Vestibulodynia: Clinical characteristics, first-line treatments, and factors associated with escalation of treatment with EMG-guided injections of botulinum toxin in a retrospective french cohort study

BACKGROUND

Vestibulodynia is a highly prevalent chronic pain disorder affecting the vulva having a major impact on women's physical, psychological, and sexual well-being. It remains an underrecognized disease that responds insufficiently to therapies such as physiotherapy and medication.

AIM

To assess the global efficacy of first-line therapies and factors associated with treatment escalation in women with vestibulodynia.

PATIENTS AND METHODS

This retrospective cohort study was conducted at the dermatology outpatient clinic of the University Hospital in Besancon (France) between 2013 and 2017 and follow-up until 2021.

RESULTS

Among 132 patients, the mean [standard deviation] age at diagnosis was 27.2 [±9.45] years, with an average duration of symptoms of 42.3 [±37.92] months. Most cases comprised provoked (75.0%) or secondary (72.7%) vestibulodynia. At least one comorbid pain or psychologic condition was identified respectively in 63 (47.7%) and 23 patients (54.5%). Vulvar hyperesthesia associated with pelvic floor muscle dysfunction was present in 121 patients (91.6%) and vulvar erethism was noted in 94 patients (71.2%). First-line treatments consisted of pelvic floor physiotherapy with biofeedback in 85% of patients, associated with amitriptyline in 36% of cases, and of additional lidocaine cream in 17%. Fifty-two patients (39%) presented at least a good response to first-line treatment, with only 21 (15%) being in complete remission, irrespective of therapeutic strategy (p = 0.25). Botulinum toxin injections were performed in 54 patients. Patients with either primary vestibulodynia (p = 0.04) or spontaneous vestibulodynia (p = 0.03) were more likely to receive this treatment.

CONCLUSION

Our study highlights the current lack of efficacy of first-line treatments in vestibulodynia. Considering the high prevalence of muscular dysfunction, botulinum toxin injections are of particular interest despite a lack of randomized controlled trials in this indication.

Safety and feasibility of percutaneous needle tunneling with platelet-rich plasma injections for Peyronie's disease in the outpatient setting: a pilot study

The objective of this study is to evaluate the safety and feasibility of the combined simultaneous percutaneous needle tunneling coupled with injection of platelet-rich plasma in the outpatient department for the treatment of Peyronie's disease. This prospective, non-randomized, cohort and preliminary study included patients who underwent this procedure from November 2020 to July 2022. The main outcome was an improvement in penile curvature. Fifty-four patients were enrolled and underwent 6 sessions under local anesthesia followed by vacuum therapy for the treatment of Peyronie's disease in our outpatient unit. The amendment of the curvature angle was significant with a median correction percentage of -44.40% interquartile range (-66.70 to (-39.70)), [p-value = 0.001, 95% CI (-29.76 to (-18.02)), paired Student's t-test]. The median pre-treatment curvature angle was 45° (40-75), and the median post-treatment was 30° (20-40). The median score for pain during the procedure was 3 (0-4.25) according to a 10-point visual analogic scale. After two hours, 20.37% of patients still had pain but none required any pain medication. 50% of patients had a minor hematoma and 75.93% patients reported penile ecchymosis. A single patient reported an injection site skin infection. In our experience percutaneous needle tunneling with platelet-rich plasma injections for Peyronie's disease in the outpatient setting is a safe, effective, and feasible treatment of penile deformity for PD.

New protocol in the treatment of Peyronie's disease by combining platelet-rich plasma, percutaneous needle tunneling, and penile modeling: Preliminary results

INTRODUCTION

Intra-lesional injections of collagenase (Xiapex®) were the only non-invasive treatment option for Peyronie's disease (PD), until their withdrawal from the European market.

OBJECTIVE

To evaluate the feasibility, efficacy, and safety of a combined treatment of percutaneous needle tunnelling (PNT) with penile modelling (PM) and the injection of platelet-rich plasma (PRP) under general anesthesia in the treatment of PD.

PATIENTS AND METHOD

A prospective case series study included patients with PD in a stable phase who underwent this procedure between March 2020 and January 2023. The main outcome was an improvement in curvature.

RESULT

Thirty-six patients underwent this novel approach for the treatment of PD. The pretreatment mean±standard deviation (SD) curvature degree was 57.5±20.61° (range 20-90°). After the protocol, the mean curvature degree was 40.86±25.13° (range 0-90°). The curvature angle improved significantly (P=0.0001), with a mean improvement difference of 16.85±14.81° (range 0-50°) and a mean improvement percentage of 47.7±40.29% (range 0-100%).

CONCLUSION

Our preliminary experience suggests that PNT and PRP injections with PM are effective and safe for the treatment of penile deformity of PD.

LEVEL OF EVIDENCE

4: case series study.

A qualitative study of the perceptions and experiences of healthcare providers caring for critically ill patients during the first wave of the COVID-19 pandemic: A PsyCOVID-ICU substudy

Background

Intensive care unit (ICU) staff have faced unprecedented levels of stress, in the context of profound upheaval of their working environment due to the COVID-19 pandemic. We explored the perceptions of frontline ICU staff about the first wave of the COVID-19 pandemic, and how this experience impacted their personal and professional lives.

Methods

In a qualitative study as part of the PsyCOVID-ICU project, we conducted semi-structured interviews with a random sample of nurses and nurses’ aides from 5 centres participating in the main PsyCOVID study. Interviews were recorded and fully transcribed, and analysed by thematic analysis.

Results

A total of 18 interviews were performed from 13 August to 6 October 2020; 13 were nurses, and 5 were nurses’ aides. Thematic analysis revealed three major themes, namely: (1) Managing the home life; (2) Conditions in the workplace; and (3) the meaning of their profession.

Conclusion

In this qualitative study investigating the experiences and perceptions of healthcare workers caring for critically ill patients during the first COVID-19 wave in France, the participants reported that the crisis had profound repercussions on both their personal and professional lives. The main factors affecting the participants were a fear of contamination, and the re-organisation of working conditions, against a background of a media “infodemic”.

Non-Inferiority of a Single Injection of Sodium Hyaluronate Plus Sorbitol to Hylan G-F20: A 6-Month Randomized Controlled Trial

Introduction

Several viscosupplement treatments are available for patients suffering from painful osteoarthritis (OA) of the knee, but few comparative clinical trials have been conducted. The primary objective of the trial was to demonstrate the non-inferiority of Synolis VA (80 mg hyaluronic acid and 160 mg sorbitol) (Group HA1) to Synvisc-One (48 mg hylan GF-20) (Group HA2) at Day 168 in terms of pain relief efficacy in patients with knee OA (Kellgren and Lawrence radiological stage II or III) in whom oral treatment with analgesics, NSAIDs or weak opioids provided insufficient clinical responses or were poorly tolerated.

Methods

This was a prospective, multicentre, comparative, randomized, double-blinded trial comparing the two previously indicated viscosupplements, HA1 and HA2. The average VAS pain score (1–100) was 62.5 at baseline (Day 0). The patients were randomized into two parallel groups at Day 0 and followed until Day 168. They received one injection of either HA1 or HA2. The primary end point was the evolution of the Western Ontario and McMaster University (WOMAC) pain index at D168 in the groups. One of the secondary end points was the daily assessment of this index by the patient for 7 days following the injection and thereafter at Day 14. The other secondary end points were the WOMAC pain, stiffness, function and total scores assessed at Day 28, Day 84 and Day 168. At Day 168, efficacy and satisfaction were assessed by the evaluator and by the patient using a Likert scale (7 points). Moreover, the number of strict responders in each group was evaluated according to the The Osteoarthritis Research Society International (OARSI) Standing Committee for Clinical Trials Response Criteria Initiative and the Outcome Measures in Rheumatology (OMERACT) criteria (OMERACT-OARSI). The per protocol (PP) population was used for the primary analysis.

Results

A total of 202 patients were randomized. The patients were predominantly female (66%). The median age of the whole population was 65 years, and the median body mass index was 27.4 kg/m². No statistically significant differences between the two treatment groups were observed for any of the demographic criteria. At Day 168, 197 had had no protocol violations (94 in the HA1 group and 103 in the HA2 group). The WOMAC pain score decreased in the two groups: − 29.2 ± 24.1 (SD) in the HA1 group and − 31.6 ± 25.5 (SD) in the HA2 group, confirming the non-inferiority of Synolis VA (P = 0.57 for the difference between groups). Regarding the secondary end points, no significant difference was observed at Day 14, Day 28, Day 84 or Day 168 for all the outcomes except stiffness at Day 28 (P = in favour of treatment received in HA2). The rate of responders was comparable between the two groups: 79% for HA1 and 77% for HA2. Both products were well tolerated. Serious adverse events were reported by four patients in the HA1 group and 3 in the HA2 group.

Conclusion

In this trial, we confirmed the non-inferiority of Synolis VA compared to Synvisc-One at Day 168 according to the WOMAC pain score. Safety was satisfying and comparable in the two groups.

Trial Registration

2017-A00034-49.

FRI0398 COMPARISON OF THE EFFICACY AND SAFETY OF TWO HYALURONIC ACIDS IN THE TREATMENT OF KNEE OSTEOARTHRITIS

Background:

Several viscosupplement treatments are available to patients suffering from osteoarthritis (OA) but few comparative clinical trials have been conducted.

Objectives:

The primary objective of the study was to demonstrate at 24 weeks the non-inferiority of on hyaluronic acid over a second one in terms of efficacy (pain relief) in knee OA patients (Kellgren and Lawrence radiologic stage II or III) with whom oral treatment had failed.

Methods:

This was a prospective, multicenter, comparative, randomized, double-blinded study (one independent physician evaluator–one physician injector), comparing two viscosupplements: one containing a solution of hyaluronic acid (SYNOLIS VA® 80mg hyaluronic acid and 160 mg sorbitol – Group HA1) and the other containing one of Hylan (SYNVISC ONE ® 48 mg Hylane GF-20 – Group HA2) over a period of 24 weeks. At inclusion, the average VAS Pain (1-100) was 62.5. The patients were randomized in 2 parallel groups at D0 and followed until D168. They received an injection of either HA1 or HA2. Efficacy was primarily assessed using the WOMAC Pain index (daily assessed by the patient during seven days following the injection, and then at D14). During the follow up visits (D28-D84-D168) WOMAC pain, stiffness and function scores were assessed as secondary objectives. At D168, efficacy and satisfaction were also evaluated by the evaluator and by the patient using Likert scale (7 points). Moreover, the number of responders strict each group was evaluated according to the OMERACT-OARSI criteria. According to methodology guidelines, the per protocol (PP) population has been used as primary analysis. The PP population included all patients from the intention to treat (ITT) population who completed the study without any major protocol violation.

Results:

202 patients were randomized (ITT population, 96 in the HA1 group and 106 in the HA2 group). Baseline demographic data for the PP population at the time of randomization by treatment group. Patients were predominantly female (66%). The median age of the whole population was 65 years and the median body mass index of 27.4 kg/m2. No statistically significant differences between the two treatment groups were observed for any demographic criteria. At D168, 197 presented no protocol violations (94 in the HA1 group and 103 in the HA2 group). This population had a decrease on the overall score of the WOMAC Pain at -29.2+/- 24.1 (SD) in the HA1 group and -31.6 +/-25.5 (SD) in the HA2 group confirming the non-inferiority (P = 0.57 for the difference between groups). Regarding the secondary endpoints, no significant difference has been observed at D14, D28, D84, D168, in the PP population for all the outcome except stiffness at D28. There was also no difference between the responders rate in two groups (79 % for HA1 and 77% for HA2). In terms of safety, both products were well tolerated. No case of allergy or infection in the course of the injection was reported. Serious adverse events have been reported by 4 patients in HA1 group and 3 in HA2 group.

Conclusion:

In this study, we confirmed the non-inferiority of HA1 compared with HA2 in terms of both efficacy and safety.

Disclosure of Interests:

Bernard Cortet Consultant of: Aptissen, Sandrine Lombion Consultant of: Aptissen, Olivier Bruyere Consultant of: Aptissen

Ultrasonography after pharmacological stimulation of erection for the diagnosis and therapeutic follow-up of erectile dysfunction due to cavernovenous leakage

The goal of this work was to demonstrate that Doppler ultrasound (DUS) after pharmacological stimulation of erection (PSE) can be used to evaluate the presence and intensity of a cavernovenous leak (CVL) suspected in erectile dysfunction (ED) patients. The study was built around 50 DUS-PSE exams of penile arteries and veins, which were carried out 3, 5, 10 and 20minutes after pharmacological stimulation. Measured parameters were end diastolic velocity of the cavernous arteries and mean velocity of the deep penile vein and/or penile superficial veins. A score from 0 to 3 was attributed to each according to the recorded velocities. A final score from 0 to 9 was established by adding the three values: patients quoting 0 and 1 were classified as "no leak" (n=8); from 2 to 9 (n=42) as "leaking". Penile computed tomography (CT-scan) under identical pharmacological stimulation identified the cavernovenous leak to be compared with the DUS-PSE results, which were valid in 47 cases (94%), with 97.6% sensitivity and 77.7% specificity. The kappa correlation coefficient for CT-scan diagnosis of suspected CVL was 0.7875 (P<0.001). In addition, we found that end diastolic velocity in the cavernous artery, considered up until now as the gold standard in cases of suspected CVL was insufficient (negative predictive value=47%). In addition to its well-known diagnostic value regarding ED of arterial origin, DUS-PSE is an excellent screening test for CVL, especially in young patients without vascular risk factors who are resistant to medical treatments. For those with well-established CVL, confirmation by CT-scan to discuss possible surgery should be the next step. Moreover, DUS-PSE is useful in postoperative monitoring.

Patterns of cerebral activation during olfactory and trigeminal stimulations

It is well known that most odorants stimulate both the olfactory system and the trigeminal system. However, the overlap between the brain processes involved in each of these sensorial perceptions is still poorly documented. This study aims to compare fMRI brain activations while smelling two odorants of a similar perceived intensity and pleasantness: phenyl ethyl alcohol (a pure olfactory stimulus) and iso-amyl-acetate (a bimodal olfactory-trigeminal stimulus) in a homogeneous sample of 15 healthy, right-handed female subjects. The analysis deals with the contrasts of brain activation patterns between these two odorant conditions. The results showed a significant recruitment of the right insular cortex, and bilaterally in the cingulate in response to the trigeminal component. These findings are discussed in relation to the characteristics of these odorants compared with those tested in previous studies.

Effects of anti-depressants on olfactory sensitivity in mice

RATIONALE AND OBJECTIVES

Some studies have underlined a decrease in olfactory sensitivity in patients suffering from depression. The present study aims to evaluate the effects of current anti-depressant drugs on the olfactory sensitivity in mice. METHODS MICE: (N degrees =22) were tested in a Y-maze with a choice between an odorant (butanol) or distilled water before and during 3 weeks of daily intra-peritoneal injection of either citalopram or clomipramine. Their performance was compared with those of a control group (N degrees =11) injected with a saline solution.

RESULTS

The results showed a significant decrease in olfactory sensitivity with both anti-depressants during the three weeks of treatment.

CONCLUSION

The antidepressant induced alteration in serotonin and/or noradrenaline transmission in the olfactory bulb may account for the altered olfactory sensitivity observed in this study.