To review the relation between adhesions and pelvic pain and the effectiveness of adhesiolysis in pain control.
Selective review of the literature.
Patients with pelvic pain and/or undergoing adhesiolysis for pain control.
Intraabdominal adhesions are accepted as etiologic factors for infertility and small bowel obstruction; however, the contribution of adhesions to pelvic pain is less clear. The most common laparoscopic findings in patients with and without pelvic pain were endometriosis and adhesions. Immunohistologic studies also have shown evidence of nerve fibers in adhesions that had been removed from patients with and without pelvic pain. Multiple adhesiolysis techniques have been employed, with outcome of surgical procedures ranging from no pain relief to pain relief in 90% of patients. However, randomized trials have shown that adhesiolysis is ineffective in improving the outcome of the treatment of pelvic pain, possibly because of adhesion reformation. Interestingly, adhesions are usually not described as an etiologic factor for pelvic pain in men; this might be related to a gender difference in pain perception or the possibility that adhesions per se do not cause pain.
The correlation between pelvic pain and adhesions is uncertain. Adhesiolysis has not been shown to be effective in achieving pain control in randomized clinical studies.
"Although chronic pelvic pain is regarded as a consequence of adhesion formation, its true importance remains uncertain [12, 13]. Women with chronic pelvic pain treated by laparoscopic adhesiolysis compared with women treated with diagnostic laparoscopy alone experienced no significant difference in pain relief. "
[Show abstract][Hide abstract] ABSTRACT: Adhesions lead to considerable patient morbidity and are a mounting burden on surgeons and the health care system alike. Although adhesion formation is the most frequent complication in abdominal and pelvic surgery, many surgeons are still not aware of the extent of the problem. To provide the best care for their patients, surgeons should consistently inform themselves of anti-adhesion strategies and include these methods in their daily routine.
Searches were conducted in PubMed and The Cochrane Library to identify relevant literature.
Various complications are associated with adhesion formation, including small bowel obstruction, infertility and chronic pelvic pain. Increasingly, an understanding of adhesion formation as a complex process influenced by many different factors has led to various conceivable anti-adhesion strategies. At present, a number of different anti-adhesion agents are available. Although some agents have proved effective in reducing adhesion formation in randomised controlled trials, none of them can completely prevent adhesion formation.
To fulfil our duty to provide best possible care for our patients, it is now time to regard adhesions as the most common complication in surgery. Further research is needed to fully understand adhesion formation and to develop new strategies for adhesion prevention. Large clinical efficacy trials of anti-adhesion agents will make it easier for surgeons to decide which agent to use in daily routine.
Archives of Gynecology 10/2011; 285(4):1089-97. DOI:10.1007/s00404-011-2097-1 · 1.36 Impact Factor
"Therefore, a conservative surgery, if shown to be effective, would represent a major improvement in its management . Recent developments in minimal access surgery using laparoscopy make ablation of the nerve plexuses and ganglions in the uterosacral ligaments (laparoscopic uterosacral nerve ablation (LUNA)) a practicable treatment option . "
[Show abstract][Hide abstract] ABSTRACT: The aim of this work is to explore the efficacy , safety, and patients' satisfaction of laparoscopic uterosacral nerve ablation (LUNA) in relief of pain in women with chronic pelvic pain in whom diagnostic laparoscopy reveals either no pathology or mild endometriosis (AFS score ≤5). The study was a prospective, single-blind, randomized trial with 12 months follow-up. It was conducted at the endoscopy unit of the Gynecology Department of El Minia University Hospital, Egypt. One hundred ninety Egyptian women consented to participate in the study. These eligible patients were randomized using computer-generated tables and were divided into two equal groups, including the control group (diagnostic laparoscopy with no pelvic denervation) and the study group (diagnostic laparoscopy plus LUNA). Diagnostic laparoscopy with or without laparoscopic uterosacral nerve ablation was done. There were no statistically significant difference between both groups regarding the efficacy and the overall success rate (between group I and group II, it was 77.64%, 76.47%, and 74.11% versus 79.06%, 75.58%, and 73.25% at 3, 6, and 12 months, respectively) and the cumulative patients' satisfaction rate (it was 74.11%, 74.11%, and 71.76% versus 75.58%, 75.58%, and 72.09% at 3, 6, and 12 months between group I and group II, respectively; P ≤ 0.05). There was no statistically significant difference between both groups as regards the effectiveness of LUNA in the treatment of primary (spasmodic) and secondary (congestive) dysmenorrhea (P ≤ 0.05), while there was a statistically significant difference between both groups in the treatment of dyspareunia (P ≥ 0.05). LUNA can be a last alternative option in well-selected patients for control of chronic pelvic pain without endometriosis; however, its effectiveness may not extend to other indications. Also, preliminary experience in the treatment of primary deep dyspareunia presents a promising perspective on the management of deep dyspareunia, especially if it will involve a team of social, psychological, and gynecological specialists.
Gynecological Surgery 02/2011; 8(1):31-39. DOI:10.1007/s10397-010-0612-1
"Th e majority of adhesions are silent and have no signifi cant eff ect, however where they do cause clinical complications, they are a major cause of morbidity, pain and expense. A total of 74% of small bowel obstructions are adhesion-related (Menzies 1993) and it is estimated that between 20% and 40% of secondary infertility in women is as a result of adhesions (Mishell and Davajan 1991; Gutt et al. 2004; Hammoud et al. 2004; Vrijland et al. 2003). Previous studies predicted that the direct annual cost of adhesion-related readmissions for the UK as a whole within the fi rst year aft er initial lower abdominal surgery would be in excess of £ 24.2 million, rising to £ 95.2 million in the 10th year aft er surgery (Wilson et al. 2002). "
[Show abstract][Hide abstract] ABSTRACT: To explore recent developments in the techniques used for the prevention of adhesion formation after gynaecological surgery as well as the current evidence for existing agents and techniques.
Recent developments are promising new biomaterials such as polyvinyl alcohol gel and hyaluronic acid cross-linked with various agents such as nanoparticles. Other substances that have recently received attention include novel anti-inflammatory agents, Oxiplex (FzioMed, Inc., San Luis Obispo, California, USA), sildenafil, statins and also, there has been some renewed interest in dextran. Furthermore, the combination of barrier and pharmacological agents has led to the introduction of interesting new hybrid systems. Finally, despite the development of many novel antiadhesion agents, good surgical technique remains the mainstay of adhesion prevention.
There is preliminary evidence to support the use of hyaluronic acid, although the best preparation is yet to be determined. The use of icodextrin, Interceed (Ethicon Inc, Somerville, New Jersey, USA) and Oxiplex seem to be justified by the currently available data. The results of interesting new technologies such as the use of hybrid systems and new forms of biomaterials are awaited.
Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):345-52. DOI:10.1097/GCO.0b013e3283073a6c · 2.07 Impact Factor
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