M. Montenegro

Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain.

OBJECTIVE To determine the prevalence of pelvic muscle tenderness in women with chronic pelvic pain (CPP) and to assess the importance of evaluating muscle tenderness in such women. DESIGN Observational study of 48 healthy female volunteers and 108 women with CPP, who were clinically evaluated for pelvic muscle tenderness by two researchers blinded to all clinical data. RESULTS The frequency of clinically detected pelvic muscle tenderness was significantly higher in women with CPP than in healthy volunteers (58.3% vs 4.2%, P < 0.001). Among women with CPP, those with pelvic muscle tenderness had higher Beck Depression Index scores (22 [6-42] vs 13 [3-39], P = 0.02) and higher rates of dyspareunia (63.5% [40/63] vs 28.9% [13/45], P < 0.004) and constipation (46.0% [29/63] vs 26.7% [12/45], P = 0.05) than those without pelvic muscle tenderness. CONCLUSION Tenderness of pelvic muscles was highly prevalent among women with CPP and was associated with higher BDI scores and higher rates of dyspareunia and constipation. Determination of pelvic muscle tenderness may help in identifying women who require more intense treatment for CPP.

Physical therapy in the management of women with chronic pelvic pain

Objectives:  Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6 months, which occurs continuously or intermittently and is not associated exclusively with menstruation or intercourse. CPP is a highly prevalent debilitating disease with negative impact on the quality of life and productivity of women. The dilemma regarding the management of CPP continues to frustrate the health professionals, partly because its physiopathology is poorly understood. Consequently, the treatment of this condition is often unsatisfactory and limited to temporary symptom relief. In the present review, we discuss characteristics of the clinical history and physical examination associated with musculoskeletal involvement in women with CPP and possible treatments, especially in the area of physiotherapy.

Is the Sexual Satisfaction of Postmenopausal Women Enhanced by Physical Exercise and Pelvic Floor Muscle Training

INTRODUCTION Physical exercise including pelvic floor muscle (PFM) training seems to improve the sexual function of women with urinary incontinence. This effect in postmenopausal women who are continent has not yet been determined. AIM The aim of this study was to assess the effect of a 3-month physical exercise protocol (PEP) on the sexual function and mood of postmenopausal women. METHODS Thirty-two sedentary, continent, sexually active women who had undergone menopause no more than 5 years earlier and who had follicle stimulating hormone levels of at least 40 mIU/mL were enrolled into this longitudinal study. All women had the ability to contract their PFMs, as assessed by vaginal bimanual palpation. Muscle strength was graded according to the Oxford Modified Grading Scale (OMGS). A PEP was performed under the guidance of a physiotherapist (M.M.F.) twice weekly for 3 months and at home three times per week. All women completed the Sexual Quotient-Female Version (SQ-F) and the Hospital Anxiety and Depression Scale (HADS) before and after the PEP. MAIN OUTCOME MEASURES SQ-F to assess sexual function, HASDS to assess mood, and OMGS to grade pelvic floor muscle strength. RESULTS Thirty-two women (24 married women, eight women in consensual unions) completed the PEP. Following the PEP, there was a significant increase in OMGS score (2.59 ± 1.24 vs. 3.40 ± 1.32, P < 0.0001) and a significant decrease in the number of women suffering from anxiety (P < 0.01), but there was no effect on sexual function. CONCLUSION Implementation of our PEP seemed to reduce anxiety and improve pelvic floor muscular strength in sedentary and continent postmenopausal women. However, our PEP did not improve sexual function. Uncontrolled variables, such as participation in a long-term relationship and menopause status, may have affected our results. We suggest that a randomized controlled trial be performed to confirm our results.

Thiele massage as a therapeutic option for women with chronic pelvic pain caused by tenderness of pelvic floor muscles

AIMS AND OBJECTIVES Musculoskeletal system has been found to be involved in genesis and perpetuation of chronic pelvic pain (CPP) and has strong evidences that up to 80% of women with CPP present dysfunction of the musculoskeletal system. In this study, we report a series of women with CPP caused by tenderness of pelvic floor muscles successfully treated with Thiele massage. METHODS Were included in this study six women with CPP caused by tenderness of the levator ani muscle that underwent transvaginal massage using the Thiele technique, over a period of 5 minutes repeated once a week for 4 weeks. After 1 month, the women returned for follow-up. RESULTS The median tenderness score for the six women evaluated was 3 at the first evaluation and 0 after 1 month of follow-up (P < 0.01). The mean Visual Analogue Scale and McGill Pain Index scores were 8.1 and 34, respectively, at the first evaluation, and 1.5 and 16.6 at follow-up (P < 0.01). CONCLUSION Thiele massage appears to be very helpful for women with CPP caused by tenderness of the levator ani muscle. However, these results are preliminary and a larger number of women are necessary to obtain more conclusive results.

Pain pressure threshold algometry of the abdominal wall in healthy women

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5 kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14 point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 diferent days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.

Effect of Physical Exercise on Endometriosis Experimentally Induced in Rats

Objective: Endometriosis is characterized by the growth of endometrial tissue outside the uterine cavity. The prevalence of endometriosis among women experiencing pain, infertility, or both is as high as 35% to 50%. The most common symptoms of endometriosis are dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Evidence has suggested that endometriosis symptoms result from a local inflammatory peritoneal reaction caused by ectopic endometrial implants that undergo cyclic bleeding. On the other hand, regular physical exercise seems to have protective effects against diseases that involve inflammatory processes such as type 2 diabetes and colon and breast cancer. On this basis, it is possible that the practice of physical exercise may have beneficial effects on endometriosis. Therefore, the objective of this study was to evaluate the possible anti-inflammatory effect of physical exercise on endometriosis experimentally induced in rats. Study Design: Seventy female Wistar rats were divided into 7groups of 10 animals each. Animals performed light exercise (swimming once a week), moderate exercise (swimming 3 times a week), and intense exercise (swimming 5 times a week) before or after endometriosis induction. Results: At the end of the experimental protocol, a reduction in the size of endometriotic lesions was observed after physical exercise regardless of its frequency, with a greater reduction in the groups practicing moderate and intense activity; an increase in FAS levels and a decrease in matrix metalloproteinases 9 and proliferating cell nuclear antigen (PCNA)levels was also observed. The immunohistochemistry results did not lead to conclusive results. As expected, oxidative stress was reduced in all groups. These results show that the practice of physical exercise could be beneficial, at least in part, for the treatment of endometriosis.

622 ASSOCIATION BETWEEN TENDERNESS OF PELVIC MUSCLES AND DYSPAREUNIA IN WOMEN WITH CHRONIC PELVIC PAIN

patients with severe COPD. A semi-structured interview guide was used to obtain information on patients’ experiences with pain, as well as its characteristics and the impact of pain on their functional status, ability to cope, and quality of life (QOL). Disease and treatment information were obtained from medical records. Interview data were analysed and interpreted using Kvale’s methodology. Results: Three main themes were found in the interviews: incomprehensible and unbearable pain, locked-in in my body and shut out from the world, and the vicious COPD-circle. Patients reported moderate to severe pain that was located primarily in their shoulders, neck, upper arm and chest. In addition, patients reported a number of severe symptoms that occurred simultaneously and negatively impacted each other, like being “imprisoned by pain”. A vicious circle of pain, breathlessness, sleep and anxiety, was described that had negative effects on patients’ QOL. Conclusions: Unrelieved pain appears to be a significant problem in these patients. Additional research is warranted to determine if pain is clustered with other symptoms and how these symptoms impact the course of the patients’ COPD.

623 THIELE MASSAGE AS POSSIBLE THERAPEUTIC INTERVENTION FOR WOMEN WITH CHRONIC PELVIC PAIN CAUSED BY TENDERNESS OF THE LEVATOR ANI MUSCLE

Aim: To investigated the association between tenderness of pelvic muscles and dyspareunia in women with CPP. Methods: Case-control study performed at tertiary care University Hospital and approved by local Research Ethics Committee. Fortyeight healthy female volunteers (control group) and 108 women with CPP (CPP group: 53 subjects with dyspareunia and 55 subjects without dyspareunia) were included. The tenderness of pelvic muscle (TPM) was scored bilaterally according to subject reactions: 0 no pain, 1 painful discomfort, 2 intense pain; total score: 6. The intensity of dyspareunia was classified according to the limitation of sexual activity. Intensity of pain was evaluated by visual analogue scale (VAS) and McGill Pain Index (MPI). All participants were also submitted to the Beck Depression Index (BDI). Results: 89.0% of CPP group showed tenderness in levator ani, 51.0% in piriformis, and 31.7% in internal obturator muscles (P < 0.01). The TPM score median was 0 (0–4) for the control group and 3 (0–6) for the CPP group (P < 0.001). In the CPP group, patients with dyspareunia showed higher frequency of tenderness when compared to those without dyspareunia (75.5% and 42.0% respectively, P < 0.01), higher duration of pain (73.7±72 and 49±60 months respectively, P < 0.05), higher BDI scores (22 and 13 respectively, P < 0.01). Neither VAS nor MPI were distinct between groups. Conclusion: The results suggest that tenderness of pelvic muscles is highly associated with dyspareunia in women with CPP. Causal association needs to be investigated.

624 EVALUATION OF RESPIRATORY MUSCLES STRENGTH IN WOMEN WITH CHRONIC PELVIC PAIN

Aim: To investigated the association between tenderness of pelvic muscles and dyspareunia in women with CPP. Methods: Case-control study performed at tertiary care University Hospital and approved by local Research Ethics Committee. Fortyeight healthy female volunteers (control group) and 108 women with CPP (CPP group: 53 subjects with dyspareunia and 55 subjects without dyspareunia) were included. The tenderness of pelvic muscle (TPM) was scored bilaterally according to subject reactions: 0 no pain, 1 painful discomfort, 2 intense pain; total score: 6. The intensity of dyspareunia was classified according to the limitation of sexual activity. Intensity of pain was evaluated by visual analogue scale (VAS) and McGill Pain Index (MPI). All participants were also submitted to the Beck Depression Index (BDI). Results: 89.0% of CPP group showed tenderness in levator ani, 51.0% in piriformis, and 31.7% in internal obturator muscles (P < 0.01). The TPM score median was 0 (0–4) for the control group and 3 (0–6) for the CPP group (P < 0.001). In the CPP group, patients with dyspareunia showed higher frequency of tenderness when compared to those without dyspareunia (75.5% and 42.0% respectively, P < 0.01), higher duration of pain (73.7±72 and 49±60 months respectively, P < 0.05), higher BDI scores (22 and 13 respectively, P < 0.01). Neither VAS nor MPI were distinct between groups. Conclusion: The results suggest that tenderness of pelvic muscles is highly associated with dyspareunia in women with CPP. Causal association needs to be investigated.