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Highlights from the 2018 Convergences in Pelvi-Perineal Pain congress in Brussels
PainSolve Editorial Team
History of Convergences in Pelvi-Perineal Pain Congress
Convergences in Pelvi-Perineal (Convergences PP) Pain is a society that aims to promote knowledge about chronic pelvic perineal pain. It is a federation of learned societies involved in the field of pain and pelvic perineal functional diseases. On October 25th, this multidisciplinary society organised its 5th congress in Brussels, after Nantes in 2009, Nîmes in 2012, the World Congress on Abdominal and Pelvic Pain in Nice in 2015 and Aix en Provence in 2016. Initially French spoken, Convergences PP confirmed its European openness in 2015 with simultaneous translations.
Day 1 Highlights
During the first day “sensitisation and pelvic pain” was the main focus with an excellent conference on the physiopathology of visceral hypersensitivity, involvement of vegetative nervous system, by Prof. Qasim Aziz highlighting that visceral pain hypersensitivity (VPH) may occur due to anomalies at any level of the visceral nociceptive neuraxis. Important peripheral and central mechanisms of sensitisation that have been postulated include a wide range of ion channels, neurotransmitter receptors and trophic factors. Data from functional brain imaging studies have also provided evidence for aberrant central pain processing in cortical and subcortical regions. In addition, descending modulation of visceral nociceptive pathways by the autonomic nervous system, hypothalamo-pituitary-adrenal axis and psychological factors have all been implicated in the generation of VPH.
Elsewhere, Dr Virginie Quistrebert described the Clinical Criteria of Central Sensitisation in Chronic Pelvic and Perineal Pain (Convergences PP Criteria). Validation and Score development. Her presentation described how a list of 63 items was submitted to 22 international chronic pelvic pain experts according to the Delphi method, and how 10 clinical criteria were adopted for the creation of a clinical evaluation tool: 1) pain influenced by bladder filling and/or urination, 2) pain influenced by rectal distension and/or defecation, 3) pain during sexual activity, 4) perineal and/or vulvar pain in response to normally non-painful stimulation, 5) pelvic trigger points (e.g. in the piriformis, obturator internus, and/or levator ani muscles), 6) pain after urination, 7) pain after defecation, 8) pain after sexual activity, 9) variable (fluctuating) pain intensity and/or variable pain distribution and 10) migraine or tension headaches and/or fibromyalgia and/or chronic fatigue syndrome and/or post-traumatic stress disorder and/or restless legs syndrome and/or temporomandibular joint dysfunction and/or multiple chemical sensitivity.
Finally, Dr Gisele Pickering targeted the controversy to continue using ketamine once sensitisation occurs, and Dr Oliver Bredeu debated where botulinum toxin should be placed in the management of sensitisation.
Day 2 Highlights
On the second day, Psychosexual impact in women with pelvic pain as well as, coccydynia were the selected topics for discussion. Psychosexual impact was discussed by gynaecologist, Dr. Lara Quintas, psychotherapist, Dr Laura Beltran, physiotherapist, Alexandrine Close and the representative of the Patient Association “Les Cles de Venus”. Related to this, controlled studies have shown that vulvovaginal pain can adversely affect women and their partners' general psychological well-being, relationship adjustment and overall quality of life. These women have significantly lower levels of sexual desire, arousal and satisfaction, as well as a lower intercourse frequency than normal controls. They also report more anxiety and depression, in addition to more distress about their body image and genital self-image. Empirical studies indicate that specific psychological and relationship factors may increase vulvovaginal pain intensity and its psychosexual sequelae. Randomised clinical trials have shown that psychosexual interventions, namely cognitive behavioural therapy, are efficacious in reducing vulvovaginal pain and improving associated psychosexual outcomes. Women reporting significant psychological, sexual and/or relationship distress should be referred for psychosexual treatment. A multimodal approach to care integrating psychosexual and medical management is thought to be optimal.
Additionally, inside the general title of Psychosexual impact in women with pelvic pain, a symposium on vulvodynia and sensitisation took place. The aim of the symposium was to establish first, second and third line therapies in Spain, Italy and France with the further outcome to write a short guideline on approach to management. The session was introduced by Dr. Micheline Moyal-Barracco, with further contributions by gynaecologists, Dr Oriol Porta from Barcelona, Dr Filippo Murina from Milan and Dr Eric Bautrant from Aix en Provence. The management is very similar within these European Southern countries with tricyclic antidepressants, lidocaine gel, even in master formulations, botulinum toxin A and surgery as the recommended treatments. The only exception was the use of low-level laser therapy in Italy as an alternative previously to surgery. The final lecture during the symposium was assumed by Hanna Muhlrad, presenting the results of an exercise, of which she has been the Project Manager assigned to the National Board of Health in Sweden, mapping the presence, treatment and need of knowledge support for the healthcare sector, as well as information for females suffering from vulvodynia. The number of females aged 15–44 who have been nursed at least once for vulvodynia, in specialised outpatient care from 2001–2016 amounts to between 8,603–53,924, as it is not clear if HCPs established a differential diagnosis in between vulvodynia and vulvar pain or vaginism. The reported occurrence of vulvodynia or other vulvar pain disorders is significantly lower in comparison to previous prevalence studies from Sweden and internationally, which may be due to the lack of clarity for clinicians when registering this disease. Opportunities for calculating prevalence are therefore limited because available data is incomplete. Furthermore, activities carried out in youth reception, primary care or childbirth care are not registered in health registers or quality records. One possible reason for under-reporting, according to data from dialogue meetings and questionnaire surveys, is that the state of knowledge about the disease in several parts of the care chain is unclear. There are also regional differences in access to specialised gynaecological care at so-called vulgar receptions. Analysis of registry data and a review of data from previous studies indicate comorbidities with other pain diseases, mental health and chronic fungal infections.
The symposium concluded with an open debate including physicians, physiotherapists, psychologists and representatives of Patient Associations from Spain, Italy and France. They agreed on the importance of a multimodal approach; integrating physiotherapy (rehabilitation) of the pelvic floor, psychosexual education and medical management of knowledge concerning the disease.
Finally, coccydynia was anatomically introduced by Dr Stephane Ploteau; Dr Jean-Yves Maigne gave an update on the current situation and Drs Thiebault Riant and Levon Doursounian, commented results of pulsed radiofrequency, which represents a potentially useful treatment option in place of surgery and when other treatment options have failed. Coccygectomy is seen as a last resort that can be associated with a high complication rate and failure to relieve the pain.