biofeedback and self management.
Discussion: Benefits have been seen both formally as part of the clinical re-evaluations and spontaneously at
consultant follow-up. For the first time there has been an opportunity for hands on and hands off
physiotherapy to be introduced for these patients as suggested by published guidelines2. There is no formal
arrangement for physiotherapy so these patients are seen in the general Out-Patient Physiotherapy. This
poses difficulties for both patients and staff as more time is required for these patients and the focus of
management is different with the potential for mixed messages being received. There is a strong case to
develop a service specifically for these patients especially as the number of male patient referrals increases.
1 Engeler S, Baranowski A, Elneil S, et al. Guidelines on Chronic Pelvic Pain. 2012
2 Map of Medicine, The British Pain Society. Chronic pelvic pain. England View. . London, November 2012
45
Patients with chronic visceral pain show sex related alterations in intrinsic oscillations of the resting brain
Jui-Yang Hong1,6, Lisa Kilpatrick1, Jennifer Labus1,3,4, Zhiguo Jiang1, Arpana Gupta1, Cody Ashe-McNalley1, Jean
Stains1,2, Bahar Ebrat1, Smith Suzanne1,2, Kirsten Tillisch1,2,5, Bruce Naliboff1,3,4, Emeran Mayer1-5
1
Oppenheimer Family Center for Neurobiology of Stress, Departments of 2Medicine, 3Psychiatry, 4Brain
Research Institute, and 5Division of Digestive Diseases, David Geffen School of Medicine, 6Department of
Bioengineering, University of CA, Los Angeles, United States
Introduction: Abnormal responses of the brain to delivered and expected aversive gut stimuli have been
implicated in the pathophysiology of Irritable Bowel Syndrome (IBS), a visceral pain syndrome occurring more
commonly in women. Task-free resting state fMRI can provide information about the dynamics of brain
activity which may be involved in the altered processing and/or modulation of visceral afferent signals. We
used fractional amplitude of low frequency fluctuation (fALFF) in order to identify differences in the resting
state activity of the human brain in IBS subjects compared to healthy control subjects (HCs), and to identify the
role of sex related differences.
Methods: We measured brain resting state activity (Siemens 3 Tesla Trio MRI scanner) in 76 female HCs, 42
male HC, 29 male IBS and 31 female IBS subjects. SPM8 was employed to preprocess and analyze the imaging
data using the general linear model and a region of interest analysis. Main effects for four subject groups
(male HC, female, HC, male IBS, female IBS), three frequency bands (LF, MF, and HF), and the interaction
between groups and bands was performed using a flexible factorial design. Results were considered significant
at p<.05, using family wise error correction.
Results: Female subjects in both HC and IBS groups showed greater HF power in affective and paralimbic
regions compared to male HC and male IBS subjects, respectively. In addition, female IBS patients had greater
HF power in the insula, and reduced low frequency (LF) power in sensorimotor cortex, compared to male IBS
patients. Correlations were observed between blood oxygen level dependent (BOLD) signals and clinical
symptoms (e.g. neuroticism, abdominal discomfort).
Conclusions: Our findings provide the first insight into sex-related differences in IBS subjects compared to HCs
using resting-state fMRI. The results are consistent with sex specific dysregulations in INS centric networks
engaged in emotional arousal/salience detection and in sensorimotor processing, confirming previous findings
obtained in studies using evoked brain responses to nociceptive stimuli and their expectation.
Grants: K08 DK071626, R03 DK084169 (JSL),K23DK073451, R01 AT007137KT),T32 K007180(CH),P50 DK064539
(EAM), R01 DK048351(EAM)
46
HPA genes show sex-specific interactions with early life trauma influencing hippocampal volume in healthy
controls and patients with Irritable Bowel Syndrome (IBS)
Lisa A Kilpatrick1, Annie Gupta1, Nuwanthi Heendeniya1, Katy Henry1, Jeanette C. Papp2, Eric M. Sobel2, Jennifer
Labus1, Emeran A. Mayer1
1
Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress and 2Human Genetics, University of
CA, Los Angeles, CA
Introduction: Although studies have suggested genetic and environmental influences interact to contribute
substantially to vulnerability to illness, the search for direct genetic x environmental influences contributing to
the risk for IBS have been inconclusive so far. Genes regulating the effects of stress via the HPA axis have been
implicated in the physiological and pathological regulation of stress reactivity as being mediated by release of
hypothalamic corticotrophin releasing hormone (CRH). HPA activity is modulated by sex hormones
progesterone and estrogen. HPA axis hyperactivity may be a function of psychosocial stressors such as early
adverse life events (EALs) and may show sex-specific effects on emotional arousal circuitry in the brain. The
hippocampus is a major component of the emotional arousal system whose morphology and gene expression
is modified by early life trauma. We aimed to examine gene-environment interactions on hippocampal
volumes in male and female IBS patients and HCs. Polymorphisms in HPA-related genes were examined for
effects on hippocampal volumes and interactions with early life trauma (ETI), sex, and diagnosis.
Methods: In a racially diverse community population of IBS and HCs, SNPs of CRHR1 (rs7209436, rs110402,
and rs242924), CRHBP (rs10055255 and rs 10062367), NR3C1 (rs33389, rs2963155, rs41423247), FKBP5
(3800373, rs9296158, rs1360780), PGR (rs1042838, rs10895068) and ESR1 (rs9340799) were genotyped.
Subjects completed structural MRIscans and the volumes of the right and left hippocampus were computed.
Superloci were created using Mendel software and were analyzed in a linear regression model controlling for
age, race, and total brain volume.
Results: 122 IBS patients (91 female) and 205 HCs (female 164) were studied. Significant Sex x Gene x ETI
interactions were seen for PGR and CRH-R1 superloci with the right hippocampus and for PGR with the left
hippocampus. For males with PGR minor alleles, higher ETI was associated with smaller right and left
hippocampal volumes, while no effect was seen in females. For males with CRH-R1 major alleles, higher ETI
was associated with smaller right hippocampal volume. In addition, ESR1 NR3C1, and CRHBP demonstrated sex
differences in healthy controls (more deleterious effects of genotype in men than in women) that were not
seen in IBS patients.
Conclusion: Sex differences in interactions between EALs and polymorphisms in genes modulating the CRH
system were demonstrated for volume of the hippocampus, a region involved in emotional arousal.
Specifically, PGR and CRH-R1 demonstrated male-specific effects of ETI on hippocampal volume. Both PGR and
CRH-R1 are expressed in the hippocampus. Progesterone is involved in neurogenesis and modulates HPA
activity. The results highlight the importance of considering sex in examining gene-environment effects in IBS.
47
Chronic urethral pain of difficult treatment associated with neuropathy of the pudendal nerve: A pilot study
Ramírez-García S 1, Gutiérrez-Salinas J2, Núñez-Ramos N1, Maldonado-Velázquez J1, García-Ortiz L3, HernándezRodríguez S2.
1
Uromédica OSF, México City, México; 2Lab. Biochemistry and Experimental Medicine and 3Division of Genomic
Medicine, National Medical Center “20 de Noviembre”, ISSSTE, México City, México
Introduction and objectives: The pudendal nerve neuropathy can be presented with various clinical
manifestations and usually confuse the doctor, especially when is accompanied by urinary dysfunction. The
aim of this paper is to describe the presence of chronic urethral pain refractory to conventional treatment, as a
manifestation of pudendal nerve neuropathy.
Material and methods: Retrospective study (December 2011 to October 2012) with 30 male and female
patients treated in our clinic without any pathology or previous surgery in the pelvic area. The patients had
urethral pain of at least 6 months, that increase during micturition cycle and does not diminish with anti-algic
or alpha-blockers. A questionnaire to assess the symptoms associated with the syndrome of the pudendal
nerve (taking into account the Nantes criteria) was applied. It describes the type and intensity of the pain and
the accompanying symptoms. The quality of life and urinary symptoms were rated using the IPSS. The areas
innervated by the pudendal nerve were explored, and sought the Rolling and the Tinel sign. General blood and
urine studies were performed. All patients were treated with CT-guided transgluteal infiltration of the
pudendal nerve.
Results: We included 17 women (42.74 ± 16.92 y.o.) and 13 men (52.87 ± 7.15 I y.o.). All patients had urethral
pain of 6 months to 20 years of evolution and were reviewed previously by 2 to 10 physicians. No patient had
urinary infection or other pathology. The women rated their pain intensity urethral 7.45 ± 2 and 5.67 ± 1.32 for
men. The burning pain was prevalent for women (70%) and for men (53%). The urethral pain was accompanied
with also vulva / scrotum pain in 70% of women and 84% in men, respectively. The 64.7% of the women had
poor quality of life and 53.84% of men were dissatisfied. The intermittent and incomplete emptying of the
bladder was 4-5 in both sexes and Tinel test was positive in 100% of cases. CT-guided transgluteal infiltration
of pudendal nerve improved 95% to 100% the symptoms.
Conclusions: In this paper we describe a number of cases in which the pudendal neuralgia is manifested
predominantly as urethral pain. The pudendal neuralgia was diagnosed using Nantes criteria and was
confirmed when symptoms and urethral pain decreased with pudendal nerve block.
48
The use of zinc hyaluronate in chronic cystitis treatment
Hasan P.L. , Perepanova T.S.
S.R. Urology Institute, Moscow, Russia
Introduction and objectives: Zinc Hyaluronate (ZH), a stabilizer of glycosaminoglycan layer, has been
suggested to be an effective means of treatment at chronic cystitis. The objective of the study was to improve
the results of chronic cystitis treatment.
Methods: A selection of 130 women (18-77years, the mean age 42 years) were recruited. On the basis of
standard urological tests added by cystoscopy and biopsy, 3 groups of patients have been determined: Irecurrent bacterial cystitis- 40%, II- chronic cystitis of postmenopausal period- 18%, III -non-bacterial forms of
chronic cystitis- 42%. In 92% cases morpho-immunohistochemical study of bladder found a common sign of
inflammatory infiltration in the bladder wall. The infiltration consisted of limfogystiocitarial cells with different
correlation of the types of mononuclears:I CD4-24,72±1,29, CD8-19,39±1,74, CD4\CD8-1,27±0,74, CD167,19±1,92, CD95-4,15±0,84. II: CD4-23,13±1,93, CD8- 11,72±0,97, CD4\CD8- 1,97±0,53, CD16- 5,34±1,23,
CD95- 2,21±,0,53. III: CD4- 23,94±4,56, CD8- 18,23±1,23, CD4\CD8- 1,31±0,86, CD16- 6.57±0,83, CD956,24±0,89.These alternations are evidence of aggressive types of inflammatory infiltration resulting in
disreparatory processes in interstitial tissue and bladder urothelium. Randomly chosen 30 patients from the 3
groups were treated with ZH instillations 2 times a weak (10 instillations a course/3 courses in 1 month
interval). The patients received instillations of ZH at the dose of 10ml. taken 1:1 with 0,9% NaCl sol. exposed
for not less than 2h. The control cystoscopy and biopsy were carried out on the 21th day.
Results: Considerable positive impact of the therapy (47% in VAS assessment) was reported by 83,3% of
women. Recurrence intervals shortened 2,5 times. The post-treatment study of limfogistiocitarial infiltration
revealed increase in regenerative capacity of epithelium and less signs of alteration in the interstitial and
mucous membrane of bladder: I: CD4- 26,82±1,36, CD8- 16,21±1,33, CD4\CD8- 1,65±0,82, CD16- 5,35±0,78,
CD95- 7,53±1,46. II: CD4- 22,47±2,04, CD8- 11,24±0,67, CD4\CD8- 1,99±0,45, CD16- 5,61±1,34, CD952,43±0,44.III: CD4- 28,12±3,24, CD8- 16,45±1,51, CD4\CD8- 1,711±0,82, CD16- 4,98±0,65, CD95- 8,78±1,57.
Conclusions: ZH, a stabilizer of glycosaminoglycan layer, has proved to be safe and effective means of local
intravesicular theraphy of various pathogenetic forms of chronic cystitis.
49
The standardization of terminology in chronic pelvic pain: Preliminary report from the Working Group on
Chronic Pelvic Pain of the Standardization Committee of the International Continence Society
Doggweiler R.1, Whitmore K.2 , Nordling J.3, Frawley H.4 Meijlink J.5 , Garrido G.6, El-Neil S.7, Hanno P.8, Fraser
M 9 Gomes M.10, .Birder L.11
1
University of Tennesse Knoxville, Division of Urology, Knoxville, TN, USA, 2Drexel University, Philadelphia,
College of Medicine Urology and Female pelvic medicine and reconstructive surgery, Philadelphia, PA, USA.
3
University of Copenhagen, Dept. Urology, Copenhagen, Denmark, 4University of Melbourne, Dept of
Physiotherapy, Melbourne, Australia. 5International painful Bladder Foundation, Holland, 6Clinics Hospital of
Jose de San Martin, University of Buenos Aires, Buenos Aires, Argentina. 7Urogynaecology unit at The
University College Hospital London Hospitals, London United Kingdom. 8University of Pennsylvania, Div of
Urology, Philadelphia, PA USA. 9Duke University, Division of Urology, Durham, USA, 10Urology Department, St.
António Hospital Oporto, Portugal. 11Universtity of Pittsburgh, Dept Pharmacology, Pittsburgh PA USA
Introduction & objectives: No single document is available that considers all of the pertinent elements of
CPP in females and males. This document addresses Chronic Pelvic Pain as a disease entity characterized by
certain symptoms, signs, and evaluation of the lower urinary tract (LUT), Female genital tract, Male genital
tract, gastro-intestinal (GI) tract, Musculoskeletal system, Neuropathic pain, Psychological overlay, and Comorbidities. Sexual Dysfunction is addressed where appropriate.
Methods: The authors represent an international multi-disciplinary group of chosen working group
volunteers by the standardization committee of the International Continence Society (ICS). The group
consists of health care providers and a patient advocate.
Results: CHRONIC PELVIC PAIN:
A. Duration of Pain
B.
Location of pain
C.
Perception of pain
D.
Modality of pain
SYMPTOMS: As per ICS—Alteration from normal function and perception reported by the patient or elicited
from the health care provider. Symptoms are reported in the patient’s history.
SIGNS: As per ICS—Objective evidence of disease reported by the patient or discovered on examination of
the patient. It may be anatomical, functional, sensory, or perceived. Signs are elicited during the physical
examination of the patient in order to identify pain generators. A full examination of the pelvis and body are
necessary as commonly multiple intra and extra-pelvic organ systems are involved. It is necessary to attempt
to identify all of the pain generators.
EVALUATION: Evidence that identifies the presence of disease subsequent to the history,(symptoms) and
physical examination, (signs). These include questionnaires (symptom severity and QOL), cystoscopy,
colonoscopy, laparoscopy and other diagnostic testing.
Conclusion: This report a first attempt to standardize the terminology of the complexity of CPP syndrome.
Patient perception plays a pivotal role in the diagnosis of CPP. The evidence remains sub-optimal and needs
further investigation that is evidence-based.
It is imperative to consider the mind-body aspects of chronic pelvic pain on the patient’s bio-psycho-social
structure as CPP affects the emotional, social and financial aspects significantly.
The future directions of research will involve standardization of the history, symptoms, (physical
examination), signs, (physical examination), and evaluation to identify patient populations FOR controlled
studies.
Diagnostic modalities remain limited with respect to the evaluation of chronic pelvic pain. Further studies
utilizing imaging (ultrasound and MRI) and more sophisticated procedures will help us better identify
accurately all pain generators
50
Clinicopathologic review of extrapelvic endometriosis in Korean women
Ju Eun Jeong1, Jong Kil Joo1, Young Ju Lee1, Sam Hyun Cho2, Dong Han Bae3, Kyu-Sup Lee1
1
Pusan National University School of Medicine, Department of Obstetrics and Gynecology, Busan, Korea
2
Hanyang University, Department of Obstetrics and Gynecology, Seoul, Korea
3
Soonchunhyang University, Department of Obstetrics and Gynecology, Chunan, Korea
Introduction & objectives: To evaluate the clinicopathologic features of extrapelvic endometriosis in order to
help diagnosis and treatment.
Materials & Methods: Thirty patients with extrapelvic endometriosis were surgically diagnosed at Pusan
National University Hospital from January 1998 to December 2010. We retrospectively reviewed the medical
records such as age, symptoms, preoperative diagnosis, past surgical history.
Results: There were 30 patients who were diagnosed extrapelvic endometriosis surgically with a mean age of
38 years. The main symptom was palpable mass with pain, noncyclic (33%, n=9), or cyclic (67%, n=21). Fifteen
endometriomas were found in the previous scar of cesarean section and laparoscopic surgery. Three
endometriomas were noted in episiotomy site and ten were in cervix. Inguinal and vaginal endometriosis, one
case was investigated, respectively.
Conclusion: Diagnosis of extrapelvic endometriosis is difficult to diagnose because of its rarity and diversity of
symptoms. Thus, It must be kept in mind as one of the differential diagnosis to treat patients with pain or
palpable mass during menstrual cycle in or around surgical scars, even if vaginal spotting or abnormal pap test.
Radical local excision help to treat and prevent recurrence of extrapelvic endometriosis.