Managing chronic pelvic pain following reconstructive pelvic surgery with transvaginal mesh.

Gyang AN, Feranec JB, Patel RC, Lamvu GM. Int Urogynecol J 2014;25:313-318

Beth Shelly PT, DPT, WCS, BCB PMD

May 7, 2014 Distance Journal Club

Method - expert opinion paper on management of post mesh pain

Post op mesh pain = 0% to 30%

Causes - PFM spasm, pudendal neuralgia, infection

PFM spasm

·         14% to 22% prevalence

·         Symptoms - dyspareunia, LBP, bowel sx (constipation, diarrhea, excessive flatus, painful defecation), urinary sx (frequency, urgency, nocturia)

·         Signs - PFM pain greater than 3/10, increased PFM tone

Pudendal neuralgia

·         1% incidence

·         Symptoms - vary, pain in region of pudendal nerve

Symptoms from my lecture notes

·         Stabbing, burning, electrical sensations (Prendergast 2003, Fitzgerald 2003)

·         At any point along the path of the nerve or its innervations

·         Increased when sitting (but not on the toilet), decrease with standing, best in AM

·         Hesitancy, frequency, urgency (40%), constipation/ painful BM (29%), sexual dysfunction (33%), significant limitation to normal ADL (Popeney 2007)

·         Pain on squatting (Prendergast 2003)

·         Signs - Nantes criteria (Labat 2008)

§  Pain in the region of pudendal nerve - burning anus to clitoris

§  Pain worse with sitting

§  No night pain

§  No sensory deficit

§  Relief with pudendal block

·         Obturator neuralgia - electric pain on palpation of obturator foramen 

Mesh infection

·         0% to 8% incidence

·         Sign - erosion, exposure, fistula, abscess, various pathogens 

Evaluation

·         Through history including whether pain was present before surgery (would it be helpful to do pre op screening for PFM pain, also pre existing pain predisposes to central sensitization)

·         Abdominal myofascial pain (carnet's test)

·         Bulbocavernousus spasm / pain

·         Mesh or mesh arms under tension - very tender areas laterally - when sever pain exists between central mesh graft and arm fixation, surgical release is essential.

Treatment (flow chart page 316)

·         "Although mesh excision has been shown to resolve pelvic pain in some patients, there are no randomized controlled trials to validate this result."

·         Feiner, case series, 88% and 64% reduction in vaginal pain and dyspareunia after mesh removal.  

IUGA webinar - Post mesh complication Dr Helena Frawley Australian PT

20 min discussion of PT for CPP as we have no specific studies or guidelines on post mesh pain

Determine peripheral and central sensitization