Neuromuscular treatment approach for women with chronic pelvic pain syndrome improving pelvic pain and functionality

Pathophysiology and potential multimodal therapeutic strategies for IC/BPS

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a bladder disorder with no definite aetiology and currently no effective treatment. Its clinical symptoms vary widely, and the bladder condition and extra-bladder dysfunction also show different clinical presentations. This condition is considered to have multiple factors affecting the bladder and clinical symptoms, including urothelial dysfunction, mast cell activation, autoimmune response, neurogenic inflammation, viral or bacterial infection, autonomic nervous dysfunction and central nervous sensitization. Several non-pharmacological, medical, intravesical and novel bladder therapies have been advocated, but the efficacy and durability of these treatments have not been well elucidated. Multimodal therapy has been suggested based on possible pathological mechanisms; however, the most appropriate therapeutic strategy for this disorder has not been well defined. Thus, a rational algorithm for concomitant multimodal therapy for IC/BPS has been proposed.

Common Pain Disorders in Women: Diagnosis, Treatment, and Rehabilitation Management

There is well-established epidemiologic evidence demonstrating variance in the pain disorders affecting women compared with men, although limited conclusive evidence exists regarding the pathophysiologic mechanisms to account for this difference. Six of the most common pain disorders affecting women include migraine headache, fibromyalgia, endometriosis, interstitial cystitis, temporomandibular disorders, and osteoarthritis. The sex-specific prevalence, risk factors, triggers, presentations, and treatments of these disorders are critical for physicians to appreciate and understand to provide the highest standard of care when treating these common pain conditions.

Inter-rater reliability of Mechanical Diagnosis and Therapy (MDT) in evaluating and classifying chronic pelvic pain syndrome

INTRODUCTION

Chronic pelvic pain syndrome (CPPS) involves complex interactions between the musculoskeletal system, nervous system, and psychosocial factors. A major challenge in managing CPPS is the lack of reliable assessment and classification systems. The Mechanical Diagnosis and Therapy (MDT) is a widely used and reliable classification system for assessing and managing painful musculoskeletal conditions affecting the spine and extremities. This study's primary objective was to assess the inter-rater reliability of the MDT assessment in diagnosing CPPS using clinical vignettes. Secondary objectives included determining the prevalence of MDT classification categories.

METHODS

Five MDT clinicians classified clinical vignettes into three categories: 1) Spinal Derangement, 2) Pelvic Floor Contractile Dysfunction, or 3) MDT OTHER subgroups. The vignettes were developed from the McKenzie Pelvic Pain Assessment Form. Inter-rater reliability among clinicians was calculated using the Fleiss kappa statistic with 95% confidence intervals, and Cohen's kappa examined reliability between pairs of raters.

RESULTS

A total of 76 vignettes were developed (40 females and 36 males). Good inter-rater reliability was found among clinicians (Fleiss kappa = 0.616, 95% CI = 0.598-0.633, p < 0.001). Inter-rater reliability was higher when classifying female vignettes (Fleiss kappa = 0.658, 95% CI = 0.634, 0.682) than male vignettes (Fleiss kappa = 0.546, 95% CI = 0.519, 0.573). The most common classification was Spinal Derangement (57%), followed by MDT OTHER subgroups (26%) and Pelvic Floor Contractile Dysfunction (17%).

CONCLUSIONS

The study indicates good inter-rater reliability among MDT clinicians in classifying pelvic pain syndrome. However, clinical vignettes may not fully capture the complexities of real participant interactions, potentially inflating agreement. Future studies should incorporate direct observation of real participant encounters alongside clinical vignettes to improve validity.

Efficacy of Pudendal Nerve Blocks and Ultrasound-Guided Superior Hypogastric Plexus Blocks for the Management of Refractory Interstitial Cystitis: A Case Series

Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by chronic pelvic, perineal, or bladder pain in addition to lower urinary tract symptoms. The etiology of this condition is not fully understood, which presents a challenge for effective therapeutic intervention. Current treatment guidelines recommend the use of multimodal pain management strategies including behavioral/non-pharmacologic, oral medications, bladder instillations, procedures, and major surgery. However, the safety and efficacy of these modalities vary, and there is currently no optimal treatment for the management of IC/BPS. The pudendal nerves and superior hypogastric plexus, which together mediate visceral pelvic pain and bladder control, are not addressed in the current guidelines but may serve as a therapeutic target. Here, we report improvements in pain, urinary symptoms, and functionality following bilateral pudendal nerve blocks and/or ultrasound-guided superior hypogastric plexus blocks in three patients with refractory IC/BPS. Our findings provide support for the use of these interventions in patients with IC/BPS unresponsive to prior conservative management.

When and How to Utilize Pudendal Nerve Blocks for Treatment of Pudendal Neuralgia

Chronic pelvic pain is a common cause of pain in reproductive age women with debilitating consequences for affected women's health and quality of life. Treatment providers must be well versed in all treatment options for these patients, understanding the overlap in the management and treatment of chronic pelvic pain caused by pudendal neuralgia, myofascial pelvic pain, and vulvodynia. Pudendal blocks are a simple and quick procedure that can be performed in the office and often helps improve all the above conditions when used along with other treatment options. We review the anatomy and methodology on when and how to perform pudendal blocks in the office to better inform the general gynecologist on how to implement offering this treatment in the outpatient clinical setting.

Myofascial Trigger Points and Central Sensitization Signs, but No Anxiety, Are Shown in Women with Dysmenorrhea: A Case-Control Study

Background primary dysmenorrhea (PD) is considered to be a cyclic chronic pelvic pain, with its onset in menstrual periods, often accompanied by the presence of myofascial trigger points (MTP). Most MTPs in subjects with chronic pelvic pain are in the inferior part of the abdomen, in the rectus abdominis (RA) area. Central sensitization is closely related to chronic pain processes. Previous studies in women with chronic pelvic pain reported central sensitization signs in their subjects, such as lower pain pressure threshold (PPT). Several authors agree that PPT in the tibialis anterior (TA) muscle, seems to be a reliable reference for signs of central sensitization. Amongst the factors that seem to accompany central sensitization, the presence of anxiety needs to be considered. The aim of the present study was to analyze the existence of hyperalgesic MTPs in RA, central sensitization signs and anxiety in women with PD, in comparison with a control group (CG). Methods: This study was designed following an observational, cross-sectional, case-control model. A total sample of 80 subjects was recruited trough social webs and advertising (PD n = 39) (CG n = 41). PPT in RA and AT was assessed bilaterally through algometry, and anxiety was evaluated through the State−Trait Anxiety Inventory. Results: Statistically significant differences (p < 0.001) were shown for NRS average and maximum increase, as well as lower bilaterally RA and TA PPT in favor of PD group compared to CG. State or trait STAI did not show any statistically significant differences (p > 0.05) between groups. Conclusions: In this study, women with PD reported symptoms of myofascial pain syndrome and central sensitization, when compared with healthy controls, without any sign of anxiety acting as a confounder for pain sensitivity.