Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program

[Update on the diagnosis and treatment of vulvodynia]

CONTEXT

Vulvodynia is a complex and multifactorial clinical condition. It is defined as chronic vulvar discomfort characterized by burning, stinging or irritation. Its diagnostic difficulty and treatment is known.

OBJECTIVES

To review the medical literature of the last 10 years from a critical point of view.

EVIDENCE ACQUISITION

A search was made in Medline/Pubmed and the Cochrane Library using the terms vulvodynia and vestibulodynia to which etiology, epidemiology, diagnosis, neurophysiological test and treatment or management, were added.

EVIDENCE SYNTHESIS

In spite of the advances achieved in all of the aspects of vulvodynia, the methodology used at present in many cases does not have the desirable statistical soundness: there are few control or placebo-controlled groups and double-blind studies. Uniformity is lacking in the scales, indexes and questionnaires for the correct evaluation of pain before and after the treatment and debatable diagnostic criteria are use. The limited use of neurophysiological diagnostic resources that validate the clinical findings has been observed in the studies analyzed. In most of the works, the medical treatments have been shown to be ineffective. Physiotherapy and cognitive-behavioral therapy seem to be promising therapeutic tools. Surgery (vestibulectomy) stands out by its demonstrated efficacy in the publications studied.

CONCLUSIONS

A multidisciplinary approach is always necessary. Topical medical, psychological and physical therapy treatments may have sum effects and become an alternative to surgery. New pathways of research and more regulated studies are required.

Clinical significance of pelvic floor surface electromyographic changes in patients with pelvic floor dyssynergia

AIM: To evaluate the clinical significance of changes in pelvic floor surface electromyographic parameters in patients with pelvic floor dyssynergia.

METHODS: Seventy-three patients with pelvic floor dyssynergia and 80 healthy volunteers were enrolled. Electromyographic parameters including amplitude, coefficient of variance (CV), onset time and median frequency (MF) in resting and contraction states were acquired by using the Glazer's protocol for pelvic floor surface electromyography.

RESULTS: Compared to the control group, the pelvic floor dyssynergia group had a higher amplitude during pre-baseline step (4.93 ± 3.01 vs 3.80 ± 1.97, P < 0.05), CV during tonic step (0.38 ± 0.13 vs 0.31 ± 0.11, P < 0.05), and CV during endurance step (0.35 ± 0.14 vs 0.28 ± 0.10, P < 0.05), as well as a lower contraction amplitude during flick step (59.15 ± 28.14 vs 69.95 ± 31.05, P < 0.05). A positive correlation was found between CV during tonic and endurance steps and age of patients (both P < 0.05).

CONCLUSION: Monitoring changes in pelvic floor surface electromyographic parameters may provide some clues to the diagnosis and treatment of pelvic floor dyssynergia.

Pelvic pain in women: clinical and scientific aspects

PURPOSE OF REVIEW

Pelvic pain is a common complaint of women that is frequently poorly managed. This review considers the current understanding of the mechanisms of pain perception and the development of chronic pain in the context of three gynaecological pain conditions. Recent advances in the management of these conditions are then discussed.

RECENT FINDINGS

Persistent pelvic pain is associated with central changes, reflected by alterations in psychology, brain structure and function, and dysfunction of the hypothalamic-pituitary-adrenal axis. The many similarities among the conditions support the notion that chronic pain should be treated as a symptom in its own right, however, obtaining a diagnosis remains important to patients. Few new treatments have been developed recently, however, older treatments are being subjected to more rigorous testing and improvements in phenotyping should lead to better design of clinical trials.

SUMMARY

Good quality, well designed clinical trials are urgently required to improve the treatment of pelvic pain in women. However, a variety of successful treatments exist and outcomes can be optimized by individualizing treatment strategies in the context of a multidisciplinary package.

Tenderness as measured by pressure pain thresholds extends beyond the pelvis in chronic pelvic pain syndrome in men

INTRODUCTION

Urological Chronic Pelvic Pain Syndrome (UCPPS) in men is a common complaint, and causes significant impairment in quality of life. Until recently, the focus of research has primarily been on pain symptoms or underlying prostate pathology. However, new clinical phenotyping demonstrates pelvic tenderness to be an important component of UCPPS. Unfortunately, mechanisms underlying tenderness remain to be understood, and tenderness itself has not been well quantified.

AIM

To validate the use of pressure pain thresholds as a method of measuring tenderness in UCPPS and to demonstrate that tenderness extends beyond the pelvis.

METHODS

Fifty-five men diagnosed with UCPPS and 46 healthy controls were recruited through referrals and advertisements. Each participant filled out questionnaires and was assessed by a structured interview. In addition, all UCPPS men underwent urological assessment.

MAIN OUTCOME MEASURES

Demographic information was collected as well as the National Institutes of Health-Chronic Prostatitis Symptom Index. Using a digital algometer, pressure pain thresholds on 10 genito-pelvic and one control site (deltoid) were measured. The four-glass test was used for all UCPPS men.

RESULTS

UCPPS men had reliably lower pain thresholds compared to controls in all locations, including the deltoid. UCPPS men also demonstrated consistently lower overall pain thresholds regardless of location. Furthermore, pressure pain thresholds were able to correctly distinguish patients from controls 77% of the time. Prostate infection did not influence pain thresholds.

CONCLUSIONS

Lower pelvic and nonpelvic thresholds suggest the involvement of a central mechanism in UCPPS. Overall, the data confirm the move away from a prostate-based view of UCPPS. This is supported by the failure to find threshold differences related to prostate infection. Pressure pain thresholds appear to be a promising method of assessing tenderness in UCPPS.