Background: Chronic pelvic pain is common in women in the reproductive and older age groups and causes disability and distress. Often investigation by laparoscopy reveals no obvious cause for the pain. As the pathophysiology of chronic pelvic pain is not well understood its treatment is often unsatisfactory and limited to symptom relief. Currently the main approaches to treatment include counselling or psychotherapy, attempts to provide reassurance by using laparoscopy to exclude serious pathology, progestogen therapy such as medroxyprogesterone acetate, and surgery to interrupt nerve pathways. Objectives: We aimed to identify and review treatments for chronic pelvic pain in women. The review included studies of patients with a diagnosis of pelvic congestion syndrome or adhesions but excluded those with pain known to be caused by i) endometriosis, ii) primary dysmenorrhoea (period pain), iii) pain due to active chronic pelvic inflammatory disease, or iv) irritable bowel syndrome. Search strategy: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (searched 20th January 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005), and reference lists of articles. Selection criteria: Randomised controlled trials (RCTs) with women who had chronic pelvic pain. The review authors were prepared to consider studies of any intervention including lifestyle, physical, medical, surgical and psychological treatments. Outcome measures were pain rating scales, quality of life measures, economic analyses and adverse events. Data collection and analysis: For each included trial, information was collected including the method of randomisation, allocation concealment and blinding. Data were extracted independently by the two review authors using forms designed according to the Cochrane guidelines. Main results: Nineteen studies were identified of which fourteen were of satisfactory methodological quality. Five studies were excluded. Progestogen (medroxyprogesterone acetate) was associated with a reduction of pain during treatment while goserelin gave a longer duration of benefit. Counseling supported by ultrasound scanning was associated with reduced pain and improvement in mood. A multidisciplinary approach was beneficial for some outcome measures. Benefit was not demonstrated for adhesiolysis (apart from where adhesions were severe), uterine nerve ablation, sertraline or photographic reinforcement after laparoscopy. Writing therapy and static magnetic field therapy showed some evidence of short-term benefit. Authors' conclusions: The range of proven effective interventions for chronic pelvic pain remains limited and recommendations are based largely on single studies. Given the prevalence and healthcare costs associated with chronic pelvic pain in women, randomised controlled trials of other medical, surgical and psychological interventions are urgently required. Chronic pelvic pain is common in women in the reproductive and older age groups and it causes disability and distress that result in significant costs to health services. The pathogenesis of chronic pelvic pain is poorly understood. Often investigation by laparoscopy reveals no obvious cause for the pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, and central sensitisation of the nervous system. A vascular hypothesis proposes that pain arises from dilated pelvic veins in which blood flow is markedly reduced. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. Currently the main approaches to treatment include counseling or psychotherapy, attempts to provide reassurance using laparoscopy to exclude serious pathology, progestogen therapy such as with medroxyprogesterone acetate and surgery to interrupt nerve pathways.

STUDY OBJECTIVE:To evaluate the degree of pain relief provided by laparoscopic surgical treatment of ovarian remnant and ovarian retention syndromes. DESIGN:Retrospective analysis (Canadian Task Force classification II-2). SETTING:Academic hospital and affiliated outpatient offices. PATIENTS:A total of 54 patients from 2004 to 2008 who underwent surgical treatment for suspected ovarian remnant syndrome or ovarian retention syndrome. INTERVENTIONS:Oophorectomy. MEASUREMENTS AND MAIN RESULTS:Preoperative and postoperative pain scores were recorded from patients who underwent surgical treatment for either ovarian remnant or ovarian retention syndrome. Data regarding comorbid diagnoses that would contribute to chronic abdominopelvic pain, previous surgical history, surgical complications, and pathology to confirm the preoperative diagnosis were also collected. Pathology confirmed that ovarian tissue was removed in 52 of the 54 patients. Forty percent and 41% of patients with ovarian remnant and ovarian retention, respectively, achieved a 50% reduction of their average pain levels; 50% and 56%, respectively, achieved a 30% reduction in average pain levels. There was not a statistically significant difference in postoperative pain relief between the 2 groups. Cases with ovarian remnant syndrome had more prior surgical procedures (4.8 vs 3.6, p = .049) and were more likely to have a surgical complication (25% vs 3%, p = .03) than cases with ovarian retention syndrome. Patients with a 30% or greater decrease in their pain levels postoperatively were likely to have fewer other diagnoses associated with chronic pain (1.4 ± 1.1 vs 2.1 ± 0.9, p = .009). CONCLUSION:Surgical treatment for ovarian remnant or ovarian retention syndrome is effective but is most effective in patients with no other pain-related diagnoses. Thus, it is important to thoroughly evaluate women with ovarian remnant or ovarian retention syndrome for other pelvic pain-related disorders. In almost all cases, surgery can be done laparoscopically in patients with these syndromes.

Objective: We tested the hypothesis that functional somatic syndromes (FSSs) are risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis (BPS/IC).Methods: In 312 women with incident BPS/IC, we diagnosed seven pre-BPS/IC syndromes: chronic pelvic pain (CPP), fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome (IBS), sicca syndrome, migraine, and panic disorder. Each was defined as present before 12 months (existing syndrome) or onset within 12 months (new syndrome) prior to BPS/IC onset. Retrospectively, we sought associations between prior hysterectomy and existing FSSs. Prospectively, we studied associations of existing and new syndromes with subsequent hysterectomy. Logistic regression analyses adjusted for age, race, menopause and education.Results: The retrospective study showed prior hysterectomy (N = 63) to be associated with existing CPP and the presence of multiple existing FSSs. The prospective study revealed that 30/249 women with a uterus at baseline (12%) underwent hysterectomy in early BPS/IC This procedure was associated with new CPP (OR 6.0; CI 2.0, 18.2), new IBS (OR 5.4; CI 13, 223), and existing FSSs (OR 3.9; CI 1.1, 13.9).Conclusion: Accounting for CPP and IBS, the presence of multiple FSSs (most without pelvic pain) was a separate, independent risk factor for hysterectomy in early BPS/IC. This suggests that patient features in addition to abdominopelvic abnormalities led to this procedure. Until other populations are assessed, a prudent approach to patients who are contemplating hysterectomy (and possibly other surgeries) for pain and who have IBS or numerous FSSs is first to try alternative therapies including treatment of the FSSs. (C) 2014 Elsevier Inc. All rights reserved.

Pudendal neuralgia is a neuropathic condition. Entrapment is a common cause, often encountered at the small space between the sacrosopinous and the sacrotuberous ligament. When entrapment is diagnosed, 4 different approaches to decompression have been described. In this video we will present the laparoscopic approach. We will review the neurovascular anatomy of the pelvic side wall, related to the sacrospinous ligament and the pudendal nerve; and the technique to expose these structures in order to transect the sacrospinous ligament. Knowledge of the neurovascular structures at the pelvic side wall is essential to safely perform this procedure. This technique can be used as a minimally invasive approach in patients with pudendal nerve entrapment at the sacrospinous and sacrotuberous ligament, with adequate improvement of symptoms and faster recovery than other techniques.

To analyze the effect of surgical volume on rates of lower urinary tract injury (LUTI) during conventional laparoscopic, robotic-assisted and laparotomic hysterectomy.

OBJECTIVE:The objective of the study was to compare with controls the incidence of nonbladder pelvic surgeries in the months before and after the onset of interstitial cystitis/bladder pain syndrome (IC/BPS).STUDY DESIGN:The design of the study used an existing database from a retrospective case-control study of 312 incident IC/BPS cases and matched controls plus a longitudinal study of the cases that examined lifetime approximated annual incidence of surgeries with that in the months before and after the onset of IC/BPS.RESULTS:In cases, in the month before the onset of IC/BPS, the approximated annual incidence of nonbladder pelvic surgeries was 15 times higher and of hysterectomy 25 times higher than the incidences of previous years and similarly higher than controls. This rate declined to preindex levels over the first 2 years of IC/BPS.CONCLUSION:There may be a very high incidence of nonbladder surgeries just before IC/BPS onset that decreases to historical levels over the first years of the syndrome.

It has been suggested that improvement of pain and pain relief after total hysterectomy and bilateral salpingoophorectomy, can be as high as 85-90%. Recurrence of endometriosis after hysterectomy and salpingoophorectomy is an uncommon scenario, only described in case reports. There are no clear risk factors, but incomplete resection of the ovaries and endometriosis lesions at the time of hysterectomy, infiltrative endometriosis and hormonal replacement therapy (HRT) might be associated. We present a patient who underwent a total laparoscopic hysterectomy with bilateral salpingoophorectomy, was placed on HRT and had persistent pelvic pain with bilateral pelvic masses. She had menopausal hormonal levels. Was taken to the operating room for removal of masses. We outline the importance of adequate dissection of bowel, ureters and recognition of the pertinent anatomical structures before removal of the masses, as well as the rare but not impossible scenario of persistent endometriosis after a radical surgery for endometriosis.

Objective: Certain functional somatic syndromes (FSSs) such as fibromyalgia and irritable bowel syndrome are accompanied by diffuse pain amplification. Women with interstitial cystitis/bladder pain syndrome (IC/BPS) have numerous FSSs, as well as other non-bladder syndromes (NBSs) that are linked to the FSSs. They also report multiple surgeries. Since pain is a common indication for surgery, we tested the hypothesis that NBSs were associated with surgeries.Methods: We interviewed 312 incident IC/BPS cases and controls on NBSs and number of surgeries before the index date (for cases, IC/BPS onset date). Poisson and logistic regression analyses adjusted for age, race, educational level, and menopause.Results: Number of surgeries increased with number of NBSs in both cases and controls whether chronic pelvic pain (CPP), the only NBS generally accepted as an indication for surgery, Was present or not. Logistic regression analysis showed that among cases CPP was the only individual NBS associated with a history of multiple surgeries, and then only modestly [odds ratio (OR) 1.9, confidence intervals (CI) 1.06, 32]. By far the strongest association was the number of NBSs. The OR for multiple surgeries increased with number of NBSs: for cases with 4-5 NBSs the OR was 14.1 (1.8, 113) and with 6-9 NBSs, 33.1 (3.9, 279). Controls had fewer syndromes and fewer surgeries and this linkage was less prominent.Conclusion: Among IC/BPS cases, the number of NBSs was strongly correlated with the number of surgeries. Understanding temporal relationships will be necessary to explore causal linkages and may modify surgical practice. (C) 2013 Elsevier Inc. All rights reserved.

To describe long-term outcomes for women who underwent a hysterectomy for treatment of chronic pelvic pain (CPP). Retrospective cohort study. University of Rochester chronic pelvic pain specialty clinic. Surgical billing forms were reviewed from 2004-2009. Patients were included in the study if there was a completed initial intake visit for CPP; they had at least one ovary; their hysterectomy was completed through the pelvic pain center; and follow up could be confirmed for ≥ 24 months. Hysterectomy. 106 women underwent a hysterectomy for CPP, and 80 patients had a complete initial intake visit. Of these, 49 patients had follow-up for ≥24 months with an average of 46 months. The 31 patients who had <24 months of follow up are included for comparison. Demographic characteristics are show in Table 1.Table 1Characteristics of Women who had a Hysterectomy for CPPAge at First Pain (years)Age at Hysterectomy (years)Number of Prior SurgeriesBeck Depression ScoreMcGill Pain ScoreNumber of CPP DiagnosesInitial Pain Level Out of 10≥ 24 month follow upImproved by 50% or more (33)29382.6132336Minimal Improvement/Worse (16)27353.5202536< 24 month follow up (31)27373121835 Open table in a new tab At an average of 46 months of follow up, 67% (33/49) had 50% or better improvement in their pain levels. 22 (45%) had complete resolution of their pain, and 11 (22%) had a 63% improvement in pain. Of the 16 patients whose pain did not improve, 4 (8%) had their pain worsen and 12 (24%) had an 18% improvement in their pain. Histologically, the improved group had a higher rate of biopsy proven endometriosis, the minimal improvement/worse pain group had a higher rate of adenomyosis. The patients who had <24 months of follow up had similar characteristics and findings to the improved cohort.Table 2Operative Findings and Long term Outcomes after Hysterectomy for CPPMinimally Invasive Hysterectomy% BSO at time of HysterectomyDense Adhesions Present% Biopsy proven EndometriosisAdenomyosisFollow up Time (months)Follow up Pain Level≥ 24 monthsfollow upImproved by 50% or more (33)100%70%18%33% (11/33)33% (11/33)471Minimal Improvement/Worse (16)88%63%19%13% (2/16)44% (7/16)446< 24 monthsfollow up (31)97%61%23%32% (10/31)35% 11/3172 Open table in a new tab After 46 months of follow up after hysterectomy for CPP, 67% of patients had a clinically significant 50% or greater improvement in their pain, while 8% had their pain worsen.

Study Objective: To determine the incidence and clinical significance of iliohypogastric-ilioinguinal neuropathy from lower abdominal lateral port placement and fascia] closure during laparoscopic gynecologic surgery.Design: Retrospective cohort study (Canadian Task Force classification II-2).Setting: University-based referral center specializing in minimally invasive gynecologic surgery and chronic abdominopelvic pain.Patients: Women who underwent a laparoscopic procedure because of benign gynecologic indications during a 3-year study period from 2008 to 2011. A total of 317 women met study criteria.Interventions: Operative laparoscopy using a lateral port in the lower abdomen. Closure of port-site fascial defects was achieved using either a Carter-Thomason or EndoClose suture device.Measurements and Main Results: Nerve injury was identified by symptoms, and was confirmed with a nerve block after a positive test for allodynia in the distribution of the iliohypogastric-ilioinguinal nerve. Of 173 cases that did not involve fascial closure of a port-site defect, none were associated with nerve injury. Of 144 cases that involved fascial closure, 7 (4.9%) included nerve injury that resulted in pain requiring treatment (p =.004). In 1 patient, symptoms improved with medical management alone. Six patients required surgical management, and 5 of them had resolution of pain after removal of the fascial suture. There was no statistically significant difference in the incidence of nerve injury between the Carter-Thomason and EndoClose groups (4.7% vs 5.4%; p = .87).Conclusions: There is an estimated 5% risk of clinically significant postoperative neuropathic pain due to injury of the iliohypogastric-ilioinguinal nerve with fascial closure of laparoscopic incisions in the lower abdomen. Pain seems to be due to suture entrapment of sensory fibers because it is usually resolved by removal of the suture. Prompt recognition and treatment may prevent subsequent development of chronic abdominopelvic pain. Journal of Minimally Invasive Gynecology (2012) 19, 448-453 (C) 2012 AAGL. All rights reserved.

The cause of noncyclical chronic pelvic pain (CPP) in many women is unknown: 30% have no identifiable pelvic pathology, and in those who do the relationship of CPP and the pathology is often unclear. Moreover, epidemiologic studies demonstrate that the common findings of endometriosis and adhesions do not greatly increase the odds of having CPP. CPP and the functional somatic syndromes (fibromyalgia, irritable bowel syndrome, and others) share many characteristics including pain as a prominent symptom and comorbidity. For the functional somatic syndromes, the initial focus of etiologic investigations has been on local mechanisms and then on systemic pathogeneses. We believe that the research trajectories of the functional somatic syndromes and CPP are converging. Their juncture might reveal an important pathologic mechanism for CPP in some women that is primarily outside the pelvis. This observation would open up new areas of exploration and treatment of CPP.

To determine the prevalence of ilioinguinal and iliohypogastric nerve injuries sustained during laparoscopic gynecologic surgery with lateral port placement in the lower abdomen and fascial closure using a Carter-Thomason or Endoclose device. Retrospective cohort study. University-based center specializing in minimally invasive gynecologic surgery and chronic pelvic pain. All women who underwent a laparoscopic procedure over a 3-year study period from 2008 to 2010. A total of 316 cases met study criteria. Operative laparoscopy utilizing lateral 5mm or 12mm ports in the lower abdomen. Closure of 12mm fascial defects with either a Carter-Thomason or Endoclose device. Nerve injury was identified by symptoms and confirmed with a nerve block following a positive test for allodynia in the distribution of the ilioinguinal and iliohypogastric nerves. Of 172 cases which solely utilized 5mm ports, none were associated with nerve injury. Of 144 cases that involved a lateral 12mm port, there were 7 cases (4.9%) of nerve injury that resulted in pain requiring treatment. There was no statistically significant difference in the risk of nerve injury associated with using either a Carter-Thomason or Endoclose device for fascial closure (4.7% vs. 5.4%, p = 1.00). One of the 7 patients improved with lidoderm patches and a series of nerve blocks. The other 6 patients required surgical management. All but one of these patients had resolution of pain after release of the fascial stitch. During laparoscopic gynecologic surgery, the ilioinguinal and iliohypogastric nerves are at approximately 5% risk for injury with lateral placement of a 12mm port in the lower abdomen and subsequent closure of its fascial defect with either a Carter-Thomason or Endoclose device. Pain resulting from mechanical or ischemic insult to these sensory fibers can be debilitating. Prompt recognition and treatment are necessary to prevent chronic disease.

OBJECTIVES To determine whether interstitial cystitis/painful bladder syndrome (IC/PBS) in women is associated with antecedent sexual and reproductive characteristics.METHODS By multivariate analyses, 312 incident IC/PBS cases were compared with matched controls for antecedent sexual and reproductive characteristics, adjusted by demographics, previous surgery, and nonbladder syndromes (NBSs), such as chronic pelvic pain, irritable bowel syndrome, and panic disorder.RESULTS IC/PBS was significantly associated with previous female hormone use, a history of fewer pregnancies (in premenopausal women), and antecedent NBSs, especially when expressed by the number of such syndromes.CONCLUSIONS Three antecedents to IC/PBS were prominent. Female hormone use was consistent with a pharmacologic effect or as a marker of its indications. A history of fewer pregnancies among premenopausal, but not postmenopausal, women with IC/PBS was consistent with pregnancy postponing the occurrence of IC/PBS, a marker for decisions to avoid pregnancy, or a result of recruitment bias. NBSs, especially the total number experienced by the participant, had the strongest correlation with IC/PBS. This finding suggests that knowledge of the pathogeneses of these NBSs, many of which are functional somatic syndromes, might reveal that of IC/PBS. UROLOGY 77: 570-575, 2011. (C) 2011 Elsevier Inc.