(Abstracted from Am J Obstet Gynecol 2018;218:114.e1–114.e12) Chronic pelvic pain (CPP) is a common clinical problem among women. Its etiology is complex and involves an interplay of gynecologic, urologic, gastrointestinal, musculoskeletal, and psychosocial comorbidities.
Introduction Deep dyspareunia is a common symptom in women, including in half of women with endometriosis, but little is known about its response to treatment and predictors of persistent deep dyspareunia over time. Aim To follow up deep dyspareunia severity over a 1-year prospective cohort at an interdisciplinary center, and to identify baseline predictors of more persistent deep dyspareunia at 1 year. Methods Prospective 1-year cohort study at a tertiary referral center for pelvic pain and endometriosis, where a range of interdisciplinary treatments are provided at a single center (surgical, hormonal, physical, and psychological therapies). Exclusion criteria were menopause, age >50 years, and never previously sexually active. Primary outcome (deep dyspareunia severity) and secondary outcome (sexual quality of life) were followed up over 1 year. Ordinal logistic regression was performed, controlling for baseline severity of deep dyspareunia, to identify baseline predictors of deep dyspareunia severity at 1 year. Main Outcome Measure Primary outcome was severity of deep dyspareunia on an 11-point numeric rating scale (0–10), categorized into absent-mild (0–3), moderate (4–6), and severe (7–10); secondary outcome was sexual quality of life measured by the Endometriosis Health Profile-30. Results 1-year follow-up was obtained for 278 subjects (56% response rate at 1 year; 278/497). Severity of deep dyspareunia improved over the 1 year (McNemar test, P < .0001): the proportion of patients in the severe category decreased from 55.0% to 30.4%, the moderate category remained similar from 17.7% to 25.0%, and the absent-mild category increased from 27.3% to 44.6%. Sexual quality of life also improved (56% to 43% on the sex subscale of the Endometriosis Health Profile-30) (Welch t test, P < .001). On ordinal regression, severity of deep dyspareunia at 1 year was independently associated with younger age (OR = 0.94, 95% CI = 0.91–0.97, P = .008), and with a higher baseline depression score on the Patient Health Questionnaire-9 (OR = 1.07, 95% CI = 1.03–1.11, P = .01). Clinical Implications Clinicians should consider employing an interdisciplinary approach for deep dyspareunia, and screening for and treating depression symptoms in these women. Strength & Limitations Strengths of the study include its prospective nature, and assessment of deep dyspareunia specifically (as opposed to superficial dyspareunia). Limitations include non-randomized design, and the patients lost to follow-up over the 1 year. Conclusion Over 1 year in an interdisciplinary setting, improvements were observed in deep dyspareunia and sexual quality of life, but younger women and those with more severe depression at baseline had more persistent deep dyspareunia at 1 year.
Introduction Bladder base tenderness can be present on pelvic exam in women with pelvic pain. However, its exact prevalence and clinical implications are not well understood. Aim The aim of this study was to determine whether bladder base tenderness is associated with specific symptoms or signs in women, particularly dyspareunia. Methods Retrospective review of 189 consecutive women seen by a gynecologist in 2012 at a tertiary referral center for pelvic pain was conducted. Associations were tested between bladder base tenderness and variables on history/examination using bivariate analyses and multiple logistic regression. Main Outcome Measure Deep dyspareunia and superficial dyspareunia (present/absent) were the main outcome measures. Results Bladder base tenderness was present in 34% of pelvic pain patients (65/189), which was significantly greater than the prevalence of bladder base tenderness of 3% (1/32) in a control sample of women without pelvic pain (odds ratio [OR] = 16.3, 95% confidence interval [CI] 2.17–121.7, Fisher exact test, P < 0.001). For the pelvic pain patients, on bivariate analyses, bladder base tenderness was significantly associated with deep dyspareunia (P < 0.001), superficial dyspareunia (P < 0.001), bladder symptoms (P = 0.026), abdominal wall trigger point (P < 0.001), and pelvic floor tenderness (P < 0.001). In contrast, bladder base tenderness was similarly present in women with or without endometriosis. On logistic regression, bladder base tenderness was independently associated with only deep dyspareunia (OR = 6.40, 95% CI: 1.25–32.7, P = 0.011), abdominal wall trigger point (OR = 3.44, 95% CI: 1.01–11.7, P = 0.037), and pelvic floor tenderness (OR = 8.22, 95% CI: 3.27–20.7, P < 0.001). Conclusions Bladder base tenderness is present in one-third of women with pelvic pain, and contributes specifically to the symptom of deep dyspareunia. Bladder base tenderness was also associated with the presence of an abdominal wall trigger point and with pelvic floor tenderness, suggesting a myofascial etiology and/or nervous system sensitization.
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