Central sensitization in urogynecological chronic pelvic pain : a systematic literature review

Background: Chronic pelvic pain (CPP) is a complex pain syndrome. Since its pathogenesis is still poorly understood and structural alterations in pain related brain regions may be present, there is a greater acceptance that sensitization of the central nervous system (CNS) plays an important role in the development and maintenance of chronicity. Objective: The purpose of this study is to systematically review the scientific evidence regarding central sensitization (CS) in female patients with urogynecological CPP. Study Design: Systematic review of the literature. Methods: A systematic literature search was conducted in PubMed and Web of Science using different keyword combinations related to urogynecological CPP and central sensitization. Full text clinical reports addressing CS in adult women with urogynecological CPP were included and assessed for methodological quality by 2 independent reviewers. Results: After screening for the eligibility, a total of 29 full-text articles with low to good methodological quality were retained. All studies were observational, 27 of which were case-control and 2 of which were cohorts. Sensitivity of the CNS was investigated by using a variety of methods. Although different central mechanisms seem to be involved in pain processing, the present evidence suggests hyperexcitability of the CNS in patients with urogynecological CPP. Altered brain morphology and function, generalized hyperalgesia to different type of stimuli, overactive bottom-up nociceptive mechanisms, and autonomic dysregulation were established in patients with urogynecological CPP. Nevertheless, diffuse noxious inhibitory control seemed normal, and therefore the contribution of an impaired endogenous pain inhibition mechanism to CPP requires further study. The same goes for the contribution of psychological factors. Limitations: The level of evidence of retained studies is low due to the observational study designs and a wide range of diagnoses and assessment methods. Conclusion: Although the majority of the literature provides evidence for the presence of CS in urogynecological CPP with changes in brain morphology/function and sensory function, it is unclear whether these changes in central pain processing are secondary or primary to CPP, especially since evidence regarding the function of endogenous pain inhibition and the role of psychosocial pain facilitation is scarce. Further studies with good methodological quality are needed in order to clarify exact mechanisms

Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain.

Myofascial pelvic pain (MFPP) is a major component of chronic pelvic pain (CPP) and often is not properly identified by health care providers. The hallmark diagnostic indicator of MFPP is myofascial trigger points in the pelvic floor musculature that refer pain to adjacent sites. Effective treatments are available to reduce MFPP, including myofascial trigger point release, biofeedback, and electrical stimulation. An interdisciplinary team is essential for identifying and successfully treating MFPP

Chronic pelvic pain

Chronic pelvic pain is defined as pain in the pelvis lasting for more than six months (some say three). The pain may be experienced in any of the structures of the pelvis, including the gynaecological organs; the lower urinary and gastrointestinal tract; and the vascular, neural and musculoskeletal systems. The pain can be continual, cyclical, provoked or unprovoked, and is frequently multifocal. A woman who complains of painful sex, for example, may also report vulvovaginal pain and dyspareunia; bladder frequency, urgency and  suprapubic pain, as well as irritable bowel symptoms. Although an initiating event is sometimes described, such as an episode of severe “thrush” or cystitis, or following pelvic surgery or childbirth, this initial insult may be long forgotten and no longer relevant. Vulvodynia, endometriosis, bladder pain syndrome and irritable bowel syndrome are common causes of chronic pelvic pain in women but are often misdiagnosed and poorly  managed.Keywords: chronic pelvic pain, vulvodynia, vulvar vestibulitis, dyspareunia, painful sex, endometriosi

Vulval Vestibulitis Syndrome.

Objective: This project investigates ways of assessing Vulval Vestibulitis Syndrome (VVS), possible aetiological factors, and response to a range of treatments. Materials and Methods: 1. Data were collected and analysed to identify possible epidemiological characteristics and compared to existing evidence. 2. Technology (an algesiometer) was used to reliably assess patients, and quantify response to treatment. 3. Immunohistochemistry was used to determine whether VVS is an inflammatory condition. 4. Immunohistochemistry was also used to investigate the expression of oestrogen and progesterone receptors in the vulval tissue of women with VVS and biochemical techniques were used to investigate any relationship with serum oestradiol. Results: The cohort of women fulfilling the criteria for VVS were aged 22 to 53 (mean age 34.6) and for some there appeared to be an association with use of the combined oral contraceptive pill (cOCP). The algesiometer allowed quantification of pain, and improvement with treatment. There appears to be an overall decreased expression of inflammatory markers in women with VVS. There appears to be no correlation between serum oestradiol and VVS, however vulval tissue from women with VVS appears to express less oestrogen receptors, although there is no difference in the expression of progesterone receptors. Discussion: VVS is a condition which appears to have well defined epidemiological characteristics, although subgroups may exist. There is evidence that it is not an inflammatory condition, as previously thought, giving weight to the current argument that it is not an "itis" and the condition should be defined as localised provoked vulvodynia, as proposed by the International Society for the Study of Vulvovaginal Disease (ISSVD) at their congress in 2003. The nomenclature and classification of vulval pain forever appears to be evolving. Since late 2003 the term Vulval Vestibulitis Syndrome is no longer recommended by the ISSVD, although it was the term in use at the time this work was performed. The patients were selected for the studies by fulfilling Friedrich's criteria for WS, and therefore this term is used throughout this thesis

Fibromyalgia syndrome: an overview of pathophysiology, diagnosis and management

Fibromyalgia Syndrome (FMS) is a chronic condition causing pain, stiffness, and tenderness of the muscles, tendons, and joints. It is also characterized by restless sleep, tiredness, fatigue, anxiety, depression, and disturbances in bowel functions. The etiology of fibromyalgia remains unknown, but recent advances and discoveries have helped to unravel some of the mysteries of this disease. Research highlights some of the biochemical, metabolic, and immunoregulatory abnormalities associated with fibromyalgia. Management of FMS at the present time is very difficult as it has multiple etiological factors and psychological predispositions; however, a patient centered approach is essential to handle this problem

Mucosal versus muscle pain sensitivity in provoked vestibulodynia

An estimated 8.3%—16% of women experience vulvovaginal discomfort during their lifetime. Frequently these patients report provoked pain on contact or with attempted intercourse, commonly referred to as provoked vestibulodynia (PVD). Despite the burden of this condition, little is known about its potential etiologies including pelvic floor muscular dysfunction and mucosal components. This knowledge would be beneficial in developing targeted therapies including physical therapy

Avoiding the sexual: Visual attention and distraction in dyspareunia

Dyspareunia, defined as genital pain associated with intercourse, holds the unenviable status of being one of the most prevalent yet understudied of the sexual dysfunctions. The coupling of sex and pain creates an interesting theoretical conundrum of clinical significance: are women with dyspareunia distracted from sexual stimuli (as the sexual dysfunction literature would suggest), or are they hypervigilant to sexual stimuli because these stimuli elicit thoughts and expectations of pain (as the pain literature would suggest)? Eye-tracking may be a uniquely relevant tool to measure potential differences in attention between women with and without dyspareunia. The current study tested distraction by presenting women with and without dyspareunia a series of erotic images, each containing a semantically-inconsistent object, while tracking their eye movements as they looked at them. Significant group differences were found for two of the three visual attention dependent variables (total number of fixations, total gaze duration), such that women with dyspareunia looked fewer times and for less total time at the sexual scene regions (i.e., the bodies) than both women with low sexual desire (p = .018, and p = .024, respectively) and the no-dysfunction control women (p = .003, and p \u3c .001, respectively). Women with dyspareunia were also found to have looked at the context scene region significantly more times and for longer periods of time than the no-dysfunction control women (p = .013, and p = .042, respectively). No group differences were found for average fixation duration, or any of the four memory variables (e.g., number of semantically inconsistent objects correctly recalled, number of intrusions, number correctly recognized, number of false positives). Results did not support the attentional hypervigilance that would have been consistent with the pain disorder conceptualization, but were potentially supportive of the attentional distraction hypothesis that is consistent with the sexual dysfunction theory. There appeared to be evidence of a cognitive avoidance process occurring in women with dyspareunia, such that sexual information may have triggered anxiety (due to fear of threat or harm), thus creating overall attentional avoidance of these scene regions. Limitations of the current study and future directions are provided

Overlap Between Orofacial Pain and Vulvar Vestibulitis Syndrome

To explore the prevalence of Orofacial Pain (OFP) among patients with Vulvar Vestibulitis Syndrome (VVS) and to examine the relationship between signs and symptoms of OFP and clinical characteristics of women with VVS; we specifically sought to investigate differences in psychological characteristics and self-reported severity of painful intercourse