Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Plenary 7 – Pain Issues
MODERATORS
Maurice K. Chung, MD & Tamer A. Seckin, MD
Maryam Hadiashar, MDJustin K. To, MD
Kumari A. Hobbs, MDFrank F. Tu, MD
Sangeeta Senapati, MD
Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Anxiety, Sleep, Pain Sensitivity and the Response to Laparoscopic Management of Pelvic Pain S. Senapati .................................................................................................................................................... 3 Predictors of Pain and Recovery Time after Benign Laparoscopic Gynecologic Surgery K.A. Hobbs .................................................................................................................................................... 6 Comparative Study of Clinical vs. Experimental Measures of Pelvic Sensitivity F.F. Tu ........................................................................................................................................................... 9 Image‐Guided Drainage Versus Antibiotics‐Only Treatment of Pelvic Abscesses: Long‐Term Outcomes J.K. To ......................................................................................................................................................... 12 Outcomes in Patients with Pudendal Neuralgia Using a Multidisciplinary Approach: A Retrospective Analysis M. Hadiashar .............................................................................................................................................. 18 Cultural and Linguistics Competency ......................................................................................................... 21
Plenary 7 – Pain Issues
Moderators: Maurice K. Chung and Tamer A. Seckin Faculty: Maryam Hadiashar, Kumari A. Hobbs, Sangeeta Senapati, Justin K. To, Frank F. Tu
This session is designed to provide all surgeons with a better understanding of pain management and various surgical interventions for patients with chronic pelvic pain. The session will also provide an evidence-based approach to pre-operative evaluation and management of post-operative complications associated with pain. This session will discuss conditions that cause pelvic pain and chronic pelvic pain physiology. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) review pain physiology in patients with acute or chronic pain; 2) discuss evidence-based management and evaluation of chronic pelvic pain; 3) discuss surgical interventions routinely performed for pain management in an office or hospital setting and discuss resources for management of post-operative pain complications.
Course Outline 2:15 Anxiety, Sleep, Pain Sensitivity and the Response to Laparoscopic Management
of Pelvic Pain S. Senapati
2:25 Predictors of Pain and Recovery Time after Benign Laparoscopic Gynecologic Surgery K.A. Hobbs
2:35 Comparative Study of Clinical vs. Experimental Measures of Pelvic Sensitivity F.F. Tu
2:45 Image-Guided Drainage Versus Antibiotics-Only Treatment of Pelvic Abscesses: Long-Term Outcomes J.K. To
2:55 Outcomes in Patients with Pudendal Neuralgia Using a Multidisciplinary Approach: A Retrospective Analysis M. Hadiashar All Faculty
3:15 Closing Remarks/Adjourn
1
PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Kimberly A. Kho* Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathan Solnik* Johnny Yi*
SCIENTIFIC PROGRAM COMMITTEE Ceana H. Nezhat Consultant: Ethicon Endo-Surgery, Lumenis, Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Arnold P. Advincula Consultant: Blue Endo, CooperSurgical, Covidien, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical Linda D. Bradley* Victor Gomel* Keith B. Isaacson* Grace M. Janik Grants/Research Support: Hologic Consultant: Karl Storz C.Y. Liu* Javier F. Magrina* Andrew I. Sokol* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Maurice K. Chung* Maryam Hadiashar* Kumari A. Hobbs* Tamer A. Seckin* Sangeeta Senapati Consultant: Emmi Justin K. To* Frank F. Tu* Asterisk (*) denotes no financial relationships to disclose.
Anxiety, Sleep, Pain Sensitivity and the Response to Laparoscopic Management of Pelvic Pain
Sangeeta Senapati, MD MSNorthShore University HealthSystem
Pritzker School of Medicine, University of Chicago
Disclosures
• Consultant: Emmi
Background• Chronic pelvic pain (CPP) is a common and
significant problem – Prevalence 14-16%
– Primary indication for» 12% of hysterectomies
» 15-40% of laparoscopies
• Somatic pain sensitivity (pelvic floor pain) is co-morbid in many CPP states– Pain sensitivity can be quantified by pressure-pain
testing
– Post operative pain may be predicted by experimental pain testing (thoracotomy, shoulder surgery)
Zondervan et al 2001; Mathias et al 1996; Howard et al 2003; Tu et al 2008; Yarnitsky et al 2008; Gwilym et al 2011
Background
• Pressure‐pain testing with a palpometer on • pelvic floor (right and left
iliococcygeus, anterior and posterior vaginal surfaces,
• external sites (forehead and right trochanter, hip, and medial knee fat pad, respectively)
10
2
4
3
Background• Response to surgical treatment for pelvic pain
may vary based on multiple factors– Source and duration of pain
– Type of surgery
– Psychosocial factors
• Psychosocial factors may be predictive of surgical outcomes – Mood factors strongly predictive
– Personality factors less predictive
• Anxiety– Three times higher risk of persistent symptoms 3
months after cholecystectomyRosenberger et al 2006; Fox et al 2013; Singh et al 2013
Objective
• To determine differences in pain sensitivity and psychological risk factors between women reporting improvement in pelvic pain from prior surgery vs. no improvement in a pilot study.
3
Methods
• 28 subjects – Comprehensive surgical history evaluated
» Data included for surgery addressing pelvic pain
– Success of surgery was assessed via a 5 point scale» (0 = not at all, 4 = very great deal)
– Anxiety, depression and sleep status was assess via standardized questionnaires (STAI-T, CESD, and NIH PROMIS)
– Participants underwent pressure-pain testing with a palpometer at both external and vaginal sites.
Methods
• Kendall’s tau correlations were used to assess relationships between psychosocial variables and pain sensitivity
• F‐test to determine the difference in variance of psychosocial variables between subjects with poor vs. positive surgical outcomes
0
2
4
6
8
10
12
0 0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3
Fre
quen
cy
Surgical Helpfulness
Very HelpfulNot Helpful
Surgical outcome had wide distributionInitially, no observed strong
correlations to surgical outcomeParameter tau-b p
Age -0.04 0.76Duration of Pain 0.25 0.06
Pain during exam -0.01 0.93External Pain Threshold 0.01 0.95Vaginal Pain Threshold -0.04 0.78
McGill Sensory 0.20 0.12McGill Affective 0.06 0.68
Depression (CESD) 0.02 0.90Depression (Promis) -0.02 0.88
Anxiety (Promis) 0.17 0.18Anxiety (STAI) -0.04 0.78
Fatigue (Promis) 0.00 0.98Sleep (Promis) 0.02 0.91
Higher variance of anxiety and sleep was observed with poor surgical outcome
F-test p = 0.02
F-test p = 0.01
F-test p = 0.02
≤1 >1 ≤1 >1
≤1 >1
Abnormal sleep & anxiety predict poor surgical outcome with 82% accuracy
R = 0.52p =0.02
Coef SEMAbnormal Anxiety -0.059 0.034Abnormal Sleep -0.050 0.041
4 false positives
1 false negative
6 true negatives
17 true positives
4
Conclusion
• Experimentally measured pain sensitivity was unrelated to prior surgical outcomes
• A combination of anxiety and sleep impairment was associated with 27% of the variability in surgical outcomes
Future Directions
• Larger cross sectional or prospective study design required to better evaluate these associations– Pain testing post-operatively
– Compare an unbiased population (both women with and without pain)
ReferencesFox JP, Philip EJ, Gross CP, Desai RA, Killelea B, Desai MM. Associations between mental health and
surgical outcomes among women undergoing mastectomy for cancer. Breast J. 2013 May-Jun;19(3):276-84.
Gwilym SE, Oag HC, Tracey I, Carr AJ. Evidence that central sensitisation is present in patients with shoulder impingement syndrome and influences the outcome after surgery. J Bone Joint Surg Br. 2011 Apr;93(4):498-502
Howard FM, Donnez J, Pirard C, et al. The role of laparoscopy in the chronic pelvic pain patient. Clin Obstet Gynecol 2003;46:749–66.
Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996;87: 321–7.
Rosenberger PH, Jokl P, Ickovics J. Psychosocial factors and surgical outcomes: an evidence-based literature review. J Am Acad Orthop Surg. 2006 Jul;14(7):397-405.
Singh JA, Lewallen DG Medical and psychological comorbidity predicts poor pain outcomes after total knee arthroplasty.Rheumatology (Oxford). 2013 May;52(5):916-23.
Tu FF, Fitzgerald CM, Kuiken T, Farrell T, Norman Harden R. Vaginal pressure-pain thresholds: initial validation and reliability assessment in healthy women.Clin J Pain. 2008 Jan;24(1):45-50.
Yarnitsky D, Crispel Y, Eisenberg E, Granovsky Y, Ben-Nun A, Sprecher E, Best LA, Granot M. Prediction of chronic post-operative pain: pre-operative DNIC testing identifies patients at risk. Pain. 2008 Aug 15;138(1):22-8
Zondervan KT, Yudkin PL, Vessey MP, et al. Chronic pelvic pain in the community: symptoms,
investigations, and diagnoses. Am J Obstet Gynecol 2001;184:1149 – 55.
5
Predictors of Pain and Recovery Time after Benign Laparoscopic Gynecologic
Surgery
Kumari A. Hobbs, MD
Disclosures
I have no financial relationships to disclose.
Objectives
• Examine potential risk factors for longer recovery times and worse pain scores in the postoperative period.
• Discuss prospective research opportunities and interventions for improving postoperative outcomes.
• Discuss the importance of adequate postoperative pain control.
• Review the incidence and pathophysiology of chronic postsurgical pain.
Postoperative pain
• Adverse physical effects1:
– Immune function, wound healing, cardiopulmonary and thromboembolic diseases
• Adverse psychosocial effects2:
– Decreased functional status, fatigue, depression/anxiety
• Chronic postsurgical pain (CPSP)3,4,5:
– Up to 50% depending on type of surgery
– 5‐30% reported after hysterectomy
Literature Review
• Inconsistent data, limited laparoscopic data
• Prospective data:
– Suboptimal pain control after discharge home6,7
– Postoperative recovery longer than expected2,6
• Risk factors for worse outcomes1,3,4,5:
– Type of surgery, younger age, psychological distress (ie anxiety, catastrophization), preoperative pain, preoperative narcotic use, poor quality of life, length of surgery
Our Study
• Objective: To identify potential predictors of postoperative pain and recovery time after laparoscopic gynecologic surgery
• Design: Retrospective cohort study
• Setting: University tertiary referral center
• Patients: 217 women who underwent surgery with a single provider in the Division of Advanced Laparoscopic Surgery and Pelvic Pain between 2011‐2013
6
Interventions
• Preoperative Visual Analog Scale (VAS) pain scores and demographic data were abstracted from medical records.
• Patients were queried at their 4‐6 week postoperative visit with two questions:
1) When did you feel 75% recovered?
2) What is your current pain level , measured on a Visual Analog Scale?
Patient Characteristics(n=217)
Characteristic Mean (±SD) / Percentage
Age 39 years (8.5)
BMI 31 (9)
Preoperative VAS score 16mm (26)
Index surgery: laparoscopic hysterectomy 63%
Chronic pelvic pain 21%
Dysmenorrhea 40%
Preoperative narcotic use 11%
Centralized pain disorder 14%
Pelvic floor muscle spasm 18%
Mean Outcome Data
Outcome Mean (±SD)Recovery time (days) 21 (9)
Postoperative VAS score (mm) 13 (21)
15
20
25
30
for
Bet
terc
ontin
uous
20 30 40 50 60Age
Predicted Value 95% CI
Pre
dict
ed V
alue
s an
d 95
% C
Ip=0.03
Predicted Values for
Recovery Tim
e (days)
‐ ‐ ‐ ‐ ‐ 95% CI
Age (years)
0
10
20
30
for
Pos
topV
AS
20 30 40 50Age
Predicted Value 95% CI
Pre
dict
ed V
alue
s an
d 95
% C
IPredicted Values for
Postoperative VAS (m
m)
Age (years)
p=0.02
‐ ‐ ‐ ‐ ‐ 95% CI
0
10
20
30
40
for
Pos
topV
AS
20 30 40 50 60BMI
Predicted Value 95% CI
Pre
dict
ed V
alue
s an
d 95
% C
Ip=0.03
‐ ‐ ‐ ‐ ‐ 95% CI
BMI (kg/m2)
Predicted Values for
Postoperative VAS (m
m)
15
20
25
30
35
40
for
Bet
terc
ontin
uous
0 1 2 3 4Hospstay
Predicted Value 95% CI
Pre
dict
ed V
alue
s an
d 95
% C
IPredicted Values for
Recovery Tim
e (days)
Hospital stay (days)
p=0.007
‐ ‐ ‐ ‐ ‐ 95% CI
15
20
25
30
35
for
Bet
terc
ontin
uous
0 20 40 60 80 100PreopVAS
Predicted Value 95% CI
Pre
dict
ed V
alue
s an
d 95
% C
IPredicted Values for
Recovery Tim
e (days)
Preoperative VAS (mm)
p=0.004
‐ ‐ ‐ ‐ ‐ 95% CI
0
10
20
30
40
50
for
Pos
topV
AS
0 20 40 60 80 100PreopVAS
Predicted Value 95% CI
Pre
dict
ed V
alue
s an
d 95
% C
IPredicted Values for
Postoperative VAS (m
m)
Preoperative VAS (mm)
p<0.001
‐ ‐ ‐ ‐ ‐ 95% CI
* Predicted values based on simple linear regression model
PreoperativeCharacteristic
Meanrecovery time
(days)p‐value
Meanpostoperative VAS score (mm)
p‐value
Dysmenorrhea YesNo
2419
.001 189
.003
Chronic pelvic painYesNo
2420
.01 2210
.002
Narcotic useYesNo
2520
.03 2212
.03
Centralized pain disorderYesNo
2620
.003 2212
.02
Pelvic floor muscle spasmYesNo
2720
<.001 319
<.001
* Means and p‐values calculated with one‐way ANOVA
Study limitations
• Retrospective design
• No validated questionnaire
• Heterogeneous surgery population
• Short follow up for the assessment of CPSP
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Future Directions
• Prospectively report (laparoscopic gynecologic procedures):
– Postoperative pain scores (to one year)
– Postoperative recovery time (to 100% recovered)
– Incidence of chronic postsurgical pain
– Effect of surgery on overall quality of life
• Prospectively report risk factors for worse outcomes:– Preoperative patient characteristics
– Operative characteristics
– Potential for predictive modeling
Future Directions
• Potential interventions:–Dependent on risk factors
–May include:• Improved counseling regarding postoperative expectations
• Preoperative use of centrally‐acting medications
• Preoperative treatment of psychological disorders
• Pre‐ and/or postoperative treatment of pelvic floor muscle spasm and other preexisting pain syndromes
• Customized postoperative pain medication regimens
Thank you!
References
1. Ip et al. Predictors of Postoperative Pain and Analgesic Consumption: A Qualitative Systematic Review. Anesthesiology 2009; 111: 657‐77.
2. Horvath, K. Postoperative Recovery at Home After Ambulatory Gynecologic Laparoscopic Surgery. Journal of PeriAnesthesia Nursing 2003; 18: 324‐334.
3. Brandsborg et al. A Prospective Study of Risk Factors for Pain Persisting 4 Months after Hysterectomy. The Clinical Journal of Pain 2009; 25: 263‐268.
4. Peters et al. Somatic and Psychologic Predictors of Long‐term Unfavorable Outcome After Surgical Intervention. Annals of Surgery 2007; 245: 487‐494.
5. Brandsborg et al. Risk Factors for Chronic Pain after Hysterectomy: A Nationwide Questionnaire and Database Study. Anesthesiology 2007; 106: 1003‐1012.
6. Evenson et al. Recovery at Home After Major Gynecologic Surgery: How Do Our Patients Fare? Obstetrics & Gynecology 2012; 119: 780‐784.
7. Lovatsis et al. Assessment of Patient Satisfaction with Postoperative Pain Management after Ambulatory Gynaecologic Laparoscopy. Journal of Obstetrics and Gynaecology Canada 2007;29: 664‐667.
8
Comparative Study of Clinical vs. Quantitative Measures of Pelvic Sensitivity
Frank Tu, MPH, MD
Disclosure
I have no financial relationships to disclose.
Introduction
• Chronic pelvic pain (CPP) has poorly understood mechanisms.
• Enhanced pain sensitivity is a hallmark of idiopathic pain disorders (lBS, migraine, fibromyalgia)
Zondervan K et al 2001, Tu FF et al 2007
Introduction
• Work by our group and others has focused on quantifying this pain sensitivity via transvaginal pressure-pain testing (PPT).
• Prior studies by us and others show pelvic and global mechanoreception is altered in dysmenorrhea as a contributing factor in the development of CPP
• Our broader objective is to determine how somatic sensitivity influences/interfaces with visceral sensitivity (bladder, uterus, bowel)
Tu FF et al 2007, Tu FF et al 2008, Tu FF et al 2013, Zolnoun D et al 2012, Fitzgerald MP et al 2012
Study Description Objective: To profile the relative
distribution of clinical palpation and quantitative sensory testing (QST) findings for vaginal pain sensitivity in chronic pelvic pain (CPP) conditions.◦ Determining their diagnostic test properties
(sensitivity/specificity) may help determine if simpler tests can replace QST
Design: Cross-sectional study Setting: Academic community hospital
Methods Study aim: determine if simple clinical
palpation (transvaginal) parallels QST in discriminating CPP/IC patients from healthy age matched controls
84 women enrolled in study examining standardized visceral and somatic pain stimulation
Interstitial cystitis (IC); n=23, chronic pelvic pain (CPP; n=22) and healthy controls (n=39).
CPP/(IC): pelvic pain of at least 3 months duration (+ urgency or frequency)
9
Methods
• Participants underwent pressure‐pain testing on • pelvic floor (right and left iliococcygeus, anterior and posterior vaginal surfaces,
• external sites (forehead and right trochanter, hip, and medial knee fat pad, respectively)
• 1 cm2 circular steel flat probe, 0.5 kg/cm2/s ramp rate
• Clinical examination consisted of gentle palpation of the vaginal tissues at the right and left iliococcygeus sites (< 0.2 kg/cm2)
1
2
4
3
Methods• Estimations of general population pain
sensitivity were performed with Monte Carlo simulations (assuming 5% prevalence of CPP/IC) and optimal diagnostic test parameters calculated with receiver-operator characteristic curves.
• Results for CPP and IC were combined due to similar results.
• Analysis: STATA 11, Microsoft Excel, rank order tests, chi-squared test of proportions, t-tests, nonparametric equivalents
Table 1: Baseline DemographicsControls n=39 CPP/IC n=45 P-value
Age 31 (23-44) 32 (28-40) 0.48Weight (lb) 148 (128-192) 158 (132-195) 0.35
Marital Status 0.19Married or Committed
SingleDivorced or Widowed
49%51%0%
62%27%10%
Parity StatusNo prior births1 birth or more:
72%28%
55%44%
0.76
Hx Depression 15% 47% 0.025Hx Anxiety 31% 44% 0.041
Hx Abuse 15% 60% 0.001Dyspareunia 10% 71% 0.001
Prior abd/pelvic surgeries
54% 84% 0.023
0123456789
10
Pa
in w
ith P
alp
atio
nCPP/IC
Healthy
*p < 0.001
Palpation pain is exclusive to CPP/IC
Whereas healthy subjects rarely reported pain with palpation (95%CI: 0-14%), 60% of CPP/IC subjects reported pain with palpation (95% CI: 45-73%).
Subjects with CPP/IC reported more right (median 0 [0-5]) and left (median 2 [0-5]) iliococcygeus pain (p<0.001) than healthy subjects.
CPP/IC subjects had lower PPTs than Healthy subjects
Healthy subjects had higher average PPTs (1.37±0.1 kg/cm2) than CPP/IC subjects (1.01±0.06 kg/cm2; p=0.01).
0
1
2
3
Pa
lpo
me
ter
Pre
ssur
ekg
/cm
2
*p < 0.001 *p < 0.001*p < 0.001 *p < 0.001
CPP/IC
Healthy
PPT has considerable overlap in CPP/IC from healthy subjects vs. palpation-
related pain
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10
% s
ubj
ect
s
Pain with Palpation
Healthy
CPP/IC
0
25
50
75
100
0 0.5 1 1.5 2 2.5 3
% s
ubje
cts
PPT kg/cm2
Healthy
CPP/IC
Palpation: PPT:
10
.0
.2
.4
.6
.8
1.0
.0 .2 .4 .6 .8 1.0
Tru
e P
osi
tive
Ra
te
False Positive Rate
AUC = .687 ± .043
.0
.2
.4
.6
.8
1.0
.0 .2 .4 .6 .8 1.0
Tru
e P
osi
tive
Ra
te
False Positive Rate
AUC = .843 ± .035
Receiver-operator curves on simulated data set demonstrate the superiority of palpation for phenotyping
Sensitivity: 70%Specificity: 92%
Sensitivity: 64%Specificity: 58%
Palpation: PPT:
Palpation pain and reduced mechanical threshold phenotypes partially overlap in CPP/
IC Regression model: Combined ROC:
.0
.2
.4
.6
.8
1.0
.0 .2 .4 .6 .8 1.0
Tru
e P
osi
tive
Ra
te
False Positive Rate
PPT and PalpationPPT onlyPalpation only
0
0.5
1
1.5
2
2.5
3
3.5
0 5 10
PP
T k
g/cm
2
Palpation Pain
Healthy
CPP/IC
r = 0.45p<0.001
Healthy SubjectsCPP/IC
Palpation Pain
Reduced PPTs
Conclusions Clinical pelvic exam with simple palpation
(even not at the site of primary symptoms) provides better sensitivity and specificity for identifying pelvic pain than pressure pain thresholds.
Alterations in mechanical thresholds still maycontributing to the observed hyperalgesiawith palpation in CPP/IC
QST’s role in characterizing risk for pain chronicity may be more relevant in preclinical risk assessment, but needs refinement
References 1. Tu, F.F., Fitzgerald, C.M., Kuiken, T., et al., Vaginal pressure-pain
thresholds: initial validation and reliability assessment in healthy women.Clin J Pain, 2008. 24(1): p. 45-50.
2. Tu, F.F., Fitzgerald, C.M., Kuiken, T., et al., Comparative measurement of pelvic floor pain sensitivity in chronic pelvic pain.Obstet Gynecol, 2007. 110(6): p. 1244-8.
3. Zolnoun, D., Bair, E., Essick, G., et al., Reliability and reproducibility of novel methodology for assessment of pressure pain sensitivity in pelvis. J Pain, 2012. 13(9): p. 910-20.
4. Tu, F.F., Epstein, A.E., Pozolo, K.E., et al., A Noninvasive Bladder Sensory Test Supports A Role for Dysmenorrhea Increasing Bladder Noxious Mechanosensitivity. Clin J Pain, 2013.
5. Fitzgerald, M.P., Payne, C.K., Lukacz, E.S., et al., Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol, 2012. 187(6): p. 2113-8.
11
Justin To, MD, FACOG
• Director of Minimally Invasive Surgery – Weiler Division• Montefiore Medical Center
I have no financial relationships to disclose.
Efficacy of antibiotic treatment of pelvic abscesses
Efficacy of image-guided drainage for treatment of pelvic abscesses
Long-term outcomes of patients with pelvic abscess
66,000 cases of tuboovarian abscess are diagnosed in the United States annually1
Sequelae of pelvic inflammatory disease2
This can be a life-threatening diagnosis, given the risk of rupture and sepsis3
1 Washington AE, Katz. Cost of and payment source for pelvic inflammatory disease. JAMA. 1991;266(18):25652 Benigno BB. Medical and surgical management of the pelvic abscess. Clinical Obstet and Gyn. 1981; 24(4): 1187-97 3 Vermeeren J. Te Linde RW. Intraabdominal rupture of pelvic abscesses. Am J Obstet Gynecol. 1954;68(1):402
Other pelvic abscesses, such as postoperative and gastrointestinal abscesses, can also significantly affect patients and their reproductive
Definitive treatment of tuboovarian abscess: total abdominal hysterectomy with bilateral salpingo-oophorectomy In 1964, Pedowitz et al found that 24 of 143 patients
with ruptured TOA had prior conservative surgery
6 of 17 patient that had any remains of adnexa eventually needed hysterectomy4
Unilateral adnexectomy has also gained acceptance5
4 Pedowitz P, Bloomfield RD. Ruptured Adnexal Abscess with Generalized Peritonitis. Am J Obstet Gynecol 1964;88:721-7295 Landers DV, Sweet RL. Current trends in the diagnosis and treatment of tuboovarian abscess. Am J Obstet Gynecol. 1985; 151(8):1098-1110
Surgery may be complicated Distorted anatomy
Obliterated surgical planes
Infected and friable tissue
Complications may include Hemorrhage
GI or GU injury
Patients are often premenopausal and may desire future fertility6
6 Wiesenfeld HC, Sweet RL. Progressing the management of tuboovarian abscesses. Clin Obstet Gynecol 1993; 36:433-444.
12
IV antibiotic treatment has been shown to be effective in approximately 70% of patients7
Vaginal drainage is possible with a palpable abscess in the cul-de-sac
Laparoscopic drainage studies have shown greater effectiveness than antibiotics 8
Surgical and anesthetic risk
7 Goharkhay et al. Comparison of CT or ultrasound-guided drainage with concomitant intravenous antibiotics vs. intravenous antibiotics alone in the management of tubo-ovarian abscess. Ultrasound Obstet Gynecol 2007: 29: 65-69.
8 Rosen M et al. Tubo-Ovarian abscess Management Options for Women Who Desire Fertility. Obstet and Gynecol Survey. 64(10): 681-689.
Image-guided drainage has the advantage of minimal anesthetic risk
Acute benefits have been shown in multiple trials
sciencedirect.com
Gjelland et al Retrospective case series
302 patients – US-guided drainage
282 patients (93.4%) were successfully treated
Goharkhay et al Retrospective cohort analysis
58 subjects total
42% of the primary antibiotics group failed treatment versus 0% in the primary drainage group
Perez-Medina et al Randomized prospective cohort analysis
40 patients total
Favorable short term response in 90% of patients who received early transvaginal drainage
Favorable outcomes in 65% in the control group who received antibiotics alone
Mainly only case series in the literature
Cohort analyses have few patients
No studies have significantly looked at long-term (>3 years) outcomes for these patients Readmission rate
Further surgical intervention
Associated pain
Pregnancy rate
The rate of surgical intervention in women with pelvic abscesses treated with image-guided drainage will be lower than those who received antibiotic-only treatment
13
To compare the rates of surgical intervention in women with pelvic abscesses initially treated with antibiotics versus those who underwent image-guided drainage
Type and length of antibiotic therapy
Length of hospital stay
Days from treatment to discharge
Type of surgery if failed treatment
Rate of readmission
Mortality rate
Residual pain
Attempts at spontaneous or un-assisted pregnancy after discharge
Pregnancy rate
Infertility rate
Retrospective cohort analysis
Approved by Einstein/Montefiore IRB
Subjects were identified by performing a query in Clinical Looking Glass
Ages 11 to 49
Patients admitted to Montefiore Medical Center hospitals with the diagnosis of ICD-9 code 614.x between 1998-2008
ICD-9 code 614.x: inflammatory diseases of ovary, fallopian tube, pelvic cellular tissue, and peritoneum
Control group: Patients who received antibiotics-only treatment
Study group: Patients who received image-guided drainage
Attempt made to contact all subjects
Verbal consent
Phone survey
14
Diagnosed with malignancy
Lack of radiologic evidence of abscess
Lack of pus obtained during image-guided drainage
No evidence of abscess during surgery
Prior hysterectomy and/or bilateral salpingo-oophorectomy
Pregnant patients
bromleyartsociety.org.uk
Age
Parity
Past medical history
Past surgical history
History of PID
IUD in-situ or history of IUD
HIV status
BMI
Unilateral or bilateral abscess
Abscess dimensions
STATA 12.0
Continuous data: Student t test or Mann Whitney depending upon the data distribution
Categorical variables: Χ2 or Fischer’s exact test
Initial associations: Pearson’s correlation
twainquotes.com
6,151 patients identified in Clinical Look Glass with
ICD-9 diagnosis 614.x, ages 11 to 49, between 1998 and 2008
198 patients who received antibiotics
120 patients contacted by phone
41 patients who underwent image-guided drainage
Chart review
5,912 patients excluded due to:• Diagnosed with gynecologic malignancy• Lack of radiologic evidence of abscess• Lack of pus obtained during image-guided drainage
• Lack of abscess during surgery• Prior hysterectomy or BSO• Pregnancy
239 patients meet criteria
78 patients unable to be contacted by phone
30 patients contacted by phone
11 patients unable to be contacted by phone
Antibiotics (n=198) Drainage (n=41) P-value
Age 32.7 32.2 0.78
BMI 28.9 30.4 0.27
Parity 1.2 1 0.25
PMH of:
• Diabetes 7.1% (14) 2.4% (1) 0.24
• Obesity 65.7% (130) 73.2% (30) 0.47
• Endometriosis 3.0% (6) 2.4% (1) 1.0
• HIV 14.1% (28) 2.5% (1) 0.04
• PID 22.3% (44) 17.1% (7) 0.54
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No associated mortality
2 patients in the antibiotic treatment cohort were noted to have a ruptured abscess
Treatment selection was not affected by presence of bilateral abscesses
Antibiotics (n total=198)
Drainage (n total=41) P-value
Average follow up years 10 years 8.5 years <0.01
Largest abscess dimension 5.9 cm 8.5 cm <0.01
Unilateral abscess 80.3% (159) 78.0% (32) 0.83
Bilateral abscess 19.7% (39) 22% (9) 0.44Average hospital stay - initial admission 7.4 13.3 <0.01
Days from treatment till discharge 7.4 6.7 0.52
Surgery required - initial admission 15.7% (31) 2.4% (1) 0.02
Type of surgery
• Adnexectomy 54.8%(17) 0% 0.47
• Adnexectomy with hysterectomy 32.2% (10) 100%(1) 0.47
• Gyn and bowel surgery 12.9%(4) 0% 0.47
Readmission for similar disease 22.7%(45) 29.3%(12) 0.54
• Surgery required - readmission 40%(18) 33.3%(4) 0.75
Statistically significant difference in hospital stay (7.4 days vs. 13.3 days, p<0.01) Average time to drainage = 6.6 days
The time from treatment to discharge in both groups was similar (7.4 days vs. 6.7 days, p=0.52)
Antibiotics (n total = 120)
Drainage(n total = 30) P-value
Residual pain 32.5%(39) 33.3%(10) 0.53
Attempted pregnancy 44.2%(53) 56.7%(17) 0.42
• Achieved pregnancy 56.6% (30) 41.2% (7) 0.4Pregnancy outcomes
- Full term delivery 76.6%(23) 86%(6) 0.76
- TOP/Sab 16.7%(5) 14%(1) 0.76
- Ectopic 6.7%(2) 0% 0.76
• Infertility 49%(26) 70.6%(12) 0.16
Patients who received antibiotics alone were more likely to require further surgical intervention when compared to patients who received image-guided drainage
Hospital stay may be shortened with earlier consideration of image-guided drainage
There were no other observable long-term differences between the groups
16
Retrospective analysis and associated biases Recall bias
Incomplete records
No standardization/randomization of who received different treatments
Unable to contact and obtain long-term follow up on all patients
Prospective cohort analysis
Randomization to treatment arm
Washington AE, Katz. Cost of and payment source for pelvic inflammatory disease. JAMA. 1991;266(18):2565
Benigno BB. Medical and surgical management of the pelvic abscess. Clinical Obstet and Gyn. 1981; 24(4): 1187-97
Vermeeren J. Te Linde RW. Intraabdominal rupture of pelvic abscesses. Am J Obstet Gynecol. 1954;68(1):402
Pedowitz P, Bloomfield RD. Ruptured Adnexal Abscess with Generalized Peritonitis. Am J Obstet Gynecol 1964;88:721-729
Landers DV, Sweet RL. Current trends in the diagnosis and treatment of tuboovarian abscess. Am J Obstet Gynecol. 1985; 151(8):1098-1110
Wiesenfeld HC, Sweet RL. Progressing the management of tuboovarian abscesses. Clin Obstet Gynecol 1993; 36:433-444.
Rosen M et al. Tubo-Ovarian abscess Management Options for Women Who Desire Fertility. Obstet and Gynecol Survey. 64(10): 681-689.
Gerzof SH, Robbins AH, Johnson WC, Birkett DH, Nabseth DC. Percutaneous catheter drainage of abdominal abscesses: a five-year experience. N Engl J Med. 1981;305(12):653.
Gerzof SH, Johnson WC, Birkett DH, Nabseth DC. Expanded criteria for percutaneous abscess drainage. Arch Surg. 1985;120(2):227.
Worthen NJ, Gunning JE. Percutaneous drainage of pelvic abscesses: management of the tubo-ovarian abscess. J Ultrasound Med. 1986;5(10):551.
Nelson AL, Sinow RM, Renslo R, Renslo J, Atamdede F. Endovaginal ultrasonographically guided transvaginal drainage for treatment of pelvic abscesses. Am J Obstet Gynecol. 1995;172(6):1926.
Harisinghani MG, Gervais DA, Maher MM, Cho CH, Hahn PF, Varghese J, Mueller PR. Transgluteal approach for percutaneous drainage of deep pelvic abscesses: 154 cases. Radiology. 2003;228(3):701.
Gjelland K, Ekerhovd E, Granberg S. Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases. Am J Obstet Gynecol. 2005;193(4):1323.
Goharkhay N, Verma U, Maggiorotto F. Comparison of CT- or ultrasound-guided drainage with concomitant intravenous antibiotics vs. intravenous antibiotics alone in the management of tubo-ovarian abscess. Ultrasound Obstet Gynecol 2007; 29:65-69.
Perez-Medina T, Huertas MA, Bajo JM. Early ultrasound-guided transvaginal drainage of tubo-ovrian abscesses: a randomized study. Ultrasound Obstet Gynecol 1996;7:435-438.
Henry-Suchet J, Soler A, Loffredo V. Laparaoscopic treatment of tuboovarian abscesses. J Reprod Med 1984; 29: 579-582.
Raiga J, Denoix S, Canis M, et al. [Laparoscopic treatment of adnexal abscesses. A seris of 39 patients]. J Gynecol Obstet Biol Reprod (Paris) 1995;24:381-385.
Irwin Merkatz, MD
Gary L. Goldberg, MD
Mark Levie, MD
Scott Chudnoff, MD
Diana Aldape, MD
Andrei Frost, MD (Interventional Radiology)
Minimally Invasive Gynecologic Surgery Division
Department of OB/GYN and Women’s Health
17
Outcomes in Patients with Pudendal Neuralgia Using a Multidisciplinary Approach: A
Retrospective Analysis
Maryam Hadiashar MD
*University of Tennessee College of Medicine, Chattanooga
Disclosures
• I HAVE NO FINANCIAL RELATIONSHIPS TO DISCLOSE
Learning Objectives
At the conclusion of this talk, the participants should be able to clinically define Pudendal Neuralgia(PN), define Nante’s criteria, and describe what constitutes conservative multidisciplinary management of PN.
Background
• Difficult to determine incidence
• Common in pelvic pain referral centers
• Other underlying pain diagnoses
• Nante’s Diagnostic criteria
Background: Management options
• Pudendal nerve release• Amarenco et al and
Popeney et al: 27-60% of pts responded to surgical decompression of pudendal nerve
• Pudendal nerve blockade under fluoroscopy
• Choi et al in 2006 saw 62% of patients pain respond to nerve blocks
• Multidisciplinary approach utilizing serial pudendal nerve blockade under fluoroscopy, pelvic floor PT, and medical management?
Study Design
• Retrospective chart review from 2007-2012 of patients with ICD-9 code for Pudendal Neuralgia (729.1)
• Private practice pelvic pain referral center in a community setting
• Primary outcome: improvement in visual analog pain scores by 50% at 12 weeks
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Study design
• Inclusion and exclusion criteria
• Serial pudendal nerve blockade in the office or under fluoroscopy
• Medical management
• Pelvic floor physiotherapy
• Treatment of other underlying pain conditions
Methods
• SPSS v21 (IBM, 2013)
• Categorical variables expressed as proportions
• Continuous variables as mean +/- SD and standard error
• Visual analog score compared at initial visit and 12 weeks with the paired T-test
Table 1. Demographics %(n) %(n)
n=37 n=37
Age (mean +/-SD) 43 +/-14.7 Insurance
Sex Self 5.4(2)
Female 89.2(33) Medicare/Medicaid 13.5(5)
Male 10.8(4) PPO/HMO 81.1(30)
Education Race
Less than 12 years 13.5(5) African-American 8.1(3)
High school 54(20) Caucasian 89.2(33)
College 27(10) Other 2.7(1)
Post graduate 5.4(2)
OccupationStudent 8.1(3)
Employed 59.5(22)
Unemployed 21.6(8)
Retired 10.8(4)
Marital StatusSingle 18.9(7)
Married/Committed 73(27)
Divorced/Separated 8.1(3)
Results: Patient Characteristics
Main Result
*p<0.0001
Mean N SD Std Error Mean
Initial Pain Score
9.0278* 36 1.46358 .24393
3 month pain score
5.2778* 36 2.84466 .47411
ResultsPrevalence of other coexisting pain triggers(+PN)
Number of patients
%
Pelvic Floor Myalgia(n=37)
33 89
Vulvodynia (n=33) 27 81
Vulvodynia+PFM (n=33) 25 75
PBS/IC(n=37) 20 54
Endometriosis(n=33) 4 12
ObturatorNeuralgia(n=37)
3 8
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Discussion
• Strengths Less invasive management
Scarcely studied
• Weakness One facility and One provider
Lack of pain score documentation/lost to follow up
Multiple diagnoses
Retrospective
Small sample size
Conclusion
• Consider Pudendal Neuralgia as diagnosis in patient that presents with Chronic Pelvic Pain
• Multidisciplinary conservative management of Pudendal Neuralgia is effective in decreasing pain scores
• Often multiple diagnoses
REFERENCES
1. Amarenco G, Lanoe Y, Perrigot M, Goudal H. A new canal syndrome: compression of the pudnedal nerve in Alcock’s canal or perineal paralysis of cyclists. Presse Med 1987:16:399.2. Hibner,M. Castellanos, M et al. Global Library of Women’s Medicine. ISSN:1756-2228)2011; DOI 10.3843/GLOWM.10463. Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment(Nantes Criteria) Neurourol Urodyn 2008;27:306-310.Choi SS, Lee PB, Kim YC, et al. C- arm guided pudendal nerve block: a new technique. Int J Clin Pract 2006;60:553-556.4. Popeney C, Ansell V, Renney K. Pudendal entrapment as an etiology of chronic perineal pain: Diagnosis and Treatment. Neurology and Urodynamics. 2007;26(6):820-7.5. Amarenco G, Kerdraon J, Bouju P, Le Budet C, Cocquen AL, Bosc S, Goldet R. Treatments of perineal neuralgia caused by involvement of the pudendal nerve. Rev Neurol (Paris). 1997 Jun;153(5): 331-4.6. Sandoval,R and Nieves-Gonzalez,A. Undiagnosed co-existing pain triggers contributing to the perpetuation of pelvic pain in patients with endometriosis(abstract). 41st Annual meeting of the American Association of Gynecologic Laparoscopy, Las Vegas, Nov 5-9 2012.
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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsian
Indo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
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