Clinique Axium - Centre L’Avancée

de Chirurgie et Réhabilitation
Pelvi-périnéale
AIX-EN-PROVENCE
FRANCE

•! E Bautrant, L Quintas-Marquès, J Vochelet, P Carbone, R Boyer,

D Bartoli, M Serfaty, P Weber, L Roux, V Morel, E Poirson et S Collet.
 What are we going to speak about?
•  Definitions : what do we mean by « uterine pain »?
•  How to definite a CPP where the type of the pain is uterine?

•  Which pelvic pathologies can be involved in chronic uterine pain?

•  Introduction to the concept of a « Painfull Uterine Syndrome »
•  IBS, PBS and PUS?
 DEFINITIONS
•  Dysmenorrhea: painfull cramping sensation in
the lower abdomen occuring before or during the
menses and often accompanied by sweeting,
headaches, nausea, vomiting, diarrhea…

•  Uterine pain: CPP with pain criteria focusing to

the uterus: uterine contraction, painfull uterine
cramping, heavyness, myometrial trigger point and
often accompanied by deep dyspareunia,
hypermenorrhea, false prolapse sensation...
 PREVALENCE
• The Prevalence and Risk Factor of Dysmenorrhea
Hong Ju, Mark Jones and Gita Mishra
Centre for Longitudinal and Life Course Research, School of Population Health,
University of Queensland, Herston Road, Herston, QLD 4006, Australia
Epidemiologic reviews (2014), 36 (1): 104-113
- Primary dysmenorrhea : 60-91%
- Severe and dysmenorrhea-limiting activity: 16-29%
- Risks factors : family history of dysmenorrhea ++++
- Inconclusive evidence for : smoking, diet, obesity, depression and abuse
- Inversely associated with dysmenorrhea: age, parity and pill.

• The Prevalence and Risk factor of Uterine Pain Syndrome

- PubMed = 0
- Uterine pain in Adenomyosis
Uterine chronic pelvic pain "
and fashions
 Uterine Chronic pelvic pain
and fashions
•  Chronic Pelvic Pain and Allen-Masters syndrome : Zivi E Harefuah
(2009)
•  Pelvic pain may be caused by utero-sacral ligament laxity: Petros PE
Acta Obstet Gynecol Scand (2011)
•  TFS posterior sling improves overactive bladder, pelvic pain and
abnormal emptying, even with minor prolapse: Petros PE
Pelviperineology (2010)
•  Intensity of menstrual pain and estimated angle of uterine flexion:
Cagnacci A Acta Obstet Gynecol Scand (2014)
•  Adhesions in patients with Chronic Pelvic pain. A role for adhesiolysis?
Hammoud A Fertil Steril (2004)
•  Chronic Pelvic Pain and varices in women: Vercellini P Gynecol
Endocrinol (2009)
•  Chronic Pelvic Pain and endometriosis: Stratton P Human Reprod
Update (2011)
 Allen-Masters, ligament laxity
and uterine retroversion
•  Hypothesis: Autonomic denervation? Quinn MJ (Wenzhou, China)
Med hypothesis 2016, Arch Gynecol Obstet 2011, J Obstet Gynaecol 2009
•  Type of the pain: pelvic and uterine heaviness sensation and
deep dyspareunia
•  Surgery: Douglassectomy (1972), laparoscopic suture of the tear
+ Douglassectomy (P Von Theobald, 1997), sling reinforcement
(PE Petros 2010)
•  Uterine Retroversion: improvement of dysmenorrhea with the
surgical treatment of high angles of uterine flexion (A Cagnacci
2014, J Ott 2010)
Adhesions in patients with Chronic Pelvic pain.
A role for adhesiolysis?
Hammoud A Fertil Steril (2004)

•  « adhesiolysis has not been shown to be

effective in achieving pain control in
randomized clinical studies »
 Chronic Pelvic Pain and varices in women:
Vercellini P Gynecol Endocrinol (2009)"
•! Pain characteristics are different:
•! Orthostatic pelvic heaviness, no pain
in lying positions
•! Aggravation before the menses
•! Association with vein incompetence
•! Improves with progestins
•! No dysmenorrhea, deep dyspareunia is
possible
Could endometriosis explain
uterine pain?
 The role of rich innervation and
inflammation in deep endometriotic lesions
« The preponderance of the inflammatory
milieu and subsequent hyperinnervation
might be involved in the pathophysiology
of pain generation in woman with
endomeriosis »
Kobayashi H (Nara, Japan)
Arch Gynecol Obstet (2014)

« The rich innervation of Deep Infiltrating

Endometriosis may help to explain why
patient with this type of lesion have severe
pelvic pain »
Wang G (Jinan, China) Human Reprod (2009)

« Endometriotic lesions are associated

with inflammation and nerve groth »
McKinnon BD (Berne, Switzerland)
Trends Endocrinol Metab (2015)
Deep endometriosis: adenomyosis
Model of uterine pain
 CPPS due to uterine adenomyosis
Diagnostic score: 4 major criteria
Or 3 major criteria and 2 minor criteria (*)
•  5 MAJOR CRITERIA •  5 MINOR CTITERIA

•  Deep external endometriosis associated

•  Hypogastric chronic pelvic pain: type of with unexplained infertility with normal
painfull uterine cramping, heavyness or tubes
contraction.
•  Ultrasound findings of heterogeneous
•  Dysmenorhea I or II. Or deep myometrial zone. Bigger uterus
dyspareunia. Or hypermenorhea. « globulous »
•  Myometrial trigger point •  Hysterographic
•  MRI: principal undirect sign and/or •  Hysteroscopic signs
direct signs
•  Positive response to the LH-RH
•  Histological findings of adenomyosis agonists

(*) Bautrant E, Itza F et al UROD A (2011)

Bautrant E, Bryselbout MA Pelvi-perineologie (2011)
IRM Adenomyosis criteria
IRM Adenomyosis criteria
 CPPS due to uterine adenomyosis
Bautrant E, Itza F et al UROD A (2011)

•  2001-2008: 270 patients linked to uterine

adenomyosis
•  Retrospective study validated diagnostic criteria:
- 98% sensitivity
- 90% specificity
•  Hysterectomy:
- 91% improved
- 81% cured
•  25% (61 patients) wanted to conserve their fertility
 CPPS due to uterine adenomyosis
Bautrant E, Itza F et al UROD A (2011)
the conservative treatment:

•  Combined surgical and

medical treatment:
= hysteroscopic myometrial
resection/
adenomyomectomy+
uterosacral neurectomy +
gonadorelin analogues

-  54 % pain free 2 years

-  5 pregnancies
 CPPS due to uterine adenomyosis
Mrs Sa…, age 42
3 Cesarean sections
Painfull since the
age of 38:
•!Severe pelvic pain: bearing
down. prolapse sensation.
•!Dysmenorrhea with
hypermenorrhea
•!Dyspareunia
•!Urinary frequency and
urgencies
•!Severe myometrium trigger
point
 CPPS due to uterine adenomyosis
Mrs Ga…, age 28
Painfull since the
age of 26:
•!Severe left pelvic pain with
violent crisis at night after
emptying of the bladder
•!No dysmenorrhea /
Dyspareunia
•!Normal laparoscopy: myoma of
the broad ligament
•!Improve with the mense break
•!Severe myometrium trigger
point
 Chronic pelvic pain and endometriosis: "
translation evidence of the relationship and implications"
Human Reprod Update (2011)

«!Causality remain an enigma,

because pain symptoms attributed
to endometriosis occur without
endometriosis and because pain
symptoms ans severity correlate
poorly with lesion characteristics!»
Stratton P (Bethesda, USA)
 Uterine visceral pain?
•  Allodynia and dysmenorrhea Jarrell J, J Obstet Gynaecol
Can (2016)
•  Evolutionary considerations in the development of chronic
pelvic pain: Jarrell J, Am J Obstet Gynecol (2016)
•  Woman with dysmenorrhea are hypersensitive to
experimental deep muscle pain across the menstrual cycle:
Iacovides S, J Pain (2013) Chronic
•  What we know about primary dysmenorrhea today: a
critical review: Iacovides S, Human Reprod Update (2015)
•  Pain threshold variations as function of menstrual cycle:
Giamberardino MA, Pain (1997)
•  Pain thresholds in woman with chronic pelvic pain:
Giamberardino MA, Curr Opin Obstet Gynecol (2014)
 Arguments for a:
« Painfull Uterine Syndrome »
•  Uterine pain criteria without adenomyosis or other reason of
pain.
•  Normal imaging.
•  Uterine myometrial trigger point.
•  Dysmenorrhea associate with uterine pain outside the
menstruations.

•  Association with myo-fascial contraction of the internal

obturator muscles +/- levator ani.
•  Association with provoked vulvodynia.
•  Association with PBS or/and IBS.
•  Dysuria or/and dyschesia.
•  Association with hypersensitization criteria or fibromyalgia.
 Which treatment for:
« Painfull Uterine Syndrome » ?
1: Treatment of the thresholds modifications during the menstural cycle:
continuous combined estrogen-progestins or continuous progestins.

2/ Multidisciplinary treatment of central sensitization:

• Introduction of a medical treatment: Pregabaline, Gabapentine, Amitryptiline,
Doluxetine, etc…
• Physical-therapy
• Treatment of the peripheral sensitization: PBS, provoked vulvodynia, etc…
• Psychotherapies, hypnosis, behavioral and lifestyle measures.

3/ Very few surgical options:

• Laparoscopy: to eliminate endometriosis? utero-sacral neurectomy?
• Very few indications of hysterectomy (after 40, in patients who perfectly
understand their illness?)
 Take home messages

1  Analyze the type of the CPP with uterine components.

2  Relate CPP to a uterine pain syndrome.
5  Check a possible cause : main cause is Adenomyosis.
6  When there is no reason for uterine pain, think to
visceral sensitization.
7  We have many arguments allowing us to approach the
idea of a « Painfull uterine syndrome ».
8  IBS, PBS and PUS?
9  Check criteria of hypersensitization.