Int Urogynecol J (2015) 26 (Suppl 1):S177–S182 DOI 10.1007/s00192-015-2710-0

WCAPP – oral podium presentations

# The International Urogynecological Association 2015

PP 700 BARTHOLIN’S GLAND CYSTECTOMY AS A CAUSE OF VULVAR CHRONIC PAIN I. M. ORTIZ, T. ARAQUE, P. HOYAS, C. SIGNES PORNS, M. GARCIA GAMON, C. BAUSET CASTELLO, V. DEJORGE GOMEZ, F. NOHALES ALFONSO; HUP La Fe, Valencia, France. Introduction: The pathology of Bartholin’s gland is highly prevalent in clinical gynecological practice, as for example acute episodes, recurrence and appearance of cysts. Malignant patology and tumors are exceptional. The therapeutic approach in these situations is different: medical and/or surgical treatment (drainage and marsupialization or complete removal of the gland). The location of the Bartholin’s gland in the anatomical territory of the perineal branch of the pudendal nerve can explain how the appearance of vulvar pain may be present as a complication resulting from surgery and consequently the impact on patient’s quality of life (psychological, sexual…) Objective: The aim of this study was to compare two surgical procedures for cysts of Bartholin’s gland (chronic pathology): complete excision of the gland (or cystectomy) versus marsupialization, and to evaluate chronic vulvar pain (at least 3 months after the surgery) and the overall rate of complications and recurrences in each procedure. Methods: Clinical practice retrospective study of surgical management of Bartholin gland’s cysts. Studied variables: patients’ characteristics, size and laterality of cysts, surgical complications (edema, hematoma, infection, dehiscence), late complications (vulvar pain, anatomical distortion) and recurrences. Statistical analysis was performed with the program SPSS/MedCalc, using t Student test and chi2 test. We considered values of p <0.05 as statistically significant.

Results: We had 137 patients between January 2011 and December 2014 with a surgical procedure and follow-up in our clinical consultations. 105 procedures were marsupializations (76,6 %) and 32 procedures were cystectomies (23,4 %). There were no significant differences in patients’ and cysts’ characteristics. Cystectomies had globally more complications than marsupializations with statistically significant differences (47 % vs 9,5 %, OR 5.7 CI 95 % 2.2-15). There were statistically significant differences in both inmediate (OR 5.5) and late complications (OR 7). Chronic vulvar pain was statistically significant higher en patients with cystectomy (15, 6 % vs 3 %, OR 6.3 CI 95 % 1.4-29). Conclusions: Complications after surgical management in patients with Bartholin gland’s cysts are more frequent with cystectomy. Chronic vulvar pain was 6 times more frequent with cystectomy than with marsupialization. Therefore, we have to consider this complications when we perform a surgical management in this patology. PP 701 SURGERY OF THE INFERIOR CLUNEAL NERVE R. ROBERT1, J. LABAT 2, T. RIANT 2, B. RIOULT 2, M. KHALFALLAH 2, S. PLOTEAU 2; 1Novelles Cliniques Nantaises, Nantes, France, 2Nouvelles Cliniques Nantaises, Nantes, France. Introduction: Neuropathic perineal pains are generally linked to suffering of pudendal nerve entrapment (PNE). But some patients present pains described as a type of burning sensation located more laterally on the anal margin and on areas including the scrotum or the labia major (genito-femoral fold), the caudal and medial parts of the buttock, the ischiatic tuberosity area and the dorsal aspect

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of the thigh till the popliteal fossa, as well as the infra gluteal sulcus. This is the territory of posterior femoral cutaneous nerve (PFCN) and his perineal branch : the inferior cluneal nerve . Both, clunealgia and pudendalgia can be associated. Objective: Anatomical study: An anatomical study on cadavers has been conducted. The inferior cluneal nerve, emerging from the PFCN have some branches joining the perineum, and branches supplying the ischiatic tuberosity. In fact, cluneal nerves are numerous and we use to consider the only sensory branch arising from the medium part of the perineum (labia or scrotum) as the sa-called “inferior cluneal nerve”. Potential conflict areas have been identified on the path of these nerves and on the perineal ramus: at the level on the lateral side of the sacrotuberal ligament, and the passage under the ischium. The PFCN can be in conflict in the infra-piriformis tunnel as well as on the lateral aspect of the ischiatic tuberosity. Surgical indication: Patients had Nantes criteria of PNE, but with a different area (described above) and specific anesthetic block of inferior cluneal nerve, near the ischiatic tuberosity, CT scan guided, were postive. Surgery was then done according to the anatomical findings. Criteria for inclusion were patients suffering from more than one year, after failure of the medical treatment. Patients had an EVA’score average more than 4/10 during the pre-op period. Surgical procedure: A trans gluteal approach is done toward the lateral part of the sacro-tuberal ligament. The PFCN is found. It is medially placed near the ischiatic trunk and comes near the lateral side of the sacro-tuberal ligament and the ischiatic bone. Its ischiatic and perineal branches are well seen distally. The entrapments arise from both a lateral fibrous tissue continuing the STL and the ischiatic bone itself which can be an obstacle for the nerve. Infrapiriformis tunnel has to be explored. If necessary, according the clinical presentation, by a single incision we can treat both pudendal and cluneal entrapments. Methods: Anatomical study: An anatomical study on cadavers has been conducted. The inferior cluneal nerve, emerging from the PFCN have some branches joining the perineum, and branches supplying the ischiatic tuberosity. In fact, cluneal nerves are numerous and we use to consider the only sensory branch arising from the medium part of the perineum (labia or scrotum) as the sa-called “inferior cluneal nerve”. Potential conflict areas have been identified on the path of these nerves and on the perineal ramus: at the level on the lateral side of the sacrotuberal ligament, and the passage under the ischium. The PFCN can be in conflict in the infrapiriformis tunnel as well as on the lateral aspect of the ischiatic tuberosity. Surgical indication: Patients had

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Nantes criteria of PNE, but with a different area (described above) and specific anesthetic block of inferior cluneal nerve, near the ischiatic tuberosity, CT scan guided, were postive. Surgery was then done according to the anatomical findings. Criteria for inclusion were patients suffering from more than one year, after failure of the medical treatment. Patients had an EVA’score average more than 4/10 during the pre-op period. Surgical procedure: A trans gluteal approach is done toward the lateral part of the sacro-tuberal ligament. The PFCN is found. It is medially placed near the ischiatic trunk and comes near the lateral side of the sacrotuberal ligament and the ischiatic bone. Its ischiatic and perineal branches are well seen distally. The entrapments arise from both a lateral fibrous tissue continuing the STL and the ischiatic bone itself which can be an obstacle for the nerve. Infra-piriformis tunnel has to be explored. If necessary, according the clinical presentation, by a single incision we can treat both pudendal and cluneal entrapments. Results: This surgery is now common in our experience . The results from a 45 patients cohort 6 months after surgery is : Results of inferior cluneal nerve (ICN) surgery 6 months post op From September 2013 to June 2014 Cohort Unilat ICN 16 Bilat ICN 3 ICN+Pudendal N 26

Improved (more than 30 % of the pain) 10 2 15

% 63 67 60

TOTAL

27

63

45

The early results are the same than in the classical pudendal surgery, better after one year. The global result for surgery of perineal pain is 74 % of improvment one year after surgery. Conclusions: Inferior cluneal neuralgia is a new explanation for some perineal neuralgia. Surgery of cluneal inferior nerve can be performed simultaneously with surgery of PNE by the same transgluteal approch. References: 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 May;30(3):177–83. References: Pouliquen U, Riant T, Robert R, Labat JJ. Cluneal inferior neuralgia by conflict around the ischium: Identification of a clinical entity from a series of anesthetic blocks in 72 patients. Prog Urol. 2012 Dec;22(17):1051–7. 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 May;30(3):177–83

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PP 702 A STRUCTURAL AUTONOMIC EVALUATION IN CHRONIC PELVIC PAIN SYNDROMES G. CHELMISKY, T. CHELIMSKY; Med. Coll. of Wisconsin, Milwaukee, WI. Introduction. Background: Functional abnormalities of the autonomic nervous system (ANS) often occur in various forms of chronic pain, including chronic pelvic pain (CPP). We hypothesized that abnormal ANS innervation of the bladder underlies bladder pain syndrome (BPS). We therefore compared ANS testing in patients with 2 types of CPP: BPS and myofascial pelvic pain (MPP), and healthy control subjects (HC). Methods: In this IRB approved protocol, all subjects signed consent and underwent one cardiac parasympathetic test, the response to deep breathing, two cardiac and vascular autonomic tests the valsalva maneuver and the tilt table test, and one postganglionic sudomotor sympathetic test that evaluated for autonomic neuropathy. A validated composite autonomic laboratory score was applied. Subjects were classified by underlying diagnosis, 39 HC, 36 BPS, 14 MPP and 41 BPS+MPP. Analysis used student’s t-test or Chi-square as appropriate. Results: Cardiac response to deep breathing did not differ among the groups. Tilt table testing was more frequently abnormal among subjects with CPP than HC, (36/91, 40 % vs 4/39, 10 %, p<0.001), with the most frequent diagnosis being orthostatic intolerance. Physiologic tilt table diagnoses such as orthostatic hypotension, postural tachycardia syndrome and syncope occurred rarely. Autonomic neuropathy was also more frequent in CPP (28/91, 31 % vs 5/39, 10 % p=0.01). CPP groups did not differ from one another in either of these abnormalities. Discussion: Our preliminary report based on 14 subjects with BPS and 15 HC found no structural autonomic abnormality in subjects with CPP. This final report based on 130 subjects confirms the absence of autonomic cardiovascular abnormalities. Symptoms in the upright position (orthostatic intolerance) on tilt may suggest central sensitization. The increased frequency of autonomic neuropathy in almost a third of subjects with CPP needs further investigation. Funding Source: ICEPAC project funded by NIH-NIDDK R01DK083538 PP 703 THE RELATIONSHIP BETWEEN PELVIC VEIN INCOMPETENCE AND CHRONIC PELVIC PAIN IN WOMEN: AN EVIDENCE SYNTHESIS R. CHAMPANERIA1, L. SHAH 1, J. MOSS 2, J. GUPTA 1, J. BIRCH 3, L. MIDDELTON 1, J. DANIELS 1; 1Univ. of

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Birmingham, Birmingham, United Kingdom, 2North Glasgow Univ. Hosptials, Glasgow, United Kingdom, 3Pelvic Pain Support Network, Birmingham, United Kingdom. Introduction: Pelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence (PVI) and CPP is not established. Non-invasive screening methods such as Doppler ultrasound and magnetic resonance (MR) venography are used before confirmation by venography. Percutaneous embolisation has become the principal treatment for PCS, with high success rates often cited. Objective: Our proposal aimed to systematically and critically review the definitions and diagnostic criteria of PCS; the association between PVI and CPP; the accuracy of various non-invasive imagining techniques; the effectiveness of embolisation for PVI and to identify factors associated with successful outcome. We also wished to survey clinicians and patients to assess awareness and management of PCS and gauge the enthusiasm for further research. Methods: A comprehensive search strategy encompassing various terms for pelvic congestion, pain, imaging techniques and embolisation was deployed in 17 bibliographic databases. There was no restriction on study design. Methodological quality was assessed using appropriate tools. Online surveys were sent to clinicians and patients. The quality and heterogeneity generally precluded meta-analysis and so results were tabulated and described narratively. Results: We identified six association studies, ten studies involving ultrasound and two of magnetic resonance venography, and 21 case series and one poor quality randomised trial of embolisation. There were no consistent diagnostic criteria for PCS. We found the associations between CPP and PVI were generally fairly similar, with three of five studies with sufficient data showing statistically significant associations (odds ratios of between 31 and 117). The prevalence of PVI ranged widely, although the majority of women with PVI had CPP. Transvaginal ultrasound with Doppler and magnetic resonance venography are both useful screening methods, although the data on accuracy is limited. Early substantial relief from pain symptoms was observed in approximately 75 % of women undergoing embolisation, which generally increased over time and was sustained. Re-intervention rates were generally low. Transient pain was a common occurrence following foam embolisation, whilst there was a <2 % risk of coil migration. Confidence in the embolisation is reasonably high, although there is a desire to strengthen the evidence base. Even amongst women with CPP, less than half had any knowledge about PCS.

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Conclusions: The quality of data supporting the diagnosis and treatment of PCS is limited and of variable methodological quality. There is some evidence to tentatively support a causative association, but it cannot be categorically stated that PVI is the cause of CPP in women with no other pathology. Embolisation appears to provide symptomatic relief in the majority of women and is safe. There is scope and demand for considerable further research. The question of the association of PVI and CPP requires a well-designed and powered casecontrolled study, which will also provide data to derive a diagnostic standard. An adequately powered randomised trial is essential to provide evidence on the effectiveness of embolisation, but faces methodological challenges. Disclosure Block: Prospero CRD42012002237 and CRD42012002238 Funding Details NIHR Health Technology Assessment programme (project number 11/29/01) PP 704 SOMATIC AND PSYCHOSOCIAL DETERMINANTS OF SYMPTOM SEVERITY AND QUALITY OF LIFE IN PATIENTS WITH CHRONIC PELVIC PAIN SYND ROME K. LAU1, G. KETELS 2, B. LOWE 2, C. BRUNAHL 2, B. RIEGEL Department of Psychosomatic Medicine and Psychotherapy, Unversity Med. Ctr., Hamburg, Germany, 2Unversity Med. Ctr., Hamburg, Germany. Introduction: The burden of disease in patients with chronic pelvic pain syndrome (CPPS) is high as symptoms are persistent or recurrent resulting in a strong impairment of quality of life. Although research has increasingly focused on the importance of psychosocial aspects, how psychosocial and somatic factors combine and affect CPPS symptom severity and both physical and mental quality of life (QoL) is still unclear. The present study aims to examine the association between somatic and psychosocial factors and CPPS symptom severity and physical and mental QoL in male and female patients with CPPS. Methods: We examined 121 patients (58.6 % female) aged 19 to 84 years attending an interdisciplinary outpatient clinic for patients with CPPS in Hamburg, Germany. Using self-report measures, we assessed CPPS symptom severity (NIH-Chronic Prostatitis Symptom Index; CPSI), physical and mental QoL (Short form-12 physical and mental; SF-12-PCS and SF-12MCS) as well as symptoms of depression and anxiety, pain catastrophizing cognitions, social support and medication

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intake. A physiotherapy examination according to the WiseAnderson protocol was conducted in 85 patients to evaluate the presence of trigger and tender points. A four stage hierarchical multiple regression analyses was calculated with CPPS symptom severity being the dependent variable. Corresponding analyses were conducted using physical and mental QoL as outcomes. Results: Analyses revealed that introducing trigger and tender points as well as psychosocial factors to the model contributed significantly to CPPS symptom severity and accounted for 15.7 % and 36.4 % of the variation in CPPS symptom severity, respectively. When all predictors were included simultaneously, increasing age, increasing number of trigger points, low perception of social support and higher extent of pain catastrophizing cognitions were significantly associated with increased CPPS symptom severity. Corresponding analyses revealed a differential pattern of factors predicting physical and mental QoL. Conclusions: Results from the present study indicate that both somatic and psychosocial aspects play an important role in CPPS symptom severity and both physical and mental quality of life. Given the wide range of contributing factors, interdisciplinary treatment encompassing psychotherapeutic and physiotherapeutic elements should be considered. Present data suggest that focusing on the reduction of pain catastrophizing cognitions, strengthening social support and a reduction of trigger and tender points are possible elements of importance. OP 705 ENDOMETRIOSIS AND PELVIC SENSITIZATION. INFLUENCE OF THE DURATION OF THE DISEASE S. PLOTEAU1, A. DE PITRAY 2, A. LEVESQUE 2, J. LABAT Ctr. Federatif de Pelvi-Perineologie; Service de Gynecologie et Obestetrique, Nantes, France, 2Ctr. Federatif de PelviPerineologie, Nantes, France. Introduction: Clinical expression of endometriosis is various, without obvious anatomical correlation. Some clinical signs cannot be the direct reflection of the lesion and can evoke phenomenons of pelvic sensitization. The objective of this study is to compare the importance of these signs to the duration of the disease, on the occasion of the surgical management of painful endometriosis. Methods: Surgery was performed on 56 patients with endometriosis stade 3 and 4 during a period of 9 months (September 2013 - June 2014). Before surgery, all patients

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were evaluated clinically using factors which can evoke pelvic sensitization. The criteria used were defined by an opinion consensus of a group of experts using the Delphi method (criteria of Convergences PP 2012). The criteria are : 1. Urinary functional disorder : pollakiuria, dysuria 2. Digestive functional disorder : diarrhea, constipation, dyschesia 3. Urinary sensitization : pain with bladder filling, relieved with urination / urethral pain during urination or persistant after urination 4. Bowel sensitization : pain relieved by defecation or wind elimination 5. Pain during or after sexual intercourse 6. Intolerance with tight clothes (allodynia) 7. Myofascial pain on the abdominal wall, deep glutal muscles, or during vaginal/rectal examination 8. Pain during bone digital pressure of the pelvis (pubis, inferior branch of the pubis, coccyx)Pain during vulvar contact (vulvodynia) or testicular pressure 9. Presence or history of other functional pains : fibromyalgia, tension type headache, dysmenorrhea, irritable bowel syndrome, complex regional pain syndrome, temporomandibular dysfunction⋯ We compared the rate of these signs in 2 populations : patients with history of pain for less than 10 years (group A, 21 patients) and patients with history of pain for more than 10 years (group B, 35 patients). Results: 33 % of the patients of group A have got some signs in favour of pelvic sensitization (at least 4 criteria), for 85 % in group B (p=000,007). Excluding the signs that could be attributed directly in relation to endometriosic lesions (digestive disorders (2), bladder pains(3), bowel pain(4)and pain during sexual intercourse(5 and 9), we found : – – – – –

Urinary functional disorder (criteria 1) : A=14 %, B= 47 % (p<0004) Cutaneous allodynia (criteria 6) : A =14 %, B =17 % NS Myofascial pain (criteria 7) : A=28 %, B=87 % (p<000, 003) Hypersensibility during bone digital pressure on the pelvis (criteria 8) : A=0 %, B=10 % (p<0016) Other functional pains : A=14 %, B=100 % (p<10E-9) Conclusions: There is a correlation between the duration of the pain in relation to endometriosis and presence of signs in favour of pelvic sensitization.

References: Bajaj P, Bajaj P, Madsen H, Arendt-Nielsen L. Endometriosis is associated with central sensitization: a psychophysical controlled study. J Pain. 2003 Sep;4(7):372– 80.

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Giamberardino MA, Berkley KJ, Affaitati G, Lerza R, Centurione L, Lapenna D,Vecchiet L. Influence of endometriosis on pain behaviors and muscle hyperalgesia induced by a ureteral calculosis in female rats. Pain.2002 Feb;95(3):247– 57. Giamberardino MA, Costantini R, Affaitati G, Fabrizio A, Lapenna D, Tafuri E, Mezzetti A. Viscero-visceral hyperalgesia:characterization in different clinical models. Pain. 2010 Nov;151(2):307–22. OP 706 AMBULATORY DYSCONTINUOUS PERIPHERAL PUDENDAL NERVE BLOCK BY A PERINEURAL CATHETER CONNECTED TO A SUPRA-PUBIC PORTACATH FOR INTRACTABLE PUDENDAL NEURALGIA E. BAUTRANT; Private Med. Ctr., Provence, France. Introduction: AIMS OF STUDY : To describe the technique of placing a perineural pudendal catheter to block the nerve when needed in patients with Pudendal pain neuralgia resistant to all the treatments. To evaluate the efficacy of dyscontinuous peripheral pudendal nerve block to treat the pain. Methods: This technique is only indicated in Pudendal neuralgia due to neuropathies, caused by a trauma or by a severe entrapment, after the failure of the decompression surgery, in cases of severe and complex pelvic pain syndrome or patients with pelvic hipersensibility who had positive block-test. The patient must have experienced the failure of all the medical treatments. The pain must have neuropathic components and checked in the territory of the pudendal nerve after evauation from an experienced team. The patients underwent the catheter tip placement under general anesthesia. A surgical Trans-ischirectal approach under endoscopic control was performed, giving perfect access to the sacroespinous ligament and the falciform process of the Alcok’s canal. The catheter was introduced in the Alcock’s canal and than tunelized by the subcutaneaus tissue through the pubis. It was connected to a portacath placed beneth the skin over the pubis. The port has a septum throught which drugs can be injected by a nurse, or better, by the patient himself. At the beginning of the treatment we injected 2 mg/mL of ROPIVACAINE every 48 h and then the patient decided when he needed the medication according to the VAS. Results: The perineural catheter was placed in 21 patients over a period of 6 years from January 2009 and February 2015. Patients were evaluated by a team of medical

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practitioners of a large pelvic and perineal pain expertise. We evaluated the patients pain level (VAS) before and after the placement of the catheter. 18 patients undergone a unilateral surgery and 4 had it bilaterally. 18 patients came back to the postoperative visit. 6 (33 %) patients had no improvement of their level of pain and the catheter vas removed. 2 (11 %) patients experienced a reduction of their VAS and 10 (55 %) patients reported less than 2 at VAS. The undesired outcomes were infection of the portacath (1, 5 %), mouvement of the catheter out of the Alcock’s canal that needed surgery to be repositioned (2, 10 %) and pain at the portacath (1, 5 %)

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Conclusions: Ambulatory continuous peripheral pudenal nerve block with local anesthesic seems to be an interesting option to treat patients with Pudendal neuralgia resistant to all the treatments. Inclusive criteria for the patients undergoing this surgery must be very selective due to few undesired outcomes. It is, still, an experimental procedure but, taking into account our results, more than 50 % of the patients experienced a major decrease of their level of pain, it is not a negligible option when all the other treatments have already failed. References: Dadure, C., Motais, F., Ricard, C., Raux, O., Troncin, R., & Capdevila, X. (2005). Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome I in children. Anesthesiology-Hagerstown, 102(2), 387–391. Ilfeld, B. M., & Enneking, F. K. (2005). Continuous peripheral nerve blocks at home: a review. Anesthesia & Analgesia, 100(6), 1822–1833. Mollo, M., Bautrant, E., Rossi-Seignert, A. K., Collet, S., Boyer, R., & Thiers-Bautrant, D. (2009). Evaluation of diagnostic accuracy of Colour Duplex Scanning, compared to electroneuromyography, diagnostic score and surgical outcomes, in Pudendal Neuralgia by entrapment: A prospective study on 96 patients. Pain, 142(1), 159–163.

Introduction: Partner behavioral responses to pain can have a significant impact on patient pain and depression, but little is known about why partners respond in specific ways. Using a cognitive-behavioral model, the present study examined whether partner cognitions were associated with partner behavioral responses, which prior work has found to predict patient pain and depressive symptoms. Methods: Participants were 354 women with PVD and their partners. Partner pain-related cognitions were assessed using the partner versions of the Pain Catastrophizing Scale and Extended Attributional Style Questionnaire, while their behavioral responses to pain were assessed with the Multidimensional Pain Inventory. Patient pain was measured using a numeric rating scale and depressive symptoms were assessed using the Beck Depression Inventory-II. Path analysis was used to examine the proposed model.

PARTNER BEHAVIORAL RESPONSES TO PAIN MEDIATE THE RELATIONSHIP BETWEEN PART NER PAIN COGNITIONS AND PAIN OUTCOMES IN WOMEN WITH PROVOKED VESTIBULODYNIA. S. DAVIS1, S. BERGERON 2, G. SADIKAI 3, S. CORSINIMUNT 2, M. STEBEN Univ. of Toronto; Univ. de Montreal, Toronto, Canada, 2Univ. de Montreal, Montreal, Canada, 3McGill Unversity, Montreal, Canada.

Results: The effect of partner cognitions on patient outcomes was partially mediated by partner behavioural responses. Partner catastrophizing and negative attributions were associated with negative partner responses, which were associated with higher patient pain. It was also found that partner pain catastrophizing was associated with solicitous partner responses, which in turn were associated with higher patient pain and depressive symptoms. Conclusions: Findings highlight the importance of assessing partner cognitions, both in research and as a target for intervention.