Interventional Treatments for Pelvic Pain

Transcription

1 Interventional Treatments for Pelvic Pain Ameet Nagpal, MD, MS, MEd Clinical Assistant Professor, Department of Anesthesiology University of Texas Health Science Center at San Antonio

2 No relevant financial disclosures

3 Objectives Describe available interventional treatment options for patients with chronic pelvic pain Delineate which patients may benefit from interventional procedures (i.e. who to refer) Outline the existing, minimal literature to support these procedures for the treatment/diagnosis of chronic pain

4 Hypothetical A 34 year old female presents to your clinic with several year history of dyspareunia and chronic pelvic pain. Manual pelvic examination reveals asymmetric bulging of the right levator ani muscle with reproduction of the patient s typical pain with palpation. Which of the following are evidence-based treatment options? A. Trigger point injection B. Pudendal nerve block C. Botulinum toxin injection D. Superior hypogastric plexus block

5 Poll: Which of the following are evidence-based treatment options?

6 Trigger Point Injections Simons, Travell, Simons (Eds). Travell and Simon's Myofascial Pain and Dysfunction: The Trigger Point Manual, Lippincott & Williams, 1998.

7 Trigger Point Injections for Chronic Pelvic Pain Superior to conventional management up to 12 weeks post-procedure (Level 1) 1,2 33% complete resolution of pain symptoms at 3 months (Level 2) 2 1. Montenegro ML, Braz CA, Rosa-e-Silva JC, Candido-dos-Reis FJ, Nogueira AA, Poli-Neto OB. Anaesthetic injection versus ischemic compression for the pain relief of abdominal wall trigger points in women with chronic pelvic pain. BMC Anesthesiol Dec 1;15: Langford CF, Udvari Nagy S, Ghoniem GM. Levator ani trigger point injections: An underutilized treatment for chronic pelvic pain. Neurourol Urodyn. 2007;26(1):59-62.

8 Trigger Point Injections for Chronic Pelvic Pain Addition of corticosteroid for TPIs not superior to LA alone (Level 1) 1 Recent study: no difference in sexual function or pain at 1 month between levator ani TPI vs. PT alone (both groups improved implication is TPI = PT) Level 4 2 Common muscles involved: levator ani, piriformis, obturator internus, glutei, and quadratus lumborum 1. Misirlioglu TO, Akgun K, Palamar D, Erden MG, Erbilir T. Piriformis syndrome: comparison of the effectiveness of local anesthetic and corticosteroid injections: a double-blinded, randomized controlled study. Pain Physician Mar-Apr;18(2): Zoorob D, South M, Karram M, Sroga J, Maxwell R, Shah A, Whiteside J. A pilot randomized trial of levator injections versus physical therapy for treatment of pelvic floor myalgia and sexual pain. Int Urogynecol J Jun;26(6):

9 Botulinum Toxin for Pelvic Pain The use of small molecules to investigate molecular mechanisms and therapeutic targets for treatment of botulinum neurotoxin A intoxication. ACS Chem Biol Jul 21;1(6):

10 Evidence for Botulinum Toxin Serial injections in levator ani showed improvement at 6 weeks post-injection (58%); retrospective (Level 2) 1 RCT: 80 units botulinum toxin vs. saline, 30 patients per arm. No differences between groups in dyspareunia, pelvic pressure, or pain but both groups improved in all 3 (p < 0.05). (Level 1) 2 1. Adelowo A, Hacker MR, Shapiro A, Modest AM, Elkadry E. Botulinum toxin type A (BOTOX) for refractory myofascial pelvic pain. Female Pelvic Med Reconstr Surg Sep-Oct;19(5): Abbott JA, Jarvis SK, Lyons SD, Thomson A, Vancaille TG. Botulinum toxin type A for chronic pain and pelvic floor spasm in women: a randomized controlled trial. Obstet Gynecol Oct;108(4):

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12 Hypothetical A 28 year old female presents to your clinic with chronic pelvic pain due to endometriosis. She would like to get pregnant and her REI physician has asked you to perform interventional treatment options to alleviate her pain so that she does not require a hysterectomy. Which of the following is the best option? A. Superior hypogastric plexus block B. Ganglion impar block C. Trigger point injections D. Spinal cord stimulation

13 Poll: A 28 year old female presents to your clinic with chronic pelvic pain due to endometriosis. Which of the following is the best option?

14 Superior Hypogastric Plexus (SHP) Block The SHP provides visceral innervation to most pelvic structures, descending colon, rectum and internal genitalia except the ovaries and uterine tubes (and testes) Treats pain due to: endometriosis (level V), pelvic inflammatory disease (level V), postoperative adhesions (level V), and cancer unresponsive to more conservative measures (level II) 1,2 1. Mishra S, Bhatnagar S, Rana SPS, et al. Efficacy of the anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in advanced gynecological cancer patients. Pain Med 2013;14: Benzon HT, Rathmell JP, Wu CL, et al. Practical management of pain, 5 th edition. Philadelphia: Elsevier Mosby; p

15 SHP Block Lateral AP

16 SHP Block AP

17 Ganglion Impar Block The bilateral paravertebral sympathetic chain terminates anteriorly as a midline single fused ganglion impar Supply nociceptive and sympathetic fibers to the perineum, distal rectum, perianal region, distal urethra, vulva/scrotum and distal third of the vagina, as well as sympathetic innervation to the pelvic viscera. Treat visceral and sympathetic pelvic and perineal pain, both malignant and benign (Level 4) and coccydynia (Level 5) 1 1. Scott-Warren JT, Hill V, Rojasekaram A. Ganglion impar blockade: a review. Curr Pain Headache Rep 2013;17:

18 Ganglion Impar Block

19 Hypothetical A 31 year old male presents to your clinic with unilateral perineal pain as well as unilateral testicular pain that worsens with sitting. You suspect a neuralgia. Which of the following peripheral nerves is most likely irritated? A. Pudendal B. Ilioinguinal C. Iliohypogastric D. Genitofemoral

20 Poll: Which of the following peripheral nerves is most likely irritated?

21 Pudendal Nerve Blocks Innervates the penis, clitoris, bulbospongiosus, ischiocavernosus, perineum and anus Neuralgia: intractable pelvic and perineal pain, hyperalgesia, genital numbness, sexual dysfunction and even abnormal urinary frequency; unilateral the vulva, vagina, clitoris, perineum and rectum in females and to the glans penis, scrotum, perineum, and rectum in males Pulsed radiofrequency neuromodulation (Level 4) 1 1. Hong MJ, Kim YD, Park JK, et al. Management of pudendal neuralgia using ultrasound-guided pulsed radiofrequency: a reports of two cases and discussion of pudendal nerve block techniques. J Anesth 2016;30:356-9.

22 Pudendal Nerve Blocks

23 Ilioinguinal/Iliohypogastric/ Genitofemoral Nerve Block Historically used as perioperative anesthesia techniques during inguinal herniorrhaphy, orchidopexy, and hydrocelectomy They can be helpful diagnostically in the evaluation of groin pain to differentiate peripheral nerve entrapment from lumbar radiculopathy. The II and GF nerves have been known to become adhered after laparoscopy for endometriosis Successful pain relief after a diagnostic nerve block may indicate nerve entrapment; can help distinguish from upper lumbar radiculopathy Prendergast SA, Weiss JM. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol 2003;46(4):

24 IL/IH Nerve Block

25 Genitofemoral Nerve Block

26 Other Options Pulsed radiofrequency neuromodulation? Traditional radiofrequency ablation? Cryoablation? Spinal cord stimulation?

27 Spinal Cord Stimulation T12? Sacral stimulation? Retrograde or caudal? Dorsal root ganglia stimulation? High frequency? Paresthesia? No paresthesia? Targeted pudendal stimulation?

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29 Spinal Cord Stimulation?

30 Hypothetical A 34 year old female presents to your clinic with several year history of dyspareunia and chronic pelvic pain. Manual pelvic examination reveals asymmetric bulging of the right levator ani muscle with reproduction of the patient s typical pain with palpation. Which of the following are evidence-based treatment options? A. Trigger point injection B. Pudendal nerve block C. Botulinum toxin injection D. Superior hypogastric plexus block

31 Poll: Which of the following are evidence-based treatment options?

32 Hypothetical A 28 year old female presents to your clinic with chronic pelvic pain due to endometriosis. She would like to get pregnant and her REI physician has asked you to perform interventional treatment options to alleviate her pain so that she does not require a hysterectomy. Which of the following is the best option? A. Superior hypogastric plexus block B. Ganglion impar block C. Trigger point injections D. Spinal cord stimulation

33 Poll: Post-Which of the following is the best option?

34 Hypothetical A 31 year old male presents to your clinic with unilateral perineal pain as well as unilateral testicular pain that worsens with sitting. You suspect a neuralgia. Which of the following peripheral nerves is most likely irritated? A. Pudendal B. Ilioinguinal C. Iliohypogastric D. Genitofemoral

35 Poll: Post-Which of the following peripheral nerves is most likely irritated?

36 Conclusions Interventional treatment options for chronic pelvic pain are available and have variable levels of evidence with well documented safety profiles Understanding of pelvic anatomy is crucial to performing these procedures safely and appropriately Interventional treatment is an adjunct treatment to the management of chronic pelvic pain