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Cardaillac C, Levesque A, Riant T, Mortier A, Neunlist M, Perrouin-Verbe MA, Volteau C, Thubert T, Brochard C, Ploteau S. Evaluation of a scoring system for the detection of central sensitization among women with chronic pelvic pain. Am J Obstet Gynecol 2023; 229:530.e1-530.e17. [PMID: 37516398 DOI: 10.1016/j.ajog.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/10/2023] [Accepted: 07/22/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Central sensitization is frequently associated with chronic pelvic pain and requires specific management. The pain is described as hypersensitivity to an innocuous stimulus that is both widespread and persistent. However, no study has evaluated if central sensitization can be measured objectively with neurophysiological tests in the pelvic and perineal area to prove this concept in women with chronic pelvic pain. OBJECTIVE This study aimed to evaluate nociceptive thresholds (primary objective) and spatial and temporal diffusion of pain among women with chronic pelvic pain and high or low scores of central sensitization. STUDY DESIGN This prospective, assessor-blinded, comparative study compared a cohort of women with chronic pelvic pain and a high (>5/10; n=29) vs low (<5/10; n=24) score of sensitization according to the Convergences PP criteria. Participants underwent a noninvasive bladder sensory test, a rectal barostat test, and a muscular (algometer) and a vulvar (vulvagesiometer) sensory test. Poststimulation pain (minutes), quality of life (Medical Outcomes Study 36-Item Short Form Survey), and psychological state, comprising anxiety (State-Trait Anxiety Inventory), depression (Beck Depression Inventory Short Form), and catastrophizing (Pain Catastrophizing Scale), were assessed. RESULTS The participants mostly suffered from endometriosis (35.8%), irritable bowel syndrome (35.8%), bladder pain syndrome (32.1%), and vestibulodynia (28.3%). Baseline characteristics were similar. Women with a high sensitization score had more painful diseases diagnosed (2.7±1.3 vs 1.6±0.8; P=.002) and suffered for longer (11±8 vs 6±5 years; P=.028) than participants with a low score. The bladder maximum capacity was equivalent between participants (399±168 vs 465±164 mL; P=.18). However, the pain felt at each cystometric threshold was significantly increased in women with a high sensitization score. No difference was identified for the rectal pain pressure step (29.3±5.5 vs 30.7±6.5 mm Hg; P=.38). Rectal compliance was decreased in women with a high sensitization score with a considerable increase in pain felt. The average of pain pressure thresholds at the 5 vulvar sites tested was decreased in these participants (162.5±90.5 vs 358.7±196.5 g; P=.0003). Similar results were found for the average of the pain pressure thresholds at 6 muscles tested (1.34±0.41 vs 2.63±1.52 kg/m2; P=.0002). A longer period was needed for patients with high sensitization score to obtain a VAS <3 out of 10 after the stimulation of the bladder (4.52±5.26 vs 1.27±2.96 minutes; P=.01), the rectum (3.75±3.81 vs 1.19±1.23 minutes; P=.009), and the muscles (1.46±1.69 vs 0.64±0.40 minutes; P=.002). The psychological state was equivalent between groups. No association was found between the sensory thresholds and the psychological state results. The physical component of the quality of life score was reduced in women with high sensitization score (P=.0005), with no difference in the mental component. CONCLUSION Using neurophysiological tests, this study showed that there are objective elements to assess for the presence of central sensitization, independently of psychological factors.
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Affiliation(s)
- Claire Cardaillac
- Department of Obstetrics, Gynecology and Reproductive Medicine, Nantes University Hospital, Nantes, France; Federative Pelvic Pain Center, Nantes University Hospital, Nantes, France; Bretagne Loire University, Nantes University, Institut des Maladies de l'Appareil Digestif, Inserm Unit 1235-The Enteric Nervous System in Gut and Brain Disorders, Nantes, France
| | - Amélie Levesque
- Federative Pelvic Pain Center, Nantes University Hospital, Nantes, France; Department of Urology, Nantes University Hospital, Nantes, France
| | - Thibault Riant
- Federative Pelvic Pain Center, Nantes University Hospital, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Catherine de Sienne Center, Nantes, France
| | - Anaïs Mortier
- Department of Obstetrics, Gynecology and Reproductive Medicine, Nantes University Hospital, Nantes, France; Bretagne Loire University, Nantes University, Institut des Maladies de l'Appareil Digestif, Inserm Unit 1235-The Enteric Nervous System in Gut and Brain Disorders, Nantes, France
| | - Michel Neunlist
- Bretagne Loire University, Nantes University, Institut des Maladies de l'Appareil Digestif, Inserm Unit 1235-The Enteric Nervous System in Gut and Brain Disorders, Nantes, France
| | - Marie-Aimée Perrouin-Verbe
- Federative Pelvic Pain Center, Nantes University Hospital, Nantes, France; Bretagne Loire University, Nantes University, Institut des Maladies de l'Appareil Digestif, Inserm Unit 1235-The Enteric Nervous System in Gut and Brain Disorders, Nantes, France; Department of Urology, Nantes University Hospital, Nantes, France
| | | | - Thibault Thubert
- Department of Obstetrics, Gynecology and Reproductive Medicine, Nantes University Hospital, Nantes, France
| | - Charlène Brochard
- Bretagne Loire University, Nantes University, Institut des Maladies de l'Appareil Digestif, Inserm Unit 1235-The Enteric Nervous System in Gut and Brain Disorders, Nantes, France; Department of Digestive Functional Exploration, Rennes University Hospital, Rennes, France
| | - Stéphane Ploteau
- Department of Obstetrics, Gynecology and Reproductive Medicine, Nantes University Hospital, Nantes, France; Federative Pelvic Pain Center, Nantes University Hospital, Nantes, France.
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Voute M, Riant T, Amodéo J, André G, Barmaki M, Collard O, Colomb C, Créac’h C, Deleens R, Delorme C, Montgazon G, Dixneuf V, Dy L, Gaillard J, Gov C, Kieffer X, Lanteri‐Minet M, Le Borgne J, Le Caër F, Maamar F, Maindet C, Marcaillou F, Plantevin F, Pluchon Y, Rioult B, Rostaing S, Salvat E, Sep Hieng V, Sorel M, Vergne‐Salle P, Morel V, Chazeron I, Pickering G. Ketamine in chronic pain: a Delphi survey. Eur J Pain 2022; 26:873-887. [DOI: 10.1002/ejp.1914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/04/2022] [Accepted: 01/23/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Marion Voute
- CHU Clermont‐Ferrand Plateforme d’Investigation Clinique/CIC Inserm 1405 France
| | - Thibault Riant
- Unité douleur, Le Confluent, Catherine de Sienne Center Nantes France
| | | | | | | | - Olivier Collard
- Centre d'Evaluation et de Traitement de la Douleur, Clinique Sainte Clotilde Ile de la Réunion France
| | | | - Christelle Créac’h
- Centre d'Evaluation et de Traitement de la Douleur, CHU Sainte Etienne Saint Etienne France
| | - Rodrigue Deleens
- Centre d'Evaluation et de Traitement de la Douleur, CHU Rouen France
| | - Claire Delorme
- Centre d'Evaluation et de Traitement de la Douleur, CH Bayeux Bayeux France
| | | | - Véronique Dixneuf
- Evaluation et de Traitement de la Douleur, Clinique Brétéché Nantes France
| | - Lénaïg Dy
- Evaluation et de Traitement de la Douleur, Clinique mutualiste de la porte de l’orient Lorient France
| | | | - Christian Gov
- Centre d'Evaluation et de Traitement de la Douleur, Hôpital neurologique France
| | - Xavier Kieffer
- Centre de la Douleur Chronique et Rebelle, CH Versailles Le Chesnay France
| | - Michel Lanteri‐Minet
- Département d’Evaluation et Traitement de la Douleur Hopital de Cimiez Nice France
| | | | | | | | - Caroline Maindet
- Centre de la Douleur, Hôpital Albert Michallon La Tronche France
| | - Fabienne Marcaillou
- Centre d'Evaluation et de Traitement de la Douleur, CHU Clermont‐Ferrand Clermont‐Ferrand France
| | - Frédéric Plantevin
- Centre d'Evaluation et de Traitement de la Douleur, CH Mâcon Mâcon France
| | - Yves‐Marie Pluchon
- Centre d'Evaluation et de Traitement de la Douleur, CHD Vendée La Roche sur Yon France
| | - Bruno Rioult
- Unité douleur, Le Confluent, Catherine de Sienne Center Nantes France
| | | | - Eric Salvat
- Centre d'Evaluation et de Traitement de la Douleur, Hôpital de Hautepierre Strasbourg France
| | | | - Marc Sorel
- Centre de la Douleur, CH Nemours Nemours France
| | | | - Véronique Morel
- CHU Clermont‐Ferrand Plateforme d’Investigation Clinique/CIC Inserm 1405 France
| | - Ingrid Chazeron
- Service de Psychiatrie B, CHU Clermont‐Ferrand Clermont‐Ferrand France
| | - Gisèle Pickering
- CHU Clermont‐Ferrand Plateforme d’Investigation Clinique/CIC Inserm 1405 France
- Inserm, CIC 1405 UMR Neurodol 1407 Clermont‐Ferrand France
- Clermont Université, Laboratoire de Pharmacologie, Faculté de médecine Clermont‐Ferrand France
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Levesque A, Bautrant E, Quistrebert V, Valancogne G, Riant T, Beer Gabel M, Leroi AM, Jottard K, Bruyninx L, Amarenco G, Quintas L, Picard P, Vancaillie T, Leveque C, Mohy F, Rioult B, Ploteau S, Labat JJ, Guinet-Lacoste A, Quinio B, Cosson M, Haddad R, Deffieux X, Perrouin-Verbe MA, Garreau C, Robert R. Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus. Eur J Pain 2021; 26:7-17. [PMID: 34643963 DOI: 10.1002/ejp.1861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/09/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE. METHODS The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid. RESULTS The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication. CONCLUSION These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care. SIGNIFICANCE Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.
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Affiliation(s)
- Amélie Levesque
- Urology Department, Nantes University Hospital, Nantes, France
| | - Eric Bautrant
- Pelvi-Perineal Surgery and Rehabilitation Department, Private Medical Centre "l'Avancée-Clinique Axium", Aix en Provence, France
| | | | | | - Thibault Riant
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Marc Beer Gabel
- Neurogastroenterology and Pelvic Floor Unit, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | - Luc Bruyninx
- Department of Surgery, Brugmann Hospital, Brussels, Belgium
| | - Gerard Amarenco
- GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Lara Quintas
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Faculty of Medicine, Barcelona, Spain
| | - Pascale Picard
- Neurology Department, Clermont-Ferrand University Hospital, Inserm, Clermont-Ferrand, France
| | - Thierry Vancaillie
- School of Women and Children, University of New South Wales, Sydney, New South Wales, Australia
| | - Christine Leveque
- Pelvi-Perineal Surgery and Rehabilitation Department, Private Medical Centre "l'Avancée-Clinique Axium", Aix en Provence, France
| | - Frédérique Mohy
- Pain Management Center, University Hospital Felix Guyon, SAINT DENIS, La Reunion, France
| | - Bruno Rioult
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Stéphane Ploteau
- Department of Gynecology-Obstetrics and Reproductive Medicine, Nantes University Hospital, Nantes, France
| | | | - Amandine Guinet-Lacoste
- Hospices Civils de Lyon, Hôpital Henry Gabrielle, Plate-forme Mouvement et Handicap, Lyon, France
| | - Bertrand Quinio
- Pain Center, Regional University Hospital la Cavale Blanche, Brest, France
| | - Michel Cosson
- Departement of Gynecology, University Hopsital Jeanne De Flandre, Lille, France
| | - Rebecca Haddad
- GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Xavier Deffieux
- Department of Obstetrics and Gynecology, Antoine Beclere Hospital, Assistance Publique Hopitaux de Paris, Clamart University Paris-Saclay, Clamart, France
| | | | | | - Roger Robert
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
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Quistrebert-Davanne V, Hardouin JB, Riant T, Ploteau S, Rigaud J, Levesque A. [Psychometric validation of Convergence criteria PP]. Prog Urol 2021; 31:1192-1200. [PMID: 34493442 DOI: 10.1016/j.purol.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/29/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
CONTEXT The PP Convergences criteria group together 10 of the most significant clinical criteria for sensitization in the context of chronic pelvic pain. They are the result of a consensus of experts and represent to date the only clinical evaluation guide to identify patients with pelvic perineal pain in whom a pelvic sensitization component can be evoked. OBJECTIVE This work concerns the psychometric validation of these criteria. The aim is to answer 3 questions: 1) is the instrument reliable (i.e., sensitive, specific and accurate)?; 2) can we define a screening score for pelvic-perineal pain by sensitization from the CPP criteria?; 3) can combinations of criteria be defined to predict pelvic-perineal sensitization from the CPP criteria? METHODOLOGY AND SUBJECTS In total, 308 patients with pelviperineal pain were recruited during their medical consultation. PROCEDURE Fifteen expert physicians were asked to judge the presence or absence of the 10 CPP criteria and to make a diagnosis of the presence or absence of pelviperineal sensitization in their patient. RESULTS ROC curve analysis indicated that a score of 5 was the closest to a perfect score with a sensitivity of 95% and a specificity of 87%. They also indicate that the CPP criteria have a very good sensitivity (97%) and specificity (91%) and present globally a good reproducibility on all the criteria (Kappa>0.6). Finally, the statistical analyses reveal that the most discriminating criterion for predicting sensitization is Q8 (pain persisting after sexual activity). CONCLUSION The CPP criteria represent a very good screening tool for pelvic sensitization. The score of 5 corresponds to the score at which the patient has sufficient clinical criteria to be classified as sensitized. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- V Quistrebert-Davanne
- Centre fédératif de pelvipérinéologie et clinique urologique, CHU de Nantes, Nantes, France.
| | - J-B Hardouin
- Observatoire régional de la santé du Centre, Nantes, France
| | - T Riant
- CETD M Bensignor, hôpital privé du Confluent groupe VIVALTO, Nantes, France
| | - S Ploteau
- Centre fédératif de pelvipérinéologie et clinique urologique, CHU de Nantes, Nantes, France
| | - J Rigaud
- Centre fédératif de pelvipérinéologie et clinique urologique, CHU de Nantes, Nantes, France
| | - A Levesque
- Centre fédératif de pelvipérinéologie et clinique urologique, CHU de Nantes, Nantes, France
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Mortier A, Cardaillac C, Perrouin-Verbe MA, Meurette G, Ploteau S, Lesveque A, Riant T, Dochez V, Thubert T. [Pelvic and perineal pain after genital prolapse: A literature review]. Prog Urol 2020; 30:571-587. [PMID: 32651103 DOI: 10.1016/j.purol.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex. MATERIALS ET METHODS A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery. RESULTS Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex. CONCLUSION Pelvic pain after genital prolapse surgery is still obscure to this day.
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Affiliation(s)
- A Mortier
- Service de gynécologie, CHU de Nantes, 38, boulevard Jean-Monnet, 44000 Nantes, France
| | - C Cardaillac
- Service de gynécologie, CHU de Nantes, 38, boulevard Jean-Monnet, 44000 Nantes, France
| | - M-A Perrouin-Verbe
- Service d'urologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France; GREEN, groupe de recherche clinique en neuro-urologie, GRCUPMC01, 75020 Paris, France
| | - G Meurette
- Service de chirurgie viscérale, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France; Centre fédératif de pelvi-périnéologie, Nantes, France
| | - S Ploteau
- Service de gynécologie, CHU de Nantes, 38, boulevard Jean-Monnet, 44000 Nantes, France; Centre fédératif de pelvi-périnéologie, Nantes, France
| | - A Lesveque
- Service d'urologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France; Centre fédératif de pelvi-périnéologie, Nantes, France
| | - T Riant
- Centre fédératif de pelvi-périnéologie, Nantes, France
| | - V Dochez
- Service de gynécologie, CHU de Nantes, 38, boulevard Jean-Monnet, 44000 Nantes, France; CIC, Centre d'investigation clinique, CHU de Nantes, 5, allée de l'Île-Gloriette, 44093 Nantes cedex 01, France
| | - T Thubert
- Service de gynécologie, CHU de Nantes, 38, boulevard Jean-Monnet, 44000 Nantes, France; CIC, Centre d'investigation clinique, CHU de Nantes, 5, allée de l'Île-Gloriette, 44093 Nantes cedex 01, France; GREEN, groupe de recherche clinique en neuro-urologie, GRCUPMC01, 75020 Paris, France; Centre fédératif de pelvi-périnéologie, Nantes, France.
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Cardaillac C, Delga B, Thubert T, Labat JJ, Levesque A, Winer N, Riant T, Ploteau S. Description and classification of postpartum chronic pain: A multicentric prospective study. J Gynecol Obstet Hum Reprod 2020; 49:101769. [PMID: 32461069 DOI: 10.1016/j.jogoh.2020.101769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain. MATERIAL AND METHOD Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain. RESULTS 40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant's sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria. DISCUSSION The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.
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Affiliation(s)
- Claire Cardaillac
- Department of Gynecology-Obstetrics and Reproductive Medecine, 38 Boulevard Jean Monnet, 44000, Nantes, France; Pelvic Pain Center, Nantes, France
| | - Bérénice Delga
- Department of Gynecology-Obstetrics and Reproductive Medecine, 38 Boulevard Jean Monnet, 44000, Nantes, France
| | - Thibault Thubert
- Department of Gynecology-Obstetrics and Reproductive Medecine, 38 Boulevard Jean Monnet, 44000, Nantes, France
| | | | | | - Norbert Winer
- Department of Gynecology-Obstetrics and Reproductive Medecine, 38 Boulevard Jean Monnet, 44000, Nantes, France
| | - Thibault Riant
- Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine De Sienne, Nantes, France
| | - Stéphane Ploteau
- Department of Gynecology-Obstetrics and Reproductive Medecine, 38 Boulevard Jean Monnet, 44000, Nantes, France; Pelvic Pain Center, Nantes, France.
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Bautrant E, Cervigni M, Moral ED, de Vicente JMG, Usandizaga R, Levesque A, Ploteau S, Riant T, Levêque C. Pain pathway and management of pain complications after surgical vaginal meshes implantation for prolapse and incontinence. J Gynecol Obstet Hum Reprod 2020; 49:101742. [PMID: 32446849 DOI: 10.1016/j.jogoh.2020.101742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Eric Bautrant
- Symposium of the 6th Congress of Convergences in Pelvic Perineal Pain, Madrid, Spain.
| | - Mauro Cervigni
- Symposium of the 6th Congress of Convergences in Pelvic Perineal Pain, Madrid, Spain
| | - Eloy Del Moral
- Symposium of the 6th Congress of Convergences in Pelvic Perineal Pain, Madrid, Spain
| | | | - Ramón Usandizaga
- Symposium of the 6th Congress of Convergences in Pelvic Perineal Pain, Madrid, Spain
| | - Amélie Levesque
- Symposium of the 6th Congress of Convergences in Pelvic Perineal Pain, Madrid, Spain
| | - Stéphane Ploteau
- Symposium of the 6th Congress of Convergences in Pelvic Perineal Pain, Madrid, Spain
| | - Thibault Riant
- Symposium of the 6th Congress of Convergences in Pelvic Perineal Pain, Madrid, Spain
| | - Christine Levêque
- Symposium of the 6th Congress of Convergences in Pelvic Perineal Pain, Madrid, Spain
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Levesque A, Riant T, Ploteau S, Rigaud J, Labat JJ. Clinical Criteria of Central Sensitization in Chronic Pelvic and Perineal Pain (Convergences PP Criteria): Elaboration of a Clinical Evaluation Tool Based on Formal Expert Consensus. Pain Med 2019. [PMID: 29522121 PMCID: PMC7372934 DOI: 10.1093/pm/pny030] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background The evaluation of chronic pelvic and perineal pain (CPP) is often complex. The patient’s description of the pain often appears to be disproportionate to the limited findings on physical examination and/or complementary investigations. The concept of central sensitization may allow better understanding and management of patients with CPP. Objective The aim of this study was to elaborate a clinical evaluation tool designed to simply identify sensitization in pelvic pain. Methods A list of 63 items was submitted to 22 international CPP experts according to the Delphi method. Results Ten clinical criteria were adopted for the creation of a clinical evaluation tool: 1) pain influenced by bladder filling and/or urination, 2) pain influenced by rectal distension and/or defecation, 3) pain during sexual activity, 4) perineal and/or vulvar pain in response to normally nonpainful stimulation, 5) pelvic trigger points (e.g., in the piriformis, obturator internus, and/or levator ani muscles), 6) pain after urination, 7) pain after defecation, 8) pain after sexual activity, 9) variable (fluctuating) pain intensity and/or variable pain distribution, 10) migraine or tension headaches and/or fibromyalgia and/or chronic fatigue syndrome and/or post-traumatic stress disorder and/or restless legs syndrome and/or temporomandibular joint dysfunction and/or multiple chemical sensitivity. Conclusions This process resulted in the elaboration of a clinical evaluation tool designed to identify and appropriately manage patients with CPP comprising a sensitization component.
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Affiliation(s)
- Amélie Levesque
- Federative Pelvic Pain Center, Department of Urology, Nantes University Hospital, Nantes, France
| | - Thibault Riant
- Federative Pelvic Pain Center, Department of Urology, Nantes University Hospital, Nantes, France.,Department of Pain Management, Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Stéphane Ploteau
- Federative Pelvic Pain Center, Department of Urology, Nantes University Hospital, Nantes, France.,Department of Gynecology-Obstetrics and Reproductive Medicine, Nantes University Hospital, Nantes, France
| | - Jérôme Rigaud
- Federative Pelvic Pain Center, Department of Urology, Nantes University Hospital, Nantes, France
| | - Jean-Jacques Labat
- Federative Pelvic Pain Center, Department of Urology, Nantes University Hospital, Nantes, France
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Iacazio S, Foisy A, Tessier A, Riant T, Ploteau S, Perrouin-Verbe MA, Rigaud J, Levesque A. Incidence des troubles posturaux chez les patients souffrant d’algies pelvi-périnéales chroniques. Neurophysiol Clin 2019. [DOI: 10.1016/j.neucli.2019.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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10
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Iacazio S, Foisy A, Tessier A, Riant T, Ploteau S, Perrouin-verbe MA, Rigaud J, Levesque A. Incidence des troubles posturaux chez les patients souffrant d’algies pelvipérinéales chroniques. Prog Urol 2018; 28:548-556. [DOI: 10.1016/j.purol.2018.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 05/06/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022]
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Leonard G, Perrouin-Verbe MA, Levesque A, Riant T, Normand LL, Labat JJ, Rigaud J. Place of surgery in the management of post-operative chronic pain after placement of prosthetic material based on a series of 107 cases. Neurourol Urodyn 2018; 37:2177-2183. [PMID: 29573029 DOI: 10.1002/nau.23544] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/25/2017] [Indexed: 01/01/2023]
Abstract
AIMS The objective of this study was to evaluate the efficacy of surgical removal of prosthetic material, possibly combined with nerve release, on chronic postoperative pain following placement of prosthetic material. MATERIAL AND METHODS Single-tertiary-centre study on 107 patients managed between November 2004 and April 2016 for removal of prosthetic material responsible for postoperative chronic pain: retropubic suburethral sling (n = 32), transobturator suburethral sling (n = 50), prolapse mesh (n = 16), and hernia mesh (n = 9). The primary endpoint was at least 50% reduction of pain evaluated by a pain numerical rating scale (NRS). RESULTS The mean interval between the initial operation involving placement of prosthetic material and reoperation for removal of prosthetic material was 41.2 ± 35.4 months. In all cases pain apperaed immediately following prosthetic material placement surgery. Pain presented neuropathic features in almost 30% of cases and was poorly systematized in more than one-half The mean follow-up of the study population was 8.4 ± 10.3 months. The mean pain NRS score for the overall population was seven preoperatively and three at last follow-up. At least 50% reduction of the pain NRS score was observed 67% of cases at last follow-up. During follow-up, 45% of patients experienced relapse of the disorder for which the prosthetic material was initially placed with, in particular, a 62% recurrence rate of urinary incontinence after removal of transobturator suburethral tape. CONCLUSION Surgical removal of prosthetic material to treat chronic postoperative pain, achieved global improvement of pain in about two-thirds of cases, but with a risk of recurrence of the initial disorders.
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Affiliation(s)
- Grégoire Leonard
- Service d'urologie, CHU Hôtel Dieu, Nantes, France.,Service d'urologie, CHU Bretonneau, Tours, France
| | | | | | - Thibault Riant
- Centre de la douleur, Le Confluent, Centre Catherine de Sienne, Nantes, France
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Mazeaud C, Madec FX, Le Clerc QC, Levesque A, Riant T, Labat J, Le Normand L, Perrouin-Verbe MA, Rigaud J. Intérêt du calendrier mictionnel et du bilan urodynamique dans le bilan d’un syndrome douloureux vésical pour différencier le phénotype clinique. Prog Urol 2017. [DOI: 10.1016/j.purol.2017.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Le Clerc QC, Riant T, Levesque A, Labat JJ, Ploteau S, Robert R, Perrouin-Verbe MA, Rigaud J. Repeated Ganglion Impar Block in a Cohort of 83 Patients with Chronic Pelvic and Perineal Pain. Pain Physician 2017; 20:E823-E828. [PMID: 28934788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND The ganglion impar is the first pelvic ganglion of the efferent sympathetic trunk that relays pelvic and perineal nociceptive messages and therefore constitutes a therapeutic target. OBJECTIVE The objective of this single-center study was to evaluate the effectiveness of 3 repeated ganglion impar blocks in patients with chronic pelvic and perineal pain on intention-to-treat. STUDY DESIGN Retrospective single-center study. SETTING We reviewed the medical records of 83 patients with chronic refractory pelvic and perineal pain. On intention-to-treat analysis, 62 (74.7%) of the patients received 3 ganglion impar blocks. METHODS Ganglion impar block was performed with 0.75% ropivacaine via a lateral approach over the Co1-Co2 coccygeal joint with computed tomography (CT) guidance. The effectiveness of ganglion impar blocks was evaluated by visual analogue scale (VAS) before and 30 minutes after the blocks. Evaluation at least one month after the block was also performed by Patient Global Impression of Change (PGI-C). RESULTS A total of 220 blocks were performed, 193 (87.7%) of which were considered to be positive with immediate but transient improvement of pain by more than 50% and complete but transient pain relief after the procedure in 119 (54.1%) procedures. The variation of the VAS score before and after each block was statistically significant (P < 0.001). Similarly, the VAS score before repeated blocks was significantly improved with decreased pain intensity over time (P = 0.001). Analysis of the PGI-C one month after the block demonstrated improvement in 41% of cases in the overall population and in 43.6% of cases in the subgroup of 62 patients treated by 3 blocks. LIMITATIONS Retrospective study, short term follow-up. CONCLUSIONS Repeated ganglion impar blocks allowed short-term reduction of pain intensity with a moderate intermediate-term effect. Ganglion impar appears to be a useful therapeutic target to block the nociceptive message by acting on sensitization phenomena.Key words: Pudendal neuralgia, impar block, pain, perineal, coccygodynia.
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Affiliation(s)
| | - Thibault Riant
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Amelie Levesque
- Department of Urology, Nantes University Hospital, Nantes, France
| | | | - Stephane Ploteau
- Department of Gynaecology, Nantes University Hospital, Nantes, France
| | - Roger Robert
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | | | - Jerome Rigaud
- Department of Urology, Nantes University Hospital, Nantes, France
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Ploteau S, Labat JJ, Riant T, Robert R. Re: Insights gained from a negative trial of steroid blocks for perineal pain. BJOG 2017. [PMID: 28632349 DOI: 10.1111/1471-0528.14581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Stéphane Ploteau
- Federative Center of Pelvi Perineology, Nantes, France.,Department of Gynecology-obstetrics, CHU Nantes, Nantes, France
| | | | - Thibault Riant
- Federative Center of Pelvi Perineology, Nantes, France.,Pain Unit, Centre Catherine de Sienne Nantes, Nantes, France
| | - Roger Robert
- Federative Center of Pelvi Perineology, Nantes, France.,Department of Neurosurgery, Centre Catherine de Sienne Nantes, Nantes, France
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Labat JJ, Riant T, Ploteau S. Authors' reply re: Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial. BJOG 2017; 124:1123. [PMID: 28544720 DOI: 10.1111/1471-0528.14540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 11/30/2022]
Affiliation(s)
- J J Labat
- Centre fédératif de pelvi périnéologie, CHU Nantes, Nantes, France
| | - T Riant
- Centre fédératif de pelvi périnéologie, CHU Nantes, Nantes, France
| | - S Ploteau
- Centre fédératif de pelvi périnéologie, CHU Nantes, Nantes, France
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Ploteau S, Perrouin-Verbe MA, Labat JJ, Riant T, Levesque A, Robert R. Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia. Pain Physician 2017; 20:E137-E143. [PMID: 28072805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Several studies have described the course and anatomical relations of the pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with pudendal neuralgia in order to guide the surgeon in the choice of surgical approach for pudendal nerve decompression. OBJECTIVES In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the pudendal nerve in a cohort of operated patients. STUDY DESIGN Observational study. SETTING University hospital. METHODS One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for pudendal neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. RESULTS One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with pudendal neuralgia, the pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. LIMITATIONS We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. CONCLUSIONS This is the first study to describe the surgical anatomy of the pudendal nerve in a population of patients with pudendal neuralgia. In more than 70% of cases, pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, pudendal, neuralgia, transgluteal approach.
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Affiliation(s)
- Stephane Ploteau
- Federative Pelvic Pain Center, Nantes, France; Department of Gynecology-Obstetrics and Reproductive Medicine, Centre Hospitalier Universitaire, Nantes, France
| | | | - Jean-Jacques Labat
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Thibault Riant
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | | | - Roger Robert
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
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Levesque A, Riant T, Labat JJ, Ploteau S. Use of High-Concentration Capsaicin Patch for the Treatment of Pelvic Pain: Observational Study of 60 Inpatients. Pain Physician 2017; 20:E161-E167. [PMID: 28072808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Chronic pelvic, perineal and gluteal neuralgia is often experienced in a similar way to neuropathic pain, in the territories of four nerves: ilio-inguinal, pudendal, inferior cluneal and posterior gluteal nerves. These pains are often refractory to medical treatment based on the use of systemic molecules with disabling adverse effects and surgical procedure may be necessary. OBJECTIVE The objective of this study was to evaluate the efficacy and safety of treatment with a high-concentration capsaicin patch in these indications. STUDY DESIGN This study was prospective, nonrandomized, and observational. SETTING Federative Center of Pelvi-Perineology in the University Hospital of Nantes, France. METHODS Sixty patients with pelvic neuralgia were treated with high-concentration capsaicin patch. The primary endpoint was Patient Global Impression of Change (PGIC) and secondary endpoints included pain intensity on a Numerical Rating Scale (NRS), maximum sitting duration at the end of the day, Medication Consumption Score (MQS), and patient global improvement (from -100% to + 100%). RESULTS Twenty four percent of the 60 patients included in the study declared that they felt "very much improved" or "much improved" (PGIC = 1 or 2) and these patients reported an average 58% improvement and a 3.4-point reduction on the NRS. Among the "good responder" patients, patients with coccygodynia appear to obtain the bestresults, as 37% of these patients declared that they were much improved with an average 63% improvement No serious adverse effects were observed and treatment was well tolerated. LIMITATION This study is limited by its relatively small sample size and non-randomized study. CONCLUSION These results suggest the value of high-concentration capsaicin 8% patch in the treatment strategy for patients with chronic pelvic, perineal and gluteal neuralgia. This treatment would be particularly indicated in the management of coccygodynia.Key words: Pelvic pain, neuropathic pain, pudendal nerve, ilio-inguinal nerve, inferior cluneal nerve, posterior gluteal nerve, capsaicin, capsaicin patch, coccygodynia.
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Affiliation(s)
| | - Thibault Riant
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Jean-Jacques Labat
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Stephane Ploteau
- Federative Pelvic Pain Center, Nantes, France; Department of Gynecology-Obstetrics and Reproductive Medicine, Centre Hospitalier Universitaire, Nantes, France
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Leonard G, Labat J, Le-Normand L, Riant T, Levesque A, Rigaud J. Place du traitement chirurgical dans la prise en charge des douleurs chroniques après pose de matériel prothétique pelvien : à propos d’une série de 107 cas. Prog Urol 2016. [DOI: 10.1016/j.purol.2016.07.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Levesque A, Riant T, Labat J, Rigaud J. Évaluation prospective de l’efficacité du Qutenza* dans les douleurs neuropathiques pelvi-périnéales chez 60 patients. Prog Urol 2016. [DOI: 10.1016/j.purol.2016.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rigaud J, Levesque A, Labat J, Riant T, Ploteau S, Robert R. Technique de neurolyse du nerf pudendal par chirurgie robotique. Prog Urol 2016. [DOI: 10.1016/j.purol.2016.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Labat JJ, Riant T, Lassaux A, Rioult B, Rabischong B, Khalfallah M, Volteau C, Leroi AM, Ploteau S. Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial. BJOG 2016; 124:251-260. [PMID: 27465823 PMCID: PMC5215631 DOI: 10.1111/1471-0528.14222] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2016] [Indexed: 11/30/2022]
Abstract
Objective To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the pudendal nerve for pudendal nerve entrapment. Design Randomised, double‐blind, controlled trial. Setting Multicentre study. Population 201 patients were included in the study, with a subgroup of 122 women. Methods CT‐guided pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline. Main outcome measures The primary end‐point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30‐point improvement on a 100‐point visual analogue scale of mean maximum pain over a 2‐week period) or nonresponders. Results Three months’ postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality‐of‐life criteria. Conclusions Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used. Tweetable abstract Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia. Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.
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Affiliation(s)
- J J Labat
- Federative Centre of Pelvi-Perineology, CHU Nantes, Nantes, France
| | - T Riant
- Federative Centre of Pelvi-Perineology, CHU Nantes, Nantes, France.,Pain Unit, Centre Catherine de Sienne, Nantes, France
| | - A Lassaux
- Pain Clinic, Hôpital Rothschild, Paris, France
| | - B Rioult
- Pain Unit, Centre Catherine de Sienne, Nantes, France
| | - B Rabischong
- Gynaecology Department, Polyclinique Hôtel-Dieu, Clermont-Ferrand, France
| | - M Khalfallah
- Centre Hospitalier de la Cote Basque, Bayonne, France
| | | | - A-M Leroi
- Digestive Physiology Department, Hôpital Charles Nicolle, Rouen, France
| | - S Ploteau
- Federative Centre of Pelvi-Perineology, CHU Nantes, Nantes, France.,Gynaecology Department, Hôtel-Dieu, Nantes, France
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Ploteau S, Cardaillac C, Perrouin-Verbe MA, Riant T, Labat JJ. Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature. Pain Physician 2016; 19:E449-E454. [PMID: 27008300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Pudendal neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of pudendal neuralgia due to pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When pudendal neuralgia due to pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of pudendal neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the pudendal nerve) illustrate the need to recognize atypical pudendal neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of pudendal neuralgia to avoid missing pudendal neuralgia secondary to a mechanism other than nerve entrapment.
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Affiliation(s)
| | - Claire Cardaillac
- 1Federative Pelvic Pain Center, Nantes, France; Department of Gynecology-Obstetrics and Reproductive Medicine, Centre Hospitalier Universitaire, Nantes, France
| | | | - Thibault Riant
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Jean-Jacques Labat
- Federative Pelvic Pain Center, Nantes, France; Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
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Ploteau S, Labat JJ, Riant T, Levesque A, Robert R, Nizard J. New concepts on functional chronic pelvic and perineal pain: pathophysiology and multidisciplinary management. Discov Med 2015; 19:185-192. [PMID: 25828522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The management of chronic pelvic and perineal pain has been improved by a better understanding of the mechanisms of this pain and an optimized integrated multidisciplinary approach to the patient. The concept of organic lesions responsible for a persistent nociceptive factor has gradually been replaced by that of dysregulation of nociceptive messages derived from the pelvis and perineum. In this setting, painful diseases identified by organ specialists are usually also involved and share several common denominators (triggering factors, predisposing clinical context). These diseases include painful bladder syndrome, irritable bowel syndrome, vulvodynia, and chronic pelvic pain syndrome. The painful symptoms vary from one individual to another and according to his or her capacity to activate pain inhibition/control processes. Although the patient often attributes chronic pain to a particular organ (with the corollary that pain will persist until the organ has been treated), this pain is generally no longer derived from the organ but is expressed via this organ. Several types of clinical presentation of complex pelvic pain have therefore been pragmatically identified to facilitate the management of treatment failures resulting from a purely organ-based approach, which can also reinforce the patient's impression of incurability. These subtypes correspond to neuropathic pain, central sensitization (fibromyalgia), complex regional pain syndrome, and emotional components similar to those observed in post-traumatic stress disorder. These various components are also often associated and self-perpetuating. Consequently, when pelvic pain cannot be explained by an organ disease, this model, using each of these four components associated with their specific mechanisms, can be used to propose personalized treatment options and also to identify patients at high risk of postoperative pelvic pain (multi-operated patients, central sensitization, post-traumatic stress disorder, etc.), which constitutes a major challenge for prevention of these types of pain that have major implications for patients and society.
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Affiliation(s)
- Stéphane Ploteau
- Department of Anatomy, Faculty of Medicine; Federative Center of Pelvi-Perineology; and Department of Gynecology, Obstetrics and Reproductive Medicine; University Hospital, Nantes, France
| | - Jean Jacques Labat
- Federative Center of Pelvi-Perineology, University Hospital, Nantes, France
| | - Thibault Riant
- Federative Center of Pelvi-Perineology, University Hospital, Nantes, France and Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Amélie Levesque
- Department of Pain, Palliative and Supportive Care, University Hospital, Nantes, France
| | - Roger Robert
- Department of Anatomy, Faculty of Medicine, University Hospital, Nantes, France and Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Julien Nizard
- Department of Pain, Palliative and Supportive Care, University Hospital, Nantes, France
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Buffenoir K, Rioult B, Hamel O, Labat JJ, Riant T, Robert R. Spinal cord stimulation of the conus medullaris for refractory pudendal neuralgia: A prospective study of 27 consecutive cases. Neurourol Urodyn 2013; 34:177-82. [DOI: 10.1002/nau.22525] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/24/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Kevin Buffenoir
- Department of Neurosurgery and Neurotraumatology; CHU de Nantes; Nantes France
- Pain, Neuromodulation, and Quality of Life; INSERM EA3826; Nantes France
| | - Bruno Rioult
- Pain Unit; Centre Catherine-de-Sienne; Nantes France
| | - Olivier Hamel
- Department of Neurosurgery and Neurotraumatology; CHU de Nantes; Nantes France
| | - Jean-Jacques Labat
- Pain, Neuromodulation, and Quality of Life; INSERM EA3826; Nantes France
- Department of Urology; CHU de Nantes; Nantes France
| | | | - Roger Robert
- Department of Neurosurgery and Neurotraumatology; CHU de Nantes; Nantes France
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Boudry G, Labat JJ, Riant T, Le Normand L, Manunta A, Bensalah K, Rigaud J. Validation of voiding diary for stratification of bladder pain syndrome according to the presence/absence of cystoscopic abnormalities: a two-centre prospective study. BJU Int 2013; 112:E164-8. [PMID: 23795793 DOI: 10.1111/bju.12165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the value of the voiding diary in the management of patients with bladder pain syndrome for predicting the presence or absence of cystoscopic abnormalities. PATIENTS AND METHODS From November 2009 to March 2011, 54 consecutive patients (39 women and 15 men) with bladder pain syndrome, as defined by the European Society for the Study of Interstitial Cystitis/Bladder Pain Syndrome (ESSIC) criteria, were prospectively enrolled in this two-centre study. All patients completed a home voiding diary on 3 consecutive days, which included analysis of voiding frequency, voided volume and severity of pre- and post-voiding pain. The variables were evaluated on a numeric pain scale (NPS). All patients then underwent standardized cystoscopy under anaesthesia. Patients were stratified into two groups: a group with or a group without cystoscopic abnormalities. Voiding diary variables were compared using Student's t-test. RESULTS Cystoscopic abnormalities were found in 33 patients. The group of patients with cystoscopic abnormalities had significantly more severe frequency (P = 0.034), especially nocturnal frequency (P = 0.009), a significantly lower mean voiding volume and lower sd from the mean (P = 0.011 and P = 0.014), and a significantly lower mean post-voiding NPS score (P = 0.039). CONCLUSION On analysis of the voiding diaries, we found that different patient profiles were associated with the cystoscopic appearance of the bladder. A clinical voiding score was proposed to predict the cystoscopic appearance of the bladder on the basis of the voiding diary in bladder pain syndrome but needs to be validated on an independent population.
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Abstract
BACKGROUND Schwannoma is a rare benign tumor of peripheral nerves arising from Schwann cells of the ubiquitous nerve sheath. OBJECTIVE To describe the operative steps and technical aspects of robotic laparoscopic resection of pelvic schwannoma. METHODS We describe 2 patients with pelvic schwannoma: a 34-year-old woman with schwannoma of the right lumbosacral trunk and a 58-year-old woman with schwannoma of a left S1 nerve. Pain was the main symptom in both patients. The diagnosis was confirmed by magnetic resonance imaging and nerve biopsies. Both patients were operated on by robotic laparoscopy. RESULTS Lesions were totally enucleated after incising the epineurium. After dissection of the schwannoma, the vascular pedicle and nerve fascicles involved were identified, coagulated, and then sectioned. The remaining fascicles of the nerve were preserved. The postoperative course was uneventful in both patients. With follow-up of 9 and 13 months, both patients obtained complete pain relief with no neurological sequelae. CONCLUSION Robotic laparoscopic resection of pelvic nerve tumors such as schwannomas is technically feasible.
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Pouliquen U, Riant T, Robert R, Labat JJ. La névralgie clunéale inférieure par conflit au niveau de l’ischion : identification d’une entité clinique à partir d’une série de blocs anesthésiques chez 72 patients. Prog Urol 2012. [DOI: 10.1016/j.purol.2012.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Valon C, Le Normand L, Rigaud J, Riant T, Robert R, Labat JJ. Évaluation des fonctions pelvipérinéales des patients souffrant de névralgie pudendale. Prog Urol 2012. [DOI: 10.1016/j.purol.2012.08.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Labat JJ, Riant T, Rioult B, Lassaux A, Khalfallah M, Leroi AM, Rigaud J. Analyse de l’effet thérapeutique à trois mois des infiltrations du nerf pudendal dans les névralgies pudendales. Étude prospective, randomisée à trois bras, de l’efficacité des corticoïdes locaux vs bras contrôle chez 201 patients. Prog Urol 2012. [DOI: 10.1016/j.purol.2012.08.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Louppe JM, Nguyen JP, Robert R, Buffenoir K, de Chauvigny E, Riant T, Péréon Y, Labat JJ, Nizard J. Motor cortex stimulation in refractory pelvic and perineal pain: report of two successful cases. Neurourol Urodyn 2012; 32:53-7. [PMID: 22674567 DOI: 10.1002/nau.22269] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 04/19/2012] [Indexed: 11/06/2022]
Abstract
AIMS In some patients, with refractory chronic pelvic and perineal pain, pain and quality of life are barely alleviated despite optimal medical treatment, infiltrations and surgical release of the pudendal nerve. The management of these patients is complex, especially after failure of neuromodulation techniques (spinal cord stimulation. S3 nerve root stimulation and direct stimulation of the pudendal nerve). We report the first two cases illustrating the value of motor cortex stimulation (MCS), in this new indication. METHODS The history, decision-making process, intraoperative findings and results of this technique are presented. The perineal cortical area was identified by intraoperative motor evoked potentials in the external anal sphincter, confirming its location in the primary motor cortex between the inferior and superior limb positions. As predictive value of repetitive transcranial magnetic stimulation (rTMS) in the identification of responders to MCS for pain is now established, we performed pre-operative rTMS sessions for both patients. RESULTS The first patient was a 74-years-old woman who reported an 11-year history of left lateral perineal pain. The second patient was a 45-year-old woman who reported a 4-year history of perineal pain following hysterectomy with ovariectomy. After respectively 40 months and 19 months of follow up, both patients reported an improvement of pain ranging from 40 to 50%. Time to onset of pain on sitting was markedly improved from a few minutes to 90 minutes, and largely contributing to improvement of activities of daily living and of quality of life. CONCLUSION These two first cases suggest that motor cortex stimulation constitutes a new treatment for refractory pelvic and perineal pain, and should be considered after failure of conventional neuromodulation techniques, especially spinal cord stimulation.
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Affiliation(s)
- Jean-Marie Louppe
- Service de Neurochirurgie, Centre Hospitalier Universitaire, Nantes, France
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Picard-Destelan M, Rigaud J, Riant T, Labat JJ. Psychothérapie dans la prise en charge thérapeutique des douleurs pelvipérinéales chroniques : quel abord ? Prog Urol 2010; 20:1111-5. [DOI: 10.1016/j.purol.2010.08.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 08/16/2010] [Indexed: 11/30/2022]
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Riant T, Rigaud J, Delavierre D, Sibert L, Labat JJ. Traitements médicamenteux dans la prise en charge thérapeutique des douleurs pelvipérinéales chroniques. Prog Urol 2010; 20:1095-102. [DOI: 10.1016/j.purol.2010.08.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Accepted: 08/30/2010] [Indexed: 10/18/2022]
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Rigaud J, Riant T, Delavierre D, Sibert L, Labat JJ. [Somatic nerve block in the management of chronic pelvic and perineal pain]. Prog Urol 2010; 20:1072-83. [PMID: 21056387 DOI: 10.1016/j.purol.2010.08.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Accepted: 08/30/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Chronic pelvic and perineal pain can be related to a nerve lesion caused by direct or indirect trauma or by an entrapment syndrome, which must then be demonstrated by a test block. The purpose of this article is to review the techniques and modalities of somatic nerve block in the management of chronic pelvic and perineal pain. MATERIAL AND METHODS A review of the literature was performed by searching PubMed for articles on somatic nerve infiltrations in the management of chronic pelvic and perineal pain. RESULTS Nerves involved in pelvic and perineal pain are: thoracolumbar nerves (obturator, ilioinguinal, iliohypogastric and genitofemoral) and sacral nerves (pudendal and inferior cluneal branches of the posterior cutaneous nerve of the thigh). Infiltration has a dual objective: to confirm the diagnostic hypothesis by anaesthetic block and to try to relieve pain. Evaluation of the severity and site of the pain before and immediately after the test block is essential for interpretation of the block. The various infiltration techniques for each nerve are described together with their respective advantages, disadvantages and risk of complications. CONCLUSION Somatic nerve blocks are an integral part of the management of chronic pelvic and perineal pain and are predominantly performed under CT guidance in order to be as selective as possible. Once the diagnosis and the level of the nerve lesion have been defined, more specific therapeutic procedures can then be proposed.
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Affiliation(s)
- J Rigaud
- Clinique urologique, centre fédératif de pelvipérinéologie, hôpital Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France.
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Riant T, Rigaud J, Delavierre D, Sibert L, Labat JJ. [Predictive factors and prevention of chronic postoperative pelvic and perineal pain]. Prog Urol 2010; 20:1145-57. [PMID: 21056397 DOI: 10.1016/j.purol.2010.08.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Accepted: 08/16/2010] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Chronic postoperative pain has been defined as pain arising after a surgical operation, present for at least 2 months, with no organic (active cancer or chronic infection) or preexisting cause. The purpose of this article is to review the risk factors and prevention of chronic postoperative pelvic and perineal pain. MATERIAL AND METHODS A review of the literature was performed by searching PubMed for articles on risk factors and prevention of chronic postoperative pelvic and perineal pain. RESULTS Chronic postoperative pain is frequent, disabling and represent a high cost to the community. This pain is generated by variable and complex interactions between the surgical procedure (the operated zone, perioperative management, the disease requiring the operative procedure) and the patient (age, gender, genetics, concomitant diseases, personal history). The multifactorial nature of chronic postoperative pain suggests the need for multidisciplinary management with prevention and reduction of the main risk factors. Similarly, appropriate management of acute postoperative pain has a major impact on the risk of chronic pain. CONCLUSION A good knowledge of the risk factors and appropriate prevention can decrease the incidence and consequences of chronic postoperative pain.
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Affiliation(s)
- T Riant
- Unité d'évaluation et de traitement de la douleur, centre Catherine-de-Sienne, 44000 Nantes, France
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Labat JJ, Riant T, Delavierre D, Sibert L, Watier A, Rigaud J. [Global approach to chronic pelvic and perineal pain: from the concept of organ pain to that of dysfunction of visceral pain regulation systems]. Prog Urol 2010; 20:1027-34. [PMID: 21056381 DOI: 10.1016/j.purol.2010.08.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 08/16/2010] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Analysis of complex pelvic and perineal pain. MATERIAL AND METHODS Review of the literature concerning the various types of functional pelvic pain. RESULTS Various forms of pelvic pain are frequently associated: painful bladder syndrome (interstitial cystitis), irritable bowel syndrome, endometriosis pain, vulvodynia, chronic pelvic pain syndrome (chronic prostatitis). Pelvic pain is often associated with fibromyalgia or complex regional pain syndrome (reflex sympathetic dystrophy). The pathophysiological mechanisms involved in these syndromes are all very similar, suggesting a triggering element, neurogenic inflammation, reflex muscular and autonomic responses, central hypersensitization, emotional reactions and biopsychosocial consequences. DISCUSSION The concept of visceral pain is evolving and, in practice, complex pelvic pain can comprise neuropathic components, complex regional pain syndrome components, hypersensitization components, and emotional components closely resembling posttraumatic stress syndrome. CONCLUSIONS When pain cannot be explained by an organ disease, the pain must be considered to be expressed via this organ. Chronic pelvic and perineal pain can become self-perpetuating and identification of its various mechanisms can allow the proposal of individually tailored treatments.
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Affiliation(s)
- J-J Labat
- Centre fédératif de pelvipérinéologie, clinique urologique, CHU de Nantes, 44093 Nantes, France.
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Robert R, Labat JJ, Khalfallah M, Louppe JM, Riant T, Hamel O. [Pudendal nerve surgery in the management of chronic pelvic and perineal pain]. Prog Urol 2010; 20:1084-8. [PMID: 21056388 DOI: 10.1016/j.purol.2010.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 09/21/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To define the place of pudendal nerve surgery in pudendal nerve entrapment syndromes. MATERIALS AND METHODS Description of the various surgical techniques and published results. RESULTS The original surgical technique, which remains the reference technique, consists of performing surgical release of the pudendal nerve from the infrapiriformis foramen to Alcock's canal via a transgluteal approach. This surgical procedure is safe and gives encouraging results validated by a prospective, randomized protocol: 66 to 80% of patients are improved. Other transvaginal or transperineal approaches have also been proposed. CONCLUSION Pudendal nerve surgery is a reasonable treatment option when all other treatments have failed. However, the various techniques proposed and their respective criticisms must be carefully evaluated.
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Affiliation(s)
- R Robert
- Service de neurotraumatologie et laboratoire d'anatomie, CHU de Nantes, 44100 Nantes, France
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Robert R, Labat JJ, Riant T, Louppe JM, Hamel O. Le nerf pudendal : morphogenèse, anatomie, physiopathologie, clinique et thérapeutique. Neurochirurgie 2009; 55:463-9. [DOI: 10.1016/j.neuchi.2009.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 07/03/2009] [Indexed: 10/20/2022]
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Abstract
Confusion between radicular and nerve trunk syndrome is not rare. With sciatic pain, any nerve trunk pain or an atypical nerve course should suggest nerve trunk pain of the sciatic nerve in the buttocks. The usual reflex with sciatic pain is vertebral-radicular conflict. The absence of spinal symptoms and the beginning of pain in the buttocks and not in the lumbar region should reorient the etiologic search. Once a tumor of the nerve trunk has been ruled out (rarely responsible for pain other than that caused by tumor pressure), a myofascial syndrome should be explored searching for clinical, electrophysiological, and radiological evidence of compression of the sciatic trunk by the piriform muscle but also the obturator internus muscle. Hamstring syndrome may be confused with this syndrome. Treatment is first and foremost physical therapy. Failures can be treated with classical CT-guided infiltrations with botulinum toxin. Surgery should only be entertained when all these solutions have failed.
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Affiliation(s)
- J-J Labat
- Service de neurotraumatologie, Hôtel-Dieu, 2, place Alexis-Ricordeau, 44035 Nantes cedex 1, France
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Robert R, Labat JJ, Riant T, Louppe JM, Lucas O, Hamel O. [Somatic perineal pain other than pudendal neuralgia]. Neurochirurgie 2009; 55:470-4. [PMID: 19744676 DOI: 10.1016/j.neuchi.2009.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 07/03/2009] [Indexed: 10/20/2022]
Abstract
In addition to the well-established syndrome of pudendal compression, and given the rich nerve trunk innervation of the perineum, pain originating in other nerve trunks can occur and must be remembered. Nerves originating high in the thoracolumbar area (ilioinguinal nerve, iliohypogastric nerve, genitor femoral nerve) can be the seat of traumatic lesions occurring during surgical approaches through the abdominal wall or can undergo compressions when crossing the fascia of the large abdominal muscles. Misleading perineal irradiations do not resemble pudendal neuralgia and should suggest pain in these trunks whose cutaneous territories are not solely perineal and whose clinical expression as pain is does not occur in the seated position. Similarly, painful minor intervertebral dysfunction of the thoracolumbar junction is not simply in the mind and should be considered, searched for, and treated. Related more to pudendal neuralgia, pain in the inferior cluneal nerve, triggered by the seated position, should be considered when the pain reaches the lateral anal region, the scrotum, or the labia majora but not involving the glans penis or the clitoris. Specific treatments (physical therapy, infiltrations, surgery) have proven effective.
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Affiliation(s)
- R Robert
- Service de neurotraumatologie, Hôtel-Dieu, CHU de Nantes, 2, place Alexis-Ricordeau, 44035 Nantes cedex 1, France.
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Rigaud J, Labat JJ, Riant T, Guerineau M, Bouchot O, Robert R. Névralgies obturatrices : prise en charge et résultats préliminaires de la neurolyse laparoscopique. Prog Urol 2009; 19:420-6. [DOI: 10.1016/j.purol.2009.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 01/23/2009] [Accepted: 01/29/2009] [Indexed: 12/01/2022]
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Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn 2008; 27:306-10. [PMID: 17828787 DOI: 10.1002/nau.20505] [Citation(s) in RCA: 288] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIMS The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the diagnosis. We defined criteria that can help to the diagnosis. MATERIALS AND METHODS A working party has validated a set of simple diagnostic criteria (Nantes criteria). RESULTS The five essentials diagnostic criteria are: (1) Pain in the anatomical territory of the pudendal nerve. (2) Worsened by sitting. (3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5) Positive anesthetic pudendal nerve block. Other clinical criteria can provide additional arguments in favor of the diagnosis of pudendal neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms. CONCLUSION The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results of this disease. However, a combination of criteria can be suggestive of the diagnosis.
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Darnis B, Robert R, Labat JJ, Riant T, Gaudin C, Hamel A, Hamel O. Perineal pain and inferior cluneal nerves: anatomy and surgery. Surg Radiol Anat 2008; 30:177-83. [DOI: 10.1007/s00276-008-0306-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 01/09/2008] [Indexed: 11/29/2022]
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Abstract
Abstract
OBJECTIVE
Obturator neuralgia consists of pain radiating from the obturator nerve territory to the inner thigh.
METHODS
We report a case of idiopathic obturator neuralgia resulting from compression of the obturator nerve in the obturator canal, causing a case of nerve entrapment syndrome. The pain was characterized by its localization in the inguinal region and anterointernal side of the thigh, going down to the internal side of the knee. It was worse when standing or in a monopodal stance. Walking caused pain and a limp.
RESULTS
The diagnosis was confirmed by an analgesic block. The analgesic was infiltrated using a posterior approach and computer-assisted tomography, allowing the quality and specificity of the infiltration to be judged.
CONCLUSION
We describe, for the first time, a treatment of obturator neuralgia by a minimally invasive laparoscopic approach. This involved an obturator nerve neurolysis and section of the internal obturator muscle and the obturator membrane.
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Affiliation(s)
- Jérôme Rigaud
- Department of Urology, University Hospital-Hôtel-Dieu, Nantes, France.
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Riant T, Labat JJ, Roger R, Guerineau M. Blocs anesthésiques pudendaux dans le cadre de la névralgie pudendale par entrapment: indications, techniques, interprétation. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s11608-007-0112-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Benaïm J, De Tayrac R, Galaup JP, Guérineau M, Khalfallah M, Lassaux A, Le Fort M, Lucot JP, Rabischong B, Rigaud J, Siproudhis L, Arné-Bès MC, Bonniaud V, Charvier K, Dumas P, Herbault AG, Lapeyre E, Leroi AM, Prat Pradal D, Soler JM, Testut MF, Raibaut P, Scheiber-Nogueira MC, Thomas C. Critères diagnostiques d’une névralgie pudendale (Critères de Nantes). ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s11608-007-0114-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Perineal pain is the basis of presentation to different specialities. This pain is still rather unknown and leads the different teams to inappropriate treatments which may fail. For more than twenty years, we have seen these patients in a multidisciplinary consultation. Our anatomical works have provided a detailed knowledge of the nervous supply of the perineum which allowed us to propose the description of an entrapment syndrome of the pudendal nerve. Other disturbances of different origins were highlighted helping colleagues to a better analysis of this enigmatic painful syndrome. Cadaveric studies have been done to guide treatments by blocks and surgery if necessary according to well defined criteria. A randomized prospective study validated the surgery. The retrospective study concluded that two thirds of the patients improved after treatment. New anatomical concepts are leading us to enlarge the field of this type of surgery, with the hope of improving the success rate.
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Affiliation(s)
- R Robert
- Service de Neurotraumatologie, Nantes, France
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Robert R, Labat JJ, Hamel O, Khalfallah M, Roualdes V, Riant T. [Anatomical basis for perineal pain]. Prog Urol 2006; 16:9-14. [PMID: 17183965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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