Program Schedule

2016 IPPS Annual Fall Meeting On Chronic Pelvic Pain

October 12 - 16, 2016
Program Chair: Amy Stein, DPT, BCB-PMD, IF
All Sessions will be located in the Zurich Ballroom DEFG Unless otherwise noted
Speaker & times are subject to change.

DateTimeSession
OVERVIEW  
12
Wed
4:00 p.m.-6:00 p.m.
Registration/Information Desk Open
Location: Zurich Registration Area
OVERVIEW  
13
Thu
7:00 a.m.-5:00 p.m.
Registration/Information Desk Open
Location: Zurich Registration Area
13
Thu
7:00 a.m.-8:00 a.m.
Continental Breakfast
Location: Zurich Ballroom ABC
13
Thu
10:00 a.m.-6:30 p.m.
Exhibit Hall Open
GENERAL SESSION  
13
Thu
7:30 a.m. - 5:00 p.m.
Basics Session
Location: Zurich Ballroom DEFG
13
Thu
7:30 a.m. - 7:40 a.m.
Program Introduction
Session Chairs:
Kathryn Witzeman, MD
Denver Health

M. Jean Uy-Kroh, MD
Cleveland Clinic
13
Thu
7:40 a.m. - 8:30 a.m.
Neurophysiology of Chronic Pain: Learning from the past and looking to the future
Speaker:
Janelle Moulder, MD, MSCR
UNC Hospitals
13
Thu
8:30 a.m. - 10:00 a.m.
Cluster: Overlapping Pain Conditions (GYN,Uro,GI)
13
Thu
8:30 a.m. - 8:55 a.m.
GYN: Overlapping Pain Conditions
Speaker:
Nita Desai, MD, MBA
Dignity Health
13
Thu
8:55 a.m. - 9:20 a.m.
GI: Functional GI Disorders and Their Overlap with Pelvic Pain Syndromes
Speaker:
J. Christie Heller, MD
Denver Health and Hospital
13
Thu
9:20 a.m. - 9:45 a.m.
Uro: Chronic Pelvic Pain Related to the Lower Urinary Tract System: Evidence-Based Diagnosis and Treatment
Speaker:
Tyler Muffly, MD
13
Thu
9:45 a.m. - 10:00 a.m.
Q&A
13
Thu
10:00 a.m. - 10:15 a.m.
Break
13
Thu
10:15 a.m. - 10:45 a.m.
Neurophysiology and Overlapping Conditions - Panel Case Discussions
13
Thu
10:45 a.m. - 11:30 a.m.
Neuromusculoskeletal Foundations: Function and Exam - Regional considerations for Pelvic Pain Patients
Speakers:
Rhonda K. Kotarinos, DPT, MS
Kotarinos Physical Therapy

Sheila Dugan, MD
Rush University Medical Center
13
Thu
11:30 a.m. - 12:15 p.m.
Physiotherapy and Physical Medicine: Treatment Approaches - Biomedial and Adjunctive Treatment Approaches
Speakers:
Rhonda K. Kotarinos, DPT, MS
Kotarinos Physical Therapy

Sheila Dugan, MD
Rush University Medical Center
13
Thu
12:15 p.m. - 1:15 p.m.
Lunch On Own
13
Thu
1:15 p.m. - 1:45 p.m.
Pelvic Pain in Men
Speaker:
Nel Elisabeth Gerig, MD
The Pelvic Solutions Center
13
Thu
1:45 p.m. - 2:15 p.m.
Vulvodynia Update
Speaker:
Jennifer Hyer, MD
Denver Health
13
Thu
2:15 p.m. - 2:45 p.m.
A Biopsychosocial View of Chronic Pelvic Pain
Speaker:
Caryn Feldman, Ph.D.
Rehabilitation Institute of Chicago
13
Thu
2:45 p.m. - 3:15 p.m.
Pain Pharmacology 101: Pearls for Practice
Speaker:
Janelle Moulder, MD, MSCR
UNC Hospitals
13
Thu
3:15 p.m. - 3:30 p.m.
Break
13
Thu
3:30 p.m. - 4:00 p.m.
Breakout Groups - Case Discussions
13
Thu
4:00 p.m. - 4:30 p.m.
Group Presentations
13
Thu
4:30 p.m. - 5:00 p.m.
Q&A Session
Speakers:
Kathryn Witzeman, MD
Denver Health

M. Jean Uy-Kroh, MD
Cleveland Clinic

Nita Desai, MD, MBA
Dignity Health

Sheila Dugan, MD
Rush University Medical Center

Caryn Feldman, Ph.D.
Rehabilitation Institute of Chicago

Nel Elisabeth Gerig, MD
The Pelvic Solutions Center

J. Christie Heller, MD
Denver Health and Hospital

Jennifer Hyer, MD
Denver Health

Rhonda K. Kotarinos, DPT, MS
Kotarinos Physical Therapy

Tyler Muffly, MD
13
Thu
12:30 p.m. - 5:30 p.m.
Research Session
13
Thu
12:30 p.m. - 12:35 p.m.
Welcome and Announcements
Session Chair:
Georgine Lamvu, MD, MPH, FACOG
Orlando VA Medical Center
13
Thu
12:35 p.m. - 1:00 p.m.
Reserach Methodology: Study Design
Speaker:
Georgine Lamvu, MD, MPH, FACOG
Orlando VA Medical Center
13
Thu
1:00 p.m. - 1:35 p.m.
Avoiding Bias - Research Methodology for Health Care Providers
Speaker:
Georgine Lamvu, MD, MPH, FACOG
Orlando VA Medical Center
13
Thu
1:35 p.m. - 2:00 p.m.
How to Conduct a Research Project - Regulatory Requirements (Planning, IRB, etc.)
Speaker:
Kenneth Barron, MD
University of Virginia Advanced & Minimally Invasive Gynecologic Surgery
13
Thu
2:00 p.m. - 2:10 p.m.
Q&A, Break
13
Thu
2:15 p.m. - 2:50 p.m.
How to Conduct a Research Project - Databases, Data Collection and Analysis I
Speaker:
Kenneth Barron, MD
University of Virginia Advanced & Minimally Invasive Gynecologic Surgery
13
Thu
2:50 p.m. - 3:20 p.m.
How to Conduct a Research Project - Analysis II
Speaker:
Kenneth Barron, MD
University of Virginia Advanced & Minimally Invasive Gynecologic Surgery
13
Thu
3:20 p.m. - 3:30 p.m.
Q&A, Break
13
Thu
3:30 p.m. - 4:00 p.m.
How to Design a Survey for Research and for Fun
Speaker:
Insiyyah Patanwala, MD
Advanced Minimally Invasive Surgery and Gynecology
13
Thu
4:00 p.m. - 4:40 p.m.
Systematic Reviews and Meta-analysis
Speaker:
Emily Blanton, MD
Florida Hospital
13
Thu
4:40 p.m. - 5:05 p.m.
Reviewing the Literature, Reference Managers
Speaker:
Emily Blanton, MD
Florida Hospital
13
Thu
5:05 p.m. - 5:30 p.m.
Understanding the Literature and Getting Published
Speaker:
Latha Ganti, MD
University of Central Florida
13
Thu
5:30 p.m. -
Closing Remarks, Adjourn
13
Thu
5:30 p.m. - 6:30 p.m.
Welcome Reception
Location: Zurich Ballroom ABC
13
Thu
6:30 p.m. - 9:30 p.m.
IPPS Board of Directors' Meeting
Location: Room: SECL (40th Floor)
OVERVIEW  
14
Fri
7:00 a.m.-8:00 a.m.
Continental Breakfast
Location: Zurich Ballroom ABC
14
Fri
7:00 a.m.-4:00 p.m.
Exhibit Hall Open
14
Fri
7:00 a.m.-5:30 p.m.
Registration/Information Desk Open
Location: Zurich Registration Area
GENERAL SESSION  
14
Fri
7:50 a.m. - 7:55 a.m.
Welcome and Announcements
14
Fri
7:55 a.m. - 8:00 a.m.
Presidential Address
President:
Juan Diego Villegas Echeverri, MD
Clinica Comfamiliar
14
Fri
8:00 a.m. - 8:50 a.m.
C. PAUL PERRY MEMORIAL LECTURE "Clinical Approach to Male CPPS"
Speaker:
J. Curtis Nickel, MD, FRCSC
Queens University, Kingston General Hospital
14
Fri
8:50 a.m. - 9:30 a.m.
Cognitive or Top-Down Control of Autonomic Function: The "mind-body" Connection
Speaker:
Peter L Strick, PhD
University of Pittsburgh
14
Fri
9:30 a.m. - 9:50 a.m.
Q&A
14
Fri
9:50 a.m. - 10:15 a.m.
*Break & Poster Viewing Session
Location: Zurich Ballroom ABC
14
Fri
Poster #1
COMPARISON OF DISORDERS CO-MORBID WITH DIFFERENT TYPES OF CHRONIC PELVIC PAIN
Gisela Chelimsky¹, Sheng Yang², Curtis Tatsuoka², N. Patrick McCabe², Sarah Ialacci², C. A. Tony Buffington³, Jeffrey Janata² and Thomas Chelimsky¹
¹Medical College of Wisconsin; ²Case Western Reserve University; ³The Ohio State University
Presented By: Thomas Chelimsky

Objectives: A variety of chronic medical conditions commonly accompany chronic pelvic pain (CPP) in women. We compared the chronologic sequence of onset and frequency of some of these comorbid conditions in subjects with interstitial cystitis/bladder pain syndrome (IC/BPS), myofascial pelvic pain (MPP), or with both diagnoses (IC+MPP).

Methods: We used a semi-scripted interview by a physician or trained nurse practitioner based on published diagnostic criteria to identify the presence and order of onset of selected comorbid conditions in 9 women with MPP, 32 with IC/BPS, 36 with IC+MPP, 5 family members of probands, and 30 healthy controls.

Results: Co-morbid disorder frequencies were 0.6±1.0, healthy subjects, 4.6 ± 3.9 IC/BPS alone, 6.7 ± 3.3 MPP alone, and 7.4 ± 1.4 for IC+MPP (p<0.003 vs IC/BPS alone, p<0.006 vs either CPP alone). In addition, subjects with IC+MPP had increased (p<0.05) frequencies of chronic fatigue syndrome, fibromyalgia, dysmenorrhea, dyspepsia and panic disorder compared to those with a single CPP disorder. CPP was usually preceded chronologically by post-traumatic stress disorder (PTSD - generally earliest), anxiety, depression, migraine headache, fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome.

Conclusion: Comorbidities are common in patients with IC/BPS, MPP, and IC+MPP, with relatively higher burden when both pelvic pain disorders are present together. Migraine headache, fibromyalgia, chronic fatigue syndrome and irritable bowel syndrome usually develop before CPP. PTSD not only antecedes CPP but most other conditions as well, consistent with the notion that internalized stress plays a predisposing role in CPP. Some differences in co-morbid conditions were identified based on the specific CPP diagnosis.

Acknowledgment: Funded in part by NIH R01 DK083538 and by Advancing a Healthier Wisconsin (AHW) Fund (5520298).
14
Fri
Poster #2
TREATMENT SELECTION AND LONG-TERM OUTCOMES IN PATIENTS WITH VULVODYNIA: A REPORT FROM THE NATIONAL VULVODYNIA REGISTRY (NVR)
Georgine Lamvu¹ and Meryl Alappattu²
¹Orlando VA Medical Center; ²University of Florida
Presented By: Meryl Alappattu

Objective: The study presented here aims: 1) to describe the types of treatments that were selected to treat vulvodynia in women enrolled in the NVR; and 2) to describe 6- month outcomes related to self-reported pain, dyspareunia, and psychological distress for this sample.

Study Design: Prospective Cohort

Study Population: Women who were received care through the National Vulvodynia Registry from 2009-2014.

Methods: As part of the registry, women were treated according to the recommendation of their healthcare providers and these treatments were recorded over a period of 12 months. Approximately 900 women were screened and 344 women were consented and enrolled after screening positive on Harlowe’s questionnaire for assessing the presence of vaginal pain lasting longer than 3 months. Next participants underwent an extensive vaginal exam and clinical confirmation of vulvodynia. During the examination, composite pressure pain thresholds (PPT) was reported for the vestibule, and the pelvic floor muscles. Next participants completed a variety of self- report questionnaires related to demographic information and general and gynecological medical history. Self-reported pain intensity was measured using the short-form McGill Pain Questionnaire (SF-MPQ), and the Female Sexual Function Index (FSFI).
Results: After screening for eligibility, 344 women were enrolled into the NVR; 282 had at least one prescribed treatment recorded after initial examination and thus were included in this analysis. Eighty different types of treatments were identified and grouped into 9 categories (topical vaginal cream, pills, psychotherapy, injections physical therapy, vaginal dilators, surgery and experimental) and 28 sub-categories. Nearly 73% of women received more than one treatment at initial visit (38.7% two treatments, 26.6% three treatments, 6.4% four treatments, and 1.1% five or more treatments) and only 27% received one treatment. The most commonly prescribed therapies were topical creams, pills, physical therapy and psychotherapy and the most commonly used combination included creams, physical therapy and pills. At six months, all participants demonstrated statistically significant improvements in McGill pain sensory scores (p=0.001), McGill pain affective scores (p=0.005), catastrophizing (p=0.000), anxiety (p=0.000), and Beck Depression Inventory scores (p=0.000). Although women reported improvements in their intercourse related pain (p=0.000), their total sexual function scores were worse at 6 months (p=0.000).
Conclusion: Healthcare providers are using a variety of therapies to treat vulvodynia, however, in the majority of cases providers are using multi-modal therapy incorporating two or more treatments and the combinations of treatments vary widely among geographic areas. In general, after 6 months of therapy, women demonstrate improvements in pain, and distress, but not in sexual function.
14
Fri
Poster #4
INJURY TO THE PERINEAL BRANCH OF THE PUDENDAL NERVE IN WOMEN: OUTCOMES FROM SURGICAL RESECTION OF THE PERINEAL BRANCHES AND IMPLANTATION OF PROXIMAL END INTO THE OBTURATOR INTERNUS MUSCLE
Eric L. Wan¹, Hillary Tolson², Andrew T. Goldstein¹ and A Lee Dellon¹
¹Johns Hopkins University; ²Center for Vulvovaginal Disease, Annapolis
Presented By: A Lee Dellon

Objective:

The traditional transgluteal approach for the surgical treatment of “pudendal neuralgia” has been disappointing for those patients with “anterior” pudendal nerve symptoms, such a pain in the labia, vestibule, and perineum. In this study, we describe outcomes from a new surgical approach to resect the perineal branches of the pudendal nerve (PBPN).

Methods:

An IRB-approved prospective study enrolled 16 consecutive female patients from 2012 through 2015 who did not have rectal symptoms. Each woman had a successful, diagnostic, pudendal nerve block. The surgical procedure was resection of the PBPN and implantation of the nerve into the obturator internus muscle through a para-labial incision. Mean age at surgery was 49.5 years (SD = 11.6 years). Mechanism of injury was episiotomy in 31%, athletic injury in 25%, vestibulectomy in 31%, and falls in 13%. Four women (25%) had urethral symptoms. Outcomes were the Female Sexual Function Index (FSFI), the Vulvar Pain Functional Questionnaire (VQ), and the Numeric Pain Rating Scale (NPRS). 14 patients completed these questionnaires, reporting on their condition before surgery and currently.

Results:

The mean post-operative length of follow-up was 15 months (range: 6 to 43 months). Post-operative significant bruising was the only complication, occurring in 10% of the patients. The overall FSFI significantly improved after surgery (p < 0.05). The specific domains that showed significant improvement were those for arousal, lubrication, orgasm, satisfaction, and pain (p < 0.05). The VQ also significantly improved after surgery (p < 0.001) in 13 of 14 (93%) patients. The NPRS score decreased, on average, from an 8 to a 3 out of 10 (p < 0.0001). Each of the 4 women with urethral symptoms had relief of these symptoms post-operatively.

Conclusions:

Resection of the perineal branch of the pudendal nerve with implantation of the nerve into the obturator internus muscle significantly improved the sexual function, vulvar function, and pain of women who sustained injury to the perineal branches of the pudendal nerve.

Summary:

This prospective study utilized the Female Sexual Function Index, the Vulvar Questionnaire, and the Numerical Pain Rating Scale to evaluate outcomes of treating labial, vestibular and vaginal pain related to injury to the perineal branches of the pudendal nerve. These branches were resected and implanted into the obturator internus muscle. The results demonstrated that this new, anterior, surgical approach, to this portion of the pudendal nerve, is significantly effective in relieving pain and improving pelvic function
14
Fri
Poster #5
CATECHOL-O-METHYLTRANSFERASE GENE POLYMORPHISM AND VULVAR PAIN IN WOMEN WITH VULVODYNIA ENROLLED IN THE NATIONAL VULVODYNIA REGISTRY
Insiyyah Patanwala¹ and Georgine Lamvu²
¹Department of Obstetrics and Gynecology, Florida Hospital, Orlando; ²Gynecologic Surgery and Pelvic Pain Specialist, Orlando VA Medical Center
Presented By: Insiyyah Patanwala

Background: The underlying causes of vulvar pain in women with vulvodynia remain poorly understood. Catechol-O-methyltransferase (COMT), an enzyme that degrades dopamine, epinephrine and norepinephrine, which are neurotransmitters that have been demonstrated to modulate the degree of pain sensitivity. The more extensive is their degradation, the lower is the perception of pain. The val158 met polymorphism results in functional differences in COMT enzyme activity. The highest COMT enzymatic activity occurs when the H,H homozygous genotype is transcribed; intermediate activity is associated with the H,L heterozygous genotype while L,L homozygosity results in the lowest COMT enzyme activity.

Objective: To assess whether a variation in the COMT genotype is involved in increased pain sensitivity in women with vulvodynia.
Study Design: Prospective cohort study

Methods: Buccal swabs were collected from 167 Caucasian women with vulvodynia and 107 control women and their DNA was tested for a SNP at position 158 (rs4680) in the COMT gene.

Results: Overall, women with vulvodynia had a marginally increased, yet not significant, prevalence of the COMT genotype associated with high activity of the coded protein (P = 0.0543). However, stratifying the cases based on pain frequency revealed that the elevated occurrence of this COMT genotype (P = 0.0090) was uniquely present in the subset of women who experienced pain only with sexual intercourse. Also, women with primary vulvodynia had a higher prevalence of the H allele than did the controls (P = 0.0387).

Conclusion/Summary: In this investigation we show that the subgroup of women with a diagnosis of vulvodynia who have pain only with sexual intercourse have a higher prevalence of the COMT H,H genotype as well as a higher frequency of the H allele as compared to control women. Thus, maximal COMT enzyme activity occurs at a higher prevalence in this vulvodynia subgroup than in women whose vulvodynia is characterized by pain that is unprovoked and occurs every day or in unaffected women.
14
Fri
Poster #6
SPINAL CORD STIMULATION: THE FORGOTTEN THERAPY FOR PELVIC PAIN?
Sara Freitas, Micaela Costa, João Silva and Teresa Fontainhas
Presented By: Sara Freitas

INTRODUCTION: Chronic pelvic pain syndrome (CPPS) is defined by the European Association of Urology guidelines as a non-malignant pain perceived in structures related to the pelvis of either women or men for at least 6 months without proven infection or other obvious pathology. (1) CPPS affects 5.7-26.6% women worldwide, 55% have no obvious pathology and 40% have associated endometriosis. (3) We present the value of spinal cord stimulation (SCS) for chronic visceral pelvic pain in a female patient with the diagnosis of CPPS (history of endometriosis, multiple surgical explorations and hysterectomy).

CASE REPORT: 39-year-old female with a long history of endometriosis who originally presented with a lower, intense and constant abdominal pain involving the perineum with irradiation to the right lower limb, accompanied by burning, that worsened by movement and the end of the day. After a complete pain and psychiatry evaluation and a conventional therapeutic optimization, she was scheduled for neurostimulator implantation. A subcutaneous electrical voltage controlled neurostimulator was placed by epidural space with two electrodes: one implanted on posterior horn of the spinal cord to the T9 level (for the irradiated pain to the leg) and another retrograde to the cauda equina. After 3-month follow-up she reports a greatly improve, increased functional status without pain and that stimulation continues to cover the affected area. There were no complications described.

DISCUSSION: The treatment of CPPS remains a challenge despite several established first line therapies because many patients are therapy refractory. One reason that a definitive treatment for CPPS remains elusive is that its exact etiology remains unknown. (3)Although unclear, the pathophysiology of CPPS seems to parallel many common, centralized, neuropathic, and sympathetically driven pain models. (4) Patient engagement in a biopsychosocial approach is recommended with a treatment of any identifiable disease process such as endometriosis. Hysterectomy may be considered as a last resort if pain seems to be of uterine origin, although significant improvement occurs in only about one-half of cases. (1) Epidural spinal cord stimulation is a reversible but invasive procedure that may be proposed to the patients with neuropathic pain refractory to conventional management, in order to improve pain relief, functional capacity, and quality of life. A decisive factor is a careful patient selection as well as the diagnosis. In this case the most significant challenge is the correctly identification of SCS lead position, which provides adequate and appropriate coverage of the extense affected area. (4, 5)

CONCLUSION: Despite various alternatives proposed in the past, there has yet to be a true consensus on optimal lead positioning for the treatment of CPPS. The place of neurostimulation is too frequently used as a last resource, however it is a promising therapeutic alternative and should be considered more often in daily clinical practice. Epidural SCS should always be used within a interdisciplinary multimodal therapy concept and our center has been a very good results.
14
Fri
Poster #7
THE RELATIONSHIP BETWEEN FMRI EVENTS RESEMBLING SUSTAINED UTERINE CONTRACTIONS AND SPONTANEOUS MENSTRUAL CRAMPING PAIN REPORT
Caroline Kuhn¹, Frank Tu², Diana Zhou¹, Sangeeta Senapati² and Kevin Hellman¹
¹University of Chicago; ²NorthShore University HealthSystem
Presented By: Caroline Kuhn

Study Objective:
The mechanisms underlying menstrual pain are poorly understood and a method capable of identifying causes within individual participants could facilitate appropriate treatment planning. The study objective was to determine the feasibility of identifying the mechanisms underlying menstrual pain utilizing functional MR imaging.

Measurements & Main Results:
Fifteen participants with severe dysmenorrhea and 3 healthy controls presented for MRI during their menses, off any pain medication. We acquired functional MRI sequences during periods of self-reported cramping pain for those with dysmenorrhea and at random intervals for those without dysmenorrhea. Comparison imaging was performed at post-menses visits. Most women who experienced cramping pain while scanning had symmetrical and progressive decreases in T2-weighted MRI signal in the myometrium, greater than 10% and lasting longer than 16 seconds. These signal changes resembled episodes known as “sustained uterine contractions” by prior studies. These myometrial events were scored and consistent results were obtained between two blinded raters (r=0.97, p<0.001). Episodes of cramping occurred either immediately before or significantly after event onset suggesting an indirect relationship between uterine events and cramping pain. Women who did not have myometrial events on their menses either had a history of endometriosis or were not in pain. When dysmenorrhea participants returned during a non-menses visit, transient decreases in signal were not observed except in one subject reporting “bowel” pain.

Conclusion:
Myometrial events with transient decreases in uterine T2 can be reliably measured in women with menstrual pain. The directionality of signal change and delayed relationship to pain onset suggest that these events are not “uterine contractions.” Instead these events likely represent a consequence of uterine contractions such as ischemic episodes that contribute to menstrual pain via an indirect mechanism in most women with dysmenorrhea. Further research is warranted to specifically investigate mechanisms responsible for decreases in uterine T2 and determine if phenotypic subtyping can optimize subsequent treatment outcomes.

Summary:

This new technique to simultaneously evaluate MRI and spontaneous pain provides a method to identify components responsible for spontaneous pain and supports a causative role of vascular/metabolic dysfunction in menstrual pain.
14
Fri
Poster #8
MUSCULOSKELETAL FACTORS CO-EXIST WITH GYNAECOLOGICAL PATHOLOGIES IN WOMEN WITH CHRONIC PELVIC PAIN AND ARE AMENABLE TO SPECIALIST PHYSIOTHERAPY
Katie Gore¹, Alice Rodriguez¹, Lauren McLeod¹, Jane Moore¹,² and Katy Vincent¹,²
¹Oxford University Foundation Hospitals NHS Trust; ²Nuffield Department of Obstetrics and Gynaecology, University of Oxford
Presented By: Katie Gore

Background:
Chronic pelvic pain (CPP) is frequently associated with musculoskeletal dysfunction and psychological distress. Recommended treatment of CPP acknowledges these associations and thus management is multi-disciplinary, targeting all identified pain generating or maintaining factors. If CPP is associated with gynaecological pathology, such as endometriosis, however, standard management targets the pathology and referral to a CPP service may only occur after a number of years of unsuccessful treatment. We hypothesised that musculoskeletal dysfunction will coexist with underlying pathology and that treatment of this dysfunction will improve pain symptoms for these women.

Objectives:
1. To determine rates of musculoskeletal dysfunction in women attending a tertiary CPP service, categorised by underlying diagnosis.
2. To assess whether underlying diagnosis impacts on response to specialist physiotherapy.

Methods:
Data were collected on the first 100 women seen in a tertiary CPP service in 2016. Underlying diagnosis, presence of a musculoskeletal component and response to physiotherapy were assessed. Self-reported response to physiotherapy was assessed on a 0-100 visual analogue improvement scale.

Results:
97 of the women met the diagnostic criteria for CPP (pain perceived in the pelvis lasting for >6 months). 69 (71%) of these women were considered likely to have a musculoskeletal component to their pain by the assessing clinician, which was confirmed by a senior specialist women’s health physiotherapist. 28 (29%) women had a previous diagnosis of endometriosis. Other underlying/past diagnoses included adenomyosis, ovarian cysts, previous malignancy, adhesions, pelvic inflammatory disease, post-surgery and arthritis. 19 women (20%) had one or more of these diagnoses.
18 (64%) of women with a diagnosis of endometriosis also had a musculoskeletal component to their pain. 16 (84%) of those with other previous diagnoses had a musculoskeletal component.
Of the 69 women referred to physiotherapy, follow-up data is complete for 23 women (33%) to date. 8 women have not attended for follow up, whilst the remainder are still undergoing treatment. Average improvement after physiotherapy was 88%. Those women with coexisting endometriosis reported improvement of 90%. Of the 5 women where only musculoskeletal factors could be identified mean improvement was 87%.

Conclusion:
In agreement with published literature we identified high rates of musculoskeletal dysfunction in women with CPP. Moreover we demonstrate that musculoskeletal dysfunction commonly coexists with other pathologies. Our preliminary data suggests that the presence of other pathologies does not reduce the benefit of specialist physiotherapy in women with CPP. In summary, our findings support the need for adequate assessment and treatment of musculoskeletal dysfunction in women with chronic pain whatever the underlying cause.
14
Fri
Poster #9
EYE MOVEMENT DESENSITIZATION RE-PROCESSING AS TREATMENT FOR CHRONIC PELVIC PAIN
Karen Wiercinski and Scott Bush
Florida Hospital Celebration Health
Presented By: Karen Wiercinski

Objectives. Chronic pelvic pain (CPP) presents a persistent and significant clinical challenge to healthcare providers due to its often unknown etiology and poor response to treatment. CPP often requires multidisciplinary care for appropriate management, which may include psychological intervention. Eye-movement-desensitization and re-processing (EMDR) therapy, utilized for the treatment of post-traumatic stress disorder, has recently been identified as an effective mode for the treatment of chronic pain psychologically linked to disturbing emotional events. To our knowledge, there are no studies of the effects of EMDR on pelvic pain. We, therefore, report our preliminary findings on the effectiveness of this type of therapy for chronic pelvic pain.

Methods. The patient population included females with chronic pelvic pain resulting from gynecological issues, including endometriosis and adhesions. Patients rated their pain using a numeric rating scale with intensity ranging from lowest level to highest level of pain (0 to 10). After assessment of baseline pain rating scores, each patient was seen by a psychotherapist who administered EMDR therapy for a minimum session of two hours. Following the therapy, pelvic pain was again rated. Pain scores were expressed as the mean ± SEM and a student t-test was used to assess statistical difference between the two measurement periods at a probability <0.05.

Results. Pain scores prior to the EMDR session averaged 6.92 ± 0.62, range = 4 to 10, median = 7.00. Post-therapy, all but one of patient experienced significant reduction in perceived pain. Mean pain intensity scores following therapy averaged 3.46 ± 0.67 with a range of 0 to 10 and a median score of 3.0. Pain intensity scores significantly (p=0.0002) differed between the examination periods.

Conclusion. The data show that 92% of patients experienced significant reduction of chronic pelvic pain, and some experienced total relief from pain, with EMDR therapy.

Summary. EMDR may be an effective alternative therapy for the treatment of chronic pelvic pain. Future investigations are needed to examine the effectiveness of the therapy with larger CPP patient populations and longer follow-up.
14
Fri
Poster #10
CHRONIC PELVIC PAIN: THE ROLE OF EXPLORATORY LAPAROSCOPY AS DIAGNOSTIC AND THERAPEUTIC TOOL
Géraldine Brichant, Marie Denef and Michelle Nisolle
Obstetrics and Gynecology Department of Liège University
Presented By: Géraldine Brichant

Objective:
To evaluate the ability to identify pathological lesions and the improvement of painful symptoms in patients with chronic pelvic pain and normal physical examination and imaging after exploratory laparoscopy
Background: Forty percent of exploratory laparoscopies are performed for chronic pelvic pain. However a final diagnosis is still unreported in 35% of the patients.
Study design:
The prospective study was designed in the tertiary referral center for endometriosis. 41 patients complaining of chronic pelvic pain and scheduled for exploratory laparoscopy were included. Pelvic pain intensity was assessed using the visual analogue pain scale (VAS) and at inclusion negative clinical and imaging assessments were required. During exploratory laparoscopy, the recognized lesions were reported and different surgical treatment options were performed depending on the location of the lesion.
Results:
In 98% of the cases, exploratory laparoscopy demonstrated the presence of pelvic anomalies that had not been diagnosed at the time of clinical and imaging examination. After surgery, a significant improvement of chronic pelvic pain has been demonstrated in 24 (59%) patients with VAS <5 post-operatively.
Conclusions:
Exploratory laparoscopy is reasonable in patients complaining chronic pelvic pain, allowing a final diagnosis in a high percentage of patients and a significant improvement in pain symptom in 59% of the cases.
14
Fri
Poster #11
WOUND INFILTRATION WITH EXTENDED-RELEASE VERSUS SHORT-ACTING BUPIVACAINE BEFORE LAPAROSCOPIC HYSTERECTOMY: A RANDOMIZED CONTROLLED TRIAL
Kenneth Barron¹, Georgine Lamvu²,³, R. Cole Schmidt4, Matthew Fisk, Emily Blanton5,³ and Insiyyah Patanwala5,³
¹Department of Obstetrics and Gynecology, University of Virginia School of Medicine; ²Division of Surgery, Gynecology Section, Orlando Veterans Affairs Medical Center; ³Department of Obstetrics and Gynecology, University of Central Florida College of Medicine; 4Florida International University Herbert Wertheim College of Medicine; 5Department of Obstetrics and Gynecology, Florida Hospital Graduate Medical Education, Florida Hospital Orlando
Presented By: Kenneth Barron

Study Objective: To evaluate if pre-incision infiltration with extended-release liposomal bupivacaine provides improved pain relief compared to 0.25% bupivacaine after laparoscopic or robotic-assisted hysterectomy.

Methods: In a double-masked randomized controlled trial, women scheduled to undergo multiport laparoscopic or robotic-assisted total hysterectomy for benign indications were randomized to receive pre-incision infiltration with undiluted liposomal bupivacaine or 0.25% bupivacaine. The primary outcome was pain intensity by numeric rating scale (0-10) using the Brief Pain Inventory (BPI) via telephone survey on postoperative day (POD) 1, 2, 3 and 14. A sample size of 28 per group (N=56) was planned to detect a 30% change in pain scores. Secondary outcomes were numeric pain scores in hospital, BPI pain interference scores, and total opioid use.

Results: From July 2015 through January 2016, 64 patients were randomized and 60 were analyzed for the primary outcome. There were no demographic differences between the two groups. For the primary outcome, we found a decrease in worst pain scores on POD2 (P=.03) and a decrease in worst (P=.01) and average (P=.02) pain scores on POD3 in the liposomal bupivacaine group. There were no differences in pain scores while in hospital, POD1 or POD14. There were no differences in BPI pain interference scores, opioid use, or reported adverse effects.

Conclusion: For laparoscopic and robotic-assisted multiport hysterectomies there is evidence of decreased postoperative pain with liposomal bupivacaine compared to 0.25% bupivacaine for port site analgesia on POD2 and POD3, but no difference in opioid use or measures of functioning. These findings indicate limited effectiveness of liposomal bupivacaine for laparoscopic hysterectomy.
14
Fri
Poster #12
ANOVULATION AND MENSTRUAL PAIN IN GIRLS WITH AND WITHOUT PRIMARY DYSMENORRHEA
Laura Seidman¹, Andrea Rapkin², Lonnie Zeltzer¹ and Laura Payne¹
¹UCLA Pediatric Pain and Palliative Care Program; ²UCLA Department of Obstetrics and Gynecology
Presented By: Laura Seidman

Objective: Painful menstruation without an identified anatomic cause, or primary dysmenorrhea (PD), is believed to be caused in large part by the overproduction of uterine prostaglandins. The decline in progesterone during the late-luteal phase of ovulatory cycles creates an environment more favorable for prostaglandin production, which has led to the belief that ovulation is necessary for the development of PD. The current study aimed to explore frequencies of anovulation in a sample of menstruating adolescents and young adults with and without PD, and to compare levels of pelvic pain during menstruation following both ovulatory (OV) and anovulatory (AO) cycles.
Methods: Participants in the PD group had self-reported menstrual pain ≥ 4/10 on a 0-10 (0=none, 10=worst pain possible) numeric rating scale (NRS); healthy participants’ self-reported pain was ≤ 3/10. Ninety-one participants (52 healthy, 39 with PD), ages 16-24 years, completed urinary LH surge ovulation predictor kits (OPKs) to determine cycle phase. Cycles were considered AO if the participant never received a positive OPK result prior to beginning menstruation. Participants were tracked for up to three AO cycles, and were grouped as AO if they experienced at least one AO cycle. A subset of this group was considered chronically AO if they experienced three AO cycles. Pain ratings (0-10 NRS) during menstruation following both OV and AO cycles were evaluated for AO participants in the PD group.
Results: One hundred and sixty-nine full menstrual cycles were tracked across the 91 participants. Age, BMI, and race were not significantly different between pain groups, however, the PD group had a higher proportion of Hispanic participants (Χ2=6.28, p<.05). There were no group differences in age, race, ethnicity, or BMI between the OV and AO groups. Healthy girls were significantly more likely to have had at least one AO cycle (46.2%) than were girls with PD (17.9%) (Χ2=7.89, p<.01). A greater percentage of healthy girls were chronically AO compared to those with PD (11.5% vs. 2.6%), however this result did not reach statistical significance (p=.12). Within the AO PD group, mean maximum pain rating during menstruation following AO cycles was not significantly different from ratings following OV cycles (3.8, SD=2.6 v. 5.2, SD=1.9, respectively), (t=-2.18, p=.081).
Conclusion: This study demonstrates that during this observation period, healthy control adolescents and young adult women show statistically significant increases in the frequency of AO cycles compared to age-matched girls with PD. Furthermore, these data show that girls with PD report menstrual pain following AO cycles, and that this pain does not differ significantly from pain they experience following OV cycles.
Summary: These data suggest a complex relationship between ovarian sex steroids and menstrual pain. Previous implications of ovulation as a necessary component for the development of menstrual pain are likely incomplete. Given the widespread prevalence and impact of PD, future research should continue to investigate the local uterine and other peripheral and central mechanisms that contribute to dysmenorrhea.
14
Fri
Poster #13
IN OFFICE TREATMENT OF CLITORODYNIA: LYSIS OF CLITORAL ADHESIONS TO ADJACENT SKIN FOLLOWING DORSAL NERVE BLOCK
Irwin Goldstein¹ and Sherita King²
¹Alvarado Hospital; ²San Diego Sexual Medicine
Presented By: Irwin Goldstein

Objective: Dyspareunia occurs in 24.7-36.8% of women. Clitorodynia is uncommon and confined to the glans clitoris, clitoral shaft and adjacent prepucial area. In a subgroup, vulvoscopy shows adhesions of adjacent skin to the glans with numerous keratin pearls and sebum emanating through adhesions concealing the glans corona. Persistent balanitis underneath appears to account for clitoral pain or persistent genital arousal disorder (PGAD).
Methods: Instead of dorsal slit surgery of the clitoral hood with lysis of clitoral adhesions under general anesthesia, we now perform an in-office procedure under local anesthesia with a dorsal nerve block for the management of clitorodynia secondary to clitoral adhesions. We reviewed 7 patients (mean age 37 years, range 18 – 62 years) who had adhesions from the clitoral hood to the glans, obscuring the corona of the glans clitoris. Vulvoscopy identified smegma underneath the adhesions.
Results: All 7 underwent in-office management of clitoral adhesions. A dorsal nerve block was performed with 5 mL of either of mixture lidocaine/bupivacaine or bupivacaine liposome injectable suspension. After adequate local anesthesia was achieved, a Jacobson hemostat forceps was used to bluntly lyse epithelial adhesions and remove underlying keratin pearls. This process was continued until the corona was visualized completely around the circumference of the glans clitoris. An additional 5mL of local anesthetic was injected around the prepuce and frenulum of the clitoris for post-operative pain control. The patient was instructed to tub soak the area twice a day and carefully retract the clitoral hood sufficiently to visualize the corona while in the bath to prevent re-adherence of the adjacent clitoral hood to the glans. Even after the initial healing period the corona should be observed by retracting the hood daily to prevent adhesions. None of the patients had recurrence of adhesions 6 months post procedure. 5/7 women had significant reduction of clitoral pain.
Conclusion: Clitorodynia can occur secondary to adjacent skin adhesions to the glans clitoris causing underlying unrecognized balanitis. Release of these adhesions can be achieved in-office under local anesthesia with preservation of the prepuce. The corona of the glans clitoris must be observed during physical examination of women with clitorodynia.
Summary: This closed compartment balanitis clitorodynia is an outpatient treatable form of chronic clitoral pain or trigger for women with PGAD.
14
Fri
Poster #14
ESTABLISHING GOLD-STANDARD DIAGNOSTIC CRITERIA FOR MUSCULOSKELETAL FACTORS IN CHRONIC PELVIC PAIN
Katie Gore¹ and Katy Vincent¹,²
¹Oxford University Foundation Hospitals NHS Trust; ²Nuffield Department of Obstetrics and Gynaecology, University of Oxford
Presented By: Katie Gore

Background:
Musculoskeletal dysfunction can be the primary cause of chronic pain or occur secondary to other pathologies and is a common finding in chronic pain. In the context of chronic pelvic pain (CPP), studies suggest that up to 75% of women presenting to a tertiary CPP service will have a musculoskeletal component to their pain. Although specific tests have been proposed to identify muscular components, a systematic review concluded that no gold-standard diagnostic tests exist for pelvic muscular problems. Thus the diagnosis is subjective. We believe that the lack of gold-standard diagnostic criteria for musculoskeletal factors in CPP hinders research in this field.

Objective:
To reach international consensus on gold-standard diagnostic criteria for identifying and excluding musculoskeletal components in women with CPP.

Methods:
A group of leading women’s health physiotherapists with an interest in CPP has been created with international representation. The process will be facilitated by two gynaecologists, however, all decisions regarding appropriate tests and their interpretation will be made only by physiotherapists. The Delphi method will be used to reach consensus. In brief, the steps of the process will be:
1.Each participant to provide a list of the tests they consider essential to either confirm or exclude a musculoskeletal component in a woman with CPP
2.Circulation of a list of all tests suggested plus any not mentioned that are identified from a systematic review of the literature: participants to rate the value of these tests by anonymous survey
3.Removal of any tests unanimously rated as of low value
4.Circulation of the results of this survey and the opportunity to re-rate the tests
5.Re-iteration of steps 3 and 4 until consensus reached
6.Agreement on interpretation of tests: this may require further rounds of scoring if discrepancy exists amongst the group.

Results:
The results of the process will be presented.

Conclusion:
We believe that defining gold-standard diagnostic criteria for identifying and excluding musculoskeletal components in women with CPP will significantly enhance research in the field. We will use the Delphi method to establish international consensus on these diagnostic criteria. In particular, accurate identification of women with a musculoskeletal component to their pain will ensure appropriate recruitment to clinical trials (either focusing on or excluding musculoskeletal factors) and
improve prevalence data thus helping to justify service needs.
14
Fri
Poster #15
VITAMIN D CAUSES REGRESION ON SURGICALLY INDUCED ENDOMETRIAL LESIONS IN RATS: A PRELIMINARY STUDY
Rukset Attar¹, Ozge Kizilkale Yildirim², Gazi Yildirim³, Çigdem Kaspar4, Ferda Ozkan5 and Erkut Attar6
¹Yeditepe University; ²Yeditepe University Medical School, Department of Obstetrics and Gynecology; ³editepe University Medical School, Department of Obstetrics and Gynecology; 4Yeditepe University Medical School, Department of Biostatistics and Medical Informatics; 5Yeditepe University Medical School, Department of Pathology; 6Istanbul University Medical School
Presented By: Rukset Attar

Objective: Endometriosis is a chronic disease which causes pelvic pain. Our aim was to evaluate the effect of vitamin D on surgically induced endometriosis lesions in female nulligravid Sprague-Dawley rats.
Methods: This is a prospective, randomized, controlled, experimental study carried out at Yeditepe University Experimental Research Center (YUDETAM). Three operations were performed on each rat. The induction of endometriosis was performed in the first operation. Endometriosis was surgically induced by using 48 homologous uterine horn transplantation in the 12 ooferectomised rats. At the second operation endometriotic lesions were measured and the rats were divided into two groups: Vitamin D treatment and control group. Vitamin D was given orally for two weeks to Vitamin D group. After two weeks all rats were sacrified and volumes of the endometriotic lesions were measured again. The volumes of the endometriotic lesions at the second and third operations were compared with each other.
Results: The mean volumes were 199.86 ± 132.73 mm3 and 24.38 ± 33.52 mm3 on the 2th and 4 th week i.e. before and after oral Vitamin D treatment, respectively. There was a statistically significant decrease in the volumes of the endometriotic lesions after treatment with Vitamin D ( p<0.05).
Conclusion: Vitamin D treatment caused regression of endometriotic lesions in our experimental study. It seems to be a promising agent for the treatment of endometriosis.
14
Fri
Poster #16
OCCULT INGUINAL HERNIAS CAN CAUSE CHRONIC PELVIC PAIN
Shirin Towfigh¹ and Erfan Zarrinkhoo²
¹Beverly Hills Hernia Center; ²Wake Forest School of Medicine
Presented By: Shirin Towfigh

OBJECTIVES:
1) To analyze the clinical presentation of patients with CPP deemed to be due to occult inguinal hernias.
2) To evaluate the effectiveness of surgical treatment of occult inguinal hernias in curing chronic pelvic pain (CPP).

METHODS: Retrospective review of all patients in hernia database from a single general surgeon with hernia specialty. Prospective followup was performed both in-person and by phone. Patients were chosen based on the following inclusion criteria:
a) diagnosis of CPP, and
b) non-palpable inguinal hernia on examination, and
c) preoperative diagnosis of occult inguinal hernia, and
d) inguinal hernia repair by a hernia specialty surgeon.

RESULTS: Since 2008, 354 patients with CPP and a preoperative diagnosis of occult inguinal hernia underwent inguinal hernia repair. 72% were female. Average duration of preoperative pain was 96 weeks. Clinical presentation included groin/lower quadrant pain radiating around to the back, down the front of the leg, to the upper inner thigh, and/or into the vagina or testicle. On examination, none had a palpable inguinal bulge or reducible mass, and 77% had point tenderness over the internal ring. All patients underwent preoperative imaging to help confirm the diagnosis of occult inguinal hernia. Repair options included open, laparoscopic, and robotic surgery with and without mesh. After inguinal hernia repair, 78% had cure of their preoperative CPP at 2-week follow-up. Average follow-up was 2.2 years, with 87% long-term cure of preoperative CPP.

CONCLUSION: Occult inguinal hernias may cause CPP. Their clinical presentation is often atypical for a hernia, resulting in delay of diagnosis of almost 2 years. The most consistent examination finding is point tenderness over the internal ring. Surgical repair can successfully cure CPP in over ¾ of these patients.

SUMMARY: Most practitioners diagnose an inguinal hernia as a reducible, often non-tender, groin bulge. In contrast, occult inguinal hernias are symptomatic hernias without palpable bulge. Occult inguinal hernias can present atypically with radiating pain, which can be confused for other causes of pelvic pain, such as orthopedic, gynecologic, urologic, neurologic, and gastrointestinal disorders. As a result, diagnosis is delayed on average 2 years. Over ¾ of these occur in females and they are diagnosed with CPP. In our practice, we have developed an algorithm to identify these patients based on high yield questions in their history. Examination is often non-diagnostic. The most sensitive examination finding is point tenderness and vague fullness over the internal ring. Prior to surgery, every patient undergoes imaging to confirm this diagnosis. Surgical repair is tailored to each patient. Most notice an improvement in pain immediately postoperatively, and over ¾ at their 2-week follow-up appointment. Long-term follow-up confirms sustained cure of CPP after inguinal hernia repair. Occult inguinal hernias are underdiagnosed and underappreciated. Heightened awareness of occult inguinal hernia as the cause of CPP can result in early surveillance and successful treatment, thus improving patients’ overall quality of life.
14
Fri
Poster #17
SACRAL ROOT STIMULATION AS A TREATMENT FOR CHRONIC PELVIC PAIN IN FEMALES | A NOVEL CASE STUDY
Sebastian Ksionski and Lynn Miller
Neurosurgeon
Presented By: Sebastian Ksionski

Background: Chronic pelvic pain (CPP) is a prevalent and debilitating condition. In the female population it is the single most common indication for referral to women’s health services accounting for up to 20% of all outpatient appointments in secondary care. Outpatient management of pelvic pain is estimated to cost approximately 881.5 million dollars annually.

Case: We present a case of a female that has chronic lower pelvic pain that underwent ilio−inguinal, illio−hypogastric and superior/inferior hypogastric blocks as well as selected sacral nerve blocks and a lumbar/caudal epidural steroid injections which all provided poor control of her pain. At that point spinal cord stimulation with sacral root stimulation was discussed and the trial was done via a novel approach through a caudal catheter epidural approach. This approach is similar to the Racz procedure for lysis of adhesions so that we could place the leads perpendicular to the nerves versus the traditional retrograde approach. At six months after SCS implantation the patient is able to wean herself completely off of her opiate pain medications and have more energy and feel more functional.
14
Fri
Poster #18
LOCAL LIDOCAINE INJECTION FOR THE TREATMENT OF POSTPARTUM DYSPAREUNIA. A REPORT OF FOUR CASES.
Maria del Rio, Cristina Berdie, Purificación Regueiro and Enric Cayuela
Department Obstetrics and Gyneocology, Hospital General Hospitalet, CSI, Barcelona.
Presented By: Maria del Rio

Background: Postpartum dyspareunia is a common and underreported disorder, persisting after 12 months in about 8% of women. Perineal lacerations and episiotomy can result in sclerotic healing and cause entry and deep dyspareunia. Therapeutic regimens for this condition are scarcely addressed in the literature, and those described such as vaginal estrogens, physical therapy or scar surgery have shown weak evidence.
Objective: Demonstrate the feasibility, acceptability, and pain outcomes of local lidocaine vaginal injection as a treatment for postpartum dyspareunia.
Methods and results: Four patients with de novo dyspareunia at 6-24 months after vaginal delivery with episiotomy and no other perineal lacerations who had failed conservative management with vaginal estrogens and lubricants were offered vaginal injection with local anesthetic as a treatment option. The four patients had an homogeneous phenotype. Pain severity when intercourse was determined using a visual analogue scale (VAS 0-10). All cases underwent local injection with lidocaine 0.5% (5 -10 ml) at the site of the episiotomy treating all layers of the vaginal scar. Follow-up was undertaken two weeks after, average pain decreased from 7.25 to 0.5 VAS pain score, three women became essentially pain free, and none required further injections. There were no adverse effects and all cases were well tolerated.
Conclusion: Local injections of corticosteroids and local anesthtetics are accepted treatment methods for chronic pain, although gynecologists rearely consider these therapeutic methods for treating chronic pelvic pain. One group in London reported recently their experience using combined local bupivacaine and steroid injections for chronic perineal and vaginal pain after vaginal surgery, with significant improvement in pain scores. We report preliminar results of successful therapy of postpartum dyspareunia with just a single local lidocaine injection, which appears to be enough to disrupt the neuropathic pain mechanisms in such cases. Despite our enthusiasm with the reported results, efficacy may be better evaluated with a randomized controlled trial and further studies may give light on the underlying mechanism of local anesthetic in chronic pelvic pain.
Summary: Vaginal local anesthtetics injection with lidocaine 0.5% at the site of the episiotomy can give significant improvements in pain and quality of life in women with perisitent postpartum dyspareunia.
14
Fri
Poster #19
THE DISTINCT ROLES OF SOMATIZATION IN MENSTRUAL AND NON-MENSTRUAL PELVIC PAIN
Kevin Hellman¹, Rebecca Zuckerman¹, Rebecca Silton² and Frank Tu³
¹University of Chicago; ²Loyola; ³NorthShore University HealthSystem
Presented By: Kevin Hellman

Objectives: The specific factors that underlie menstrual and non-menstrual pelvic pain have rarely been examined individually as other studies often group these two pelvic pain categories together. To determine the unique factors involved in these pains as well as the role of neuropsychological factors, such as somatization, depression and anxiety, we performed regression and mediation analyses to elucidate these relationships.

Methods: 1,012 reproductive-aged women completed a 112-item questionnaire with domains including mood, fatigue, physical activity, somatic complaint, and pain. The relationship of dysmenorrhea and non-menstrual pelvic pain to key factors was modeled using linear regression and mediation analysis.

Results: Among women who regularly menstruate (n=834), a Shapley Owen regression model showed that dysmenorrhea is significantly associated with uterine factors, such as heavy bleeding and cramping pain, whereas non-menstrual pelvic pain was primarily associated with somatic complaint (p<0.001). Somatization was a significant mediating factor in the relationship between mood factors like as depression and anxiety and menstrual and non-menstrual pelvic pain (p<0.001).

Conclusion: Given that non-menstrual pelvic pain is often comorbid with dysmenorrhea, failure to perform a separate examination of these populations previously has likely led to an overestimation of anxiety, depression and somatization in dysmenorrhea. Therefore, it is important that clinicians consider uterine factors involved with menstrual pain, without overemphasizing neuropsychological factors. Additionally, proper diagnosis of comorbid non-menstrual pelvic pain will enable the development a directed treatment plan to address the sensory amplification and somatization that is an associated factor. Longitudinal studies are needed to confirm the role of these factors in order to develop targeted treatments.

Summary:

Menstrual pain and non-menstrual pelvic pain each correlated to unique factors, suggesting treatment may require algorithms specific to these factors. Our mediation anxiety and somatization interaction in women with non-menstrual pelvic pain model suggests that targeting anxiety and depression to reduce the effects of somatization in women with non-menstrual pelvic pain may be useful.
14
Fri
Poster #20
INITIAL RESULTS FROM AN OPEN TRIAL OF A MIND-BODY INTERVENTION FOR YOUNG ADULT WOMEN WITH PRIMARY DYSMENORRHEA
Laura Payne, Laura Seidman, Lonnie Zeltzer and Andrea Rapkin
David Geffen School of Medicine at UCLA
Presented By: Laura Payne

Objective: Painful menstruation without an identified cause, known as primary dysmenorrhea (PD) is the leading cause of school and work absences in reproductive age girls and women, with 20-25% of young women reporting significantly impaired functioning because of their symptoms. Despite this high prevalence and significant impact, there are no empirically-supported interventions for menstrual pain aside from hormonal contraceptives and non-steroidal anti-inflammatory drugs. Given shared features among PD and chronic pain conditions, women with PD may also benefit from mind-body approaches to reducing pain and improving functioning. The current study aimed to evaluate the feasibility, acceptability, and impact of a 5-session, group mind-body intervention for young adult women with PD.
Methods: Twenty-one participants with moderate to severe PD, ages 18-24 years, were enrolled in the study across three separate groups. Of these, 5 individuals dropped out (4 before the first session, 1 following the first session) due to scheduling difficulties; 16 participants completed the full course of treatment, which included 5, 90-minute group sessions over the course of 6 weeks. Treatment completers were young adult women (age M=20.32 years, SD=1.87) with self-reported overall menstrual pain of at least 6/10 on a numeric rating scale. All participants completed questionnaires measuring menstrual pain and menstrual symptoms at pretreatment and one month follow-up (follow-up data were used to capture the most recent menstrual period since the termination of the group). Additionally, the treatment credibility and expectancy questionnaire (CEQ), which extant research suggests is positively associated with treatment outcome, was completed after the first session.
Results: Participants rated the treatment highly on the credibility factor of the CEQ (M=20.47, SD=2.48), with an average expected improvement of 48.24%. Overall pain during the first two days of menstruation was significantly lower at one month follow-up (M=6.63, SD=2.22) compared to baseline (M=7.81, SD=1.56), t(15)=2.59, p = .02. Similarly, ratings of worst menstrual pain also significantly decreased from baseline (M=8.31, SD=1.30) to one month follow-up (M=7.19, SD=1.94), t(15)=2.42, p = .029. At one month follow-up, 56.3% of participants reported using mindfulness, 62.5% reported using decatastrophizing, and 93.8% reported using coping skills during their most recent menstrual period.
Conclusion: A group, mind-body intervention focusing on mindfulness, cognitive reappraisal, and enhancing coping shows promise as a non-drug treatment for moderate to severe menstrual pain. The treatment was rated as credible and expected to show improvement in symptoms, and menstrual pain ratings decreased significantly from baseline to one month follow-up. At follow-up, participants reported using primarily coping skills during their most recent menstrual period.
Summary: These data suggest alternative approaches may be helpful for menstrual pain. Future research should continue to systematically evaluate non-drug treatment approaches for this chronic and disabling condition.
14
Fri
10:15 a.m. - 10:55 a.m.
The Impact of Centralized Pain on Acute and Chronic Post-Surgical Pain Outcomes
Speaker:
Chad M. Brummett, MD
University of Michigan
14
Fri
10:55 a.m. - 11:35 a.m.
Transcranial Direct Current Stimulation as a Treatment for Chronic Pain
Speaker:
Felipe Fregni, MD, MPH, PhD, Med
Harvard Medical School
14
Fri
11:35 a.m. - 11:55 a.m.
Questions and Answers
Concurrent Sessions Begin  
Concurrent Session 1 of 2  
14
Fri
11:55 a.m. - 1:25 p.m.
Friday Roundtable Lunch with Experts
Location: St Gallen
14
Fri
11:55 a.m. - 1:25 p.m.
MINDING THE BODY: Psychological Factors in the Patient Experience
Moderators:
Caryn Feldman, Ph.D.
Rehabilitation Institute of Chicago

Talli Y. Rosenbaum, MSc.,
Private practice
14
Fri
11:55 a.m. - 1:25 p.m.
LEAVING NO PATIENT UN-STUDIED: a guide to forming research-clinical partnerships in the investigation of chronic pelvic pain
Moderators:
Jason James Kutch, PhD
University of Southern California

Georgine Lamvu, MD, MPH, FACOG
Orlando VA Medical Center
14
Fri
11:55 a.m. - 1:25 p.m.
PELVIC GIRDLE PAIN: A Missed Opportunity? Screening Techniques for Physicians and Physiotherapists
Moderators:
Catherine Allaire, MD, FRCSC
Women's Health Center

Susannah Britnell, Bsc Hons PT, Dip Adv
Centre for Pelvic Pain and Endometriosis
14
Fri
11:55 a.m. - 1:25 p.m.
VULVODYNIA: the burning truth about vulvodynia
Moderators:
Jennifer Hyer, MD
Denver Health

Janelle Moulder, MD, MSCR
UNC Hospitals
14
Fri
11:55 a.m. - 1:25 p.m.
OPIOIDS IN AMERICA: physicians role in the epidemic
Moderators:
Chad M. Brummett, MD
University of Michigan

Allan I. Frankel, MD
GreenBridge Medical Services, Inc.
14
Fri
11:55 a.m. - 1:25 p.m.
PITSFALLS AND TIPS: the pelvic floor MSK exam
Moderators:
Kari Bo, PhD, PT
Norwegian School of Sport Sciences

Colleen M. Fitzgerald, MD
Loyola University Medical Center
14
Fri
11:55 a.m. - 1:25 p.m.
CANCER + PELVIS = PAIN?
Moderators:
Michelle Lyons
Westmeath, Ireland

Allyson Shrikhande, MD
Lenox Hill Hospital
14
Fri
11:55 a.m. - 1:25 p.m.
THE MARTIANS TABLE: Male Pelvic Pain
Moderators:
Peter Dornan, AM DIP PHTY, FASMF
University of Queensland

J. Curtis Nickel, MD, FRCSC
Queens University, Kingston General Hospital
14
Fri
11:55 a.m. - 1:25 p.m.
BRING YOUR COMPLEX PATIENTS: Discussion with the Experts
Moderators:
Tracy Sher, MPT, CSC, CSCS
Sher Pelvic Health and Healing

Kathryn Witzeman, MD
Denver Health
14
Fri
11:55 a.m. - 1:25 p.m.
CHALLENGES IN INTERDISCIPLINARY CARE
Moderators:
Amy Benjamin, MD
University of Rochester

Karen Brandon, DSc, PT, WCS
Kaiser Permanente, OBGYN Department
Concurrent Session 2 of 2  
14
Fri
11:55 a.m. - 1:25 p.m.
Lunch on Own
Concurrent Sessions End  
14
Fri
1:30 p.m. - 2:05 p.m.
Addressing Psychosexual Components of Chronic Pelvic Pain in Medical and Physical Therapy Practice
Speaker:
Talli Y. Rosenbaum, MSc.,
Private practice
14
Fri
2:05 p.m. - 2:40 p.m.
Women, Cancer and Pelvic Pain
Speaker:
Michelle Lyons
Westmeath, Ireland
14
Fri
2:40 p.m. - 3:15 p.m.
Cancer Pain: Advances, Challenges, and Opportunities
Speaker:
Judith Paice, PhD, RN
Northwestern University
14
Fri
3:15 p.m. - 3:20 p.m.
Q&A
14
Fri
3:20 p.m. - 3:45 p.m.
*Break & Poster Viewing Session
Location: Zurich Ballroom ABC
14
Fri
Poster #1
COMPARISON OF DISORDERS CO-MORBID WITH DIFFERENT TYPES OF CHRONIC PELVIC PAIN
Gisela Chelimsky¹, Sheng Yang², Curtis Tatsuoka², N. Patrick McCabe², Sarah Ialacci², C. A. Tony Buffington³, Jeffrey Janata² and Thomas Chelimsky¹
¹Medical College of Wisconsin; ²Case Western Reserve University; ³The Ohio State University
Presented By: Thomas Chelimsky

Objectives: A variety of chronic medical conditions commonly accompany chronic pelvic pain (CPP) in women. We compared the chronologic sequence of onset and frequency of some of these comorbid conditions in subjects with interstitial cystitis/bladder pain syndrome (IC/BPS), myofascial pelvic pain (MPP), or with both diagnoses (IC+MPP).

Methods: We used a semi-scripted interview by a physician or trained nurse practitioner based on published diagnostic criteria to identify the presence and order of onset of selected comorbid conditions in 9 women with MPP, 32 with IC/BPS, 36 with IC+MPP, 5 family members of probands, and 30 healthy controls.

Results: Co-morbid disorder frequencies were 0.6±1.0, healthy subjects, 4.6 ± 3.9 IC/BPS alone, 6.7 ± 3.3 MPP alone, and 7.4 ± 1.4 for IC+MPP (p<0.003 vs IC/BPS alone, p<0.006 vs either CPP alone). In addition, subjects with IC+MPP had increased (p<0.05) frequencies of chronic fatigue syndrome, fibromyalgia, dysmenorrhea, dyspepsia and panic disorder compared to those with a single CPP disorder. CPP was usually preceded chronologically by post-traumatic stress disorder (PTSD - generally earliest), anxiety, depression, migraine headache, fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome.

Conclusion: Comorbidities are common in patients with IC/BPS, MPP, and IC+MPP, with relatively higher burden when both pelvic pain disorders are present together. Migraine headache, fibromyalgia, chronic fatigue syndrome and irritable bowel syndrome usually develop before CPP. PTSD not only antecedes CPP but most other conditions as well, consistent with the notion that internalized stress plays a predisposing role in CPP. Some differences in co-morbid conditions were identified based on the specific CPP diagnosis.

Acknowledgment: Funded in part by NIH R01 DK083538 and by Advancing a Healthier Wisconsin (AHW) Fund (5520298).
14
Fri
Poster #2
TREATMENT SELECTION AND LONG-TERM OUTCOMES IN PATIENTS WITH VULVODYNIA: A REPORT FROM THE NATIONAL VULVODYNIA REGISTRY (NVR)
Georgine Lamvu¹ and Meryl Alappattu²
¹Orlando VA Medical Center; ²University of Florida
Presented By: Meryl Alappattu

Objective: The study presented here aims: 1) to describe the types of treatments that were selected to treat vulvodynia in women enrolled in the NVR; and 2) to describe 6- month outcomes related to self-reported pain, dyspareunia, and psychological distress for this sample.

Study Design: Prospective Cohort

Study Population: Women who were received care through the National Vulvodynia Registry from 2009-2014.

Methods: As part of the registry, women were treated according to the recommendation of their healthcare providers and these treatments were recorded over a period of 12 months. Approximately 900 women were screened and 344 women were consented and enrolled after screening positive on Harlowe’s questionnaire for assessing the presence of vaginal pain lasting longer than 3 months. Next participants underwent an extensive vaginal exam and clinical confirmation of vulvodynia. During the examination, composite pressure pain thresholds (PPT) was reported for the vestibule, and the pelvic floor muscles. Next participants completed a variety of self- report questionnaires related to demographic information and general and gynecological medical history. Self-reported pain intensity was measured using the short-form McGill Pain Questionnaire (SF-MPQ), and the Female Sexual Function Index (FSFI).
Results: After screening for eligibility, 344 women were enrolled into the NVR; 282 had at least one prescribed treatment recorded after initial examination and thus were included in this analysis. Eighty different types of treatments were identified and grouped into 9 categories (topical vaginal cream, pills, psychotherapy, injections physical therapy, vaginal dilators, surgery and experimental) and 28 sub-categories. Nearly 73% of women received more than one treatment at initial visit (38.7% two treatments, 26.6% three treatments, 6.4% four treatments, and 1.1% five or more treatments) and only 27% received one treatment. The most commonly prescribed therapies were topical creams, pills, physical therapy and psychotherapy and the most commonly used combination included creams, physical therapy and pills. At six months, all participants demonstrated statistically significant improvements in McGill pain sensory scores (p=0.001), McGill pain affective scores (p=0.005), catastrophizing (p=0.000), anxiety (p=0.000), and Beck Depression Inventory scores (p=0.000). Although women reported improvements in their intercourse related pain (p=0.000), their total sexual function scores were worse at 6 months (p=0.000).
Conclusion: Healthcare providers are using a variety of therapies to treat vulvodynia, however, in the majority of cases providers are using multi-modal therapy incorporating two or more treatments and the combinations of treatments vary widely among geographic areas. In general, after 6 months of therapy, women demonstrate improvements in pain, and distress, but not in sexual function.
14
Fri
Poster #4
INJURY TO THE PERINEAL BRANCH OF THE PUDENDAL NERVE IN WOMEN: OUTCOMES FROM SURGICAL RESECTION OF THE PERINEAL BRANCHES AND IMPLANTATION OF PROXIMAL END INTO THE OBTURATOR INTERNUS MUSCLE
Eric L. Wan¹, Hillary Tolson², Andrew T. Goldstein¹ and A Lee Dellon¹
¹Johns Hopkins University; ²Center for Vulvovaginal Disease, Annapolis
Presented By: A Lee Dellon

Objective:

The traditional transgluteal approach for the surgical treatment of “pudendal neuralgia” has been disappointing for those patients with “anterior” pudendal nerve symptoms, such a pain in the labia, vestibule, and perineum. In this study, we describe outcomes from a new surgical approach to resect the perineal branches of the pudendal nerve (PBPN).

Methods:

An IRB-approved prospective study enrolled 16 consecutive female patients from 2012 through 2015 who did not have rectal symptoms. Each woman had a successful, diagnostic, pudendal nerve block. The surgical procedure was resection of the PBPN and implantation of the nerve into the obturator internus muscle through a para-labial incision. Mean age at surgery was 49.5 years (SD = 11.6 years). Mechanism of injury was episiotomy in 31%, athletic injury in 25%, vestibulectomy in 31%, and falls in 13%. Four women (25%) had urethral symptoms. Outcomes were the Female Sexual Function Index (FSFI), the Vulvar Pain Functional Questionnaire (VQ), and the Numeric Pain Rating Scale (NPRS). 14 patients completed these questionnaires, reporting on their condition before surgery and currently.

Results:

The mean post-operative length of follow-up was 15 months (range: 6 to 43 months). Post-operative significant bruising was the only complication, occurring in 10% of the patients. The overall FSFI significantly improved after surgery (p < 0.05). The specific domains that showed significant improvement were those for arousal, lubrication, orgasm, satisfaction, and pain (p < 0.05). The VQ also significantly improved after surgery (p < 0.001) in 13 of 14 (93%) patients. The NPRS score decreased, on average, from an 8 to a 3 out of 10 (p < 0.0001). Each of the 4 women with urethral symptoms had relief of these symptoms post-operatively.

Conclusions:

Resection of the perineal branch of the pudendal nerve with implantation of the nerve into the obturator internus muscle significantly improved the sexual function, vulvar function, and pain of women who sustained injury to the perineal branches of the pudendal nerve.

Summary:

This prospective study utilized the Female Sexual Function Index, the Vulvar Questionnaire, and the Numerical Pain Rating Scale to evaluate outcomes of treating labial, vestibular and vaginal pain related to injury to the perineal branches of the pudendal nerve. These branches were resected and implanted into the obturator internus muscle. The results demonstrated that this new, anterior, surgical approach, to this portion of the pudendal nerve, is significantly effective in relieving pain and improving pelvic function
14
Fri
Poster #5
CATECHOL-O-METHYLTRANSFERASE GENE POLYMORPHISM AND VULVAR PAIN IN WOMEN WITH VULVODYNIA ENROLLED IN THE NATIONAL VULVODYNIA REGISTRY
Insiyyah Patanwala¹ and Georgine Lamvu²
¹Department of Obstetrics and Gynecology, Florida Hospital, Orlando; ²Gynecologic Surgery and Pelvic Pain Specialist, Orlando VA Medical Center
Presented By: Insiyyah Patanwala

Background: The underlying causes of vulvar pain in women with vulvodynia remain poorly understood. Catechol-O-methyltransferase (COMT), an enzyme that degrades dopamine, epinephrine and norepinephrine, which are neurotransmitters that have been demonstrated to modulate the degree of pain sensitivity. The more extensive is their degradation, the lower is the perception of pain. The val158 met polymorphism results in functional differences in COMT enzyme activity. The highest COMT enzymatic activity occurs when the H,H homozygous genotype is transcribed; intermediate activity is associated with the H,L heterozygous genotype while L,L homozygosity results in the lowest COMT enzyme activity.

Objective: To assess whether a variation in the COMT genotype is involved in increased pain sensitivity in women with vulvodynia.
Study Design: Prospective cohort study

Methods: Buccal swabs were collected from 167 Caucasian women with vulvodynia and 107 control women and their DNA was tested for a SNP at position 158 (rs4680) in the COMT gene.

Results: Overall, women with vulvodynia had a marginally increased, yet not significant, prevalence of the COMT genotype associated with high activity of the coded protein (P = 0.0543). However, stratifying the cases based on pain frequency revealed that the elevated occurrence of this COMT genotype (P = 0.0090) was uniquely present in the subset of women who experienced pain only with sexual intercourse. Also, women with primary vulvodynia had a higher prevalence of the H allele than did the controls (P = 0.0387).

Conclusion/Summary: In this investigation we show that the subgroup of women with a diagnosis of vulvodynia who have pain only with sexual intercourse have a higher prevalence of the COMT H,H genotype as well as a higher frequency of the H allele as compared to control women. Thus, maximal COMT enzyme activity occurs at a higher prevalence in this vulvodynia subgroup than in women whose vulvodynia is characterized by pain that is unprovoked and occurs every day or in unaffected women.
14
Fri
Poster #6
SPINAL CORD STIMULATION: THE FORGOTTEN THERAPY FOR PELVIC PAIN?
Sara Freitas, Micaela Costa, João Silva and Teresa Fontainhas
Presented By: Sara Freitas

INTRODUCTION: Chronic pelvic pain syndrome (CPPS) is defined by the European Association of Urology guidelines as a non-malignant pain perceived in structures related to the pelvis of either women or men for at least 6 months without proven infection or other obvious pathology. (1) CPPS affects 5.7-26.6% women worldwide, 55% have no obvious pathology and 40% have associated endometriosis. (3) We present the value of spinal cord stimulation (SCS) for chronic visceral pelvic pain in a female patient with the diagnosis of CPPS (history of endometriosis, multiple surgical explorations and hysterectomy).

CASE REPORT: 39-year-old female with a long history of endometriosis who originally presented with a lower, intense and constant abdominal pain involving the perineum with irradiation to the right lower limb, accompanied by burning, that worsened by movement and the end of the day. After a complete pain and psychiatry evaluation and a conventional therapeutic optimization, she was scheduled for neurostimulator implantation. A subcutaneous electrical voltage controlled neurostimulator was placed by epidural space with two electrodes: one implanted on posterior horn of the spinal cord to the T9 level (for the irradiated pain to the leg) and another retrograde to the cauda equina. After 3-month follow-up she reports a greatly improve, increased functional status without pain and that stimulation continues to cover the affected area. There were no complications described.

DISCUSSION: The treatment of CPPS remains a challenge despite several established first line therapies because many patients are therapy refractory. One reason that a definitive treatment for CPPS remains elusive is that its exact etiology remains unknown. (3)Although unclear, the pathophysiology of CPPS seems to parallel many common, centralized, neuropathic, and sympathetically driven pain models. (4) Patient engagement in a biopsychosocial approach is recommended with a treatment of any identifiable disease process such as endometriosis. Hysterectomy may be considered as a last resort if pain seems to be of uterine origin, although significant improvement occurs in only about one-half of cases. (1) Epidural spinal cord stimulation is a reversible but invasive procedure that may be proposed to the patients with neuropathic pain refractory to conventional management, in order to improve pain relief, functional capacity, and quality of life. A decisive factor is a careful patient selection as well as the diagnosis. In this case the most significant challenge is the correctly identification of SCS lead position, which provides adequate and appropriate coverage of the extense affected area. (4, 5)

CONCLUSION: Despite various alternatives proposed in the past, there has yet to be a true consensus on optimal lead positioning for the treatment of CPPS. The place of neurostimulation is too frequently used as a last resource, however it is a promising therapeutic alternative and should be considered more often in daily clinical practice. Epidural SCS should always be used within a interdisciplinary multimodal therapy concept and our center has been a very good results.
14
Fri
Poster #7
THE RELATIONSHIP BETWEEN FMRI EVENTS RESEMBLING SUSTAINED UTERINE CONTRACTIONS AND SPONTANEOUS MENSTRUAL CRAMPING PAIN REPORT
Caroline Kuhn¹, Frank Tu², Diana Zhou¹, Sangeeta Senapati² and Kevin Hellman¹
¹University of Chicago; ²NorthShore University HealthSystem
Presented By: Caroline Kuhn

Study Objective:
The mechanisms underlying menstrual pain are poorly understood and a method capable of identifying causes within individual participants could facilitate appropriate treatment planning. The study objective was to determine the feasibility of identifying the mechanisms underlying menstrual pain utilizing functional MR imaging.

Measurements & Main Results:
Fifteen participants with severe dysmenorrhea and 3 healthy controls presented for MRI during their menses, off any pain medication. We acquired functional MRI sequences during periods of self-reported cramping pain for those with dysmenorrhea and at random intervals for those without dysmenorrhea. Comparison imaging was performed at post-menses visits. Most women who experienced cramping pain while scanning had symmetrical and progressive decreases in T2-weighted MRI signal in the myometrium, greater than 10% and lasting longer than 16 seconds. These signal changes resembled episodes known as “sustained uterine contractions” by prior studies. These myometrial events were scored and consistent results were obtained between two blinded raters (r=0.97, p<0.001). Episodes of cramping occurred either immediately before or significantly after event onset suggesting an indirect relationship between uterine events and cramping pain. Women who did not have myometrial events on their menses either had a history of endometriosis or were not in pain. When dysmenorrhea participants returned during a non-menses visit, transient decreases in signal were not observed except in one subject reporting “bowel” pain.

Conclusion:
Myometrial events with transient decreases in uterine T2 can be reliably measured in women with menstrual pain. The directionality of signal change and delayed relationship to pain onset suggest that these events are not “uterine contractions.” Instead these events likely represent a consequence of uterine contractions such as ischemic episodes that contribute to menstrual pain via an indirect mechanism in most women with dysmenorrhea. Further research is warranted to specifically investigate mechanisms responsible for decreases in uterine T2 and determine if phenotypic subtyping can optimize subsequent treatment outcomes.

Summary:

This new technique to simultaneously evaluate MRI and spontaneous pain provides a method to identify components responsible for spontaneous pain and supports a causative role of vascular/metabolic dysfunction in menstrual pain.
14
Fri
Poster #8
MUSCULOSKELETAL FACTORS CO-EXIST WITH GYNAECOLOGICAL PATHOLOGIES IN WOMEN WITH CHRONIC PELVIC PAIN AND ARE AMENABLE TO SPECIALIST PHYSIOTHERAPY
Katie Gore¹, Alice Rodriguez¹, Lauren McLeod¹, Jane Moore¹,² and Katy Vincent¹,²
¹Oxford University Foundation Hospitals NHS Trust; ²Nuffield Department of Obstetrics and Gynaecology, University of Oxford
Presented By: Katie Gore

Background:
Chronic pelvic pain (CPP) is frequently associated with musculoskeletal dysfunction and psychological distress. Recommended treatment of CPP acknowledges these associations and thus management is multi-disciplinary, targeting all identified pain generating or maintaining factors. If CPP is associated with gynaecological pathology, such as endometriosis, however, standard management targets the pathology and referral to a CPP service may only occur after a number of years of unsuccessful treatment. We hypothesised that musculoskeletal dysfunction will coexist with underlying pathology and that treatment of this dysfunction will improve pain symptoms for these women.

Objectives:
1. To determine rates of musculoskeletal dysfunction in women attending a tertiary CPP service, categorised by underlying diagnosis.
2. To assess whether underlying diagnosis impacts on response to specialist physiotherapy.

Methods:
Data were collected on the first 100 women seen in a tertiary CPP service in 2016. Underlying diagnosis, presence of a musculoskeletal component and response to physiotherapy were assessed. Self-reported response to physiotherapy was assessed on a 0-100 visual analogue improvement scale.

Results:
97 of the women met the diagnostic criteria for CPP (pain perceived in the pelvis lasting for >6 months). 69 (71%) of these women were considered likely to have a musculoskeletal component to their pain by the assessing clinician, which was confirmed by a senior specialist women’s health physiotherapist. 28 (29%) women had a previous diagnosis of endometriosis. Other underlying/past diagnoses included adenomyosis, ovarian cysts, previous malignancy, adhesions, pelvic inflammatory disease, post-surgery and arthritis. 19 women (20%) had one or more of these diagnoses.
18 (64%) of women with a diagnosis of endometriosis also had a musculoskeletal component to their pain. 16 (84%) of those with other previous diagnoses had a musculoskeletal component.
Of the 69 women referred to physiotherapy, follow-up data is complete for 23 women (33%) to date. 8 women have not attended for follow up, whilst the remainder are still undergoing treatment. Average improvement after physiotherapy was 88%. Those women with coexisting endometriosis reported improvement of 90%. Of the 5 women where only musculoskeletal factors could be identified mean improvement was 87%.

Conclusion:
In agreement with published literature we identified high rates of musculoskeletal dysfunction in women with CPP. Moreover we demonstrate that musculoskeletal dysfunction commonly coexists with other pathologies. Our preliminary data suggests that the presence of other pathologies does not reduce the benefit of specialist physiotherapy in women with CPP. In summary, our findings support the need for adequate assessment and treatment of musculoskeletal dysfunction in women with chronic pain whatever the underlying cause.
14
Fri
Poster #9
EYE MOVEMENT DESENSITIZATION RE-PROCESSING AS TREATMENT FOR CHRONIC PELVIC PAIN
Karen Wiercinski and Scott Bush
Florida Hospital Celebration Health
Presented By: Karen Wiercinski

Objectives. Chronic pelvic pain (CPP) presents a persistent and significant clinical challenge to healthcare providers due to its often unknown etiology and poor response to treatment. CPP often requires multidisciplinary care for appropriate management, which may include psychological intervention. Eye-movement-desensitization and re-processing (EMDR) therapy, utilized for the treatment of post-traumatic stress disorder, has recently been identified as an effective mode for the treatment of chronic pain psychologically linked to disturbing emotional events. To our knowledge, there are no studies of the effects of EMDR on pelvic pain. We, therefore, report our preliminary findings on the effectiveness of this type of therapy for chronic pelvic pain.

Methods. The patient population included females with chronic pelvic pain resulting from gynecological issues, including endometriosis and adhesions. Patients rated their pain using a numeric rating scale with intensity ranging from lowest level to highest level of pain (0 to 10). After assessment of baseline pain rating scores, each patient was seen by a psychotherapist who administered EMDR therapy for a minimum session of two hours. Following the therapy, pelvic pain was again rated. Pain scores were expressed as the mean ± SEM and a student t-test was used to assess statistical difference between the two measurement periods at a probability <0.05.

Results. Pain scores prior to the EMDR session averaged 6.92 ± 0.62, range = 4 to 10, median = 7.00. Post-therapy, all but one of patient experienced significant reduction in perceived pain. Mean pain intensity scores following therapy averaged 3.46 ± 0.67 with a range of 0 to 10 and a median score of 3.0. Pain intensity scores significantly (p=0.0002) differed between the examination periods.

Conclusion. The data show that 92% of patients experienced significant reduction of chronic pelvic pain, and some experienced total relief from pain, with EMDR therapy.

Summary. EMDR may be an effective alternative therapy for the treatment of chronic pelvic pain. Future investigations are needed to examine the effectiveness of the therapy with larger CPP patient populations and longer follow-up.
14
Fri
Poster #10
CHRONIC PELVIC PAIN: THE ROLE OF EXPLORATORY LAPAROSCOPY AS DIAGNOSTIC AND THERAPEUTIC TOOL
Géraldine Brichant, Marie Denef and Michelle Nisolle
Obstetrics and Gynecology Department of Liège University
Presented By: Géraldine Brichant

Objective:
To evaluate the ability to identify pathological lesions and the improvement of painful symptoms in patients with chronic pelvic pain and normal physical examination and imaging after exploratory laparoscopy
Background: Forty percent of exploratory laparoscopies are performed for chronic pelvic pain. However a final diagnosis is still unreported in 35% of the patients.
Study design:
The prospective study was designed in the tertiary referral center for endometriosis. 41 patients complaining of chronic pelvic pain and scheduled for exploratory laparoscopy were included. Pelvic pain intensity was assessed using the visual analogue pain scale (VAS) and at inclusion negative clinical and imaging assessments were required. During exploratory laparoscopy, the recognized lesions were reported and different surgical treatment options were performed depending on the location of the lesion.
Results:
In 98% of the cases, exploratory laparoscopy demonstrated the presence of pelvic anomalies that had not been diagnosed at the time of clinical and imaging examination. After surgery, a significant improvement of chronic pelvic pain has been demonstrated in 24 (59%) patients with VAS <5 post-operatively.
Conclusions:
Exploratory laparoscopy is reasonable in patients complaining chronic pelvic pain, allowing a final diagnosis in a high percentage of patients and a significant improvement in pain symptom in 59% of the cases.
14
Fri
Poster #11
WOUND INFILTRATION WITH EXTENDED-RELEASE VERSUS SHORT-ACTING BUPIVACAINE BEFORE LAPAROSCOPIC HYSTERECTOMY: A RANDOMIZED CONTROLLED TRIAL
Kenneth Barron¹, Georgine Lamvu²,³, R. Cole Schmidt4, Matthew Fisk, Emily Blanton5,³ and Insiyyah Patanwala5,³
¹Department of Obstetrics and Gynecology, University of Virginia School of Medicine; ²Division of Surgery, Gynecology Section, Orlando Veterans Affairs Medical Center; ³Department of Obstetrics and Gynecology, University of Central Florida College of Medicine; 4Florida International University Herbert Wertheim College of Medicine; 5Department of Obstetrics and Gynecology, Florida Hospital Graduate Medical Education, Florida Hospital Orlando
Presented By: Kenneth Barron

Study Objective: To evaluate if pre-incision infiltration with extended-release liposomal bupivacaine provides improved pain relief compared to 0.25% bupivacaine after laparoscopic or robotic-assisted hysterectomy.

Methods: In a double-masked randomized controlled trial, women scheduled to undergo multiport laparoscopic or robotic-assisted total hysterectomy for benign indications were randomized to receive pre-incision infiltration with undiluted liposomal bupivacaine or 0.25% bupivacaine. The primary outcome was pain intensity by numeric rating scale (0-10) using the Brief Pain Inventory (BPI) via telephone survey on postoperative day (POD) 1, 2, 3 and 14. A sample size of 28 per group (N=56) was planned to detect a 30% change in pain scores. Secondary outcomes were numeric pain scores in hospital, BPI pain interference scores, and total opioid use.

Results: From July 2015 through January 2016, 64 patients were randomized and 60 were analyzed for the primary outcome. There were no demographic differences between the two groups. For the primary outcome, we found a decrease in worst pain scores on POD2 (P=.03) and a decrease in worst (P=.01) and average (P=.02) pain scores on POD3 in the liposomal bupivacaine group. There were no differences in pain scores while in hospital, POD1 or POD14. There were no differences in BPI pain interference scores, opioid use, or reported adverse effects.

Conclusion: For laparoscopic and robotic-assisted multiport hysterectomies there is evidence of decreased postoperative pain with liposomal bupivacaine compared to 0.25% bupivacaine for port site analgesia on POD2 and POD3, but no difference in opioid use or measures of functioning. These findings indicate limited effectiveness of liposomal bupivacaine for laparoscopic hysterectomy.
14
Fri
Poster #12
ANOVULATION AND MENSTRUAL PAIN IN GIRLS WITH AND WITHOUT PRIMARY DYSMENORRHEA
Laura Seidman¹, Andrea Rapkin², Lonnie Zeltzer¹ and Laura Payne¹
¹UCLA Pediatric Pain and Palliative Care Program; ²UCLA Department of Obstetrics and Gynecology
Presented By: Laura Seidman

Objective: Painful menstruation without an identified anatomic cause, or primary dysmenorrhea (PD), is believed to be caused in large part by the overproduction of uterine prostaglandins. The decline in progesterone during the late-luteal phase of ovulatory cycles creates an environment more favorable for prostaglandin production, which has led to the belief that ovulation is necessary for the development of PD. The current study aimed to explore frequencies of anovulation in a sample of menstruating adolescents and young adults with and without PD, and to compare levels of pelvic pain during menstruation following both ovulatory (OV) and anovulatory (AO) cycles.
Methods: Participants in the PD group had self-reported menstrual pain ≥ 4/10 on a 0-10 (0=none, 10=worst pain possible) numeric rating scale (NRS); healthy participants’ self-reported pain was ≤ 3/10. Ninety-one participants (52 healthy, 39 with PD), ages 16-24 years, completed urinary LH surge ovulation predictor kits (OPKs) to determine cycle phase. Cycles were considered AO if the participant never received a positive OPK result prior to beginning menstruation. Participants were tracked for up to three AO cycles, and were grouped as AO if they experienced at least one AO cycle. A subset of this group was considered chronically AO if they experienced three AO cycles. Pain ratings (0-10 NRS) during menstruation following both OV and AO cycles were evaluated for AO participants in the PD group.
Results: One hundred and sixty-nine full menstrual cycles were tracked across the 91 participants. Age, BMI, and race were not significantly different between pain groups, however, the PD group had a higher proportion of Hispanic participants (Χ2=6.28, p<.05). There were no group differences in age, race, ethnicity, or BMI between the OV and AO groups. Healthy girls were significantly more likely to have had at least one AO cycle (46.2%) than were girls with PD (17.9%) (Χ2=7.89, p<.01). A greater percentage of healthy girls were chronically AO compared to those with PD (11.5% vs. 2.6%), however this result did not reach statistical significance (p=.12). Within the AO PD group, mean maximum pain rating during menstruation following AO cycles was not significantly different from ratings following OV cycles (3.8, SD=2.6 v. 5.2, SD=1.9, respectively), (t=-2.18, p=.081).
Conclusion: This study demonstrates that during this observation period, healthy control adolescents and young adult women show statistically significant increases in the frequency of AO cycles compared to age-matched girls with PD. Furthermore, these data show that girls with PD report menstrual pain following AO cycles, and that this pain does not differ significantly from pain they experience following OV cycles.
Summary: These data suggest a complex relationship between ovarian sex steroids and menstrual pain. Previous implications of ovulation as a necessary component for the development of menstrual pain are likely incomplete. Given the widespread prevalence and impact of PD, future research should continue to investigate the local uterine and other peripheral and central mechanisms that contribute to dysmenorrhea.
14
Fri
Poster #13
IN OFFICE TREATMENT OF CLITORODYNIA: LYSIS OF CLITORAL ADHESIONS TO ADJACENT SKIN FOLLOWING DORSAL NERVE BLOCK
Irwin Goldstein¹ and Sherita King²
¹Alvarado Hospital; ²San Diego Sexual Medicine
Presented By: Irwin Goldstein

Objective: Dyspareunia occurs in 24.7-36.8% of women. Clitorodynia is uncommon and confined to the glans clitoris, clitoral shaft and adjacent prepucial area. In a subgroup, vulvoscopy shows adhesions of adjacent skin to the glans with numerous keratin pearls and sebum emanating through adhesions concealing the glans corona. Persistent balanitis underneath appears to account for clitoral pain or persistent genital arousal disorder (PGAD).
Methods: Instead of dorsal slit surgery of the clitoral hood with lysis of clitoral adhesions under general anesthesia, we now perform an in-office procedure under local anesthesia with a dorsal nerve block for the management of clitorodynia secondary to clitoral adhesions. We reviewed 7 patients (mean age 37 years, range 18 – 62 years) who had adhesions from the clitoral hood to the glans, obscuring the corona of the glans clitoris. Vulvoscopy identified smegma underneath the adhesions.
Results: All 7 underwent in-office management of clitoral adhesions. A dorsal nerve block was performed with 5 mL of either of mixture lidocaine/bupivacaine or bupivacaine liposome injectable suspension. After adequate local anesthesia was achieved, a Jacobson hemostat forceps was used to bluntly lyse epithelial adhesions and remove underlying keratin pearls. This process was continued until the corona was visualized completely around the circumference of the glans clitoris. An additional 5mL of local anesthetic was injected around the prepuce and frenulum of the clitoris for post-operative pain control. The patient was instructed to tub soak the area twice a day and carefully retract the clitoral hood sufficiently to visualize the corona while in the bath to prevent re-adherence of the adjacent clitoral hood to the glans. Even after the initial healing period the corona should be observed by retracting the hood daily to prevent adhesions. None of the patients had recurrence of adhesions 6 months post procedure. 5/7 women had significant reduction of clitoral pain.
Conclusion: Clitorodynia can occur secondary to adjacent skin adhesions to the glans clitoris causing underlying unrecognized balanitis. Release of these adhesions can be achieved in-office under local anesthesia with preservation of the prepuce. The corona of the glans clitoris must be observed during physical examination of women with clitorodynia.
Summary: This closed compartment balanitis clitorodynia is an outpatient treatable form of chronic clitoral pain or trigger for women with PGAD.
14
Fri
Poster #14
ESTABLISHING GOLD-STANDARD DIAGNOSTIC CRITERIA FOR MUSCULOSKELETAL FACTORS IN CHRONIC PELVIC PAIN
Katie Gore¹ and Katy Vincent¹,²
¹Oxford University Foundation Hospitals NHS Trust; ²Nuffield Department of Obstetrics and Gynaecology, University of Oxford
Presented By: Katie Gore

Background:
Musculoskeletal dysfunction can be the primary cause of chronic pain or occur secondary to other pathologies and is a common finding in chronic pain. In the context of chronic pelvic pain (CPP), studies suggest that up to 75% of women presenting to a tertiary CPP service will have a musculoskeletal component to their pain. Although specific tests have been proposed to identify muscular components, a systematic review concluded that no gold-standard diagnostic tests exist for pelvic muscular problems. Thus the diagnosis is subjective. We believe that the lack of gold-standard diagnostic criteria for musculoskeletal factors in CPP hinders research in this field.

Objective:
To reach international consensus on gold-standard diagnostic criteria for identifying and excluding musculoskeletal components in women with CPP.

Methods:
A group of leading women’s health physiotherapists with an interest in CPP has been created with international representation. The process will be facilitated by two gynaecologists, however, all decisions regarding appropriate tests and their interpretation will be made only by physiotherapists. The Delphi method will be used to reach consensus. In brief, the steps of the process will be:
1.Each participant to provide a list of the tests they consider essential to either confirm or exclude a musculoskeletal component in a woman with CPP
2.Circulation of a list of all tests suggested plus any not mentioned that are identified from a systematic review of the literature: participants to rate the value of these tests by anonymous survey
3.Removal of any tests unanimously rated as of low value
4.Circulation of the results of this survey and the opportunity to re-rate the tests
5.Re-iteration of steps 3 and 4 until consensus reached
6.Agreement on interpretation of tests: this may require further rounds of scoring if discrepancy exists amongst the group.

Results:
The results of the process will be presented.

Conclusion:
We believe that defining gold-standard diagnostic criteria for identifying and excluding musculoskeletal components in women with CPP will significantly enhance research in the field. We will use the Delphi method to establish international consensus on these diagnostic criteria. In particular, accurate identification of women with a musculoskeletal component to their pain will ensure appropriate recruitment to clinical trials (either focusing on or excluding musculoskeletal factors) and
improve prevalence data thus helping to justify service needs.
14
Fri
Poster #15
VITAMIN D CAUSES REGRESION ON SURGICALLY INDUCED ENDOMETRIAL LESIONS IN RATS: A PRELIMINARY STUDY
Rukset Attar¹, Ozge Kizilkale Yildirim², Gazi Yildirim³, Çigdem Kaspar4, Ferda Ozkan5 and Erkut Attar6
¹Yeditepe University; ²Yeditepe University Medical School, Department of Obstetrics and Gynecology; ³editepe University Medical School, Department of Obstetrics and Gynecology; 4Yeditepe University Medical School, Department of Biostatistics and Medical Informatics; 5Yeditepe University Medical School, Department of Pathology; 6Istanbul University Medical School
Presented By: Rukset Attar

Objective: Endometriosis is a chronic disease which causes pelvic pain. Our aim was to evaluate the effect of vitamin D on surgically induced endometriosis lesions in female nulligravid Sprague-Dawley rats.
Methods: This is a prospective, randomized, controlled, experimental study carried out at Yeditepe University Experimental Research Center (YUDETAM). Three operations were performed on each rat. The induction of endometriosis was performed in the first operation. Endometriosis was surgically induced by using 48 homologous uterine horn transplantation in the 12 ooferectomised rats. At the second operation endometriotic lesions were measured and the rats were divided into two groups: Vitamin D treatment and control group. Vitamin D was given orally for two weeks to Vitamin D group. After two weeks all rats were sacrified and volumes of the endometriotic lesions were measured again. The volumes of the endometriotic lesions at the second and third operations were compared with each other.
Results: The mean volumes were 199.86 ± 132.73 mm3 and 24.38 ± 33.52 mm3 on the 2th and 4 th week i.e. before and after oral Vitamin D treatment, respectively. There was a statistically significant decrease in the volumes of the endometriotic lesions after treatment with Vitamin D ( p<0.05).
Conclusion: Vitamin D treatment caused regression of endometriotic lesions in our experimental study. It seems to be a promising agent for the treatment of endometriosis.
14
Fri
Poster #16
OCCULT INGUINAL HERNIAS CAN CAUSE CHRONIC PELVIC PAIN
Shirin Towfigh¹ and Erfan Zarrinkhoo²
¹Beverly Hills Hernia Center; ²Wake Forest School of Medicine
Presented By: Shirin Towfigh

OBJECTIVES:
1) To analyze the clinical presentation of patients with CPP deemed to be due to occult inguinal hernias.
2) To evaluate the effectiveness of surgical treatment of occult inguinal hernias in curing chronic pelvic pain (CPP).

METHODS: Retrospective review of all patients in hernia database from a single general surgeon with hernia specialty. Prospective followup was performed both in-person and by phone. Patients were chosen based on the following inclusion criteria:
a) diagnosis of CPP, and
b) non-palpable inguinal hernia on examination, and
c) preoperative diagnosis of occult inguinal hernia, and
d) inguinal hernia repair by a hernia specialty surgeon.

RESULTS: Since 2008, 354 patients with CPP and a preoperative diagnosis of occult inguinal hernia underwent inguinal hernia repair. 72% were female. Average duration of preoperative pain was 96 weeks. Clinical presentation included groin/lower quadrant pain radiating around to the back, down the front of the leg, to the upper inner thigh, and/or into the vagina or testicle. On examination, none had a palpable inguinal bulge or reducible mass, and 77% had point tenderness over the internal ring. All patients underwent preoperative imaging to help confirm the diagnosis of occult inguinal hernia. Repair options included open, laparoscopic, and robotic surgery with and without mesh. After inguinal hernia repair, 78% had cure of their preoperative CPP at 2-week follow-up. Average follow-up was 2.2 years, with 87% long-term cure of preoperative CPP.

CONCLUSION: Occult inguinal hernias may cause CPP. Their clinical presentation is often atypical for a hernia, resulting in delay of diagnosis of almost 2 years. The most consistent examination finding is point tenderness over the internal ring. Surgical repair can successfully cure CPP in over ¾ of these patients.

SUMMARY: Most practitioners diagnose an inguinal hernia as a reducible, often non-tender, groin bulge. In contrast, occult inguinal hernias are symptomatic hernias without palpable bulge. Occult inguinal hernias can present atypically with radiating pain, which can be confused for other causes of pelvic pain, such as orthopedic, gynecologic, urologic, neurologic, and gastrointestinal disorders. As a result, diagnosis is delayed on average 2 years. Over ¾ of these occur in females and they are diagnosed with CPP. In our practice, we have developed an algorithm to identify these patients based on high yield questions in their history. Examination is often non-diagnostic. The most sensitive examination finding is point tenderness and vague fullness over the internal ring. Prior to surgery, every patient undergoes imaging to confirm this diagnosis. Surgical repair is tailored to each patient. Most notice an improvement in pain immediately postoperatively, and over ¾ at their 2-week follow-up appointment. Long-term follow-up confirms sustained cure of CPP after inguinal hernia repair. Occult inguinal hernias are underdiagnosed and underappreciated. Heightened awareness of occult inguinal hernia as the cause of CPP can result in early surveillance and successful treatment, thus improving patients’ overall quality of life.
14
Fri
Poster #17
SACRAL ROOT STIMULATION AS A TREATMENT FOR CHRONIC PELVIC PAIN IN FEMALES | A NOVEL CASE STUDY
Sebastian Ksionski and Lynn Miller
Neurosurgeon
Presented By: Sebastian Ksionski

Background: Chronic pelvic pain (CPP) is a prevalent and debilitating condition. In the female population it is the single most common indication for referral to women’s health services accounting for up to 20% of all outpatient appointments in secondary care. Outpatient management of pelvic pain is estimated to cost approximately 881.5 million dollars annually.

Case: We present a case of a female that has chronic lower pelvic pain that underwent ilio−inguinal, illio−hypogastric and superior/inferior hypogastric blocks as well as selected sacral nerve blocks and a lumbar/caudal epidural steroid injections which all provided poor control of her pain. At that point spinal cord stimulation with sacral root stimulation was discussed and the trial was done via a novel approach through a caudal catheter epidural approach. This approach is similar to the Racz procedure for lysis of adhesions so that we could place the leads perpendicular to the nerves versus the traditional retrograde approach. At six months after SCS implantation the patient is able to wean herself completely off of her opiate pain medications and have more energy and feel more functional.
14
Fri
Poster #18
LOCAL LIDOCAINE INJECTION FOR THE TREATMENT OF POSTPARTUM DYSPAREUNIA. A REPORT OF FOUR CASES.
Maria del Rio, Cristina Berdie, Purificación Regueiro and Enric Cayuela
Department Obstetrics and Gyneocology, Hospital General Hospitalet, CSI, Barcelona.
Presented By: Maria del Rio

Background: Postpartum dyspareunia is a common and underreported disorder, persisting after 12 months in about 8% of women. Perineal lacerations and episiotomy can result in sclerotic healing and cause entry and deep dyspareunia. Therapeutic regimens for this condition are scarcely addressed in the literature, and those described such as vaginal estrogens, physical therapy or scar surgery have shown weak evidence.
Objective: Demonstrate the feasibility, acceptability, and pain outcomes of local lidocaine vaginal injection as a treatment for postpartum dyspareunia.
Methods and results: Four patients with de novo dyspareunia at 6-24 months after vaginal delivery with episiotomy and no other perineal lacerations who had failed conservative management with vaginal estrogens and lubricants were offered vaginal injection with local anesthetic as a treatment option. The four patients had an homogeneous phenotype. Pain severity when intercourse was determined using a visual analogue scale (VAS 0-10). All cases underwent local injection with lidocaine 0.5% (5 -10 ml) at the site of the episiotomy treating all layers of the vaginal scar. Follow-up was undertaken two weeks after, average pain decreased from 7.25 to 0.5 VAS pain score, three women became essentially pain free, and none required further injections. There were no adverse effects and all cases were well tolerated.
Conclusion: Local injections of corticosteroids and local anesthtetics are accepted treatment methods for chronic pain, although gynecologists rearely consider these therapeutic methods for treating chronic pelvic pain. One group in London reported recently their experience using combined local bupivacaine and steroid injections for chronic perineal and vaginal pain after vaginal surgery, with significant improvement in pain scores. We report preliminar results of successful therapy of postpartum dyspareunia with just a single local lidocaine injection, which appears to be enough to disrupt the neuropathic pain mechanisms in such cases. Despite our enthusiasm with the reported results, efficacy may be better evaluated with a randomized controlled trial and further studies may give light on the underlying mechanism of local anesthetic in chronic pelvic pain.
Summary: Vaginal local anesthtetics injection with lidocaine 0.5% at the site of the episiotomy can give significant improvements in pain and quality of life in women with perisitent postpartum dyspareunia.
14
Fri
Poster #19
THE DISTINCT ROLES OF SOMATIZATION IN MENSTRUAL AND NON-MENSTRUAL PELVIC PAIN
Kevin Hellman¹, Rebecca Zuckerman¹, Rebecca Silton² and Frank Tu³
¹University of Chicago; ²Loyola; ³NorthShore University HealthSystem
Presented By: Kevin Hellman

Objectives: The specific factors that underlie menstrual and non-menstrual pelvic pain have rarely been examined individually as other studies often group these two pelvic pain categories together. To determine the unique factors involved in these pains as well as the role of neuropsychological factors, such as somatization, depression and anxiety, we performed regression and mediation analyses to elucidate these relationships.

Methods: 1,012 reproductive-aged women completed a 112-item questionnaire with domains including mood, fatigue, physical activity, somatic complaint, and pain. The relationship of dysmenorrhea and non-menstrual pelvic pain to key factors was modeled using linear regression and mediation analysis.

Results: Among women who regularly menstruate (n=834), a Shapley Owen regression model showed that dysmenorrhea is significantly associated with uterine factors, such as heavy bleeding and cramping pain, whereas non-menstrual pelvic pain was primarily associated with somatic complaint (p<0.001). Somatization was a significant mediating factor in the relationship between mood factors like as depression and anxiety and menstrual and non-menstrual pelvic pain (p<0.001).

Conclusion: Given that non-menstrual pelvic pain is often comorbid with dysmenorrhea, failure to perform a separate examination of these populations previously has likely led to an overestimation of anxiety, depression and somatization in dysmenorrhea. Therefore, it is important that clinicians consider uterine factors involved with menstrual pain, without overemphasizing neuropsychological factors. Additionally, proper diagnosis of comorbid non-menstrual pelvic pain will enable the development a directed treatment plan to address the sensory amplification and somatization that is an associated factor. Longitudinal studies are needed to confirm the role of these factors in order to develop targeted treatments.

Summary:

Menstrual pain and non-menstrual pelvic pain each correlated to unique factors, suggesting treatment may require algorithms specific to these factors. Our mediation anxiety and somatization interaction in women with non-menstrual pelvic pain model suggests that targeting anxiety and depression to reduce the effects of somatization in women with non-menstrual pelvic pain may be useful.
14
Fri
Poster #20
INITIAL RESULTS FROM AN OPEN TRIAL OF A MIND-BODY INTERVENTION FOR YOUNG ADULT WOMEN WITH PRIMARY DYSMENORRHEA
Laura Payne, Laura Seidman, Lonnie Zeltzer and Andrea Rapkin
David Geffen School of Medicine at UCLA
Presented By: Laura Payne

Objective: Painful menstruation without an identified cause, known as primary dysmenorrhea (PD) is the leading cause of school and work absences in reproductive age girls and women, with 20-25% of young women reporting significantly impaired functioning because of their symptoms. Despite this high prevalence and significant impact, there are no empirically-supported interventions for menstrual pain aside from hormonal contraceptives and non-steroidal anti-inflammatory drugs. Given shared features among PD and chronic pain conditions, women with PD may also benefit from mind-body approaches to reducing pain and improving functioning. The current study aimed to evaluate the feasibility, acceptability, and impact of a 5-session, group mind-body intervention for young adult women with PD.
Methods: Twenty-one participants with moderate to severe PD, ages 18-24 years, were enrolled in the study across three separate groups. Of these, 5 individuals dropped out (4 before the first session, 1 following the first session) due to scheduling difficulties; 16 participants completed the full course of treatment, which included 5, 90-minute group sessions over the course of 6 weeks. Treatment completers were young adult women (age M=20.32 years, SD=1.87) with self-reported overall menstrual pain of at least 6/10 on a numeric rating scale. All participants completed questionnaires measuring menstrual pain and menstrual symptoms at pretreatment and one month follow-up (follow-up data were used to capture the most recent menstrual period since the termination of the group). Additionally, the treatment credibility and expectancy questionnaire (CEQ), which extant research suggests is positively associated with treatment outcome, was completed after the first session.
Results: Participants rated the treatment highly on the credibility factor of the CEQ (M=20.47, SD=2.48), with an average expected improvement of 48.24%. Overall pain during the first two days of menstruation was significantly lower at one month follow-up (M=6.63, SD=2.22) compared to baseline (M=7.81, SD=1.56), t(15)=2.59, p = .02. Similarly, ratings of worst menstrual pain also significantly decreased from baseline (M=8.31, SD=1.30) to one month follow-up (M=7.19, SD=1.94), t(15)=2.42, p = .029. At one month follow-up, 56.3% of participants reported using mindfulness, 62.5% reported using decatastrophizing, and 93.8% reported using coping skills during their most recent menstrual period.
Conclusion: A group, mind-body intervention focusing on mindfulness, cognitive reappraisal, and enhancing coping shows promise as a non-drug treatment for moderate to severe menstrual pain. The treatment was rated as credible and expected to show improvement in symptoms, and menstrual pain ratings decreased significantly from baseline to one month follow-up. At follow-up, participants reported using primarily coping skills during their most recent menstrual period.
Summary: These data suggest alternative approaches may be helpful for menstrual pain. Future research should continue to systematically evaluate non-drug treatment approaches for this chronic and disabling condition.
14
Fri
3:45 p.m. - 4:20 p.m.
Innovations in the Evaluation and Care of Women with Endometriosis
Speaker:
Catherine Allaire, MD, FRCSC
Women's Health Center
14
Fri
4:20 p.m. - 4:55 p.m.
The Use of Cannabis for Pain Management, Anxiety and Sleep Disorders
Speaker:
Allan I. Frankel, MD
GreenBridge Medical Services, Inc.
14
Fri
4:55 p.m. - 5:10 p.m.
Questions and Answers
14
Fri
5:10 p.m. - 5:30 p.m.
Annual Business Meeting
14
Fri
6:00 p.m. - 8:00 p.m.
2016 IPPS Fundraising Party
Location: Theory Bar and Lounge: 9 W. Hubbard St., Chicago IL 60057
OVERVIEW  
15
Sat
6:15 a.m.-7:15 a.m.
Yoga for Pelvic Pain
Location: Vevey 3 & 4TBD
15
Sat
6:30 a.m.-5:00 p.m.
Registration/Information Desk Open
Location: Zurich Registration Area
15
Sat
7:00 a.m.-8:00 a.m.
Continental Breakfast
Location: Zurich Ballroom ABC
15
Sat
7:00 a.m.-4:00 p.m.
Exhibit Hall Open
GENERAL SESSION  
15
Sat
7:00 a.m. - 7:40 a.m.
Special Morning Lecture: "Neuromodulation for chronic pelvic pain, bowel and bladder dysfunction"
Speaker:
Richard P. Marvel, MD
The Center For Pelvic Pain of Annapolis
15
Sat
7:50 a.m. - 8:00 a.m.
Welcome and Announcements
15
Sat
8:00 a.m. - 8:50 a.m.
JAMES E. CARTER MEMORIAL LECTURE "Chronic Pelvic Pain and the Pelvic Floor Muscles: What is the Evidence?"
Speaker:
Kari Bo, PhD, PT
Norwegian School of Sport Sciences
15
Sat
8:50 a.m. - 9:30 a.m.
Managing the Martians: Male Pelvic Pain
Speaker:
Peter Dornan, AM DIP PHTY, FASMF
University of Queensland
15
Sat
9:30 a.m. - 9:50 a.m.
Questions and Answers
15
Sat
9:50 a.m. - 10:15 a.m.
*Break & Poster Viewing Session
Location: Zurich Ballroom ABC
15
Sat
Poster #3
PAIN CATASTROPHIZING AND QUALITY-OF-LIFE IN WOMEN WITH ENDOMETRIOSIS
Allison McPeak¹, Catherine Allaire¹, Christina Williams¹, Arianne Albert², Sarka Lisonkova³ and Paul Yong¹
¹BC Women's Centre for Pelvic Pain and Endometriosis, University of British Columbia; ²Women's Health Research Institute; ³Child and Family Research Institute, University of British Columbia
Presented By: Allison McPeak

Objective: Our objective was to determine whether pain catastrophizing is associated with health-related quality-of-life in women with endometriosis, independent of potential confounders such as other psychological comorbidities, pelvic pain sub-types, and social-behavioural factors.

Methods: We analyzed baseline cross-sectional data from an ongoing prospective cohort at the BC Women’s Center for Pelvic Pain and Endometriosis (Vancouver, Canada). Inclusion criteria were new referral or re-referral to the Center from December 2013 to April 2015, completion of research questionnaires and physical exam, and a history of surgically confirmed endometriosis. Exclusion criteria were menopausal status, age > 50, menstrual suppression, and not sexually active. The primary outcome was the 11-item core subscale of the Endometriosis Health Profile-30 (0-100%), where a higher score indicates reduced function and poorer quality of life. Potential factors associated with the primary outcome included the Pain Catastrophizing Scale, the Patient Health Questionnaire-9 for depression, and the Generalized Anxiety Disorder-7 questionnaire; the severity of chronic pelvic pain, dysmenorrhea, deep dyspareunia, superficial dyspareunia, dyschezia, and back pain (each rated from 0-10 on a numeric rating scale); stage of endometriosis (I/II vs. III/IV); pain condition diagnoses (e.g. irritable bowel syndrome or painful bladder syndrome); physical exam findings (e.g. body mass index and abdominal wall trigger points); and social-behavioural factors (e.g. age, smoking, education, income). Associations between the factors and the primary outcome were tested with Spearman rank correlation test, Mann-Whitney test, or Kruskal-Wallis test. Factors with a statistically significant association (p < 0.05) were then entered into a multivariable linear regression model. Modelling was performed in R (version 3.2.2) using a stepwise procedure to minimize the Akaike information criterion with p < 0.05.

Results: There were 236 women who met the study criteria. The mean age of the subjects was 35±7 years, and 98 (42%) were Stage I-II, 110 (47%) were Stage III-IV, and 28 (12%) were of unknown stage after review of operative records. The final regression model indicated that worse quality-of-life was independently associated with higher pain catastrophizing (b = 0.54, p < 0.001), greater severity of chronic pelvic pain (b = 1.49, p < 0.001), greater severity of dysmenorrhea (b = 3.16, p < 0.001), and presence of abdominal wall trigger points (b = 5.02, p = 0.033). The remaining variables, including Stage, were not in the final regression model.

Conclusion: Higher pain catastrophizing was associated with worse health-related quality-of-life in women with endometriosis. This association was independent of potential confounders such as depression/anxiety, the severity of pelvic pain, and social-behavioural factors. Interventions to reduce pain catastrophizing should be investigated in women with endometriosis.

Summary: Pain catastrophizing is independently associated with worse health-related quality-of-life in women with endometriosis.
15
Sat
Poster #21
LIFESTYLE BEHAVIORS AS PREDISPOSING FACTORS IN THE ONSET OF INTERSTITIAL CYSTITIS/PAINFUL BLADDER SYNDROME
Karen Gilbert, Cindy Hayden and Phyllis Bryden
Eastern Kentucky University
Presented By: Karen Gilbert

Objective: To identify lifestyle behaviors and health conditions among women with Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) and to investigate how those factors may be associated with the onset of IC/PBS.

Methods: An eighteen-question survey was posted on a U.S. national interstitial cystitis association website. Data was analyzed from 502 women self-reporting symptoms of IC/PBS. SPSS was used for data management and analysis.

Results: Respondents were 18 to 86 yrs. of age, and were predominately white (95%). Almost all (96.6%) had been diagnosed by a medical professional as having IC/PBS. The mean age when symptoms first occurred was 34.6 yrs.; however, average age at diagnosis was 41.4 yrs. Most respondents (78.8%) had no biological relatives diagnosed with IC/PBS and 63.3% denied smoking cigarettes. A statistically significant proportion of women surveyed reported they drank coffee (² (1,n=502) =35.77,p<.0001; 51.6%)
consuming 1-2 cups/day. A statistically significant proportion (66%) reported drinking soft drinks, ² (1,n=502)= 50.996,p<.0001; 49.4% drinking 1-2 twelve-ounce soft drinks/day. Beverages were characterized as being: sugar-sweetened (47.6%), artificial-sweetened (43.6%), caffeinated (39.2%), and decaffeinated (19.7%). A significant proportion (90.8%) of study participants reported diagnoses of Urinary Tract (UTI)/Bladder Infections, ² (2,n=502)= 749.7,p<.0001): 34.9% reported 1–5 occurrences, 18.1% reported 6–10, 16.5% reported 11–20, and 21.7% reported 21 or more. When asked how long birth control pills and/or hormone replacement therapy was used, 14.5% of respondents denied any use, 27.5% reported using for 1–5 years, 21.1% for 6–10 years, 21.5% for 11–20 years, 11.4% for 21–30 years, and 3.2% used hormones for 31 or more years. Comorbid health conditions reported were: Irritable Bowel Syndrome (IBS): 41.8%; seasonal allergies: 63.9%, ² (1,n=472)= 61.229,p<.0001); Celiac Disease/gluten sensitivity:12.0%; Chronic Fatigue Syndrome: 12.9%; Fibromyalgia: 24.5%; and Pelvic Floor Dysfunction: 41.2%.

Conclusion/Summary: Professional literature regarding the etiology of IC/PBS is scarce. The mean time between first symptoms and diagnosis reported by study participants was 6.7 yrs. This indicates that recognition of symptoms could expedite diagnosis and help women get treatment sooner. Our results did not support a genetic component; a statistically significant number of respondents denied any close relatives had also been diagnosed with IC/BPS, ² (1, n=502)=158.41,p<.0001). However, since 13% didn’t know relatives’ IC status, more research is needed to highlight the role genetics play in this disease. Study results indicate a notable comorbidity of seasonal allergies in patients with IC/PBS and prevalence of a history of UTIs was high. Other potentially related comorbidities did not show a high prevalence in study participants. These results indicate a continued need for more research into the causes of IC/PBS for facilitation of earlier diagnosis and treatment.
15
Sat
Poster #22
IMPAIRMENT IN SEXUAL FUNCTION, DEPRESSION AND ALEXITHYMIA IN WOMEN WITH CHRONIC PELVIC PAIN
Alix Aboussouan, Nicolas Thompson and Kelly Huffman
Cleveland Clinic
Presented By: Alix Aboussouan

Treatment of impairment in sexual function is essential to managing Chronic Pelvic Pain (CPP). Little is known about best treatment practices. Guidelines recommend an interdisciplinary approach and preliminary research suggests that treatment of alexithymia and depression may improve outcomes. The current study examines the utility of an interdisciplinary Chronic Pain Rehabilitation Program (iCPRP) in treating impairment in sexual function, depression and alexithymia in women with CPP. Our specific aims were to 1) examine impairment in sexual function, alexithymia, and depression in women with and without CPP 2) determine if women with CPP equally benefit from treatment and 3) examine factors predicting improvement in sexual function. This study was a retrospective analysis of an IRB approved data registry. Participants were 63 women with CPP treated in a 3-4 week iCPRP between 2011 and 2015 matched by age and treatment date to women with other chronic pain conditions. Treatment included medication management, weaning from habituating medications, occupational/physical therapy, individual, group and family therapy. Participants were 87.30% white and 50.00% married, with a mean age of 41.64(±12.90). 92.9% had multiple chronic pain conditions. Impairment in sexual function, alexithymia and depression were measured with the sexual behavior subscale of the Pain Disability Index, the Toronto Alexithymia Scale, and Depression, Anxiety, and Stress Scale respectively. Unadjusted models (ANOVA) comparing group differences showed that women with CPP had higher baseline levels of depression (p<.05) and discharge levels of impairment in sexual function (p<.05) and no other group differences. Three linear mixed models, with a random intercept adjusted for marital status, examined treatment outcomes in impairment in sexual function, alexithymia and depression. Time, group and interaction terms were included as fixed factors. Results showed robust improvements across all three dimensions (p<0.01). Women with CPP reported greater improvements in depression (p<.05) and there were no group differences in outcomes. Two hierarchical linear regressions, one for women with CPP and one without, examined factors predicting post treatment impairment in sexual function. Baseline scores and marital status were included in step one and change scores for depression and alexithymia in step two. Only pre-treatment impairment in sexual function predicted outcomes for women without CPP. In women with CPP improvements in alexithymia and depression significantly improved the predictive power of the model and predicted post treatment levels of sexual impairment (p<.05). Results show that women with CPP benefit from treatment in an iCPRP and even report greater improvements in depression. Unadjusted analyses shows that while women with CPP do equally benefit from treatment, they continue to report higher post treatment impairment in sexual function. Depression and alexithymia appear to be important predictors of outcome in women with CPP. Future research should examine whether treating these comorbidities can improve treatment outcomes in women with CPP.
15
Sat
Poster #23
IS DEGREE OF RELIGIOSITY RELATED TO THE PREVALENCE OF DYSPAREUNIA IN A POPULATION?
Insiyyah Patanwala¹, Megan Mizera², Matthew Fisk³ and Georgine Lamvu4
¹Department of Obstetrics and Gynecology, Florida Hospital, Orlando; ²University of Central Florida College of Medicine; ³Florida Hospital, Orlando; 4Gynecologic Surgery and Pelvic Pain Specialist, Orlando VA Medical Center
Presented By: Insiyyah Patanwala

Objective: To assess whether increasing degree of religiosity corresponds to a change in prevalence of dyspareunia.

Design: Cross-sectional survey study. A survey with twenty-four questions was designed which incorporated the Duke Religiosity Index (DRI) questionnaire and questions about dyspareunia, attitudes towards sex, and demographic information. The DRI measures organizational religiosity, non-organizational religiosity, and intrinsic religiosity.

Results: A total of 843 surveys were collected: 673 women reported no dyspareunia, 160 women did report dyspareunia, and 10 surveys had missing data regarding experience of dyspareunia. Our results indicate that there is no significant difference in degree of organized religiosity (p=0.41), non-organized religiosity (p=0.10), nor intrinsic religiosity (p=0.69) among women with or without dyspareunia. There was also no difference in the prevalence of dyspareunia among subjects who grew up with religion versus those who did not (18.7% vs 22.6%, p= 0.33). However, women who were taught to wait until marriage before having intercourse and women who were taught that sex is bad while growing up had an increased likelihood of reporting dyspareunia compared to those who were not taught this (21.3% vs 13.0% p=0.006 and 26.7% vs 15.2%, p<0.001, respectively).

Conclusion/Summary:
A large cross-sectional survey study was completed with a 19.2% prevalence of dyspareunia among the population. While degree of religiosity was not shown to be associated with the prevalence of dyspareunia, women who were taught sex is bad or to wait until marriage before having sex when they were growing up may be at higher risk of experiencing painful intercourse.
15
Sat
Poster #24
HIP AND GROIN PAIN IN CYCLIST RESOLVED AFTER PELVIC FLOOR FASCIAL MOBILIZATION TREATMENT – A CASE REPORT
Sivan Navot and Leonid Kalichman
Ben-Gurion University of the Negev, Beer-Sheva, Israel
Presented By: Sivan Navot

Introduction
We present herein, a 32-year-old male professional cyclist, exhibiting right hip and groin pain during cycling and prolonged sitting without complaints of pelvic floor dysfunctions. After receiving several series of conventional physical therapy for the hip/groin pain, which resulted in pain relief and slight improvement of hip range of motion, pelvic floor muscles and fascia involvement were subsequently assessed and treated by Pelvic floor fascial mobilization (PFFM). Developed (by S.N.), PFFM aims to evaluate and treat restrictions in fascial movement in the pelvic floor area (per vagina and per anus). PFFM technique is associated with the sequences and movement planes of Stecco's Fascial Manipulation® technique, relying on similar main principles: Myofascial units, body segments, centers of perception, centers of coordination, centers of fusion, movement plans and myofascial sequences. Currently we completed dozens of successful treatments of groin/hip/pelvic/pelvic-floor pain and dysfunction that where treated with PFFM approach.
Aim
The aim of this case report was to demonstrate the importance of the pelvic floor myofascial assessment in cases of hip/groin pain as well as to propose PFFM as an optional treatment technique for both hip/groin and pelvic floor pain or dysfunction.
Case Report
32 y/o male professional cyclist, with complaints of Rt. hip and groin pain during cycling and prolonged sitting, which commenced after a Rt. Hip severe contusion (2013), with no complaints of pelvic floor dysfunctions. The patient received several rounds of conventional physical therapy, including myofascial release, dry needling, mobilizations of the hip joint, stretching and therapeutic exercises, with partial pain relief and slight improvement of hip range of motion. Initial evaluation: Significant limitation of Rt. Hip internal rotation (30°), impaired contraction of pelvic floor muscles during both active contraction and anticipative reaction to increasing in intra-abdominal pressure during cough. High resting tone and painful palpation of Rt. Obturator internus and Rt. Iliococygeous, and mild elevated resting tone of Lt. Obturator internus.
Intervention
PFFM floor include manual friction over the densified fascial points in combination with active motion of the hip joint. 2 treatment sessions which included internal PFFM over 2 fascial restricted points and 4 "external" fascial restricted points.
Follow-up examinations
After the first session immediate significant difference was noticed in hip joint range of motion (60°) and the pelvic floor muscle function in both, active recruitment and anticipated contraction. Pain was decreased by 80%. After 2 sessions, treatment was finished completely because patient was pain free and returned to usual sport and work activity.
Conclusions
Results of this case report as well as of many other successful treatments gives us a reason to claim that PFFM can be used as effective tool for treatment for musculoskeletal pain and dysfunction in pelvic, hip or lower limb area. Additional studies are needed to evaluate the effectiveness of this method in different conditions.
15
Sat
Poster #25
THE IMPORTANCE OF THE VAGINAL PELVIC FLOOR MUSCLE EXAM FOR WOMEN WITH LUMBAR/PELVIC GIRDLE PAIN
Arianna Griffin, Tanaka Dune, Elizabeth Gunnar, Elizabeth R. Mueller, Cynthia Brincat, Linda Brubaker and Colleen Fitzgerald
Loyola University Medical Center - Stritch School of Medicine
Presented By: Arianna Griffin

Objectives: To determine the frequency of pelvic floor myofascial (PFM) pain during vaginal examination in women with lumbar and/or pelvic girdle pain.

Methods: Comprehensive chart review of new patients presenting to the Female Pelvic Medicine and Reconstructive Surgery’s pelvic pain clinics over a two year period (2013-2014). Data extraction included demographics at initial patient evaluations with documentation of patient pain symptoms and physical exams.

Results: The cohort of 179 women had an average age of 44.7±16.1 years, an average body mass index of 27.1±7.0 kg/mg2; most (79.0%) were White. Most patients presented with a chief complaint of pelvic (30.7%), vulvovaginal (15.6%) or back (9.5%) pain; 9.5% reported laterality for the chief pain complaint. About one third (30.7%) had pre-existing pain syndromes [endometriosis (34.5%); fibromyalgia (29.1%); arthritis (38.2%); migraine (18.2%)]. Polypharmacy was common with over half (58.2%) of the women taking at least one pain medication [1 med (47.6%), 2 meds (30.1%), 3 meds (12.6%), 4 meds (9.7%)].

Eighty-three percent of patients who reported low back and/or pelvic girdle pain also presented with complaints of vaginal pain. Of women reporting a history of vaginal pain, 80.7% were found to have low back and/or pelvic girdle pain on physical exam. Also on exam, a large number of women (96.1%) were found to have both vaginal PFM pain and low back and/or pelvic girdle pain. Patients who reported symptoms of low back or pelvic girdle pain were more likely to have pain on vaginal PFM exam than patients without this history (OR, 7.24; 95% CI, 1.95-26.93, p=0.003). The majority (86.1%) of patients with vaginal PFM pain on exam described their pain as bilateral. Predominance of lateralized pain was found in 20.1% (right) and 10.4% (left) of patients with vaginal PFM pain.

Conclusions: The vaginal pelvic floor muscle examination is high yield, as most patients with lumbar and/or pelvic girdle pain have vaginal PFM pain on exam even when they do not report vaginal symptoms. Most women had diffuse bilateral PFM pain. The vaginal PFM examination should be an essential part of the physical examination of all women with lumbar and/or pelvic girdle pain and considered as a potential therapeutic target.
15
Sat
Poster #26
TITLE: MECHANICAL LOW BACK PAIN: AN ORTHOPAEDIC PROBLEM, A UROGYNECOLOGICAL PROBLEM, OR BOTH?
Sinead Dufour¹, Carolyn Vandyken² and Brittany Vandyken¹
¹McMaster University; ²Pelvic Health Solutions
Presented By: Carolyn Vandyken

Background: Low back pain represents the number one cause of disability in the world with direct and indirect worldwide costs of billions of dollars each year. The prevalence and cost continue to rise despite the wide range of available therapeutic interventions, indicating a deficiency in current approaches.
Objectives: The purpose of this study was to determine the prevalence and type of pelvic floor dysfunction among women with mechanical low back pain to better understand the relevance of pelvic floor rehabilitation herein. Based on recent European research, we hypothesized that pelvic floor dysfunction, specifically hypertonicity, to be positively correlated with mechanical low back pain.
Methods: In this prospective cross−sectional study, a total of 182 subjects were recruited from October 2014 until March 2016. Following informed consent, potential participants underwent a screening process to match inclusion and exclusion criteria. As such, participants that had features of central sensitization (Pain Catastrophizing Scale score > 30) or radiculopathy were excluded. Furthermore, refusal to complete an internal exam also translated to exclusion. A total of 82 subjects were excluded, leaving 100 subjects who completed the lower back and pelvic assessment: a mechanical low back screen using the McKenzie protocol; a series of Pelvic Girdle Pain screening tests; an internal pelvic exam (digital palpation). Additionally, participants completed the Oswestry Low Back Disability Questionnaire and were asked to self-report symptoms of pelvic floor dysfunction including urinary and fecal incontinence, chronic constipation, prolapse and pelvic pain.
Results: This sample (N=100) had a mean age of 41.6 years old (SD + 13.51). Of these, 96% (96/100) were determined to have some form of pelvic floor dysfunction by internal palpation. Specifically, 84% (84/100) of the participants had components of hypertonicitiy. Further, the digital exam of the pelvic floor was 100% congruent with the self−reported indications of pelvic floor dysfunction. Interestingly, 18.7% (34/182) of potential subjects were excluded from the study during the screening phase due to their score on the Pain Catastrophizing Scale. This finding is beyond the scope of this present study, but has important implications related to the importance of screening patients, utilizing a biopsychosocial approach when treating chronic low back pain.
Conclusions: Our findings corroborate and extend the findings of recent research supporting the hypothesis that pelvic floor dysfunction is highly correlated with mechanical lower back pain, particularly hypertonicity.
Summary: Movement towards a more comprehensive approach to better address the various features that influence mechanical lower back pain warrant further attention. Addressing pelvic floor dysfunction may be an appropriate strategy when treating mechanical low back pain. Repeated and sustained contractions of pelvic floor muscles and their synergists may represent a less than optimal treatment strategy when strengthening the trunk for mechanical low back pain in women.
15
Sat
Poster #27
WHAT MAKES A CHRONIC PELVIC PAIN PATIENT SATISFIED WITH THEIR CARE?
Jenna Miller, Nicole Bush, Isabel Green, Lois McGuire and Dan Breitkopf
Mayo Clinic, Rochester
Presented By: Jenna Miller

Introduction: Evaluating and treating females with chronic pelvic pain can be challenging and taxing for both the patient and provider. Many patients describe poor interactions with previous healthcare providers for their pain. A Chronic Pelvic Pain Clinic was established in a large academic institution to both improve patient care and provider experience with chronic pelvic pain patients. To better evaluate quality and patient satisfaction in the new clinic, we sought to identify what aspects of the health care visit contribute to patient satisfaction in female chronic pelvic pain patients.
Objective: The aim of this study was to qualitatively analyze what aspects of the healthcare visit contribute to patient satisfaction with evaluation and treatment of pelvic pain.
Methods: A survey was given to patients at the end of their visit in the Chronic Pelvic Pain Clinic. The data were collected from January to June of 2016. All female patients scheduled and seen in the integrated Chronic Pelvic Pain Clinic were eligible. No identifying information was utilized. This survey included the question:
When visiting a health care provider to talk about your pelvic pain, what are important factors that impact your satisfaction with the visit/care?
An inductive thematic analysis of responses to this question was performed. A coding process was utilized to identify themes of patient responses to determine the 8 themes described. The study received IRB exemption.
Results: 55 out of 131 patients scheduled in the clinic during this time period completed surveys. Identified themes included: being listened to, providers with caring and compassionate attitudes, acknowledgement and validation of pain concerns, overall plan of care including multiple treatment options and coordination of care with other providers, quality time spent with patient as well as being timely, knowledgeable providers who are aware of patient history, and overall good communication skills. Only 2 respondents commented on pain relief as a factor for satisfaction with their care.
Conclusion: The majority of patients surveyed reported themes of quality communication and patient-provider interactions as factors improving their satisfaction in the clinic, while few reported “relief of pain” as a contributor to satisfaction.
Summary: Treating chronic pelvic pain can be challenging. Understanding what makes a patient satisfied with their care could improve their overall quality of care. In this inductive thematic analysis, patients reported more satisfaction with their care when they are being actively listened to, when providers display a caring and compassionate attitude, and when providers acknowledge and validate their pain. These patients also appreciate knowledgeable providers and the discussion of multiple treatment options. Time spent, good communication skills, knowledge of patient history, and coordination of care were also mentioned by multiple patients as important factors for their satisfaction. Interestingly, few patients reported relief of pain as a satisfier. Data collection is ongoing.
15
Sat
Poster #28
PREVALENCE OF PSOAS MYOFASCIAL DYSFUNCTION IN MALES REFERRED TO PHYSICAL THERAPY FOR TESTICULAR PAIN.
Dawn Underwood and Nicole Cookson
Presented By: Dawn Underwood

Objective: Chronic testicular pain can be considered as part of chronic pelvic pain syndrome (CPPS) for males. Chronic testicular pain is a challenging disorder to treat. Diagnosis and therapeutic interventions can be allusive. Treatment of testicular pain continues to be challenging due to multiple etiologies and variable treatment outcomes. Review of urological literature reveals first line conservative treatments typically include NSAIDS, scrotal support and limited activity. The purpose of this study is to present the prevalence of psoas myofascial dysfunction in males referred to pelvic physical therapy (PT) with testicular pain and present PT as an additional conservative treatment option.
Methods: A retrospective chart review of males referred to pelvic physical therapy (PT) from 1/1/14 to 12/31/15 was performed. Records from 3 treating pelvic PTs at a tertiary medical center were included. Correlation between musculoskeletal examination by a physical therapist and the patient’s complaint of testicular pain, were assessed.
Results: Chart review revealed 57 males referred to PT from Urology with a variety of urological/pelvic concerns. Of these 57 males, 19 were sent specifically for testicular pain, 17 of which were found to have positive psoas myofascial dysfunction on exam.
Discussion/Summary: Chronic testicular pain can be considered as part of chronic pelvic pain syndrome (CPPS). Treatment of testicular pain continues to be challenging due to multiple etiologies and variable treatment outcomes. Conservative treatment is first line, which historically has been NSAIDS, scrotal support and limited activity. We have found that a high percentage (89%) of men referred to PT for pelvic pain, specifically testicular pain, also have psoas myofascial involvement on the same side as the pain. We would urge the urological community to consider myofascial components when faced with a patient with chronic testicular pain. Potential referral to PT could be added to the list of conservative treatments.
15
Sat
Poster #29
PREVALENCE OF DYSPAREUNIA AND VULVODYNIA IN A COLOMBIAN CLINIC SAMPLE
Ana-Lucía Herrera-Betancourt¹, Georgine Lamvu², José-Duván López-Jaramillo¹, Jorge-Darío López-Isanoa¹ and Juan-Diego Villegas-Echeverri¹
¹Advanced Laparoscopy and Pelvic Pain Center at Clinica Comfamiliar, Pereira, Colombia; ²Gynecology Section, Division of Surgery, Orlando VA Medical Center, Orlando, USA
(Presented By: Ana-Lucía Herrera-Betancourt)
ALGIA

Background: Vulvodynia affects nearly 18% of women in the United States, but its prevalence across the word is unknown.
Objective: Our goal was to report on the prevalence of vulvodynia in a population sample of Colombian women.
Study Sample: Women seen in the Clinica Comfamiliar in Pereira Colombia; a clinical setting that specializes in providing inpatient, surgical and outpatient ambulatory services to women with a variety of benign gynecologic disorders. The clinic provides primary care services as well as specialized care for women with complex disorders such as chronic pelvic pain.
Study Design: Cross-Sectional Survey
Methods: A survey was specifically created for this project to collect information on participant demographics, medical history, and sexual history. The survey contained Harlowe’s screening questions that were designed to screen women for vulvar, vaginal or genital pain lasting longer than 3 months. The survey was administered in an anonymous and confidential manner to all women that were seen in the Clinica Comfamiliar inpatient and outpatient areas and who agreed to participate in the survey. The survey was administered from September 2014 to February 2015. This study was approved by local the ethics and research institutional review board.
Results: The survey was offered to 603 women, 20 women refused to participate in the survey. Of those who agreed to participate, 582 completed the survey. The mean age of this population was 38.1 years (11.5), 63.0% were in long term relationships or married and 36.9% were single, separated or widowed. Eighty two percent of women completed high-school or higher level of education. Of the 582 that completed the survey, 490 women completed Harlow’s questionnaire that screened for genital pain; 27.5% (95%CI: 23.7-31.7) reported pain in the genital area lasting longer than 3 months; 24.1% (95%CI: 20.4-28.2) also reported burning pain and 18% (95%CI: 14.8-22.1) reported sharp stabbing pain. Overall, 66.3% (95% CI: 61.8-70.5) reported having pain during intercourse.
Conclusion: In this sample of patients attending a gynecologic clinic in Colombia, the prevalence of painful intercourse (dyspareunia) and perhaps vulvodynia is higher or at least comparable than estimates reported in the United States. As such, the incidence of these disorders and the impact it has on Colombian women and society deserves further study.
15
Sat
Poster #30
PHYSICAL THERAPY FOR CHRONIC SCROTAL CONTENT PAIN WITH ASSOCIATED PELVIC FLOOR PAIN ON DIGITAL RECTAL EXAM
M. Ryan Farrell¹, Sheila Dugan² and Laurence Levine¹
¹Department of Urology, Rush University Medical Center; ²Department of Physical Medicine and Rehabilitation, Rush University Medical Center
Presented By: M. Ryan Farrell

Introduction: Chronic scrotal content pain (CSCP) is a common condition that can be challenging to manage definitively. A cohort of patients with CSCP have referred pain from myofascial abnormalities of the pelvic floor and therefore require treatment modalities that specifically address the pelvic floor such as pelvic floor physical therapy (PFPT).
Objective: To describe our longitudinal experience with PFPT for patients with a pelvic floor component to CSCP.
Methods: We conducted a retrospective chart review of all men with a pelvic floor component of CSCP presenting to our tertiary care medical center and undergoing PFPT from 2011-2014. CSCP was defined as primary unilateral or bilateral pain of the testicle, epididymis and/or spermatic cord that was constant or intermittent, lasted greater than 3 months, and significantly interfered with daily activities. Duplex scrotal ultrasound was performed on all patients. Individuals with anatomic abnormalities including varicocele and hydrocele were excluded. Urinalysis, urine, and semen cultures were collected if indicated. Patients with evidence of infection were excluded. 360° digital rectal exam (DRE) was performed on all patients to identify a pelvic floor component to CSCP and involved application of gentle pressure to the pelvic floor muscles. Patients were requested to note areas of particular tenderness or radiation of pain to the scrotal contents that resembled the pain noted at initial presentation. Individuals with CSCP and pain on pelvic floor evaluation with 360° DRE were referred to a single pelvic floor physician specialist who established the PFPT regimen and coordinated appropriate referral to physical therapists for PFPT. Long-term follow-up was conducted by office visit and physical therapy chart review.
Results: Thirty patients with a mean age of 42 years (range 18-75) were followed for a median of 13 months (range 3-48). Median duration of pain at presentation was 24 months (range 3-300). Pre-PFPT pain score was 6/10 (range 2-10). After a mean of 12 PFPT sessions (IQR 6-16), pain improved in 50.0% of patients and median decrease in pain was 4.5/10 (range 1-10). Complete resolution of pain occurred in 13.3% and 44.0% had none to minor residual pain. The proportion of patients reporting none to minor residual pain was not different between those with pain exacerbated by voiding (41.7%) and those without (44.0%; p=1.00). The odds of pain improvement following PFPT was increased when pain was elicited at 2 or fewer scrotal content structures during initial physical exam (OR=14.0, p<0.01). Following PFPT, fewer subjects required pain medication compared with prior to PFPT (44.0% vs. 73.3%, p=0.03).
Conclusions: For men with CSCP and tenderness noted on pelvic floor exam with 360° DRE, we recommend a trial of PFPT as an effective and non-operative treatment modality. Our cohort had a significantly reduced need for pain medication and 44% of patients had none to minor residual pain.
15
Sat
Poster #31
PARTNERING TO TREAT MALE PELVIC PAIN: PELVIC FLOOR PHYSICAL THERAPY AND THE APRN
Kathryn Curry¹, Jeananne Elkins¹ and LaMicha Hogan²
¹Northeastern University, Boston, MA; ²Texas Tech University Health Sciences Center
Presented By: Kathryn Curry

Chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is a chronic, costly and at times, debilitating condition difficult to manage in both specialty and primary care settings. Though the condition is often best diagnosed through urology specialty practices, patients often utilize the primary care setting as a first point of contact to seek relief of symptoms, and primary care providers may serve to manage the condition until a referral to urology is possible. A growing sector of primary care providers encountering this population are advanced practice registered nurses, also known as nurse practitioners (APRNs). While knowledgeable concerning the screening of male patients presenting with urinary symptoms, there may presently be a lack of knowledge among APRNs regarding the use of the UPOINT classification system guidelines and other non-pharmacological methods to provide symptom relief from those suffering CP/CPPS. The purpose of this study was to assess APRNs awareness of the medical management of males with CP/CPPS in 3 rural, West Texas communities, their utilization of current guidelines for the UPOINT classification system, and knowledge of other treatment modalities, specifically pelvic floor physical therapy (PFPT), as a means to support men diagnosed with CP/CPPS.
Objective: To assess APRN awareness and treatment knowledge of CP/CPPS in males in 3 rural, West Texas communities.
Methods: An anonymous, electronic survey questionnaire was administered to 135 APRNs located in 3 separate West Texas communities. The survey as part of a pilot study, surveyed APRNs educational and practice backgrounds, knowledge of guideline treatment of males with CP/CPPS symptoms, and familiarity with PFPT for those suffering CP/CPPS.
Results: The response rate was 31.8% (43 out of 135 respondents). Of those surveyed, roughly 49% reported current practice settings in family practice and community health. 46.15% reported having no knowledge at all regarding assessing adult males with CP/CPPS with over 90% stating never having used the UPOINT classification system. 94.44% of APRNs surveyed were not aware of the role of PFPT in the treatment of males with CP/CPPS.
Conclusion/Summary: Study findings of APRNs in West Texas concurred with other studies of PCPs, primarily MDs, regarding knowledge deficits and barriers to assessing, treating and locating resources for men with CP/CPPS. Also, a significant lack of awareness regarding PFPT identified among these APRNs suggests that continuing education on the multimodal approach to CP/CPPS is needed. Recommendations for team collaboration between PFPTs and APRNs are discussed.
15
Sat
Poster #32
A RETROSPECTIVE SINGLE CENTER STUDY OF VULVOSCOPIC FINDINGS, FEMALE SEXUAL FUNCTION INDEX (FSFI) SCORES AND HORMONAL BLOOD TEST VALUES IN MENOPAUSAL WOMEN WITH FEMALE SEXUAL DYSFUNCTION PRE- AND POST-HORMONAL TREATMENT
Stephanie daSilva¹ and Irwin Goldstein²
¹UCSD; ²Alvarado Hospital
Presented By: Irwin Goldstein

Objectives: Signs and symptoms of menopause associated with estradiol deficiency include dryness, burning, thinning, itching, urinary frequency and dyspareunia. Menopausal symptoms associated with testosterone deficiency include diminished sense of well-being, reduced muscle and bone mass, provoked vestibulodynia, and decreased sexual desire, arousability, and orgasmic pleasure. The hypothesisis is that with both high patient adherence and close health care provider monitoring, hormonal management will lead to subjective and objective improvements in signs and symptoms of genitourinary syndrome of menopause (GSM).
Materials and Methods: This study evaluated clinical benefit of hormonal replacement strategies for management of sexual dysfunction and GSM utilizing pre- and post-treatment blood test monitoring, FSFI scores and vulvoscopy findings. A chart review from August 1, 2007 through December 1, 2015 was performed. Bioidentical hormonal therapy is designed to keep serum estradiol levels 35 - 50 pg/ml, serum progesterone levels at 1.0 ng/ml and calculated free testosterone levels at 0.8 ng/dl including daily topical vestibular and vaginal estradiol and testosterone applications. Subjects included were naturally or surgically peri-menopausal or post-menopausal at their initial visit, with both an initial and at least one follow-up vulvoscopy. Exclusions included cosmetic vulvar or vestibular surgery.
Results: 110 menopausal women (mean age 62 +/- 13 years) with sexual health complaints met study criteria. Mean follow-up was 2.6 +/- 1.3 years. Pre-treatment vulvoscopic findings of resorption of labia minora, telescoping of the urethral meatus, clitoral atrophy, vestibular erythema, tenderness and pallor, minimally robust peri-urethral tissue, minimal vaginal rugae with thin, pale vaginal mucosa and abnormal vaginal pH were noted in 100%. In 81% of women, serum sex steroid values returned to ideal values. In 72% FSFI total scores increased more than 5 points. In 63% post-treatment vulvoscopic changes revealed pink, moist, pain-free vestibular tissue. Conclusion: Hormonal management of menopause with good patient adherence and close monitoring has lead to subjective and objective improvement of female sexual function
Summary: Vulvoscopy supports vestibular changes post menopause and post estradiol treatment.
15
Sat
Poster #33
THE EFFECTS OF EXERCISE THERAPY ON PAIN THRESHOLD IN WOMEN WITH CHRONIC PELVIC PAIN
Arthur Zecchin-Oliveira¹, Omero Poli-Neto¹, Mariana Cecchi¹, Antônio Nogueira¹ and Julio Silva²
¹FMRP-USP; ²FMRP
Presented By: Arthur Zecchin-Oliveira

Objective: Chronic pelvic pain (CPP) is a prevalent condition between women. Many factors are involved and, frequently the symptoms control is hard. One of the presupposes for it is the pain threshold in these women is lowered when compared with healthy women. Beyond the base disease treatment, several adjuvant measures has been proposed for the pain relief, particularly the ones which aren’t pharmacological. By the way, the physical exercise, either aerobic or anaerobic, has been associated with increasing pain threshold over chronic painful subjects and, thereby, recommended as adjuvant measure. Curiously, there is no data in the literature evaluating the physical exercise interference on pain threshold in women with CPP. Based on these data the study objective is to verify if the resistance training changes the peripheral pain threshold in women with CPP.
Methods: Open trial , randomized pragmatic. Were included 20 women with CPP and 20 healthy women. CPP group were selected at the gynecologic ambulatory of pelvic pain (at the Hospital of the University of São Paulo). The resistance training occurred during a week (two sessions). The training consisted the subjects realize a strength test before the workout, the 9RM test (9 maximum repetition) and, after test were realized 4 sets of 15 repetitions with 40% at 9RM intensity, within 1 minute interval between the sets. The exercise choose was the extensor chair. It was measured pain thresholds through pression (algometry) immediately before, immediately after, 10 minutes after and 20 minutes after the intervention. The paring was done only by age (to avoid the hyper-paring phenomenon). All the other psychometric measurement instruments to be use are translated and validated to Brazil. The study was evaluated and accepted by the ethical committee in research of HCFMRP-USP. There are consent of all sectors involved.
Results: Project waiting statistical analysis and the pain threshold present in the study sample.
Key words: Chronic Pelvic Pain, Pain Threshold, Exercise.
15
Sat
Poster #34
GAIT ASSESSMENT OF WOMEN WITH CHRONIC PELVIC PAIN
Mariana Cecchi Salata, Paulo Ferreira dos Santos, Patrícia Silveira Rodrigues, Arthur Zecchin, Fernando Vieira, Rogério Ferreira Liporaci, Carla Andrea Caldas, Daniela Cristina Carvalho de Abreu, Antônio Alberto Nogueira, Júlio César Rosa e Silva and Omero Benedicto Poli-Neto
Ribeirão Preto Medical School - University of São Paulo
(Presented By: Mariana Cecchi Salata)
USP

OBJECTIVES: Chronic pelvic pain (CPP) is a common condition of complex etiology and poorly understood. There is evidence that the musculoskeletal system may be compromised although studies evaluating the motion pattern of this group are poorly. The aim of this study was to evaluate objectively the progress of women with CPP through kinematic and spatiotemporal variables and verify possible correlations of the changes found. METHODS: A cross-sectional cohort study included 20 women with CPP diagnosis, who were recruited at the Hospital of the University of São Paulo, and 20 healthy volunteers (control group). We used the three-dimensional gait analysis to obtain data on the range of motion, range of movement, moment and power of the pelvis, hip, knee, ankle and foot segments, and spatiotemporal variables. The nonparametric Mann-Whitney test was used to compare the distribution of the groups in relation to quantitative variables, and the Spearman correlation was used between the variables that showed a significant difference and the variables with TAMPA (kinesiophobia scale), VAS (visual analogue scale), time pain, McGill (pain measurement tool) and HAD (measure scale anxiety and depression). RESULTS: Women with CPP present changes in gait when compared to the control group. Kinematic variables compromised were: extension moment, flexion and internal rotation of the hip; flexion, extension, internal and external rotation of the knee; dorsiflexion and adduction of the ankle and internal and external foot rotation; power hip and ankle; deviation of motion valgus and varus knee, dorsiflexion and plantar ankle flexion and range of movement knee extension to flexion and dorsiflexion plantar ankle flexion. Already spatio-temporal variables altered were: gait speed, leg length and Step. We note occurrence of any correlation, but unsystematic. CONCLUSION: Women with CPP have gait changes compared to healthy women, and the most significant refer to kinematic and spatiotemporal variables. We note possible correlations, but not systematic in our sample. These findings suggest the need for further evaluation, in order to get better more effective diagnosis and treatment.
15
Sat
Poster #35
THE EFFECTS OF ENDOMETRIAL RADIOFREQUENCY CAUTERIZATION FOR THE TREATMENT OF HYPERMENORRHEA
HanKyung Kim, Hyuk Jung and Satbyul Kim
Chosun univ. hospital
Presented By: HanKyung Kim

Objective: To evaluate the outcome, clinical efficacy and safety of endometrial radiofrequency cauterization for the treatment of hypermenorrhea.
Methods: From January 2011 to March 2015, a total of 195 women who visited to Chosun University Hospital had their charts and telephones reviewed for demographics, procedure data, clinical history, and follow up.
Results: The mean age was 43.3 ± 5.9 years old. A decrease in days per cycle (7.9 ± 2.8vs 5.4 ± 2.3 days, P < 0.001), and in pads per day (10.1 ± 2.7 vs 5.9 ± 3.8 pads/day, P < 0.001) and an increase in hemoglobin (g/dL, mean ± SD) / hematocrit (%, mean ± SD) (7.4 ± 0.5 / 29.5 ± 2.7 vs 11.7 ± 1.3 / 36.1 ± 4.2, P < 0.001) and an improvement in self-reported quality of life scores (limitation of life: 8.1 ± 2.2 vs 2.9 ± 1.7, P < 0.0001, discomfort score: 2.1 ± 1.5 vs 0.9 ± 1.5, P < 0.001) were observed after endometrial heat therapy. Assessment of the level of satisfaction showed that 83.6% of patients were satisfied with the procedure. No major complications or deaths were found. The prognostic factors of endometrial heat therapy were age, parity, uterine pressure and depth, position. But age and uterine pressure had no significant difference statistically.
Conclusion: Endometrial radiofrequency cauterization is a safe and efficient method to treat of hypermenorrhea. It reduces the menstrual flow, improves the quality of life, and remarkably satisfies patients with a desire to preserve a uterus.
Key Words: hypermenorrhea, endometrial heat therapy
15
Sat
Poster #36
OSTEOMYELITIS PUBIS PRESENTING WITH PELVIC FLOOR DYSFUNCTION AND ANTALGIC GAIT IN A PROSTATE CANCER SURVIVOR: A CASE REPORT
Stacey Bennis¹, Danielle Duley² and Nicole Wysocki²
¹Rehabilitation Institute of Chicago/Northwestern University; ²Rehabilitation Institute of Chicago
Presented By: Stacey Bennis

Objective: To review the presenting signs and symptoms that can indicate the presence of osteomyelitis pubis in male prostate cancer survivors.

Methods: A 69-year-old male with prostate cancer (gleason 7) status post radiation therapy (15 years prior) and recent salvage prostatectomy (7 months prior to presentation) initially presented to a pelvic floor physical therapist via referral from his urologist with a 4-month history of acute onset, progerss right groin pain and urinary incontinence. He had no acute provoking injury or trauma, though the temporal relationship of his symptom onset was several months following a salvage prostatectomy for gleason 7 prostate cancer. His symptoms improved but did not resolve with pelvic floor physical therapy (PT), which prompted referral to a musculoskeletal/pelvic floor rehabilitation (MSK/PF) outpatient clinic. His pain was located in the right scrotum with radiation to the anteromedial thigh. His exam revealed pelvic floor muscle weakness, bilateral hip flexor weakness (right > left), and antalgic gait. Urologic workup done prior to referral to the pelvic floor PT and physiatrist included scrotal ultrasound, urodynamic studies, and cystoscopy which were all unremarkable. During his evaluation with the musculoskeletal physiatrists, radiography of the pelvis was also unremarkable. A non-contrast MRI of the pelvis was ordered and demonstrated inguinal lymphadenopathy, and inferior bladder diverticulum with direct communication of urine between the inferior bladder wall and pubic symphysis, and T1 stir changes concerning for osteomyelitis of the bilateral superior and inferior pubic rami,.

Results: The patient was referred to Urology and Infectious Disease specialists. Repeat non-contrast MRI of the pelvis demonstrated worsening osteomyelitis and a urine culture was positive (escherichia coli). An extended course of broad spectrum IV vancomycin and ciprofloxacin was initiated. Urology recommended bladder diverticulum closure but the patient elected for continued observation and conservative management with musculoskeletal physiatrist oversight given overall improvement of his symptoms with pelvic floor physical therapy.

Conclusion: Pelvic floor muscle dysfunction and urinary incontinence are known sequelae following treatment for prostate cancer. However, the presence of concomitant pelvic pain and antalgic gait have rarely been reported in the literature. This symptom constellation in patients with history of prostate cancer has rarely been associated with osteomyelitis pubis.

Summary: In the absence of alternative musculoskeletal diagnoses as etiology for symptoms of antalgic gait, pelvic pain, urinary incontinence, and pelvic floor dysfunction, we recommend keeping low threshold to pursue advanced imaging to assess for osteomyelitis pubis in males with history of prostate cancer.
15
Sat
Poster #37
SEXUAL AND NON-SEXUAL IMPROVEMENTS IN WOMEN WITH HSDD: PERSONAL EXPERIENCES WITH FLIBANSERIN TREATMENT OF WOMEN WITH AND WITHOUT RESOLVED SEXUAL PAIN AND POST-TRAUMATIC STRESS DISORDER
Sue Goldstein¹ and Irwin Goldstein²
¹San Diego Sexual Medicine; ²Alvarado Hospital
Presented By: Irwin Goldstein

Objectives: As of October 2015 women with hypoactive sexual desire disorder (HSDD) have an FDA approved prescription medication available for treatment, flibanserin (Addyi). Pivotal clinical trials show a 40-60% response rate. With more than 135 of our patients prescribed flibanserin for HSDD, we retrospectively reviewed the personal reflections of those who responded favorably. We analyzed the subset who also had either a history of resolved sexual pain a history of sexually based post-traumatic stress disorder (PTSD).
Material and Methods: Patients currently prescribed flibanserin were asked to share their experiences with the medication by email in an attempt to follow their progress. Responses were collected and later examined for responsivity to flibanserin, and for themes with regard to response time to the drug, short-term improvements, longer-term changes, and other general observations. Testimonials from 42 respondents were analyzed including 7 (17%) who had either history of sexual pain that had been resolved or sexual-based PTSD.
Results: Average time to experiencing positive change in HSDD symptoms was 7 weeks (range 10 days -16 weeks). Responsive users have been on the drug for an average of 6 months (range 1-10 months). Improvements in HSDD symptoms were both sexual and non-sexual. Regarding HSDD, overall changes included increases in: sexual responsiveness, sexual thoughts/dreams, initiation of sexual activity, positive anticipation, and articulation of sexual desires. In those women with resolved sexual pain or ongoing PTSD related to prior physical/emotional abuse, we observed reports of decreased inhibition. Other non-HSDD sexual responses in flibanserin responders, included: intensified and/or faster lubrication/arousal, increased clitoral engorgement, stronger or increased number of orgasms, and enhanced sexual satisfaction. Non-sexual responses involved improved relationships including partners being more attentive, and mood changes such as having fun, feeling more alive, feeling less stressed and general happiness. One woman with previous sexual pain reported: “Flibanserin ELIMINATED my pain with sex along with the use of estradiol and coconut oil; I actually WANT sex for the first time in my life; Positively improved our relationship and feeling of closeness and intimacy.” In addition, most respondents also lost several pounds of weight, and most slept better. Some stopped all alcohol intake while others continued without consequences. No serious adverse events were noted.
Conclusions: Responder experiences have shown us that for some women, use of flibanserin for HSDD is life changing in multiple dimensions. The improvement in desire in women with resolved sexual pain and sexual PTSD has not been previously reported. Both sexual and non-sexual positive changes have been observed in this population of women, resulting in their increased sexual satisfaction and overall happiness.
Summary: The improvement in desire as well of other positive changes in women with HSDD with and without resolved sexual pain and sexual PTSD has resulted in increased sexual satisfaction and overall happiness.
15
Sat
Poster #38
A SYSTEMATIC REVIEW OF PAIN MANAGEMENT MEDICATIONS IN BENIGN LAPAROSCOPIC GYNECOLOGIC SURGERY
Emily Blanton¹,²,³, Georgine Lamvu²,³, Insiyyah Patanwala¹,² and Kenneth Barron¹,²,³
¹Department of Graduate Medical Education, Florida Hospital, Orlando, Florida; ²Division of Surgery, Gynecology Section, Orlando Veterans Affairs Medical Center, Orlando, Florida; ³Department of Obstetrics and Gynecology, University of Central Florida, Orlando, Florida
Presented By: Emily Blanton

Objective:
To evaluate if there is enough evidence within the benign gynecology literature to make recommendations for pain control in patients undergoing benign minimally invasive gynecologic surgeries.

Data Sources:
PubMed, ClinicalTrials.gov and Cochrane databases were queried with MeSH terms: “postoperative pain”, “perioperative pain”, “postoperative analgesia”, “pain management”, “pain control”, “minimally invasive gynecologic surgery” and “hysterectomy”. Trials were restricted to minimally invasive gynecological surgeries for primarily benign indications and excluded studies evaluating tubal ligations or intrauterine surgeries.

Methods:
Included studies were restricted to minimally invasive gynecological surgeries for primarily benign indications and excluded studies evaluating tubal ligations or intrauterine surgeries.

Results:
Initially 1,154 studies were identified, 49 met all inclusion criteria. Of these total 49 papers, 24 exclusively evaluated minimally invasive hysterectomies, seven examined hysterectomy and non-hysterectomy procedures and 18 evaluated non-hysterectomy procedures only. An in-depth review was completed for study characteristics and results. A risk assessment was performed and a quality rating assigned.

Conclusion and Summary:
Intravenous acetaminophen and ketorolac show promise in treating all aspects of postoperative pain in women undergoing benign laparoscopic hysterectomies while neuroleptics and dexamethasone demonstrate opioid-sparing benefits only. Paracervical blocks have been shown to help pain control after vaginal hysterectomies, while local anesthetics appear to benefit non-hysterectomy gynecologic laparoscopies. However, convincing conclusions are difficult to draw because of the heterogeneous and contradictory nature of the literature. There is a clear need for more high-quality research evaluating each medication type for postoperative pain control in the gynecologic population.
15
Sat
Poster #39
EVIDENCE-BASED CLASSIFICATION OF WOMEN WITH VULVODYNIA ENROLLED IN THE NATIONAL VULVODYNIA REGISTRY (NVR).
Meryl Alappattu¹ and Georgine Lamvu²
¹University of Florida; ²Orlando VA Medical Center
Presented By: Meryl Alappattu

Background: Vulvodynia is a chronic pain condition that affects nearly 14 million women. Its diagnosis is based on exclusion of other conditions and on the location, duration and timing onset of the pain. Research has shown that vulvodynia is associated with depression, anxiety, and limitations in sexual activity. Yet, current vulvodynia classification is based only on the sensory aspects of vulvar pain and do not take into account emerging evidence that women with vulvodynia demonstrate emotional and cognitive factors known to impact the pain experience, including depression, anxiety, and pain catastrophizing.
Objective: The objective of this study was to use cluster analysis to determine whether we can identify subgroups of women with vulvodynia using measures of pain sensitivity and psychological distress. We used cluster analysis because it is a method that can be used to empirically classify individuals into clusters based on data which in our study consisted of prospectively collected clinical characteristics and standardized psychometric testing.
Study Design: Women were screened with Harlow’s questionnaire and clinical examination and included if they presented with vaginal or vulvar pain lasting longer than 3 months and severe enough to impair sexual activity and quality of life. An exploratory hierarchical agglomerative cluster analysis using Ward’s cluster method and squared Euclidean distances was conducted to determine if we could identify unique subgroups based on psychological distress and pain sensitivity measures. Validation of the cluster solution was performed with analyses of variance. The variables included in the cluster analysis included the catastrophizing subscale of the Coping Strategies Questionnaire, the Beck Depression Inventory, the State Trait Anxiety Index, and vulvar and pelvic muscle pressure pain sensitivity.
Results: Approximately 900 women were screened for eligibility into the NVR and 344 women provided consent to participate. Of the 344 women, 127 with complete distress and pain sensitivity data at baseline were included in these analyses. Two distinct subgroups, high pain sensitivity with high distress (n=27) and low pain sensitivity with low distress (n=100), emerged from the cluster analysis. Validation of the cluster also indicated that subgroups also differed on clinical pain intensity, sensory aspects of pain, and intercourse pain. No subgroup differences existed in age or duration of pain.
Conclusions: By definition, it is now generally accepted that chronic pain is a sensory and emotional experience and it is usually required that both of these aspects be addressed in managing pain. The results of our study demonstrate two empirically-derived subgroups from a heterogeneous sample of women with vulvodynia. One subgroup is characterized by high pain sensitivity and distress and the other by low pain sensitivity and distress. Thus, it may be appropriate to re-visit the classification of vulvodynia which currently do not provide guidance on how to include psychometric and emotional factors into the diagnosis or treatment of vulvodynia.
15
Sat
10:15 a.m. - 10:55 a.m.
Stress, inflammation, and pain in interstitial cystitis/painful bladder syndrome
Speaker:
Susan Lutgendorf, PhD
University of Iowa
15
Sat
10:55 a.m. - 11:35 a.m.
Long Term Health Consequences of Childhood Poverty
Speaker:
Greg Miller
Northwestern University
15
Sat
11:35 a.m. - 11:55 a.m.
Questions and Answers
Speakers:
Susan Lutgendorf, PhD
University of Iowa

Greg Miller
Northwestern University
Concurrent Sessions Begin  
Concurrent Session 1 of 2  
15
Sat
11:55 a.m. - 1:25 p.m.
Saturday Roundtable Lunch with Experts
Location: St Gallen
15
Sat
11:55 a.m. - 1:25 p.m.
OPIOIDS AND CHRONIC PELVIC PAIN
Moderators:
Jorge F. Carrillo, MD
University of Rochester

Allan I. Frankel, MD
GreenBridge Medical Services, Inc.
15
Sat
11:55 a.m. - 1:25 p.m.
INTERSTITIAL CYSTITIS: Clinical Indicators to guide treatment
Moderators:
Karen Brandon, DSc, PT, WCS
Kaiser Permanente, OBGYN Department

Christopher F. Tenggardjaja, MD
15
Sat
11:55 a.m. - 1:25 p.m.
UROGENITAL PELVIC PAIN: What a MESH!
Moderators:
Sandra Hilton, PT, DPT, MS
Entropy Physiotherapy and Wellness

Shirin Towfigh, MD
Beverly Hills Hernia Center
15
Sat
11:55 a.m. - 1:25 p.m.
PELVIC FLOOR DYSFUNCTION IN ATHLETES
Moderators:
Sheila Dugan, MD
Rush University Medical Center

Rhonda K. Kotarinos, DPT, MS
Kotarinos Physical Therapy
15
Sat
11:55 a.m. - 1:25 p.m.
SEXUAL DYSFUNCTION AND PELVIC PAIN
Moderators:
Bridgid Ellingson, PT, DPT, OCS
Lakeview Physical Therapy, PC

Nel Elisabeth Gerig, MD
The Pelvic Solutions Center
15
Sat
11:55 a.m. - 1:25 p.m.
BRING YOUR COMPLEX PATIENTS: Discussion with the Experts
Moderators:
Tyler Muffly, MD

Tracy Sher, MPT, CSC, CSCS
Sher Pelvic Health and Healing
15
Sat
11:55 a.m. - 1:25 a.m.
HORMONES ARE FUEL FOR GENITAL TISSUE HEALTH
Moderators:
Irwin Goldstein, MD, IF
San Diego Sexual Medicine

Stephanie Prendergast, MPT
Pelvic Health and Rehabilitation Center
15
Sat
11:55 a.m. - 1:25 p.m.
VULVODYNIA: Coordinating Care and Common Comorbilities in our Patients with Vulvodynia
Moderators:
Sophie Bergeron, PhD
Université de Montréal

Hope Haefner, MD
University of Michigan Health System, Departments of Obstetrics and Gynecology
15
Sat
11:55 a.m. - 1:25 p.m.
PELVIC GIRDLE PAIN: A Missed Opportunity? Screening Techniques for Physicians and Physiotherapists
Moderators:
Catherine Allaire, MD, FRCSC
Women's Health Center

Susannah Britnell, Bsc Hons PT, Dip Adv
Centre for Pelvic Pain and Endometriosis
15
Sat
11:55 a.m. - 1:25 p.m.
PELVIC NEURALGIAS: Curing the Uncurable
Moderators:
Richard P. Marvel, MD
The Center For Pelvic Pain of Annapolis

Amy Stein, DPT, BCB-PMD, IF
Beyond Basics Physical Therapy
Concurrent Session 2 of 2  
15
Sat
11:55 a.m. - 1:25 p.m.
Lunch On Own
Concurrent Sessions End  
15
Sat
1:25 p.m. - 2:05 p.m.
Disorders Associated with Vulvar Pain
Speaker:
Hope Haefner, MD
University of Michigan Health System, Departments of Obstetrics and Gynecology
15
Sat
2:05 p.m. - 2:45 p.m.
Vulvoscopic Evidence of Changes during Hormonal Treatment
Speaker:
Irwin Goldstein, MD, IF
San Diego Sexual Medicine
15
Sat
2:45 p.m. - 3:25 p.m.
Why Us? How Relationship Factors shape the experience of vulvodynia
Speaker:
Sophie Bergeron, PhD
Université de Montréal
15
Sat
3:25 p.m. - 3:45 p.m.
Questions and Answers
15
Sat
3:45 p.m. - 4:05 p.m.
*Break & Poster Viewing Session
15
Sat
Poster #3
PAIN CATASTROPHIZING AND QUALITY-OF-LIFE IN WOMEN WITH ENDOMETRIOSIS
Allison McPeak¹, Catherine Allaire¹, Christina Williams¹, Arianne Albert², Sarka Lisonkova³ and Paul Yong¹
¹BC Women's Centre for Pelvic Pain and Endometriosis, University of British Columbia; ²Women's Health Research Institute; ³Child and Family Research Institute, University of British Columbia
Presented By: Allison McPeak

Objective: Our objective was to determine whether pain catastrophizing is associated with health-related quality-of-life in women with endometriosis, independent of potential confounders such as other psychological comorbidities, pelvic pain sub-types, and social-behavioural factors.

Methods: We analyzed baseline cross-sectional data from an ongoing prospective cohort at the BC Women’s Center for Pelvic Pain and Endometriosis (Vancouver, Canada). Inclusion criteria were new referral or re-referral to the Center from December 2013 to April 2015, completion of research questionnaires and physical exam, and a history of surgically confirmed endometriosis. Exclusion criteria were menopausal status, age > 50, menstrual suppression, and not sexually active. The primary outcome was the 11-item core subscale of the Endometriosis Health Profile-30 (0-100%), where a higher score indicates reduced function and poorer quality of life. Potential factors associated with the primary outcome included the Pain Catastrophizing Scale, the Patient Health Questionnaire-9 for depression, and the Generalized Anxiety Disorder-7 questionnaire; the severity of chronic pelvic pain, dysmenorrhea, deep dyspareunia, superficial dyspareunia, dyschezia, and back pain (each rated from 0-10 on a numeric rating scale); stage of endometriosis (I/II vs. III/IV); pain condition diagnoses (e.g. irritable bowel syndrome or painful bladder syndrome); physical exam findings (e.g. body mass index and abdominal wall trigger points); and social-behavioural factors (e.g. age, smoking, education, income). Associations between the factors and the primary outcome were tested with Spearman rank correlation test, Mann-Whitney test, or Kruskal-Wallis test. Factors with a statistically significant association (p < 0.05) were then entered into a multivariable linear regression model. Modelling was performed in R (version 3.2.2) using a stepwise procedure to minimize the Akaike information criterion with p < 0.05.

Results: There were 236 women who met the study criteria. The mean age of the subjects was 35±7 years, and 98 (42%) were Stage I-II, 110 (47%) were Stage III-IV, and 28 (12%) were of unknown stage after review of operative records. The final regression model indicated that worse quality-of-life was independently associated with higher pain catastrophizing (b = 0.54, p < 0.001), greater severity of chronic pelvic pain (b = 1.49, p < 0.001), greater severity of dysmenorrhea (b = 3.16, p < 0.001), and presence of abdominal wall trigger points (b = 5.02, p = 0.033). The remaining variables, including Stage, were not in the final regression model.

Conclusion: Higher pain catastrophizing was associated with worse health-related quality-of-life in women with endometriosis. This association was independent of potential confounders such as depression/anxiety, the severity of pelvic pain, and social-behavioural factors. Interventions to reduce pain catastrophizing should be investigated in women with endometriosis.

Summary: Pain catastrophizing is independently associated with worse health-related quality-of-life in women with endometriosis.
15
Sat
Poster #21
LIFESTYLE BEHAVIORS AS PREDISPOSING FACTORS IN THE ONSET OF INTERSTITIAL CYSTITIS/PAINFUL BLADDER SYNDROME
Karen Gilbert, Cindy Hayden and Phyllis Bryden
Eastern Kentucky University
Presented By: Karen Gilbert

Objective: To identify lifestyle behaviors and health conditions among women with Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) and to investigate how those factors may be associated with the onset of IC/PBS.

Methods: An eighteen-question survey was posted on a U.S. national interstitial cystitis association website. Data was analyzed from 502 women self-reporting symptoms of IC/PBS. SPSS was used for data management and analysis.

Results: Respondents were 18 to 86 yrs. of age, and were predominately white (95%). Almost all (96.6%) had been diagnosed by a medical professional as having IC/PBS. The mean age when symptoms first occurred was 34.6 yrs.; however, average age at diagnosis was 41.4 yrs. Most respondents (78.8%) had no biological relatives diagnosed with IC/PBS and 63.3% denied smoking cigarettes. A statistically significant proportion of women surveyed reported they drank coffee (² (1,n=502) =35.77,p<.0001; 51.6%)
consuming 1-2 cups/day. A statistically significant proportion (66%) reported drinking soft drinks, ² (1,n=502)= 50.996,p<.0001; 49.4% drinking 1-2 twelve-ounce soft drinks/day. Beverages were characterized as being: sugar-sweetened (47.6%), artificial-sweetened (43.6%), caffeinated (39.2%), and decaffeinated (19.7%). A significant proportion (90.8%) of study participants reported diagnoses of Urinary Tract (UTI)/Bladder Infections, ² (2,n=502)= 749.7,p<.0001): 34.9% reported 1–5 occurrences, 18.1% reported 6–10, 16.5% reported 11–20, and 21.7% reported 21 or more. When asked how long birth control pills and/or hormone replacement therapy was used, 14.5% of respondents denied any use, 27.5% reported using for 1–5 years, 21.1% for 6–10 years, 21.5% for 11–20 years, 11.4% for 21–30 years, and 3.2% used hormones for 31 or more years. Comorbid health conditions reported were: Irritable Bowel Syndrome (IBS): 41.8%; seasonal allergies: 63.9%, ² (1,n=472)= 61.229,p<.0001); Celiac Disease/gluten sensitivity:12.0%; Chronic Fatigue Syndrome: 12.9%; Fibromyalgia: 24.5%; and Pelvic Floor Dysfunction: 41.2%.

Conclusion/Summary: Professional literature regarding the etiology of IC/PBS is scarce. The mean time between first symptoms and diagnosis reported by study participants was 6.7 yrs. This indicates that recognition of symptoms could expedite diagnosis and help women get treatment sooner. Our results did not support a genetic component; a statistically significant number of respondents denied any close relatives had also been diagnosed with IC/BPS, ² (1, n=502)=158.41,p<.0001). However, since 13% didn’t know relatives’ IC status, more research is needed to highlight the role genetics play in this disease. Study results indicate a notable comorbidity of seasonal allergies in patients with IC/PBS and prevalence of a history of UTIs was high. Other potentially related comorbidities did not show a high prevalence in study participants. These results indicate a continued need for more research into the causes of IC/PBS for facilitation of earlier diagnosis and treatment.
15
Sat
Poster #22
IMPAIRMENT IN SEXUAL FUNCTION, DEPRESSION AND ALEXITHYMIA IN WOMEN WITH CHRONIC PELVIC PAIN
Alix Aboussouan, Nicolas Thompson and Kelly Huffman
Cleveland Clinic
Presented By: Alix Aboussouan

Treatment of impairment in sexual function is essential to managing Chronic Pelvic Pain (CPP). Little is known about best treatment practices. Guidelines recommend an interdisciplinary approach and preliminary research suggests that treatment of alexithymia and depression may improve outcomes. The current study examines the utility of an interdisciplinary Chronic Pain Rehabilitation Program (iCPRP) in treating impairment in sexual function, depression and alexithymia in women with CPP. Our specific aims were to 1) examine impairment in sexual function, alexithymia, and depression in women with and without CPP 2) determine if women with CPP equally benefit from treatment and 3) examine factors predicting improvement in sexual function. This study was a retrospective analysis of an IRB approved data registry. Participants were 63 women with CPP treated in a 3-4 week iCPRP between 2011 and 2015 matched by age and treatment date to women with other chronic pain conditions. Treatment included medication management, weaning from habituating medications, occupational/physical therapy, individual, group and family therapy. Participants were 87.30% white and 50.00% married, with a mean age of 41.64(±12.90). 92.9% had multiple chronic pain conditions. Impairment in sexual function, alexithymia and depression were measured with the sexual behavior subscale of the Pain Disability Index, the Toronto Alexithymia Scale, and Depression, Anxiety, and Stress Scale respectively. Unadjusted models (ANOVA) comparing group differences showed that women with CPP had higher baseline levels of depression (p<.05) and discharge levels of impairment in sexual function (p<.05) and no other group differences. Three linear mixed models, with a random intercept adjusted for marital status, examined treatment outcomes in impairment in sexual function, alexithymia and depression. Time, group and interaction terms were included as fixed factors. Results showed robust improvements across all three dimensions (p<0.01). Women with CPP reported greater improvements in depression (p<.05) and there were no group differences in outcomes. Two hierarchical linear regressions, one for women with CPP and one without, examined factors predicting post treatment impairment in sexual function. Baseline scores and marital status were included in step one and change scores for depression and alexithymia in step two. Only pre-treatment impairment in sexual function predicted outcomes for women without CPP. In women with CPP improvements in alexithymia and depression significantly improved the predictive power of the model and predicted post treatment levels of sexual impairment (p<.05). Results show that women with CPP benefit from treatment in an iCPRP and even report greater improvements in depression. Unadjusted analyses shows that while women with CPP do equally benefit from treatment, they continue to report higher post treatment impairment in sexual function. Depression and alexithymia appear to be important predictors of outcome in women with CPP. Future research should examine whether treating these comorbidities can improve treatment outcomes in women with CPP.
15
Sat
Poster #23
IS DEGREE OF RELIGIOSITY RELATED TO THE PREVALENCE OF DYSPAREUNIA IN A POPULATION?
Insiyyah Patanwala¹, Megan Mizera², Matthew Fisk³ and Georgine Lamvu4
¹Department of Obstetrics and Gynecology, Florida Hospital, Orlando; ²University of Central Florida College of Medicine; ³Florida Hospital, Orlando; 4Gynecologic Surgery and Pelvic Pain Specialist, Orlando VA Medical Center
Presented By: Insiyyah Patanwala

Objective: To assess whether increasing degree of religiosity corresponds to a change in prevalence of dyspareunia.

Design: Cross-sectional survey study. A survey with twenty-four questions was designed which incorporated the Duke Religiosity Index (DRI) questionnaire and questions about dyspareunia, attitudes towards sex, and demographic information. The DRI measures organizational religiosity, non-organizational religiosity, and intrinsic religiosity.

Results: A total of 843 surveys were collected: 673 women reported no dyspareunia, 160 women did report dyspareunia, and 10 surveys had missing data regarding experience of dyspareunia. Our results indicate that there is no significant difference in degree of organized religiosity (p=0.41), non-organized religiosity (p=0.10), nor intrinsic religiosity (p=0.69) among women with or without dyspareunia. There was also no difference in the prevalence of dyspareunia among subjects who grew up with religion versus those who did not (18.7% vs 22.6%, p= 0.33). However, women who were taught to wait until marriage before having intercourse and women who were taught that sex is bad while growing up had an increased likelihood of reporting dyspareunia compared to those who were not taught this (21.3% vs 13.0% p=0.006 and 26.7% vs 15.2%, p<0.001, respectively).

Conclusion/Summary:
A large cross-sectional survey study was completed with a 19.2% prevalence of dyspareunia among the population. While degree of religiosity was not shown to be associated with the prevalence of dyspareunia, women who were taught sex is bad or to wait until marriage before having sex when they were growing up may be at higher risk of experiencing painful intercourse.
15
Sat
Poster #24
HIP AND GROIN PAIN IN CYCLIST RESOLVED AFTER PELVIC FLOOR FASCIAL MOBILIZATION TREATMENT – A CASE REPORT
Sivan Navot and Leonid Kalichman
Ben-Gurion University of the Negev, Beer-Sheva, Israel
Presented By: Sivan Navot

Introduction
We present herein, a 32-year-old male professional cyclist, exhibiting right hip and groin pain during cycling and prolonged sitting without complaints of pelvic floor dysfunctions. After receiving several series of conventional physical therapy for the hip/groin pain, which resulted in pain relief and slight improvement of hip range of motion, pelvic floor muscles and fascia involvement were subsequently assessed and treated by Pelvic floor fascial mobilization (PFFM). Developed (by S.N.), PFFM aims to evaluate and treat restrictions in fascial movement in the pelvic floor area (per vagina and per anus). PFFM technique is associated with the sequences and movement planes of Stecco's Fascial Manipulation® technique, relying on similar main principles: Myofascial units, body segments, centers of perception, centers of coordination, centers of fusion, movement plans and myofascial sequences. Currently we completed dozens of successful treatments of groin/hip/pelvic/pelvic-floor pain and dysfunction that where treated with PFFM approach.
Aim
The aim of this case report was to demonstrate the importance of the pelvic floor myofascial assessment in cases of hip/groin pain as well as to propose PFFM as an optional treatment technique for both hip/groin and pelvic floor pain or dysfunction.
Case Report
32 y/o male professional cyclist, with complaints of Rt. hip and groin pain during cycling and prolonged sitting, which commenced after a Rt. Hip severe contusion (2013), with no complaints of pelvic floor dysfunctions. The patient received several rounds of conventional physical therapy, including myofascial release, dry needling, mobilizations of the hip joint, stretching and therapeutic exercises, with partial pain relief and slight improvement of hip range of motion. Initial evaluation: Significant limitation of Rt. Hip internal rotation (30°), impaired contraction of pelvic floor muscles during both active contraction and anticipative reaction to increasing in intra-abdominal pressure during cough. High resting tone and painful palpation of Rt. Obturator internus and Rt. Iliococygeous, and mild elevated resting tone of Lt. Obturator internus.
Intervention
PFFM floor include manual friction over the densified fascial points in combination with active motion of the hip joint. 2 treatment sessions which included internal PFFM over 2 fascial restricted points and 4 "external" fascial restricted points.
Follow-up examinations
After the first session immediate significant difference was noticed in hip joint range of motion (60°) and the pelvic floor muscle function in both, active recruitment and anticipated contraction. Pain was decreased by 80%. After 2 sessions, treatment was finished completely because patient was pain free and returned to usual sport and work activity.
Conclusions
Results of this case report as well as of many other successful treatments gives us a reason to claim that PFFM can be used as effective tool for treatment for musculoskeletal pain and dysfunction in pelvic, hip or lower limb area. Additional studies are needed to evaluate the effectiveness of this method in different conditions.
15
Sat
Poster #25
THE IMPORTANCE OF THE VAGINAL PELVIC FLOOR MUSCLE EXAM FOR WOMEN WITH LUMBAR/PELVIC GIRDLE PAIN
Arianna Griffin, Tanaka Dune, Elizabeth Gunnar, Elizabeth R. Mueller, Cynthia Brincat, Linda Brubaker and Colleen Fitzgerald
Loyola University Medical Center - Stritch School of Medicine
Presented By: Arianna Griffin

Objectives: To determine the frequency of pelvic floor myofascial (PFM) pain during vaginal examination in women with lumbar and/or pelvic girdle pain.

Methods: Comprehensive chart review of new patients presenting to the Female Pelvic Medicine and Reconstructive Surgery’s pelvic pain clinics over a two year period (2013-2014). Data extraction included demographics at initial patient evaluations with documentation of patient pain symptoms and physical exams.

Results: The cohort of 179 women had an average age of 44.7±16.1 years, an average body mass index of 27.1±7.0 kg/mg2; most (79.0%) were White. Most patients presented with a chief complaint of pelvic (30.7%), vulvovaginal (15.6%) or back (9.5%) pain; 9.5% reported laterality for the chief pain complaint. About one third (30.7%) had pre-existing pain syndromes [endometriosis (34.5%); fibromyalgia (29.1%); arthritis (38.2%); migraine (18.2%)]. Polypharmacy was common with over half (58.2%) of the women taking at least one pain medication [1 med (47.6%), 2 meds (30.1%), 3 meds (12.6%), 4 meds (9.7%)].

Eighty-three percent of patients who reported low back and/or pelvic girdle pain also presented with complaints of vaginal pain. Of women reporting a history of vaginal pain, 80.7% were found to have low back and/or pelvic girdle pain on physical exam. Also on exam, a large number of women (96.1%) were found to have both vaginal PFM pain and low back and/or pelvic girdle pain. Patients who reported symptoms of low back or pelvic girdle pain were more likely to have pain on vaginal PFM exam than patients without this history (OR, 7.24; 95% CI, 1.95-26.93, p=0.003). The majority (86.1%) of patients with vaginal PFM pain on exam described their pain as bilateral. Predominance of lateralized pain was found in 20.1% (right) and 10.4% (left) of patients with vaginal PFM pain.

Conclusions: The vaginal pelvic floor muscle examination is high yield, as most patients with lumbar and/or pelvic girdle pain have vaginal PFM pain on exam even when they do not report vaginal symptoms. Most women had diffuse bilateral PFM pain. The vaginal PFM examination should be an essential part of the physical examination of all women with lumbar and/or pelvic girdle pain and considered as a potential therapeutic target.
15
Sat
Poster #26
TITLE: MECHANICAL LOW BACK PAIN: AN ORTHOPAEDIC PROBLEM, A UROGYNECOLOGICAL PROBLEM, OR BOTH?
Sinead Dufour¹, Carolyn Vandyken² and Brittany Vandyken¹
¹McMaster University; ²Pelvic Health Solutions
Presented By: Carolyn Vandyken

Background: Low back pain represents the number one cause of disability in the world with direct and indirect worldwide costs of billions of dollars each year. The prevalence and cost continue to rise despite the wide range of available therapeutic interventions, indicating a deficiency in current approaches.
Objectives: The purpose of this study was to determine the prevalence and type of pelvic floor dysfunction among women with mechanical low back pain to better understand the relevance of pelvic floor rehabilitation herein. Based on recent European research, we hypothesized that pelvic floor dysfunction, specifically hypertonicity, to be positively correlated with mechanical low back pain.
Methods: In this prospective cross−sectional study, a total of 182 subjects were recruited from October 2014 until March 2016. Following informed consent, potential participants underwent a screening process to match inclusion and exclusion criteria. As such, participants that had features of central sensitization (Pain Catastrophizing Scale score > 30) or radiculopathy were excluded. Furthermore, refusal to complete an internal exam also translated to exclusion. A total of 82 subjects were excluded, leaving 100 subjects who completed the lower back and pelvic assessment: a mechanical low back screen using the McKenzie protocol; a series of Pelvic Girdle Pain screening tests; an internal pelvic exam (digital palpation). Additionally, participants completed the Oswestry Low Back Disability Questionnaire and were asked to self-report symptoms of pelvic floor dysfunction including urinary and fecal incontinence, chronic constipation, prolapse and pelvic pain.
Results: This sample (N=100) had a mean age of 41.6 years old (SD + 13.51). Of these, 96% (96/100) were determined to have some form of pelvic floor dysfunction by internal palpation. Specifically, 84% (84/100) of the participants had components of hypertonicitiy. Further, the digital exam of the pelvic floor was 100% congruent with the self−reported indications of pelvic floor dysfunction. Interestingly, 18.7% (34/182) of potential subjects were excluded from the study during the screening phase due to their score on the Pain Catastrophizing Scale. This finding is beyond the scope of this present study, but has important implications related to the importance of screening patients, utilizing a biopsychosocial approach when treating chronic low back pain.
Conclusions: Our findings corroborate and extend the findings of recent research supporting the hypothesis that pelvic floor dysfunction is highly correlated with mechanical lower back pain, particularly hypertonicity.
Summary: Movement towards a more comprehensive approach to better address the various features that influence mechanical lower back pain warrant further attention. Addressing pelvic floor dysfunction may be an appropriate strategy when treating mechanical low back pain. Repeated and sustained contractions of pelvic floor muscles and their synergists may represent a less than optimal treatment strategy when strengthening the trunk for mechanical low back pain in women.
15
Sat
Poster #27
WHAT MAKES A CHRONIC PELVIC PAIN PATIENT SATISFIED WITH THEIR CARE?
Jenna Miller, Nicole Bush, Isabel Green, Lois McGuire and Dan Breitkopf
Mayo Clinic, Rochester
Presented By: Jenna Miller

Introduction: Evaluating and treating females with chronic pelvic pain can be challenging and taxing for both the patient and provider. Many patients describe poor interactions with previous healthcare providers for their pain. A Chronic Pelvic Pain Clinic was established in a large academic institution to both improve patient care and provider experience with chronic pelvic pain patients. To better evaluate quality and patient satisfaction in the new clinic, we sought to identify what aspects of the health care visit contribute to patient satisfaction in female chronic pelvic pain patients.
Objective: The aim of this study was to qualitatively analyze what aspects of the healthcare visit contribute to patient satisfaction with evaluation and treatment of pelvic pain.
Methods: A survey was given to patients at the end of their visit in the Chronic Pelvic Pain Clinic. The data were collected from January to June of 2016. All female patients scheduled and seen in the integrated Chronic Pelvic Pain Clinic were eligible. No identifying information was utilized. This survey included the question:
When visiting a health care provider to talk about your pelvic pain, what are important factors that impact your satisfaction with the visit/care?
An inductive thematic analysis of responses to this question was performed. A coding process was utilized to identify themes of patient responses to determine the 8 themes described. The study received IRB exemption.
Results: 55 out of 131 patients scheduled in the clinic during this time period completed surveys. Identified themes included: being listened to, providers with caring and compassionate attitudes, acknowledgement and validation of pain concerns, overall plan of care including multiple treatment options and coordination of care with other providers, quality time spent with patient as well as being timely, knowledgeable providers who are aware of patient history, and overall good communication skills. Only 2 respondents commented on pain relief as a factor for satisfaction with their care.
Conclusion: The majority of patients surveyed reported themes of quality communication and patient-provider interactions as factors improving their satisfaction in the clinic, while few reported “relief of pain” as a contributor to satisfaction.
Summary: Treating chronic pelvic pain can be challenging. Understanding what makes a patient satisfied with their care could improve their overall quality of care. In this inductive thematic analysis, patients reported more satisfaction with their care when they are being actively listened to, when providers display a caring and compassionate attitude, and when providers acknowledge and validate their pain. These patients also appreciate knowledgeable providers and the discussion of multiple treatment options. Time spent, good communication skills, knowledge of patient history, and coordination of care were also mentioned by multiple patients as important factors for their satisfaction. Interestingly, few patients reported relief of pain as a satisfier. Data collection is ongoing.
15
Sat
Poster #28
PREVALENCE OF PSOAS MYOFASCIAL DYSFUNCTION IN MALES REFERRED TO PHYSICAL THERAPY FOR TESTICULAR PAIN.
Dawn Underwood and Nicole Cookson
Presented By: Dawn Underwood

Objective: Chronic testicular pain can be considered as part of chronic pelvic pain syndrome (CPPS) for males. Chronic testicular pain is a challenging disorder to treat. Diagnosis and therapeutic interventions can be allusive. Treatment of testicular pain continues to be challenging due to multiple etiologies and variable treatment outcomes. Review of urological literature reveals first line conservative treatments typically include NSAIDS, scrotal support and limited activity. The purpose of this study is to present the prevalence of psoas myofascial dysfunction in males referred to pelvic physical therapy (PT) with testicular pain and present PT as an additional conservative treatment option.
Methods: A retrospective chart review of males referred to pelvic physical therapy (PT) from 1/1/14 to 12/31/15 was performed. Records from 3 treating pelvic PTs at a tertiary medical center were included. Correlation between musculoskeletal examination by a physical therapist and the patient’s complaint of testicular pain, were assessed.
Results: Chart review revealed 57 males referred to PT from Urology with a variety of urological/pelvic concerns. Of these 57 males, 19 were sent specifically for testicular pain, 17 of which were found to have positive psoas myofascial dysfunction on exam.
Discussion/Summary: Chronic testicular pain can be considered as part of chronic pelvic pain syndrome (CPPS). Treatment of testicular pain continues to be challenging due to multiple etiologies and variable treatment outcomes. Conservative treatment is first line, which historically has been NSAIDS, scrotal support and limited activity. We have found that a high percentage (89%) of men referred to PT for pelvic pain, specifically testicular pain, also have psoas myofascial involvement on the same side as the pain. We would urge the urological community to consider myofascial components when faced with a patient with chronic testicular pain. Potential referral to PT could be added to the list of conservative treatments.
15
Sat
Poster #29
PREVALENCE OF DYSPAREUNIA AND VULVODYNIA IN A COLOMBIAN CLINIC SAMPLE
Ana-Lucía Herrera-Betancourt¹, Georgine Lamvu², José-Duván López-Jaramillo¹, Jorge-Darío López-Isanoa¹ and Juan-Diego Villegas-Echeverri¹
¹Advanced Laparoscopy and Pelvic Pain Center at Clinica Comfamiliar, Pereira, Colombia; ²Gynecology Section, Division of Surgery, Orlando VA Medical Center, Orlando, USA
(Presented By: Ana-Lucía Herrera-Betancourt)
ALGIA

Background: Vulvodynia affects nearly 18% of women in the United States, but its prevalence across the word is unknown.
Objective: Our goal was to report on the prevalence of vulvodynia in a population sample of Colombian women.
Study Sample: Women seen in the Clinica Comfamiliar in Pereira Colombia; a clinical setting that specializes in providing inpatient, surgical and outpatient ambulatory services to women with a variety of benign gynecologic disorders. The clinic provides primary care services as well as specialized care for women with complex disorders such as chronic pelvic pain.
Study Design: Cross-Sectional Survey
Methods: A survey was specifically created for this project to collect information on participant demographics, medical history, and sexual history. The survey contained Harlowe’s screening questions that were designed to screen women for vulvar, vaginal or genital pain lasting longer than 3 months. The survey was administered in an anonymous and confidential manner to all women that were seen in the Clinica Comfamiliar inpatient and outpatient areas and who agreed to participate in the survey. The survey was administered from September 2014 to February 2015. This study was approved by local the ethics and research institutional review board.
Results: The survey was offered to 603 women, 20 women refused to participate in the survey. Of those who agreed to participate, 582 completed the survey. The mean age of this population was 38.1 years (11.5), 63.0% were in long term relationships or married and 36.9% were single, separated or widowed. Eighty two percent of women completed high-school or higher level of education. Of the 582 that completed the survey, 490 women completed Harlow’s questionnaire that screened for genital pain; 27.5% (95%CI: 23.7-31.7) reported pain in the genital area lasting longer than 3 months; 24.1% (95%CI: 20.4-28.2) also reported burning pain and 18% (95%CI: 14.8-22.1) reported sharp stabbing pain. Overall, 66.3% (95% CI: 61.8-70.5) reported having pain during intercourse.
Conclusion: In this sample of patients attending a gynecologic clinic in Colombia, the prevalence of painful intercourse (dyspareunia) and perhaps vulvodynia is higher or at least comparable than estimates reported in the United States. As such, the incidence of these disorders and the impact it has on Colombian women and society deserves further study.
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Poster #30
PHYSICAL THERAPY FOR CHRONIC SCROTAL CONTENT PAIN WITH ASSOCIATED PELVIC FLOOR PAIN ON DIGITAL RECTAL EXAM
M. Ryan Farrell¹, Sheila Dugan² and Laurence Levine¹
¹Department of Urology, Rush University Medical Center; ²Department of Physical Medicine and Rehabilitation, Rush University Medical Center
Presented By: M. Ryan Farrell

Introduction: Chronic scrotal content pain (CSCP) is a common condition that can be challenging to manage definitively. A cohort of patients with CSCP have referred pain from myofascial abnormalities of the pelvic floor and therefore require treatment modalities that specifically address the pelvic floor such as pelvic floor physical therapy (PFPT).
Objective: To describe our longitudinal experience with PFPT for patients with a pelvic floor component to CSCP.
Methods: We conducted a retrospective chart review of all men with a pelvic floor component of CSCP presenting to our tertiary care medical center and undergoing PFPT from 2011-2014. CSCP was defined as primary unilateral or bilateral pain of the testicle, epididymis and/or spermatic cord that was constant or intermittent, lasted greater than 3 months, and significantly interfered with daily activities. Duplex scrotal ultrasound was performed on all patients. Individuals with anatomic abnormalities including varicocele and hydrocele were excluded. Urinalysis, urine, and semen cultures were collected if indicated. Patients with evidence of infection were excluded. 360° digital rectal exam (DRE) was performed on all patients to identify a pelvic floor component to CSCP and involved application of gentle pressure to the pelvic floor muscles. Patients were requested to note areas of particular tenderness or radiation of pain to the scrotal contents that resembled the pain noted at initial presentation. Individuals with CSCP and pain on pelvic floor evaluation with 360° DRE were referred to a single pelvic floor physician specialist who established the PFPT regimen and coordinated appropriate referral to physical therapists for PFPT. Long-term follow-up was conducted by office visit and physical therapy chart review.
Results: Thirty patients with a mean age of 42 years (range 18-75) were followed for a median of 13 months (range 3-48). Median duration of pain at presentation was 24 months (range 3-300). Pre-PFPT pain score was 6/10 (range 2-10). After a mean of 12 PFPT sessions (IQR 6-16), pain improved in 50.0% of patients and median decrease in pain was 4.5/10 (range 1-10). Complete resolution of pain occurred in 13.3% and 44.0% had none to minor residual pain. The proportion of patients reporting none to minor residual pain was not different between those with pain exacerbated by voiding (41.7%) and those without (44.0%; p=1.00). The odds of pain improvement following PFPT was increased when pain was elicited at 2 or fewer scrotal content structures during initial physical exam (OR=14.0, p<0.01). Following PFPT, fewer subjects required pain medication compared with prior to PFPT (44.0% vs. 73.3%, p=0.03).
Conclusions: For men with CSCP and tenderness noted on pelvic floor exam with 360° DRE, we recommend a trial of PFPT as an effective and non-operative treatment modality. Our cohort had a significantly reduced need for pain medication and 44% of patients had none to minor residual pain.
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Poster #31
PARTNERING TO TREAT MALE PELVIC PAIN: PELVIC FLOOR PHYSICAL THERAPY AND THE APRN
Kathryn Curry¹, Jeananne Elkins¹ and LaMicha Hogan²
¹Northeastern University, Boston, MA; ²Texas Tech University Health Sciences Center
Presented By: Kathryn Curry

Chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is a chronic, costly and at times, debilitating condition difficult to manage in both specialty and primary care settings. Though the condition is often best diagnosed through urology specialty practices, patients often utilize the primary care setting as a first point of contact to seek relief of symptoms, and primary care providers may serve to manage the condition until a referral to urology is possible. A growing sector of primary care providers encountering this population are advanced practice registered nurses, also known as nurse practitioners (APRNs). While knowledgeable concerning the screening of male patients presenting with urinary symptoms, there may presently be a lack of knowledge among APRNs regarding the use of the UPOINT classification system guidelines and other non-pharmacological methods to provide symptom relief from those suffering CP/CPPS. The purpose of this study was to assess APRNs awareness of the medical management of males with CP/CPPS in 3 rural, West Texas communities, their utilization of current guidelines for the UPOINT classification system, and knowledge of other treatment modalities, specifically pelvic floor physical therapy (PFPT), as a means to support men diagnosed with CP/CPPS.
Objective: To assess APRN awareness and treatment knowledge of CP/CPPS in males in 3 rural, West Texas communities.
Methods: An anonymous, electronic survey questionnaire was administered to 135 APRNs located in 3 separate West Texas communities. The survey as part of a pilot study, surveyed APRNs educational and practice backgrounds, knowledge of guideline treatment of males with CP/CPPS symptoms, and familiarity with PFPT for those suffering CP/CPPS.
Results: The response rate was 31.8% (43 out of 135 respondents). Of those surveyed, roughly 49% reported current practice settings in family practice and community health. 46.15% reported having no knowledge at all regarding assessing adult males with CP/CPPS with over 90% stating never having used the UPOINT classification system. 94.44% of APRNs surveyed were not aware of the role of PFPT in the treatment of males with CP/CPPS.
Conclusion/Summary: Study findings of APRNs in West Texas concurred with other studies of PCPs, primarily MDs, regarding knowledge deficits and barriers to assessing, treating and locating resources for men with CP/CPPS. Also, a significant lack of awareness regarding PFPT identified among these APRNs suggests that continuing education on the multimodal approach to CP/CPPS is needed. Recommendations for team collaboration between PFPTs and APRNs are discussed.
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Poster #32
A RETROSPECTIVE SINGLE CENTER STUDY OF VULVOSCOPIC FINDINGS, FEMALE SEXUAL FUNCTION INDEX (FSFI) SCORES AND HORMONAL BLOOD TEST VALUES IN MENOPAUSAL WOMEN WITH FEMALE SEXUAL DYSFUNCTION PRE- AND POST-HORMONAL TREATMENT
Stephanie daSilva¹ and Irwin Goldstein²
¹UCSD; ²Alvarado Hospital
Presented By: Irwin Goldstein

Objectives: Signs and symptoms of menopause associated with estradiol deficiency include dryness, burning, thinning, itching, urinary frequency and dyspareunia. Menopausal symptoms associated with testosterone deficiency include diminished sense of well-being, reduced muscle and bone mass, provoked vestibulodynia, and decreased sexual desire, arousability, and orgasmic pleasure. The hypothesisis is that with both high patient adherence and close health care provider monitoring, hormonal management will lead to subjective and objective improvements in signs and symptoms of genitourinary syndrome of menopause (GSM).
Materials and Methods: This study evaluated clinical benefit of hormonal replacement strategies for management of sexual dysfunction and GSM utilizing pre- and post-treatment blood test monitoring, FSFI scores and vulvoscopy findings. A chart review from August 1, 2007 through December 1, 2015 was performed. Bioidentical hormonal therapy is designed to keep serum estradiol levels 35 - 50 pg/ml, serum progesterone levels at 1.0 ng/ml and calculated free testosterone levels at 0.8 ng/dl including daily topical vestibular and vaginal estradiol and testosterone applications. Subjects included were naturally or surgically peri-menopausal or post-menopausal at their initial visit, with both an initial and at least one follow-up vulvoscopy. Exclusions included cosmetic vulvar or vestibular surgery.
Results: 110 menopausal women (mean age 62 +/- 13 years) with sexual health complaints met study criteria. Mean follow-up was 2.6 +/- 1.3 years. Pre-treatment vulvoscopic findings of resorption of labia minora, telescoping of the urethral meatus, clitoral atrophy, vestibular erythema, tenderness and pallor, minimally robust peri-urethral tissue, minimal vaginal rugae with thin, pale vaginal mucosa and abnormal vaginal pH were noted in 100%. In 81% of women, serum sex steroid values returned to ideal values. In 72% FSFI total scores increased more than 5 points. In 63% post-treatment vulvoscopic changes revealed pink, moist, pain-free vestibular tissue. Conclusion: Hormonal management of menopause with good patient adherence and close monitoring has lead to subjective and objective improvement of female sexual function
Summary: Vulvoscopy supports vestibular changes post menopause and post estradiol treatment.
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Poster #33
THE EFFECTS OF EXERCISE THERAPY ON PAIN THRESHOLD IN WOMEN WITH CHRONIC PELVIC PAIN
Arthur Zecchin-Oliveira¹, Omero Poli-Neto¹, Mariana Cecchi¹, Antônio Nogueira¹ and Julio Silva²
¹FMRP-USP; ²FMRP
Presented By: Arthur Zecchin-Oliveira

Objective: Chronic pelvic pain (CPP) is a prevalent condition between women. Many factors are involved and, frequently the symptoms control is hard. One of the presupposes for it is the pain threshold in these women is lowered when compared with healthy women. Beyond the base disease treatment, several adjuvant measures has been proposed for the pain relief, particularly the ones which aren’t pharmacological. By the way, the physical exercise, either aerobic or anaerobic, has been associated with increasing pain threshold over chronic painful subjects and, thereby, recommended as adjuvant measure. Curiously, there is no data in the literature evaluating the physical exercise interference on pain threshold in women with CPP. Based on these data the study objective is to verify if the resistance training changes the peripheral pain threshold in women with CPP.
Methods: Open trial , randomized pragmatic. Were included 20 women with CPP and 20 healthy women. CPP group were selected at the gynecologic ambulatory of pelvic pain (at the Hospital of the University of São Paulo). The resistance training occurred during a week (two sessions). The training consisted the subjects realize a strength test before the workout, the 9RM test (9 maximum repetition) and, after test were realized 4 sets of 15 repetitions with 40% at 9RM intensity, within 1 minute interval between the sets. The exercise choose was the extensor chair. It was measured pain thresholds through pression (algometry) immediately before, immediately after, 10 minutes after and 20 minutes after the intervention. The paring was done only by age (to avoid the hyper-paring phenomenon). All the other psychometric measurement instruments to be use are translated and validated to Brazil. The study was evaluated and accepted by the ethical committee in research of HCFMRP-USP. There are consent of all sectors involved.
Results: Project waiting statistical analysis and the pain threshold present in the study sample.
Key words: Chronic Pelvic Pain, Pain Threshold, Exercise.
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Poster #34
GAIT ASSESSMENT OF WOMEN WITH CHRONIC PELVIC PAIN
Mariana Cecchi Salata, Paulo Ferreira dos Santos, Patrícia Silveira Rodrigues, Arthur Zecchin, Fernando Vieira, Rogério Ferreira Liporaci, Carla Andrea Caldas, Daniela Cristina Carvalho de Abreu, Antônio Alberto Nogueira, Júlio César Rosa e Silva and Omero Benedicto Poli-Neto
Ribeirão Preto Medical School - University of São Paulo
(Presented By: Mariana Cecchi Salata)
USP

OBJECTIVES: Chronic pelvic pain (CPP) is a common condition of complex etiology and poorly understood. There is evidence that the musculoskeletal system may be compromised although studies evaluating the motion pattern of this group are poorly. The aim of this study was to evaluate objectively the progress of women with CPP through kinematic and spatiotemporal variables and verify possible correlations of the changes found. METHODS: A cross-sectional cohort study included 20 women with CPP diagnosis, who were recruited at the Hospital of the University of São Paulo, and 20 healthy volunteers (control group). We used the three-dimensional gait analysis to obtain data on the range of motion, range of movement, moment and power of the pelvis, hip, knee, ankle and foot segments, and spatiotemporal variables. The nonparametric Mann-Whitney test was used to compare the distribution of the groups in relation to quantitative variables, and the Spearman correlation was used between the variables that showed a significant difference and the variables with TAMPA (kinesiophobia scale), VAS (visual analogue scale), time pain, McGill (pain measurement tool) and HAD (measure scale anxiety and depression). RESULTS: Women with CPP present changes in gait when compared to the control group. Kinematic variables compromised were: extension moment, flexion and internal rotation of the hip; flexion, extension, internal and external rotation of the knee; dorsiflexion and adduction of the ankle and internal and external foot rotation; power hip and ankle; deviation of motion valgus and varus knee, dorsiflexion and plantar ankle flexion and range of movement knee extension to flexion and dorsiflexion plantar ankle flexion. Already spatio-temporal variables altered were: gait speed, leg length and Step. We note occurrence of any correlation, but unsystematic. CONCLUSION: Women with CPP have gait changes compared to healthy women, and the most significant refer to kinematic and spatiotemporal variables. We note possible correlations, but not systematic in our sample. These findings suggest the need for further evaluation, in order to get better more effective diagnosis and treatment.
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Poster #35
THE EFFECTS OF ENDOMETRIAL RADIOFREQUENCY CAUTERIZATION FOR THE TREATMENT OF HYPERMENORRHEA
HanKyung Kim, Hyuk Jung and Satbyul Kim
Chosun univ. hospital
Presented By: HanKyung Kim

Objective: To evaluate the outcome, clinical efficacy and safety of endometrial radiofrequency cauterization for the treatment of hypermenorrhea.
Methods: From January 2011 to March 2015, a total of 195 women who visited to Chosun University Hospital had their charts and telephones reviewed for demographics, procedure data, clinical history, and follow up.
Results: The mean age was 43.3 ± 5.9 years old. A decrease in days per cycle (7.9 ± 2.8vs 5.4 ± 2.3 days, P < 0.001), and in pads per day (10.1 ± 2.7 vs 5.9 ± 3.8 pads/day, P < 0.001) and an increase in hemoglobin (g/dL, mean ± SD) / hematocrit (%, mean ± SD) (7.4 ± 0.5 / 29.5 ± 2.7 vs 11.7 ± 1.3 / 36.1 ± 4.2, P < 0.001) and an improvement in self-reported quality of life scores (limitation of life: 8.1 ± 2.2 vs 2.9 ± 1.7, P < 0.0001, discomfort score: 2.1 ± 1.5 vs 0.9 ± 1.5, P < 0.001) were observed after endometrial heat therapy. Assessment of the level of satisfaction showed that 83.6% of patients were satisfied with the procedure. No major complications or deaths were found. The prognostic factors of endometrial heat therapy were age, parity, uterine pressure and depth, position. But age and uterine pressure had no significant difference statistically.
Conclusion: Endometrial radiofrequency cauterization is a safe and efficient method to treat of hypermenorrhea. It reduces the menstrual flow, improves the quality of life, and remarkably satisfies patients with a desire to preserve a uterus.
Key Words: hypermenorrhea, endometrial heat therapy
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Poster #36
OSTEOMYELITIS PUBIS PRESENTING WITH PELVIC FLOOR DYSFUNCTION AND ANTALGIC GAIT IN A PROSTATE CANCER SURVIVOR: A CASE REPORT
Stacey Bennis¹, Danielle Duley² and Nicole Wysocki²
¹Rehabilitation Institute of Chicago/Northwestern University; ²Rehabilitation Institute of Chicago
Presented By: Stacey Bennis

Objective: To review the presenting signs and symptoms that can indicate the presence of osteomyelitis pubis in male prostate cancer survivors.

Methods: A 69-year-old male with prostate cancer (gleason 7) status post radiation therapy (15 years prior) and recent salvage prostatectomy (7 months prior to presentation) initially presented to a pelvic floor physical therapist via referral from his urologist with a 4-month history of acute onset, progerss right groin pain and urinary incontinence. He had no acute provoking injury or trauma, though the temporal relationship of his symptom onset was several months following a salvage prostatectomy for gleason 7 prostate cancer. His symptoms improved but did not resolve with pelvic floor physical therapy (PT), which prompted referral to a musculoskeletal/pelvic floor rehabilitation (MSK/PF) outpatient clinic. His pain was located in the right scrotum with radiation to the anteromedial thigh. His exam revealed pelvic floor muscle weakness, bilateral hip flexor weakness (right > left), and antalgic gait. Urologic workup done prior to referral to the pelvic floor PT and physiatrist included scrotal ultrasound, urodynamic studies, and cystoscopy which were all unremarkable. During his evaluation with the musculoskeletal physiatrists, radiography of the pelvis was also unremarkable. A non-contrast MRI of the pelvis was ordered and demonstrated inguinal lymphadenopathy, and inferior bladder diverticulum with direct communication of urine between the inferior bladder wall and pubic symphysis, and T1 stir changes concerning for osteomyelitis of the bilateral superior and inferior pubic rami,.

Results: The patient was referred to Urology and Infectious Disease specialists. Repeat non-contrast MRI of the pelvis demonstrated worsening osteomyelitis and a urine culture was positive (escherichia coli). An extended course of broad spectrum IV vancomycin and ciprofloxacin was initiated. Urology recommended bladder diverticulum closure but the patient elected for continued observation and conservative management with musculoskeletal physiatrist oversight given overall improvement of his symptoms with pelvic floor physical therapy.

Conclusion: Pelvic floor muscle dysfunction and urinary incontinence are known sequelae following treatment for prostate cancer. However, the presence of concomitant pelvic pain and antalgic gait have rarely been reported in the literature. This symptom constellation in patients with history of prostate cancer has rarely been associated with osteomyelitis pubis.

Summary: In the absence of alternative musculoskeletal diagnoses as etiology for symptoms of antalgic gait, pelvic pain, urinary incontinence, and pelvic floor dysfunction, we recommend keeping low threshold to pursue advanced imaging to assess for osteomyelitis pubis in males with history of prostate cancer.