Pelvic Pain Injections and Surgery

Injections
Trigger point injections with anesthetics (bupivacane 0.25%) have provided significant relief for patients with chronic pelvic pain. Response rates have been as high as 80% to 90% after repeated injections.¹ Recently, evidence has shown that injections with Botulinum Toxin A have decreased pain scores by producing local, temporary muscle paralysis and possibly reducing mediators of neurogenic inflammation.² Injecting Botulinum Toxin A into the genitofemoral and ilio-inguinal nerves or into spastic muscles with trigger points has been shown successful in patients with high tone pelvic floor dysfunction.

Surgery
Of all the treatment modalities for chronic pelvic pain, surgery is the most controversial. There have been many procedures that have arisen both for the diagnosis and treatment of chronic pelvic pain that have met with limited success.

Sacral neuromodulation of the third nerve root is a FDA-approved modality for the treatment of refractory interstitial cystitis patients and urgency incontinence. Because pain is a major component of interstitial cystitis, sacral neuromodulation has proven to be effective in decreasing pain.³ For information on spinal cord stimulation, click here.

With the widespread use of laparoscopy, many procedures have been proposed for helping chronic pelvic pain including cutting (lysis) adhesions, removing endometrial lining outside the uterus either through laser or electric current (ablation or fulguration), destruction of the uterosacral nerve ablation (burning the ligaments that attach the uterus to the sacrum, which is a part of the pelvic bone), and pelvic pain mapping.

Traditionally laparoscopy has been thought of as the gold standard for evaluation and treatment of chronic pelvic pain with the improvement rates reported as high as 65% to 84%.⁴ There has been success in the treatment of chronic pelvic pain associated with endometriosis in the short term with laparoscopy, with symptom relief gained by 62.5% of the patients and those who have laser treatment of their endometriosis showing a 70% improvement of pain.⁵ Of these patients undergoing ablative (destruction of abnormal areas) procedures, 44% will recur after one year.

Multiple neuroablative procedures (destroying nerves) have been used to treat chronic pelvic pain, including laparoscopic uterosacral nerve ablation and presacral neurectomy, with improvement rates as high as 75% to 95% when compared with diagnostic laparoscopy alone within the first year.⁶ Long-term data are not as promising with success rates seen as low as 39.5% four years after the procedure and even lower success rates in patients with moderate to severe endometriosis.⁷

For those patients felt to have pelvic congestion syndrome with associated dyspareunia (painful intercourse), the use of embolization (clotting off abnormal blood vessels) of the ovarian veins by transcathater embolization has proven to be successful.⁸ One study showed that there was a relief of symptoms in 57.9% of patients with a complete relief in approximately 16%;⁹ however, 28% of patients had no relief.¹⁰

Approximately 12% of hysterectomies in the United States (approximately 60,000 annually) are for chronic pelvic pain. Success rates, which some experts believe are exaggerated, range from 60% to 95%.¹¹ Researchers have found that one in four women experienced some pain one year following hysterectomy.¹² Another group of researchers demonstrated that 40% of patients who have had a hysterectomy will have continued chronic pain.¹³ Recurrence rates of 40% were also observed in women in whom hysterectomy was performed without identifiable disease. Another study showed that, in the United States, more than 60% of uteri removed from patients with chronic pelvic pain were pathologically normal.¹⁴

References:

1. Slocumb JC. Neurologic factors in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome. Am J Obstet Gynecol 1984;149:536-540.
2. Guyer BM, Mechanism of botulinum toxin in the relief of chronic pain. Curr Rev Rapin 1999;3:427-431.
3. Aboseif S, Tamaddon K, Chalfin S, et al. Sacral neuromodulation as an effective treatment for refractory pelvic floor dysfunction. Urology 2002; 60:52-56.
4. Howard FM. The role of laparoscopy in chronic pelvic pain: Promise and pitfalls. Obstet Gynecol Surv 1993;48:357-387; Ripps BA, Martin DC. Endometriosis and chronic pelvic pain. Obstet Gynecol North Am 1993;20:765-768; Stout AL, Steege JF, Dodson WC, Hughes CL. Relationship of laparoscopic findings to self-report of pelvic pain. Am J Obstet Gynecol 1991;164:73-79.
5. Sutton CJG, Hill D. Laser laparoscopy in the treatment of endometriosis. A five year study. Br J Obstet Gynaecol 1990;97:181-185.
6. Wiborny R, Pichler B. Endoscopic dissection of the utreosacral ligaments for the treatment of chronic pelvic pain. Gynaecological Endoscopy 1998;7:33-35; Papasakelariou C. Long term results of laparoscopic uterosacral nerve ablation. Gynaecological Endocopy 1996;5(3):177-179.
7. Papasakelariou C. Long term results of laparoscopic uterosacral nerve ablation. Gynaecological Endoscopy 1996;5(3):177-179.
8. Venbrux A, Lambert D. Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opinion Obstet Gynecol 1999;11(4):395-399.
9. Capasso P, Simons C, Trotteur G, Dondelinger RF, Henroteaux D, Gaspard U. Treatment of symptomatic pelvic varices by ovarian vein embolization. Cardiovasc Intervent Radiol 1997;20:107-111.
10. Maleux G, Stockx L, Wilms G, Marchal G. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J Vasc Intervent Radiol 2000;11(7):859-864.
11. Stovall TG, Ling FW, Crwford DA. Hysterectomy for chronic pelvic pain of presumed uterine etiology. Obstet Gynecol 1990;75:676-679; Kjerulff KH, Langenberg PW, Rhodes JC, et al. Effectiveness of hysterectomy. Obstet Gynecol 2000;95:318-326; Carlson KJ, Miller BA, Fowler FJ. Outcomes of hysterectomy. Obstet Gynecol 1994;83:556-565; Marchbanks PA, Peterson HB. The effects of hysterectomy for chronic pelvic pain. Obstet Gynecol 1995;86:941-945.
12. Stovall TG, Ling FW, Crwford DA. Hysterectomy for chronic pelvic pain of presumed uterine etiology. Obstet Gynecol 1990;75:676-679.
13. Hillis SD, Marchbanks PA, Peterson HB. The effectiveness of hysterectomy for chronic pelvic pain. Obstet Gynecol 1995;86:941-945.
14. Lee NV, Dicker RC, Rubin GL, Ovy HW. Confirmation of the preoperative diagnoses of hysterectomy. Am J Obstet Gynecol 1984;150:283-287.

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