Interstitial cystitis and endometriosis in patients with chronic pelvic pain: The "Evil Twins" syndrome.
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OBJECTIVE: To determine the prevalence of interstitial cystitis and endometriosis in patients with chronic pelvic pain. METHODS: A prospective analysis was conducted in 178 women with CPP who presented with bladder base/anterior vaginal wall and/or uterine tenderness, with or without irritative voiding symptoms. The Potassium Sensitivity Test was used to assess bladder epithelial dysfunction. Patients were evaluated with concurrent laparoscopy and cystoscopy with hydrodistention. RESULTS: Laparoscopic findings among the 178 patients with chronic pelvic pain supported a diagnosis of endometriosis in 134 (75%) patients, and cystoscopy confirmed a diagnosis of interstitial cystitis in 159 (89%) patients. Both interstitial cystitis and endometriosis were diagnosed in 115 patients (65%). The Potassium Sensitivity Test was positive in 146 (82%) patients, with 140 (96%) of these patients diagnosed with interstitial cystitis and 105 (72%) with endometriosis. CONCLUSIONS: Results of this prospective study show that interstitial cystitis and endometriosis may frequently coexist in patients with chronic pelvic pain. A positive Potassium Sensitivity Test accurately predicted the presence of interstitial cystitis in 96% of these patients with chronic pelvic pain, as confirmed by cystoscopic hydrodistention. It is necessary to consider the diagnosis of endometriosis and interstitial cystitis concurrently in the evaluation of patients with chronic pelvic pain to avoid unnecessary delay in identifying either condition. (+info)
The response to sertraline in men with chronic pelvic pain syndrome.
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OBJECTIVES: Male chronic pelvic pain syndrome (CPPS) is difficult to manage. Although antidepressants are frequently used in clinical practice, to date no interventional study has been published. We investigated men with CPPS to assess their response to the serotonin specific reuptake inhibitor (SSRI) antidepressant, sertraline. METHODS: Men with CPPS underwent a four glass test to exclude an infective cause for their symptoms. They were randomised to sertraline or matched placebo for 13 weeks after which they were unblinded. They were then allowed to either continue sertraline or cross over to active treatment for a further 13 weeks. Prostatic symptom severity (PSS) and frequency (PSF) scores, the Hospital Anxiety and Depression (HAD) scale and a psychosexual (PSex) questionnaire were completed at 0, 6, 13, and 26 weeks. Statistical analysis was by the Mann-Whitney U and Wilcoxon signed rank tests. RESULTS: 14 men enrolled. At week 13 there was a mean reduction in PSS scores of 6.1 in the active and 2.0 in placebo group, and in PSF scores of 3.6 and 1.0, respectively. There was no statistically significant difference in the PSS and PSF scores between the active versus placebo group because of the small subject numbers. If analysed as a case series, there was a significant reduction in PSS (11.7; p = 0.01) and PSF (5.9; p = 0.03) from baseline following 13 weeks of sertraline. There was also a decrease in mean HAD depression score from 4.6 at baseline to 2.4. CONCLUSION: Sertraline led to a significant improvement in prostatic symptom severity and frequency from baseline following 13 weeks of treatment. Although this analysis does not exclude a placebo effect, the randomised placebo controlled findings show a trend to improvement with sertraline when compared to placebo. (+info)
Symptomatic local recurrence of prostate carcinoma after radiation therapy.
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BACKGROUND: Symptomatic local recurrence of prostate carcinoma (SLRPC) after radiation therapy (RT) is associated with morbidity and debilitating symptoms that have a substantial impact on the patient's quality of life. Most reports on the results of RT for localized prostate carcinoma (PC) do not address this endpoint. The objective of this study was to determine the incidence of SLRPC and to identify the risk factors for this endpoint. METHODS: The medical charts of 1006 patients who received RT for localized PC at the University of Texas M. D. Anderson Cancer Center between 1987 and 1997 were reviewed. Local symptoms were defined as hematuria, voiding symptoms, urinary obstruction, and pelvic pain. Progressive symptoms accompanied by either confirmatory histology or cystoscopic findings were attributed to PC. Univariate and multivariate analyses using Cox proportional hazards models were applied to identify risk predictors. RESULTS: Among 964 patients for whom follow-up data were available, 277 patients had prostate-specific antigen (PSA) progression, and 45 patients died of PC during a median follow-up of 9.4 years. In total, 33 patients (3.4%) developed SLRPC. In patients who experienced biochemical progression, the actuarial 5-year incidence of SLRPC was 8.3%. Among the patients who had developed SLRPC, 23 patients (69.7%) died of PC at a median of 25.3 months from the onset of local symptoms. Adverse histologic tumor subtypes (ductal, small cell, and sarcomatoid) were associated significantly with SLRPC (hazard ratio, 8.4; 95% confidence interval, 2.99-23.63). Clinical T classification at diagnosis, Gleason score, and initial PSA level showed a trend toward an increased hazard ratio. CONCLUSIONS: SLRPC after radiotherapy therapy was an uncommon but clinically significant event. Aggressive histologic subtypes were predictive of this endpoint. Clinical T classification, Gleason score, and initial prostate-specific antigen levels also may have predictive value. (+info)
A new technique for superior hypogastric plexus block: the posteromedian transdiscal approach.
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Superior hypogastric plexus block has been advocated for the treatment of cancer related pelvic pain. Neurolysis is usually established using the classical posterolateral approach in the prone position, in which correct placement of the needle is sometimes difficult due to vertebral anatomy and the patient's inability to lie prone. We describe an alternative posteromedian transdiscal approach under fluoroscopic guidance for the treatment of intractable pelvic pain in three patients, in whom the classical approach was not possible. The L5-S1 interdiscal space was identified with fluoroscopy. The needle was then introduced through the disc and advanced under lateral fluoroscopic control. After verifying correct needle placement, neurolysis was performed with 8 ml of 10% phenol solution. All patients had significant pain relief immediately after the block, lasting from 6 to 12 months, and their pain severity scores and opioid consumption were reduced by more than 50%. There were no complications such as discitis, disc rupture or nerve injury. Since this new posteromedian transdiscal approach provides easy access to the superior hypogastric plexus with a single puncture and with any patient position, it may be an alternative to the classical approach. (+info)
Agreement between diagnoses reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain.
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BACKGROUND: The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards. METHODS: We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, "exact" agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, "clinical agreement" was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on six pathoanatomic diagnoses. RESULTS: In a sample of chronic LBP patients (n = 216) with high levels of disability and distress, 67% received a patho-anatomic diagnosis based on available reference standards, and 10% had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13%. "Exact" agreement between clinical and reference standard diagnoses was 32% and "clinical agreement" 51%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33% with actual agreement 56%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatomic categories produced a kappa of 0.31. CONCLUSION: Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified. (+info)
Toe spreading ability in men with chronic pelvic pain syndrome.
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BACKGROUND: We examined toe-spreading ability in subjects with chronic pelvic pain syndrome (CPPS) to test the hypothesis that subjects with CPPS could have deficiencies in lower extremity functions innervated by sacral spinal roots. METHODS: Seventy two subjects with CPPS and 98 volunteer controls were examined as part of a larger study on CPPS. All the subjects underwent a detailed urologic and neurological examination including a toe-spreading examination with a quantitative scoring system. We compared the groups in terms of ability of toe-spreading as either "complete" (all toes spreading) or "incomplete" (at least one interdigital space not spreading) and also by comparing the number of interdigital spaces. For CPPS subjects only, we also analyzed the variation of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) scales by toe-spreading categories. RESULTS: CPPS subjects were less often able to spread all toes than subjects without CPPS (p = 0.005). None of the NIH-CPSI sub-scales (pain, urinary symptoms, and quality of life), nor the total score showed an association with toe spreading ability. CONCLUSION: We found toe spreading to be diminished in subjects with CPPS. We hypothesize that incomplete toe spreading in subjects with CPPS may be related to subtle deficits involving the most caudal part of the spinal segments. (+info)
Psychosocial and physical work environment, and risk of pelvic pain in pregnancy. A study within the Danish national birth cohort.
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OBJECTIVE: The sparse knowledge of the aetiology of pelvic pain in pregnancy makes evidence based prevention a limited option. The aim of this study was to examine the relation between pelvic pain in pregnancy and physical and psychosocial working conditions. METHODS: This study used self reported data on working conditions for 1219 cases and 1539 controls, sampled as a nested case-control study within the Danish national birth cohort. Cases and controls were selected on the basis of self reported pelvic pain intensity, pain localisation, and pain impact on daily living activities. Exposure data were collected prospectively; early in pregnancy and before the onset of pelvic pain. Main outcome measures were odds ratios for pelvic pain in pregnancy as a function of physical and psychosocial working conditions. RESULTS: Pregnant women with fixed evening work and with rotating shifts (without night shift) had odds ratios for pelvic pain in pregnancy of 1.76 (95% confidence intervals 1.04 to 2.96) and 1.65 (1.22 to 2.24), respectively, compared with women with day work. Physically strenuous work was associated with an almost 50% increased risk of pelvic pain in pregnancy (1.47; 1.17 to 1.84). In women who were under high psychosocial strain at work odds ratio was 1.39 (1.12 to 1.74) compared with women with low job strain. CONCLUSION: Both physically and psychosocially demanding working conditions, measured by physically strenuous work, rotating shifts, and high job strain, are associated with an increased reporting of pelvic pain in pregnancy. (+info)
Diagnosis and laparoscopic repair of type I obturator hernia in women with chronic neuralgic pain.
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BACKGROUND: We performed a pilot study review of 7 female patients suffering with obturator neuralgia produced by a type I obturator hernia. Diagnosis and laparoscopic treatment of this rare hernia are presented. METHODS: Patients with chronic pelvic pain and signs of obturator neuralgia were identified retrospectively by chart review. These patients had been referred to our chronic pelvic pain clinic. Outcomes of their surgery from February through November 2001 were analyzed. Median length of follow-up was 11 months (range, 6 to 16). A new technique using Cooper's ligament and arcus tendineus fasciae pelvis was used for the tension-free mesh hernia repair. RESULTS: In this pilot study, 6 of 7 patients (86%) received greater than 50% relief of their chronic pelvic pain, which leads to the conclusion that we have at least 95% confidence that the pain reduction achieved is greater that 50%. Due to the small sample size, no statistically meaningful conclusions could be reached. All of the patients have reported some pain relief and increased function since surgery. CONCLUSION: Symptomatic type I obturator hernias may be more common than previously thought. Patients with obturator neuralgia, persisting longer than 6 months despite conservative therapy, may respond to laparoscopic reduction of the pilot fat tag and mesh overlay of the obturator canal. (+info)