AGES XXIII Annual Scientific Meeting 2013 Abstracts & Program

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The Pelvis in Pain Program Abstracts - Saturday 9 March Endometriosis and Beyond • A doctor finds bladder wall inflammation, pinpoint bleeding or ulcers during an exam with a special telescope (called a cystoscope) that looks inside your bladder • Your doctor has ruled out other diseases such as urinary tract infections, vaginal infections, bladder cancer, sexually transmitted diseases. Diagnostic tests that help identify other conditions include urinalysis, urine culture, urine cytology, cystoscopy with distension of the bladder under anaesthesia, and occasionally biopsy of the bladder wall. How is interstitial cystitis treated Because the causes of IC are unknown, current treatments are aimed at relieving symptoms. One or a combination of treatments helps most people for variable periods. As researchers learn more about IC, the list of potential treatments will change, so patients should discuss their options with a doctor. Most people feel better after trying one or more of the following treatments: • Diet. You may need to avoid alcohol, spicy, acidic foods and tobacco. • Bladder distension. About one third of people feel better after having a bladder distension. Under anaesthesia, a doctor overfills your bladder with fluid. This stretches the walls of the bladder. Doctors don’t know why distension helps. It may interfere with pain signals sent by nerves in the bladder. In some people they feel their pain is worse after this procedure • Medication. Your doctor may have you take an oral medicine called pentosan polysulfate (brand name: Elmiron). This medicine helps to protect the lining of the bladder wall from the toxic parts of urine. Elmiron may be expensive in some countries. It helps about 40% of patients. Another medicine that may help is amitriptyline (brand name: Endep). It blocks pain and reduces bladder spasms. This medicine can make you sleepy, so it’s usually taken at bedtime. Oral antihistamines or cimetidine have helped some patients with an allergic tendency. Physical therapies and trigger point therapy can help the pelvic floor muscle spasm that accompanies bladder pain syndrome. Bladder instillation. During a bladder instillation, a catheter (a thin tube) is used to fill your bladder with a liquid medicine. You hold the medicine inside your bladder for a few seconds to 15 minutes. Then the liquid drains out through the catheter. Treatments are given every one to two weeks for six to eight weeks. The treatment can be repeated as needed. The substances used can include • Heparin alone or in combination • Steroids alone or in combination • Local anaesthetic with or without sodium bicarbonate • Dimethyl sulfoxide or DMSO (Rimso-50), a chemical solvent from wood pulp which has several uses in medicine. It is known to reduce inflammation and block pain in about 3/4 of IC patients. It has the side-effect of leaving patients smelling of garlic that may last up to 72 hours after treatment. Difficult Cases Some treatments which are being currently assessed for people who do not respond to the above options include botulinum toxin bladder injection and sacral nerve stimulation. Some people need stronger pain medication such as morphine like drugs or gabapentin (nerve modulating drugs). Referral to a multidisciplinary pain clinic may be of benefit in severe cases. An extremely small minority of patients are not helped with regular treatments and require surgery. Many approaches and techniques are used, each of which has its own advantages and complications that should be discussed with a surgeon. Surgery should be considered only if all available treatments have failed and the pain is disabling. What else can I do to help my symptoms • Diet - Alcohol, tomatoes, spices, chocolate, caffeine, citrus drinks, artificial sweeteners and acidic foods may irritate your bladder. Try eliminating these foods from your diet for a couple of weeks. Then try eating one food at a time to see if it makes your symptoms worse. • Smoking - Many people with interstitial cystitis find that smoking makes their symptoms worse. Because smoking is also a main cause of bladder cancer, people with interstitial cystitis have another good reason to quit smoking. • Bladder training – If you have no pain, many people can train their bladder to hold more. You can train your bladder by going to the bathroom at scheduled times and using relaxation techniques. After a while, you try to make the time you can wait longer. Your physiotherapist can help you with bladder training and relaxation techniques. • Physical therapy and biofeedback - People with interstitial cystitis may have painful spasms of the pelvic floor muscles. If you have muscle spasms, you can learn exercises to help strengthen and relax your pelvic floor muscles. • TENS (“transcutaneous electrical nerve stimulation”). You can use a TENS machine to put mild electrical pulses often over the bladderdo this at least two times a day. You might do it for a few minutes, or you might do it for a longer time. Ideally, this is commenced under the supervision of a physical therapist. • Relaxation therapy, stress reduction, hypnotherapy and acupuncture can have a beneficial role in some people. Where can I get more information about interstitial cystitis The support of family, friends and other people with interstitial cystitis is very important to help you cope with this problem. People who learn about interstitial cystitis and participate in their own care do better than people who don’t. People with interstitial cystitis can get more information on this disease from these groups: • Interstitial Cystitis Support Group of Australia Chairman: Alice Terry P.O. Box 767, Kingswood 2747 New South Wales Australia http://www.users.bigpond.net.au/ICSG/
AGES XXIII Annual Scientific Meeting 2013 Program Abstracts - Saturday 9 March • Interstitial Cystitis Support Group Mercy Hospital for Women Clarendon Street, East Melbourne, 3002 Victoria Australia Phone : (03) 8458 4444 Contact: Christine Murray Websites for further information: • Interstitial Cystitis Network (Australia) http://www.icnaustralia.com/ • Interstitial Cystitis Association http://www.ichelp.org/ This handout provides a general overview on this topic and may not apply to everyone. To find out if this handout applies to you and to get more information on this subject, talk to your doctor. AUTHOR AFFILIATION: Dr Anna Rosamilia; Urogynaecologist, Monash Medical Centre, Clayton, Victoria, Australia. SESSION 9 / 0905-0925 Musculoskeletal issues Hallam T Pelvic pain of greater than 6months duration has commonly been sub-categorised into one of two broad, yet distinct clinical entities. The term CPP or ‘chronic pelvic pain’, has tended to be allocated when the clinical assumption has been one of underlying visceral pathology, whilst ‘chronic pelvic girdle pain’ has been used when the assumed pathophysiology has been one of orthopaedic/myofascial dysfunction of the sacroiliac joint, pubic symphysis and/or external pelvic musculature. There is no doubt that this historical demarcation of pelvic pain into either visceral (chronic pelvic pain) or somatic (chronic pelvic girdle pain) has enabled a clear, simple distinction between the role of the physiotherapist and gynaecologist for the patient presenting with pelvic pain. However, recent advances in understanding the pathophysiological mechanisms behind chronic pelvic pain have now led to questions surrounding a model that attempts to demarcate chronic pelvic pain as either visceral OR somatic. This presentation will therefore have two main foci. PART One The presentation will begin by exploring the anatomical research now implicating myofascial dysfunction as a possible factor in chronic gynaecological pelvic pain. Direct musculoskeletal pain mechanisms including myofascial trigger point referral patterns, as well as muscular hypertonicity and associated myalgia will be discussed. In addition, recent research surrounding theories of viscerosomatic and somato-visceral convergence, antidromic propagation and the possible role of myofascial dysfunction in neurogenic inflammation within the viscera will be discussed. Part TWO This possibility that myofascial dysfunction may contribute to chronic “gynaecological” pelvic pain has now led to challenges for both the gynaecologist, whose expertise has traditionally been focused on visceral pathology, and the physiotherapist whose expertise has tended to focus on myofascial dysfunction. For the physiotherapist, whose traditional area of expertise has been the anatomy and physiology of striated skeletal muscle, the challenge is to now develop the necessary knowledge to assess and monitor changes in visceral symptomatology that may be impacted by a myofascial approach. In contrast, for the gynaecologist, whose area of expertise has traditionally been visceral pathology, the challenge is to now identify the subgroup of patients in which myofascial dysfunction may be of relevance. Many assessments of myofascial dysfunction utilise specialised equipment including SEMG, manometry and 3D ultrasound. However, baseline screening of myofascial dysfunction can occur during a routine vaginal examination involving observation, palpation and functional assessment of both the levator ani and obturator internus. The second half of this presentation will therefore provide instruction on the observation of function and use of palpation in the screening of pelvic floor and obturator internus myofascial dysfunction which may be related to CPP. Cadaver images will be utilised to provide a detailed understanding of anatomical landmarks that can be utilised when undertaking a vaginal examination to assess the internal musculature. REFERENCES: 1. Abbott JA, Jarvis SK, Lyons SD, Thomson A and Vancaillie TG 2006, Botulinum toxin type A for chronic pain and pelvic floor spasm in women: a randomized controlled trial, Obstet Gynecol, vol 108, no.4, 915-923 2. Fitzgerald M, Payne C, Lukacz E, Yang C, Peters K, Chair T et al 2012, Randomized multicentre clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness, The Journal of Urology, vol 187, issue 6, pp 2113-2118 3 George S, Clinton S and Borello-France D 2013, Physical Therapy Management of Female Chronic Pelvic Pain: Anatomical Considerations, Clinical Anatomy, vol 26, pp77-88 4. Hoffman D 2011, Understanding multisymptom presentations in chronic pelvic pain: the interrelationships between the viscera and myofascial pelvic floor dysfunction, Curr Pain Headache Rep, vol 15, pp 343-346 5. Jantos M 2007, Understanding Chronic Pelvic Pain, Pelviperineology, vol 26, pp66-69 6. Kavvadias T, Pelikan S, Roth P, Baessler K, Scheussler B 2013, Pelvic floor muscle tenderness in asymptomatic, nulliparous women: topographical distribution and reliability of a visual analogue scale, International Urogynaecology Journal, vol 24, issue 2, pp. 281-286. 7. Khachikyan I, Sinaii N, Shah J et al 2010, CNS sensitisation and myofascial dysfunction in patients with endometriosis and chronic pelvic pain, 66th Annual 19
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