Abigail Bayer−Mertens Human, Charity Hill MD, Tayyaba Ahmed DO, Gautam Shrikhande MD FACS, Allyson Shrikhande MD

Pelvic Rehabilitation Medicine, New York, NY

Objective.

Endometriosis is a disorder characterized by the abnormal growth of uterine tissue outside of the uterus. Its symptoms are known to be painful and debilitating to patient functionality. Treatment options for these symptoms are not well understood despite a growing need. The objective of this study is to determine the effectiveness of pelvic floor musculature trigger point injections and peripheral nerve hydrodissection in treating endometriosis symptoms, associated pain and pelvic functionality.

 

Study Design and Outcomes.

The participants in our study consisted of 16 female patients, aged 21-67, with endometriosis. Pre-treatment, all patients were evaluated with a detailed history and physical exam. This included an internal pelvic floor evaluation. Each patient took part in physical therapy before and throughout the treatment process, with individualized pelvic floor physical therapy programs.

 

Methods.

Treatment consisted of ultrasound guided pelvic floor trigger point injections to the iliococcygeus, pubococcygeus, and puborectalis. The first two injections combined 1% lidocaine with dexamethasone, while the next 4 injections consisted of 1% lidocaine with traumeel. Traumeel is a homeopathic, plant derived anti-inflammatory medication. Patients concurrently underwent peripheral nerve hydrodissection performed on the pudendal nerve and the posterior femoral cutaneous nerve.  Nerve hydrodissection allows the nerves to reset, decreasing hypersensitivity. These treatments were performed once a week for 6 weeks, and were all office based and ultrasound guided. Patients were evaluated using two scales to quantify their pain and functionality before treatment and 3 months after treatment; the 0−10 Visual Analogue Scale (VAS) and the Functional Pelvic Pain Scale (FPPS). The FPPS rates pelvic functionality in 8 categories: bladder, bowel, intercourse, walking, sleeping, working, running, and lifting. The patient rates each category from 0 to 4, with 0 being normal functionality, and 4 being severe debilitation. Thus, each patient can be given a total score from 0 to 32.

 

Results.

The mean age of patients was 32.4. Pre-treatment, the mean VAS score was 6.00 (SD 2.68) and post-treatment the mean VAS score was 2.94 (SD 2.59); P<.05, 95% CI 1.16-4.97. The mean total FPPS score before treatment was 14.44 (SD 5.24)  and post-treatment it was 9.13 (SD 5.75); P<.05, 95% CI 1.34-9.28. Analysis of the subcategories within the FPPS indicated the improvement was statistically significant in the categories of intercourse, sleeping, and working. In the category of intercourse the mean score before treatment was 3.07 (SD 1.14)  and post-treatment it was 1.79 (SD 1.48); P<.05, 95% CI 0.26-2.31 . In the category of sleeping the mean score before treatment was 2.00(SD 1.22) and post-treatment it was 0.85(SD 0.8); P<.05, 95% CI 0.32 -1.99. In the category of working, the mean score before treatment was 2.00 (SD 0.96)  and post-treatment it was 1.14 (SD 0.77); P<.05, 95% CI 0.18-1.53 .

 

Conclusions.

This study set out to determine the effectiveness of pelvic floor musculature trigger point injections and peripheral nerve hydrodissection as a treatment option for endometriosis related symptoms. Analysis suggests the treatment was effective at relieving pain related to endometriosis; it also reflected promise in improving overall pelvic functionality, particularly in relation to intercourse, working and sleeping. This study provides the foundation for future research with larger sample size and longer follow up.

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