ICS 1999, Denver
Read by title abstracts
Pelvic floor
THE PAIN CYCLE, IMPLICATIONS FOR THE DIAGNOSIS AND TREATMENT OF PELVIC PAIN SYNDROMES

K. Everaert, J. Devulder, M. De Muynck, S. Stockman, H. Depaepe, D. De Looze, J. Van Buyten, W. Oosterlinck
Gent unimversity hospital, Gent, Belgium.

Objectives The aim of the study is to evaluate the treatment modalities of perineal pain in urology in order to improve patient selection and the success rate of treatment.

Patients from 4/1992 to 8/1998, we treated ill patients (40 man/71 women, age: 46± 6 years) with chronic pelvic pain. Urodynamics were available in all patients. All patients with causal treatment were excluded from this study. Sacral neuromodulation (transcutaneous electrical nerve stimulation (TENS), intrarectal-intravaginal electrostimulation or sacral nerve stimulation) was used for treatment in all patient. Treatment success was evaluated with visual analogue scales. Multinomial logit regression analysis was used to explain the probability that a certain observation will belong to a given category.

Results Urodynamics of the patients are summarized in table 1.

cystometry

N

VAS <3,

<50% pain relief

VAS <3,

50-90% pain relief

VAS <3,

>90% pain relief

sphincterinstabilities

76

17

17

42

Mean sphincterpressure, cmH2O

111

89± 53

102± 49

98± 34

Compliance

111

56± 22

67± 34

60± 17

Micturition analysis

Normal flowpattern

50

42

2

6

Dysfunctional voiding

61

5

19

37

Q max, ml/sec

111

20± 11

23± 16

25± 18

 

Monovariate multinomial regression analysis (residual chi2: 87.5; 16 df; p<0.001; 110 cases included) revealed that pain relief was significantly better in patients with symptoms of voiding dysfunction (p<0.0001), dyschezia (p<0.001) and not to dyspareunia. Pain relief was better with decreasing age (p<0.0001) and better in men compared to women (p < 0.05). pain localized to the urethra was significantly (p <0.001) related to treatment (p<0.01). urodynamic evidence of dysfunctional micturition was the main criterion of success (Wald score 83.3, p<0.0001). after correction for all above mentionned variables, no treatment was significantly better then another (table4). Neurostimulation of the s3 nerves, intravaginal or intrarectal electrostimulation and TENS relieved 84% of these `pelvic-floor pain syndromes`. In patients without pelvic-floor dysfunction (p<0.01). 9 patients were implanted successfully with a follow-up of 24± 8 months. Sofar, no late failures were seen in contrast to our results of sacral nerve stimulation in patients with urge incontinence or retention.

Conclusion patients with chronic pelvic pain are treated efficiently with neuromodulation if concomittant pelvic floor muscle spasms are present. Pain cycle theory explainswhy pelvic floor spasms and pelvic pain are linked physiopathologically. Uroflowmetry is necessary in the diagnosis of all patients with pelvic pain. Sacral nerve stimulation is necessary in the diagnosis of all patients with pelvic pain. Sacral nerve stimulation is a promising new treatment modality for pelvic pain.