Bradford W. Fenton

A preliminary study of transcranial direct current stimulation for the treatment of refractory chronic pelvic pain.

BACKGROUNDnThe modulatory effects of transcranial direct current stimulation (tDCS) appear beneficial for different chronic pain syndromes; however, it is unclear whether this method can be used to treat refractory chronic pelvic pain.nnnOBJECTIVEnThe objective of this preliminary study was to determine the efficacy and safety of tDCS for the management of refractory chronic pelvic pain.nnnMETHODSnSeven patients with chronic pelvic pain having failed standard medical or surgical therapy underwent a crossover, double-blind sham controlled tDCS treatment protocol consisting of 1 mA applied for 20 minutes on two consecutive days with 2 weeks of follow-up symptom recording. Symptoms were recorded using multiple scoring systems, including visual analog scales for different pains, as well as organ-specific symptom scales. Comparison between active and sham treatment was performed by using paired t tests.nnnRESULTSnOverall and pelvic pain scores were significantly lower after active compared with sham treatment, as were disability and traumatic stress scores. No patient discontinued the study because of side effects, which were infrequent.nnnCONCLUSIONSnActive tDCS treatment induces a modest pain reduction in refractory chronic pelvic pain patients as compared with sham tDCS treatment. These results can guide the design and implementation of further studies investigating this method of neuromodulation for the treatment of refractory chronic pelvic pain.

Application of Patient-Reported Outcomes Measurement Information System to Chronic Pelvic Pain

STUDY OBJECTIVESnTo apply the Patient-Reported Outcomes Measurement Information System (PROMIS) recently developed by the National Institutes of Health in patients with chronic pelvic pain. Secondary objectives included evaluation of individual pain categories and of the effect of the occurrence of myofascial abdominal wall and pelvic floor muscle pain.nnnDESIGNnRetrospective study (Canadian Task Force classification III).nnnSETTINGnChronic pelvic pain multidisciplinary referral center.nnnPATIENTSnA total of 149 consecutive patients with chronic pelvic pain provided evaluable results.nnnINTERVENTIONSnAs part of a comprehensive evaluation, patients were assigned diagnoses based on standard criteria, and completed the 96-item short-form PROMIS.nnnMEASUREMENTS AND MAIN RESULTSnPain-related and global PROMIS scores were significantly worse than in the reference population (p <.05). The presence of myofascial pain was also associated with worse PROMIS scores.nnnCONCLUSIONnChronic pelvic pain is associated with impaired quality of life regardless of the diagnosis, including myofascial pain.

Chronic Pelvic Pain Syndrome-Related Diagnoses in an Outpatient Office Setting

Background: Chronic pelvic pain (CPP) is a syndrome composed of one or more pain diagnoses arising from pelvic organs. Although the prevalence of many individual diagnoses has been determined in a variety of settings, the concurrent assessment of overlapping pain syndromes in an outpatient gynecology clinic, which would be most pertinent to practitioners, has not been reported. Methods: Patients waiting to be seen in an outpatient general gynecology clinic completed a survey composed of validated instruments for different pain diagnoses. Cyclic and constant CPP, irritable bowel syndrome (IBS), interstitial cystitis (IC), and vulvodynia (VVD) were assessed. Results: In the 498 completed surveys, 24% of patients met at least one criterion for CPP, and of these, 23% also met criteria for a second diagnosis. Of all patients, 15% reported symptoms consistent with IBS, 6% with IC, and 5% with VVD. Cyclic CPP was found in 20%, and of these patients, 30% had at least one other CPP-related diagnosis. Discussion: Although limited by its design as a survey, this study demonstrates that CPP frequently (between 30 and 43%) occurs with other pain syndromes. Clinicians should be prepared to evaluate nongynecologic causes of pelvic pain.

Interstitial Cystitis - Elucidation of Psychophysiologic and Autonomic Characteristics (the ICEPAC Study): design and methods.

Background and purpose Interstitial cystitis/bladder pain syndrome (IC/BPS) is relatively common and associated with severe pain, yet effective treatment remains elusive. Research typically emphasized the bladder’s role, but given the high presence of systemic comorbidities, the authors hypothesized a pathophysiologic nervous system role. This paper reports the methodology and approach to study the nervous system in women with IC/BPS. The study compares neurologic, urologic, gynecologic, autonomic, gastrointestinal, and psychological features of women with IC/BPS, their female relatives, women with myofascial pelvic pain (MPP), and healthy controls to elucidate the role of central and peripheral processing. Methods and results In total, 228 women (76 IC/BPS, 76 MPP, 38 family members, and 38 healthy controls) will be recruited. Subjects undergo detailed screening, structured neurologic examination of limbs and pelvis, tender point examination, autonomic testing, electrogastrography, and assessment of comorbid functional dysautonomias. Interpreters are blinded to subject classification. Psychological and stress response characteristics are examined with assessments of stress, trauma history, general psychological function, and stress response quantification. As of December 2012, data collection is completed for 25 healthy controls, 33 IC/BPS ± MPP, eight MPP, and three family members. Recruitment rate is accelerating and strategies emphasize maintaining and encouraging investigator participation in study science, internet advertising, and presentations to pelvic pain support groups. Conclusion The study represents a comprehensive, interdisciplinary approach to sampling autonomic and psychophysiologic characteristics of women with IC/BPS. Despite divergent opinions on study methodologies based on specialty experiences, the study has proven feasible to date and different perspectives have proved to be one of the greatest study strengths.

Phenotyping Chronic Pelvic Pain Based on Latent Class Modeling of Physical Examination

Introduction. Defining clinical phenotypes based on physical examination is required for clarifying heterogeneous disorders such as chronic pelvic pain (CPP). The objective of this study was to determine the number of classes within 4 examinable regions and then establish threshold and optimal exam criteria for the classes discovered. Methods. A total of 476 patients meeting the criteria for CPP were examined using pain pressure threshold (PPT) algometry and standardized numeric scale (NRS) pain ratings at 30 distinct sites over 4 pelvic regions. Exploratory factor analysis, latent profile analysis, and ROC curves were then used to identify classes, optimal examination points, and threshold scores. Results. Latent profile analysis produced two classes for each region: high and low pain groups. The optimal examination sites (and high pain minimum thresholds) were for the abdominal wall region: the pair at the midabdomen (PPT threshold depression of > 2); vulvar vestibule region: 10:00 position (NRS > 2); pelvic floor region: puborectalis (combined NRS > 6); vaginal apex region: uterosacral ligaments (combined NRS > 8). Conclusion. Physical examination scores of patients with CPP are best categorized into two classes: high pain and low pain. Standardization of the physical examination in CPP provides both researchers and general gynecologists with a validated technique.

Induction of labor in women with a history of fast labor

Abstract Objective: History of fast labor is currently subjectively defined and inductions for non-medical indications are becoming restricted. We hypothesized that women induced for a history of fast labor do not have faster previous labors and do not deliver more quickly. Methods: A retrospective case-control cohort design studied multiparas undergoing elective induction at one high risk center. Outcomes of dyads electively induced for a history of previous fast labor indication (PFast) were compared to controls with a psychosocial indication. Results: A total of 612 elective inductions with 1074 previous deliveries were evaluated: 81 (13%) PFast and 531 (87%) control. PFast had faster previous labors (median 5.5u2009h, IQR: 4.5–6) versus. control (10u2009h, IQR: 9–10.5; pu2009<u20090.001). Subsequent delivery time from start to expulsion was shorter for PFast (median 7u2009h, IQR: 5–9, pu2009<u20090.001) than controls with and without a previous labor <5.5u2009h (8.6u2009h, IQR: 6–14 and 9.5u2009h, IQR: 7–15, respectively). PFast were less likely to have a serious maternal complication. Neonatal complications were similar. Conclusions: Patients induced for a history of fast labor do have faster previous labors, suggesting a significant history of fast labor can be defined as <5.5u2009h. These women deliver more quickly and with lower morbidity than controls when subsequently induced, therefore the benefit may warrant the risk for a select number of women with a history of a prior labor length <5.5u2009h.

A Method for the Consistent Creation and Quantitative Testing of Postoperative Pelvic Adhesions in a Porcine Model

Introduction: The assessment of methods for the prevention of postoperative pelvic adhesions is hampered by the lack of a quantifiable adhesion measurement technique. Currently available methods for adhesion model assessment rely on qualitative grading scales; a quantitative method would have many attendant benefits, including standardized reporting. Methods: A technique was developed to generate consistent and significant adhesions in a swine model that are suitable for quantitative assessment using a Material Testing System (MTS) machine platform. In this method, the uterine horns are cannulated and then attached to the pelvic sidewall using loose silk sutures. The underlying sidewall and adjacent uterine serosa are injured with electrocautery. Following a two-week survival the entire complex of uterine horn and sidewall are excised en bloc and prepared for MTS testing. Results: Extrication of the adhesion, as measured by the MTS platform, generates a quantitative assessment of adhesion strength that can be scaled and analyzed to produce several continuous variable descriptions. Discussion: This technique represents a novel quantitative method for adhesion assessment in an animal model. This quantitative technique may then be applied to accurately assess a range of adhesion prevention techniques, producing results which can be standardized for comparison.