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There is no recommendation in Europe for the use of ketamine in patients with chronic pain. The heterogeneity of practice highlights the need to seek the advice of experts in order to establish a national consensus. This Delphi survey aimed to reach a national consensus on the use of ketamine in chronic pain in Pain clinics.A collaborative four-round internet-based questionnaire was used. It was created after literature search on ketamine administration in chronic pain and included about 96 items. It discussed utility and advantages, adverse events and deleterious aspects, methods of administration, concomitant treatments and assessment of results.Twenty-eight experts completed all rounds of the survey with a total of 81.3% items reaching a consensual answer. Neuropathic pain represents the first indication to use ketamine, followed, with a good to moderate utility, by other situations (fibromyalgia, complex regional pain syndrome, central neuropathic pain, peripheral neuropathic pain, nociceptive pain, sensitization, opioid withdrawal, palliative care, depression). Experts agreed on the rare occurrence of adverse events. Concerning routes of administration, intravenous infusion with doses of 0.5-0.9 mg/kg/d for 4 days of treatment is preferred. Place of care is hospital, as in- or out-patient, with a quarterly administration of ketamine. Finally, ketamine effectiveness is assessed 1 month after infusion, and experts encourage combination with non-pharmacological treatment.This Delphi survey established a consensus of pain specialists on the use of ketamine in refractory chronic pain, thus providing a basis for future comparative trials.This Delphi survey in chronic pain reached agreement on four main aspects: (1) Priority to treat neuropathic pain with evaluation of effectiveness at 1 month; (2) No deleterious effects in the majority of listed diseases/situations with the absence or3% of suggested adverse events; (3) 0.5-0.9 mg/kg/d IV infusion; (4) Combination with non-pharmacological treatment.

Resume Contexte Les criteres de Convergences PP regroupent 10 criteres cliniques les plus significatifs d’une sensibilisation dans un contexte de douleurs pelviperineales chroniques. Ils sont le fruit d’un consensus d’experts et representent, a ce jour, le seul guide d’evaluation clinique permettant de reperer, parmi les patients souffrant de douleurs pelviperineales, ceux pour lesquels une composante de sensibilisation pelvienne peut etre evoquee. Objectif Ce travail concerne la validation psychometrique de ces criteres. Il s’agit de repondre a 3 questions : 1) l’instrument est-il fiable (i.e., sensible, specifique et fidele) ; 2) peut-on definir un score de depistage des douleurs pelviperineales par sensibilisation a partir des criteres CPP ? ; 3) peut-on definir des combinaisons de criteres pour predire la sensibilisation pelviperineale a partir des criteres CPP ? Methodologie et sujets Au total, 308 patients souffrant de douleurs pelviperineales ont ete recrutes lors de leur consultation medicale. Procedure Quinze medecins experts ont du juger de la presence ou de l’absence des 10 criteres CPP et etablir un diagnostic quant a la presence ou l’absence d’une sensibilisation pelviperineale chez leur patient. Resultats L’analyse de la courbe ROC indique qu’un score de 5 correspond au score le plus proche du score parfait avec une sensibilite egale a 95 % et une specificite a 87 %. Ils indiquent egalement que les criteres CPP possedent une tres bonne sensibilite (97 %) et specificite (91 %) et presentent globalement une bonne reproductibilite sur l’ensemble des criteres (Kappa > 0,6). Enfin, les analyses statistiques revelent que le critere les plus discriminant pour predire une sensibilisation est Q8 (douleurs persistant apres activite sexuelle). Conclusion Les criteres CPP representent un tres bon outil de depistage de la sensibilisation pelvienne. Le score de 5 correspond au score a partir duquel le patient possede suffisamment de criteres cliniques pour etre classes parmi les patients sensibilises. Niveau de preuve 4.

Resume Les douleurs pelvi-perineales chroniques sont frequentes, invalidantes et meconnues. Elles sont le reflet de lesions parfois patentes mais souvent meconnues. Leur comprehension et donc leurs traitements imposent de connaitre leur physiopathologie. Leur localisation particuliere, leur innervation singuliere induisen des presentations souvent proteiformes et souvent deconcertantes. Les specialites impliquees sont nombreuses (urologie, gastro enterologie, psychologie, algologie, gynecologie, rhumatologie) et ont longtemps travaille au sein de leur discipline avec leur prisme particulier pour ameliorer leur comprehension. Le but de cet expose est de tenter de presenter la vision 2021 qui se veut plus holistique, pour une « simplexification » du concept de douleur pelvi-perineale chronique. Nous verrons successivement les differents tableaux cliniques, les grands syndromes fonctionnels, puis les outils therapeutiques actuels.

BACKGROUND Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE. METHODS The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid. RESULTS The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication. CONCLUSION These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care. SIGNIFICANCE Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.

International audience; ABSTRACT: Nitrous oxide (N2O) is an odorless and colorless gas routinely used as an adjuvant of anesthesia and for short-duration analgesia in various clinical settings mostly in the form of an N2O/O2 50%-50% equimolar mixture (EMONO). Experimental studies have suggested that EMONO could also induce long-lasting analgesic effects related to the blockade of N-methyl-D-aspartate receptors. We designed the first international multicenter proof of concept randomized, placebo-controlled study to assess the efficacy and safety of a 1-hour administration of EMONO or placebo (medical air) on 3 consecutive days up to 1 month after the last administration in patients with chronic peripheral neuropathic pain. A total of 240 patients were recruited in 22 centers in France and Germany and randomly assigned to 1 study group (120 per group). Average pain intensity (primary outcome), neuropathic pain characteristics (Neuropathic Pain Symptom Inventory), Patient Global Impression of Change, anxiety, depression, and quality of life were systematically assessed before and after treatment. The changes in average pain intensity between baseline and 7 days after the last administration were not significantly different between the 2 groups. However, evoked pain intensity (predefined secondary endpoint) and Patient Global Impression of Change (exploratory endpoint) were significantly improved in the EMONO group, and these effects were maintained up to 4 weeks after the last treatment administration. Mostly transient side effects were reported during the treatment administration. These encouraging results provide a basis for further investigation of the long-term analgesic effects of EMONO in patients with neuropathic pain. Copyright

Resume Introduction Les douleurs pelvi-perineales postchirurgie du prolapsus genital sont des complications postoperatoires graves et frequentes dont le diagnostic et le traitement peuvent etre complexes. Materiels et methodes Nous avons realise une revue de la litterature sur la base de donnees Pubmed en utilisant les mots et MeSH suivants : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery. Resultats Parmi les 133 articles trouves, 74 ont ete retenus. Les douleurs pelvi-perineales chroniques evoluent depuis plus de 3 mois selon l’International Association for the Study of Pain, et peuvent etre de type nociceptif, neuropathique ou dysfonctionnel. Leur definition est avant tout clinique. Leur incidence varie de 1 a 50 % et les facteurs de risques suspectes sont un âge jeune, des comorbidites, un antecedent de chirurgie de prolapsus, un stade eleve de prolapsus, des douleurs preoperatoires, une voie d’abord chirurgicale invasive, la pose simultanee de plusieurs protheses, une moindre experience de l’operateur, une duree importante d’intervention et des douleurs postoperatoires precoces. La voie vaginale peut favoriser une modification de la compliance ou de la longueur vaginale, des lesions des nerfs pudendaux, sciatiques ou obturateurs ou un syndrome myofascial pelviens ; la voie cœlioscopique est a risque de lesion des nerfs parietaux ; la chirurgie prothetique implique des complications liees aux modifications de prothese. La prise en charge therapeutique est complexe et doit etre multimodale et pluridisciplinaire. Conclusion Les connaissances sur les douleurs pelvi-perineales apres chirurgie du prolapsus genital sont encore limitees a ce jour.

Objective To compare the data of score symptoms (Interstitial Cystitis Problem Index, Interstitial Cystitis Symptom Index, Pelvic Pain and Urgency/Frequency Patient Symptom Scale and SF-36quality of life), voiding diaries, urodynamic studies, and cystoscopy under general anesthesia according to the anatomical bladder capacity for patients with interstitial cystitis/bladder pain syndrome (IC/BPS). Material and Method Single-centre descriptive observational epidemiological study based on retrospective review of 134 patients managed for IC/BPS between January 2010 and December 2016. Patients were stratified into 2 groups according to anatomical bladder capacity measured under general anesthesia: ≤400 mL (n = 40) and >400 mL (n = 94). Results Patients with an anatomical bladder capacity less than 400 of mL presented significantly different results for voiding diary data: higher total frequency (P = .0023) especially at night (P = .0008), lower functional bladder capacity (P = .0082) and lower maximum bladder capacity (P = .0001); urodynamic data: earlier onset of painful urge during bladder filling (P = .0002), lower maximum bladder filling capacity (P = .0001) and lower compliance (P = .0067); and the findings of cystoscopy under general anesthesia: more Hunner's lesions (P = .00013). These patients presented poorer Pelvic Pain and Urgency/Frequency Patient Symptom Scale symptom scores (P = .0176) but associated with better overall quality of life as assessed by SF-36 (P = .0295). Conclusion The anatomical bladder capacity, measured under general anesthesia, can be used objectively to define 2 distinct groups of patients with symptoms of IC/BPS.

Resume Objectif Les algies pelviperineales s’accompagnant souvent de douleurs musculaires du perinee et des muscles pelvitrochanteriens, nous avons cherche a observer la frequence des troubles de la posture en lien avec les muscles pelviperineaux chez des patients consultant pour des algies pelviperineales par rapport a une population temoin exempte de ces douleurs. Methodologie L’etude prospective monocentrique a ete menee lors de consultations d’algies pelviperineales dans le service d’urologie du CHU de Nantes et reposait sur 5 tests cliniques recherchant successivement la presence d’un syndrome de la charniere thoracolombaire, de syndromes myofasciaux au niveau du diaphragme pelvien, d’une instabilite pelvienne, de dysfonctions du quadrilatere pelvipedieux et d’hypertonies musculaires paravertebrales. Resultats Au total, 51 sujets etaient inclus dans l’etude et divises en deux populations : 26 patients, 25 temoins. Le syndrome de la charniere thoracolombaire etait retrouve chez 28 % des patients vs 4 % des temoins (p = 0,024) ; les syndromes myofasciaux etaient presents chez 68 % des patients vs 25 % des temoins (p = 0,005) ; l’instabilite pelvienne concernait 76 % des patients vs 33 % des temoins (p = 0,002) ; les dysfonctions du quadrilatere pelvipedieux concernaient 96 % des patients vs 58 % des temoins (p = 0,001) ; l’hypertonie musculaire paravertebrale etait retrouvee bilateralement chez 32 % des patients vs 4 % des temoins (p = 0,077) et unilateralement chez 36 % des patients vs 0 % des temoins (p = 0,001). Conclusion Les patients presentant des douleurs pelviperineales chroniques presentaient de facon significative plus de troubles de la posture que les patients non douloureux. Il nous paraissait pertinent que le bilan postural soit integre a leur examen clinique habituel. Niveau de preuve 4.

Resume Les douleurs pelviperineales chroniques neurogenes sont largement dominees a l’etage perineal par la nevralgie pudendale. Son etiologie principale est un syndrome canalaire. Il peut se situer a trois niveaux differents : le canal sous piriforme, la pince ligamentaire entre le ligament sacroepineux et le ligament sacrotuberal, le canal d’Alcock. Elle est diagnostiquee par les seules donnees de l’interrogatoire et de l’examen clinique perineal. L’imagerie complementaire par resonance magnetique pelvienne ne sera realisee qu’en cas d’atypie clinique, relativement rare, a la recherche d’une autre cause de nevralgie pudendale : principalement a la recherche d’un syndrome de masse sur le trajet de son tronc nerveux. Les autres entites de nevralgie perineales sont rares et de diagnostic principalement clinique. Le radiologue a une place importante dans le diagnostic positif de nevralgie perineale puisque l’infiltration, idealement sous controle scanographique, en est une etape incontournable.

AIMS The objective of this study was to evaluate the efficacy of surgical removal of prosthetic material, possibly combined with nerve release, on chronic postoperative pain following placement of prosthetic material. MATERIAL AND METHODS Single-tertiary-centre study on 107 patients managed between November 2004 and April 2016 for removal of prosthetic material responsible for postoperative chronic pain: retropubic suburethral sling (n = 32), transobturator suburethral sling (n = 50), prolapse mesh (n = 16), and hernia mesh (n = 9). The primary endpoint was at least 50% reduction of pain evaluated by a pain numerical rating scale (NRS). RESULTS The mean interval between the initial operation involving placement of prosthetic material and reoperation for removal of prosthetic material was 41.2 ± 35.4 months. In all cases pain apperaed immediately following prosthetic material placement surgery. Pain presented neuropathic features in almost 30% of cases and was poorly systematized in more than one-half The mean follow-up of the study population was 8.4 ± 10.3 months. The mean pain NRS score for the overall population was seven preoperatively and three at last follow-up. At least 50% reduction of the pain NRS score was observed 67% of cases at last follow-up. During follow-up, 45% of patients experienced relapse of the disorder for which the prosthetic material was initially placed with, in particular, a 62% recurrence rate of urinary incontinence after removal of transobturator suburethral tape. CONCLUSION Surgical removal of prosthetic material to treat chronic postoperative pain, achieved global improvement of pain in about two-thirds of cases, but with a risk of recurrence of the initial disorders.

BackgroundThe evaluation of chronic pelvic and perineal pain (CPP) is often complex. The patient’s description of the pain often appears to be disproportionate to the limited findings on physical examination and/or complementary investigations. The concept of central sensitization may allow better understanding and management of patients with CPP.ObjectiveThe aim of this study was to elaborate a clinical evaluation tool designed to simply identify sensitization in pelvic pain.MethodsA list of 63 items was submitted to 22 international CPP experts according to the Delphi method.ResultsTen 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 nonpainful 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, 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.Conclusions This process resulted in the elaboration of a clinical evaluation tool designed to identify and appropriately manage patients with CPP comprising a sensitization component.

BACKGROUND The ganglion impar is the first pelvic ganglion of the efferent sympathetic trunk that relays pelvic and perineal nociceptive messages and therefore constitutes a therapeutic target. OBJECTIVE The objective of this single-center study was to evaluate the effectiveness of 3 repeated ganglion impar blocks in patients with chronic pelvic and perineal pain on intention-to-treat. STUDY DESIGN Retrospective single-center study. SETTING We reviewed the medical records of 83 patients with chronic refractory pelvic and perineal pain. On intention-to-treat analysis, 62 (74.7%) of the patients received 3 ganglion impar blocks. METHODS Ganglion impar block was performed with 0.75% ropivacaine via a lateral approach over the Co1-Co2 coccygeal joint with computed tomography (CT) guidance. The effectiveness of ganglion impar blocks was evaluated by visual analogue scale (VAS) before and 30 minutes after the blocks. Evaluation at least one month after the block was also performed by Patient Global Impression of Change (PGI-C). RESULTS A total of 220 blocks were performed, 193 (87.7%) of which were considered to be positive with immediate but transient improvement of pain by more than 50% and complete but transient pain relief after the procedure in 119 (54.1%) procedures. The variation of the VAS score before and after each block was statistically significant (P < 0.001). Similarly, the VAS score before repeated blocks was significantly improved with decreased pain intensity over time (P = 0.001). Analysis of the PGI-C one month after the block demonstrated improvement in 41% of cases in the overall population and in 43.6% of cases in the subgroup of 62 patients treated by 3 blocks. LIMITATIONS Retrospective study, short term follow-up. CONCLUSIONS Repeated ganglion impar blocks allowed short-term reduction of pain intensity with a moderate intermediate-term effect. Ganglion impar appears to be a useful therapeutic target to block the nociceptive message by acting on sensitization phenomena.Key words: Pudendal neuralgia, impar block, pain, perineal, coccygodynia.

Introduction To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain. Material and method Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain. Results 40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant’s sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria. Discussion The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.

Background: Chronic pelvic, perineal and gluteal neuralgia is often experienced in a similar way to neuropathic pain, in the territories of four nerves: ilio-inguinal, pudendal, inferior cluneal and posterior gluteal nerves. These pains are often refractory to medical treatment based on the use of systemic molecules with disabling adverse effects and surgical procedure may be necessary. Objective: The objective of this study was to evaluate the efficacy and safety of treatment with a high-concentration capsaicin patch in these indications. Study Design: This study was prospective, nonrandomized, and observational. Setting: Federative Center of Pelvi-Perineology in the University Hospital of Nantes, France. Methods: Sixty patients with pelvic neuralgia were treated with high-concentration capsaicin patch. The primary endpoint was Patient Global Impression of Change (PGIC) and secondary endpoints included pain intensity on a Numerical Rating Scale (NRS), maximum sitting duration at the end of the day, Medication Consumption Score (MQS), and patient global improvement (from -100% to + 100%). Results: Twenty four percent of the 60 patients included in the study declared that they felt “very much improved” or “much improved” (PGIC = 1 or 2) and these patients reported an average 58% improvement and a 3.4-point reduction on the NRS. Among the “good responder” patients, patients with coccygodynia appear to obtain the best results, as 37% of these patients declared that they were much improved with an average 63% improvement No serious adverse effects were observed and treatment was well tolerated. Limitation: This study is limited by its relatively small sample size and non-randomized study. Conclusion: These results suggest the value of high-concentration capsaicin 8% patch in the treatment strategy for patients with chronic pelvic, perineal and gluteal neuralgia. This treatment would be particularly indicated in the management of coccygodynia. Key words: Pelvic pain, neuropathic pain, pudendal nerve, ilio-inguinal nerve, inferior cluneal nerve, posterior gluteal nerve, capsaicin, capsaicin patch, coccygodynia

Resume Introduction Les vulvodynies sont frequentes et invalidantes. Les traitements sont nombreux mais peu efficaces. Le ganglion Impar recoit les afferences vegetatives nociceptives du perinee. C’est une cible therapeutique potentielle pour traiter les douleurs de cette region. L’objectif etait d’evaluer l’interet de l’infiltration du ganglion Impar chez les patientes souffrant de vulvodynies rebelles. Materiel Cette etude etait retrospective et monocentrique. Les infiltrations du ganglion Impar etaient realisees par un operateur unique sur huit patientes souffrant de vulvodynies rebelles. Une injection de ropivacaine et de iopamidol etait administree par abord lateral sous scanner. Le bloc anesthesique diagnostique a ete positif pour l’ensemble des huit patientes de cette population. Les patientes beneficiaient alors, a visee therapeutique, d’infiltrations en serie du ganglion. Deux patientes ont ensuite recu une infiltration de 100 UI de toxine botulique en regard du ganglion Impar par un abord bilateral sous scanner. L’efficacite antalgique etait evaluee par une echelle visuelle analogique (EVA) avant, immediatement apres, et a j15 pour chaque injection. Une evaluation subjective de la douleur recueillant le pourcentage d’amelioration globale et la duree d’efficacite antalgique etait realisee apres la 3 e infiltration. Resultats La comparaison entre l’EVA avant et immediatement apres l’injection lors du premier bloc anesthesique du ganglion Impar a montre une diminution significative des douleurs, l’EVA mediane passant de 51/100 a 16/100 ( p = 0,01). De meme pour le second bloc, l’EVA passant de 52,5/100 a 15/100 ( p = 0,02). La douleur maximale a j15 etait significativement inferieure apres la 3 e infiltration qu’apres la premiere ( p = 0,03). Cinq patientes ont decrit une amelioration globale de leur qualite de vie (six semaines en moyenne). Les deux patientes qui ont beneficie d’une infiltration de toxine botulique ont eu une efficacite antalgique prolongee. Conclusion L’infiltration du ganglion Impar pourrait etre une technique interessante pour traiter les vulvodynies rebelles. Niveau de preuve 4.

Objective To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the pudendal nerve for pudendal nerve entrapment. Design Randomised, double‐blind, controlled trial. Setting Multicentre study. Population 201 patients were included in the study, with a subgroup of 122 women. Methods CT‐guided pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline. Main outcome measures The primary end‐point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30‐point improvement on a 100‐point visual analogue scale of mean maximum pain over a 2‐week period) or nonresponders. Results Three months’ postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality‐of‐life criteria. Conclusions Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used. Tweetable abstract Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia., Tweetable abstract Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.

Introduction Les algies pelvi-perineales s’accompagnent souvent de problematiques musculaires du perinee et des muscles pelvi-trochanteriens (contractures, syndromes myo-fasciaux) et le recours aux techniques manuelles offre parfois des effets uniquement temporaires. L’etude de la regulation posturale, impliquant les muscles pelvi-perineaux, pourrait permettre de comprendre les mecanismes de la recidive. Nous avons cherche a observer la frequence des troubles posturaux en lien avec les muscles pelvi-perineaux chez des patients consultant pour des algies pelvi-perineales par rapport a une population temoin exempte de ces douleurs. Methode L’etude prospective mono centrique, menee lors de consultations d’algies pelvi-perineales dans le service d’urologie du CHU de Nantes, reposait sur 5 tests cliniques recherchant successivement la presence d’un syndrome de la charniere thoraco-lombaire, de syndromes myofasciaux au niveau du diaphragme pelvien, d’une instabilite pelvienne, de dysfonctions du quadrilatere pelvi-pedieux et d’hypertonies musculaires para-vertebrales. Resultats Le syndrome de la charniere thoraco-lombaire est retrouve chez 28 % des patients vs 4 % des temoins (p = 0,024). Les syndromes myo-fasciaux sont presents chez 68 % des patients vs 25 % des temoins (p = 0,005). L’instabilite pelvienne concerne 76 % des patients vs 33 % des temoins (p = 0,002). Les dysfonctions du quadrilatere pelvi-pedieux concernent 96 % des patients vs 58 % des temoins (p = 0,001). L’hypertonie musculaire para-vertebrale est retrouvee bilateralement chez 32 % des patients vs 4 % des temoins (p = 0,077) et unilateralement chez 36 % des patients vs 0 % des temoins (p = 0,001). Conclusion Cette etude a permis, grâce a cinq tests cliniques simples, ne necessitant aucun materiel, de confirmer que les patients presentant des algies pelvi-perineales chroniques ont davantage de troubles posturaux que les sujets exempts de ces douleurs. Nous suggerons qu’un examen postural puisse enrichir le bilan clinique des patients presentant des algies pelvi-perineales chroniques et devenir un des aspects de leur prise en charge.

Resume Introduction et objectif Mise au point sur les douleurs epididymo-testiculaires projetees dans le cadre du syndrome de la charniere dorso-lombaire de Maigne. Materiel et methodes Recherche bibliographique a l’aide de la base de donnees Medline en utilisant les mots cles : abdominal pain, epididymis, low back pain, pelvic pain, referred pain, testis . Resultats Les douleurs projetees sont ressenties a distance de la lesion causale. En urologie, une douleur projetee sur la region epididymo-testiculaire peut etre d’origine vertebrale dans le cadre du syndrome de la charniere dorso-lombaire decrit par Robert Maigne. Dans ce syndrome, la douleur ne se situe pas au niveau de la charniere dorso-lombaire mais plus bas, dans la region lombosacree ou sacro-iliaque. Ce syndrome peut egalement etre responsable de douleurs abdominales basses pseudo-viscerales et d’infiltrats cellulalgiques dans un territoire metamerique concerne. La cause habituelle du syndrome de Maigne est un derangement intervertebral mineur au niveau articulaire posterieur, le plus souvent sur le segment T12-L1. Seul un examen clinique attentif permet la mise en evidence d’un segment vertebral douloureux. Conclusion La topographie d’une douleur n’est pas toujours un indicateur fiable de l’organe ou de la region qui souffre. Face a des douleurs epididymo-testiculaires chroniques, l’interrogatoire et un examen clinique attentif permettent le diagnostic de douleurs projetees et notamment, dans le syndrome de Maigne, orientent vers le segment vertebral dorso-lombaire en souffrance.

Objective To assess the value of the voiding diary in the management of patients with bladder pain syndrome for predicting the presence or absence of cystoscopic abnormalities. Patients and Methods From November 2009 to March 2011, 54 consecutive patients (39 women and 15 men) with bladder pain syndrome, as defined by the European Society for the Study of Interstitial Cystitis/Bladder Pain Syndrome (ESSIC) criteria, were prospectively enrolled in this two-centre study. All patients completed a home voiding diary on 3 consecutive days, which included analysis of voiding frequency, voided volume and severity of pre- and post-voiding pain. The variables were evaluated on a numeric pain scale (NPS). All patients then underwent standardized cystoscopy under anaesthesia. Patients were stratified into two groups: a group with or a group without cystoscopic abnormalities. Voiding diary variables were compared using Student's t-test. Results Cystoscopic abnormalities were found in 33 patients. The group of patients with cystoscopic abnormalities had significantly more severe frequency (P = 0.034), especially nocturnal frequency (P = 0.009), a significantly lower mean voiding volume and lower sd from the mean (P = 0.011 and P = 0.014), and a significantly lower mean post-voiding NPS score (P = 0.039). Conclusion On analysis of the voiding diaries, we found that different patient profiles were associated with the cystoscopic appearance of the bladder. A clinical voiding score was proposed to predict the cystoscopic appearance of the bladder on the basis of the voiding diary in bladder pain syndrome but needs to be validated on an independent population.

Background: Several studies have described the course and anatomical relations of the pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with pudendal neuralgia in order to guide the surgeon in the choice of surgical approach for pudendal nerve decompression. Objectives: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the pudendal nerve in a cohort of operated patients. Study Design: Observational study. Setting: University hospital. Methods: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for pudendal neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. Results: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the pudendal nerve (infrapiriform foramen, ischial spine, and Alcock’s canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients. Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with pudendal neuralgia, the pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. Limitations: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. Conclusions: This is the first study to describe the surgical anatomy of the pudendal nerve in a population of patients with pudendal neuralgia. In more than 70% of cases, pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe pudendal nerve decompression by allowing constant visual control of the nerve. Key words: Surgical, operative technique, pudendal, neuralgia, transgluteal approach

Pudendal neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of pudendal neuralgia due to pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When pudendal neuralgia due to pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of pudendal neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the pudendal nerve) illustrate the need to recognize atypical pudendal neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of pudendal neuralgia to avoid missing pudendal neuralgia secondary to a mechanism other than nerve entrapment.

Resume Introduction Certains patients presentent des douleurs neuropathiques du perinee, de topographie atypique pour une nevralgie pudendale par syndrome canalaire. Le but de cette etude etait de valider l’hypothese d’une nouvelle entite clinique correspondant a une souffrance d’un autre tronc nerveux, le nerf cluneal inferieur, branche du nerf cutane posterieur de la cuisse et d’evaluer l’interet therapeutique d’une infiltration de corticoides. Patients Etude retrospective de 72 patients presentant ces douleurs perineales atypiques par leur topographie. Realisation d’un bloc anesthesique avec adjonction de corticoides du nerf cluneal inferieur, sous scanner, au niveau de la region endo-ischiatique. Evaluation de la douleur, par l’echelle visuelle analogique (EVA) au cours d’un questionnaire, huit jours et quelques minutes avant l’infiltration, puis cinq minutes et trois semaines apres le geste. Resultats Population composee de 40 (55 %) femmes et d’âge moyen 55 ans. Quarante-neuf (68 %) patients ont eu un bloc positif. Ces patients etaient caracterises par des douleurs neuropathiques ischio-perineales, respectant la verge ou le clitoris, aggravees en station assise (98 %), surtout sur les sieges durs, ne reveillant pas la nuit, et ne s’accompagnant pas d’hypoesthesie superficielle. L’adjonction de corticoides associes lors de l’infiltration n’a qu’un effet modeste sur l’evolution de la douleur a trois semaines avec une diminution de 30 % de l’EVA maximale (au cours de la semaine precedent l’evaluation) pour 40 % (n = 29) des patients. Conclusion Cette etude a permis de decrire une population de patients qui presentaient des criteres cliniques communs pouvant caracteriser une nevralgie cluneale inferieure par conflit ischiatique.

Objectifs Le syndrome douloureux vesical est defini depuis 2008 par l’ESSIC comme etant une douleur pelvienne chronique evoluant depuis plus de 6 mois avec une pression ou un inconfort percu en relation avec la vessie ; accompagne par une envie persistante et forte d’uriner ou une pollakiurie. Cependant, cette definition est tres vaste et englobe a la fois les patients ayant une cystopathie parietale (ancienne cystite interstitielle) et ceux ayant une hypersensibilite vesicale. L’objectif de notre etude a ete d’analyser les donnees du calendrier mictionnel et du bilan urodynamique pour les correler a la capacite vesicale anatomique evaluee sous anesthesie generale. Methodes Etude monocentrique retrospective reprenant les dossiers de 134 patients ayant tous eu une cystoscopie sous anesthesie generale pour le bilan d’un syndrome douloureux vesical entre janvier 2010 a septembre 2016. Les patients ont ete stratifies en 2 groupes en fonction de la capacite vesicale anatomique mesuree sous anesthesie generale : ≤ 400 mL (n = 40) et > 400 mL (n = 94). Les donnees du calendrier mictionnel, de l’endoscopie sous anesthesie generale et du bilan urodynamique realisees lors du bilan initial ont ete comparees en fonction des groupes. Resultats Les comparaisons entre les 2 groupes pour les donnees du calendrier mictionnel, de la cystoscopie et du bilan urodynamique sont representees dans les Tableau 1 , Tableau 2 , Tableau 3 ci-dessous. Conclusions Les donnees du calendrier mictionnel, de l’endoscopie sous anesthesie generale et du bilan urodynamique ont ete correlees a la capacite vesicale anatomique qui est un element primordial objectif pour stratifier le « phenotype vesicale » des patients ayant un syndrome douloureux vesicale entre l’ancienne cystite interstitielle et l’hypersensibilite vesicale. Ces donnees pourraient donc permettre a elles seules d’orienter de facon precoce la prise en charge des patients et de comparer des groupes homogenes de patients.

Resume Introduction Les douleurs pelviperineales chroniques peuvent etre en lien avec une atteinte nerveuse par traumatisme direct, indirect ou par syndrome canalaire qu’il faut alors mettre en evidence par un test d’infiltration. Le but de cet article a ete de faire une mise au point sur les techniques et les modalites des infiltrations des nerfs somatiques dans la prise en charge des douleurs pelviperineales chroniques. Materiel et methodes Une revue de la litterature a ete realisee en reprenant les articles publies dans PubMed sur les infiltrations des nerfs somatiques dans la prise en charge des douleurs pelviperineales chroniques. Resultats Dans le cadre des douleurs pelviperineales, les nerfs concernes ont ete : les nerfs d’origine thoracolombaire (obturateur, ilio-inguinal, iliohypogastrique et genitocrural) et les nerfs d’origine sacree (pudendal et branches cluneales inferieures du nerf cutane posterieur de la cuisse). Le but de l’infiltration a ete double : a la fois de confirmer l’hypothese diagnostique par le bloc anesthesique et de tenter de calmer la douleur. Une evaluation (par l’intensite et la topographie de la douleur) avant et juste apres l’infiltration a ete primordiale pour l’interpretation de l’infiltration. Les differentes techniques d’infiltration de chaque nerf ont ete decrites en reprenant les avantages, inconvenients et risque de complications. Conclusion Les infiltrations nerveuses font partie integrantes de la prise en charge des douleurs pelviperineales chroniques d’origine nerveuse somatique. Elles sont majoritairement realisees sous controle tomodensitometrique afin d’etre le plus selectif possible. Une fois le diagnostic et le niveau d’atteinte nerveuse connu, des gestes therapeutiques plus specifiques peuvent alors etre proposes.

Resume Objectif Preciser la place de la chirurgie du nerf pudendal dans les syndromes canalaires du nerf pudendal. Materiels et methodes Expose des differentes techniques chirurgicales et des resultats publies. Resultats La chirurgie princeps, et qui reste la chirurgie de reference, consiste a realiser une liberation chirurgicale du nerf pudendal du canal sous piriforme au canal d’Alcock par un abord transfessier. Cette chirurgie est sure. Les resultats sont encourageants, valides par un protocole prospectif, randomise. De 66 a 80 % des patients sont ameliores. D’autres abords (transvaginal ou transperineal) sont proposes. Conclusion La chirurgie du nerf pudendal reste une possibilite therapeutique non dedaignable lorsque le reste a echoue. Il apparait cependant fondamental de faire etat des differentes techniques proposees et des critiques que l’on peut en faire.

Resume Introduction La douleur chronique postoperatoire a ete definie comme etant une douleur developpee dans les suites d’une intervention chirurgicale, evoluant depuis au moins deux mois, excluant une cause organique (evolution carcinologique ou une infection chronique) ou preexistante. Le but de cet article a ete de faire une mise au point sur les facteurs de risque et la prevention des douleurs pelviperineale chronique postoperatoire. Materiel et methodes Une revue de la litterature a ete realisee en reprenant les articles publies dans PubMed sur les facteurs de risque et la prevention des douleurs pelviperineales chroniques postoperatoires. Resultats Les douleurs chroniques postoperatoires sont frequentes, invalidantes et couteuses. Elles sont generees par une alchimie complexe qui fait interreagir de facon variable : l’acte chirurgical proprement dit (la zone operee, la prise en charge perioperatoire, la pathologie ayant motive l’acte operatoire) et le patient lui-meme (âge, sexe, genetique, pathologies associees, histoire personnelle). La plurifactorialite du phenomene plaide pour une prise en charge transdisciplinaire avec la prevention et la diminution des principaux facteurs de risques. De meme, une prise en charge adaptee de la douleur aigue postoperatoire a un impact majeur sur l’eventuelle chronicite de la douleur. Conclusion Une bonne connaissance des facteurs de risque et une prevention adaptee peut permettre de diminuer l’incidence et les consequences des douleurs chroniques postoperatoires.

Resume Objectif Comment proposer une psychotherapie a un patient souffrant de douleurs pelviperineales ? Patients et methodes Expose concernant les traits psychocomportementaux du patient porteur d’une douleur pelviperineale chronique, les raisons poussant a proposer une psychotherapie et les raisons du choix du type de psychotherapie. Resultats Il n’y a que tres peu d’etudes ayant vraiment analyse l’impact des psychotherapies dans le cadre du traitement des douleurs pelviperineales chroniques, ces etudes meritent d’etre developpees. Conclusions Conseils concernant la facon d’adresser un patient au psychotherapeute et plaidoyer pour une transdisciplinarite.

Resume Introduction Les douleurs pelviperineales chroniques sont frequentes avec des etiologies tres variees. La strategie therapeutique est bien entendue en relation avec les etiologies reconnues qui constituent la premiere cible du traitement. Toutefois, avec le temps, se cree, souvent une autonomisation de la symptomatologie douloureuse qui va generer et se nourrir de consequences fonctionnelles et sociales responsables d’une pathologie particuliere la douleur chronique ou douleur maladie. Objectifs Situer la place des therapeutiques medicamenteuses dans l’arsenal therapeutique des douleurs pelviperineales chroniques. Methodes Analyse de litterature consacree aux therapeutiques medicales. Resultats La place des medicaments dans cette strategie est incontournable, mais mal connue et rarement completement efficace. Les medicaments ne sont, ici, qu’une part du traitement et ne peuvent se concevoir que dans le cadre d’une strategie predefinie. D’autres moyens sont disponibles et souvent indispensables : kinesitherapie, prise en charge globale, TENS (neurostimulation transcutanee), chirurgie, neuromodulation (stimulation peripherique, medullaire, corticale, perfusion intrathecale). A l’image des douleurs chroniques neuropathiques, les traitements medicamenteux a visee antalgique que l’on peut proposer font principalement appel au tramadol, aux antidepresseurs et aux antiepileptiques. Conclusion La pauvrete en etudes cliniques randomisees specifiques, les resultats therapeutiques medicamenteux parfois insuffisants, pourvoyeurs d’effets secondaires non nuls, le caractere tres invalidant de cette pathologie, « l’obligation » frequente de prescrire hors autorisation de mise sur le marche (AMM) rendent necessaire une prise en charge transdisciplinaire effective.

Resume Objectif La nevralgie obturatrice est une douleur mal definie et surtout mal connue des cliniciens. Nous rapportons ici les etiologies, la prise en charge et les resultats du traitement laparoscopique conservateur par neurolyse du nerf obturateur dans les cas de nevralgie obturatrice. Patients et methodes Treize patients (15 nerfs) ayant une nevralgie obturatrice ont ete pris en charge dans notre service depuis 2005. Les etiologies ont ete idiopathiques (quatre cas), consecutives a une chirurgie de hernie inguinale (deux cas), un traumatisme du bassin (un cas), une bandelette de TVT (trois cas) ou une bandelette de TOT (trois cas). Le diagnostic a ete porte sur des douleurs de type neuropathique de la face antero-interne de la cuisse. Il a ete confirme par un bloc anesthesique sous tomodensitometrie par un abord posterieur. Le traitement a consiste en une neurolyse laparoscopique. Resultats Les patients avaient des douleurs cotees en moyenne a 8/10 sur l’echelle visuelle analogique (EVA) en preoperatoire. Dans tous les cas la neurolyse a ete realisee par voie laparoscopique transperitoneale en dissequant le nerf et en sectionnant la fibrose cicatricielle ou les plaques prothetiques a son contact. Dans les cas idiopathiques, la liberation du nerf a ete realisee par une section du muscle obturateur interne et de la membrane obturee permettant d’elargir le canal obture. Avec un recul moyen de 17 mois, le taux d’amelioration d’au moins 50 % des douleurs a ete de 77 % (10/13 cas) dont une disparition complete des douleurs dans 54 % des cas (7/13). Une absence totale d’amelioration a ete observee dans 23 % des cas (3/13). Conclusion Le traitement conservateur mini-invasif de la nevralgie obturatrice par neurolyse laparoscopique du nerf obturateur, apres confirmation diagnostique par l’infiltration selective, a permis d’obtenir 75 % d’amelioration avec un recul moyen de 17 mois.

Obturator neuralgia is a cause of pelvic and perineal pain that is rarely suggested, probably because it is poorly understood. We report the results of a pilot study of laparoscopic treatment for obturator neuralgia.Seven patients (8 nerves) with obturator neuralgia were treated at our department. The etiology was idiopathic in 3 cases and iatrogenic following inguinal hernia surgery in 3 and TVT(R) repair in 2. The diagnosis was based on allodynic pain of the anterior and internal surface of the thigh, which was associated with limping with a sidestepping gait. It was confirmed by an anesthetic block under computerized tomography monitoring using a posterior approach.Treatment consisted of transperitoneal laparoscopic neurolysis with dissection of the nerve and section of the scarring fibrosis or prosthetic mesh in contact with it. In idiopathic cases nerve release was performed by sectioning the internal obturator muscle and the obturator membrane, causing compression and making it possible to widen the obturator foramen. At a mean followup of 16 months the rate of an at least 50% improvement in pain was 87.5% (7 of 8 cases), including complete disappearance of pain in 50% (4 of 8).Minimally invasive treatment with laparoscopic truncular release of obturator neuralgia yielded encouraging and good results.

Aims: The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the diagnosis. We defined criteria that can help to the diagnosis. Materials and Methods: A working party has validated a set of simple diagnostic criteria (Nantes criteria). Results: The five essentials diagnostic criteria are: (1) Pain in the anatomical territory of the pudendal nerve. (2) Worsened by sitting. (3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5) Positive anesthetic pudendal nerve block. Other clinical criteria can provide additional arguments in favor of the diagnosis of pudendal neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms. Conclusion: The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results of this disease. However, a combination of criteria can be suggestive of the diagnosis. Neurourol. Urodynam. 2007 Wiley-Liss, Inc.

The management of chronic pelvic and perineal pain has been improved by a better understanding of the mechanisms of this pain and an optimized integrated multidisciplinary approach to the patient. The concept of organic lesions responsible for a persistent nociceptive factor has gradually been replaced by that of dysregulation of nociceptive messages derived from the pelvis and perineum. In this setting, painful diseases identified by organ specialists are usually also involved and share several common denominators (triggering factors, predisposing clinical context). These diseases include painful bladder syndrome, irritable bowel syndrome, vulvodynia, and chronic pelvic pain syndrome. The painful symptoms vary from one individual to another and according to his or her capacity to activate pain inhibition/control processes. Although the patient often attributes chronic pain to a particular organ (with the corollary that pain will persist until the organ has been treated), this pain is generally no longer derived from the organ but is expressed via this organ. Several types of clinical presentation of complex pelvic pain have therefore been pragmatically identified to facilitate the management of treatment failures resulting from a purely organ-based approach, which can also reinforce the patient's impression of incurability. These subtypes correspond to neuropathic pain, central sensitization (fibromyalgia), complex regional pain syndrome, and emotional components similar to those observed in post-traumatic stress disorder. These various components are also often associated and self-perpetuating. Consequently, when pelvic pain cannot be explained by an organ disease, this model, using each of these four components associated with their specific mechanisms, can be used to propose personalized treatment options and also to identify patients at high risk of postoperative pelvic pain (multi-operated patients, central sensitization, post-traumatic stress disorder, etc.), which constitutes a major challenge for prevention of these types of pain that have major implications for patients and society.

Objectifs La frequence des douleurs chroniques postoperatoires apres pose de materiel prothetique au niveau pelvien est estimee jusqu’a 5 % des cas avec une prise en charge souvent complexe. L’objectif de notre etude a ete d’evaluer les resultats a distance de l’ablation du materiel prothetique comme pouvant etre responsable des douleurs. Methodes De novembre 2004 a avril 2016, 107 patients ont ete pris en charge dans notre centre pour des douleurs chroniques apparues apres a la mise en place de materiel prothetique : bandelette sous-uretrale retropubienne (32 patientes) ou trans-obturatrice (50 patientes), bandelette de promontofixation (16 patientes) ou plaque de hernie inguinale (9 patients) En fonction de la prothese en place et du tableau clinique, le materiel etait retire en totalite ou partiellement par abord vaginal et/ou laparoscopique et/ou par abord de la racine de la cuisse. Les patients etaient revus systematiquement a 2 mois postoperatoire, puis le rythme du suivi etait adapte en fonction de l’evolution clinique. Resultats Le delai moyen entre la mise en place de la prothese et son ablation a ete de 41,2 mois. Le recul postoperatoire moyen de la population a ete de 8,4 mois. Sur l’ensemble de la population, 69/107 (64,5 %) ont observe une diminution de la douleur d’au moins 50 % sur l’echelle numerique analogique. Dans le groupe des patientes operees pour une ablation de bandelette sous-uretrale, une recidive de l’incontinence urinaire d’effort a ete notee dans 62 % des cas de bandelette trans-obturatrice et 34 % des cas de bandelette retro-pubienne. Dans le groupe des patients operes pour une ablation de plaque de hernie, une recidive de la hernie a ete notee dans 11 % des cas. Aucune patiente operee d’une ablation de promontofixation n’a eu de recidive du prolapsus. Conclusion Une ablation du materiel prothetique responsable de douleurs chroniques postoperatoires a permis d’ameliorer significativement les douleurs dans pres de deux tiers des cas, mais avec un risque de recidive de la pathologie initiale.

Objectifs La douleur est mediee par le systeme orthosympathique le long des chaines latero-thoraciques en une chaine ramifiee qui se termine en un ganglion unique : le ganglion impar. L’hypothese d’un treillis de fibres nociceptives en direction de ce ganglion en fait une cible privilegiee des therapeutiques infiltratives pour pallier aux douleurs de cette region. Notre etude evalue l’efficacite de l’infiltration de ce ganglion apres trois infiltrations. Methodes Il s’agit d’une etude retrospective monocentrique menee de septembre 2012 a octobre 2014 realisee par un meme operateur. Nous avons analyse 61 patients qui ont beneficie de trois infiltrations consecutives du ganglion impar. L’infiltration etait realisee par de la xylocaine 2 % non adrenaline et s’effectuait sur un patient en procubitus apres reperage scannographique de la position du ganglion avec le scanner Siemens SOMATOM. Tous les patients ont ete evalues a la premiere, deuxieme et troisieme infiltration par l’echelle visuelle analogique avant et apres puis avec une evaluation subjective sur l’efficacite apres la troisieme infiltration. L’analyse statistique a ete realisee par le logiciel R. Resultats L’âge moyen au moment du diagnostic est de 46,40 ± 15,2 ans (15–82). L’analyse clinique revelait que les douleurs unilaterales du nerf pudendal (50,82 %) predominait au sein de notre population suivi des coccygodynies (39,34 %). Le delai entre le diagnostic clinique et la premiere infiltration est de 71,74 mois (7–374). L’analyse des differentes EVA avant chaque infiltrations montre une amelioration franche a ( p = 0,0001) L’evaluation subjective apres les trois infiltrations montrait 45 ; 9 % d’amelioration dont 1/3 (31,15 %) avaient une amelioration sensible. Neanmoins, 47,54 % des infiltrations ont ete jugees comme inefficaces a la troisieme infiltrations avec seulement 4,92 % des patients qui ont presente une aggravation de leur symptomatologie. Conclusion L’infiltration repetee du ganglion impar est une technique efficace chez des patients bien selectionnes avec une efficacite augmentee et durable pour 45,9 % des patients. Il faut donc poursuivre l’infiltration du ganglion impar chez les patients repondeurs pour favoriser la disparition du phenomene douloureux ( Fig. 1 et 2 ).

La chirurgie du nerf pudendal a fait ses preuves depuis sa creation il y a maintenant vingt-cinq ans [1]. Elle trouve sa place lorsque les differentes approches medicales ont echoue. Chirurgie des syndromes canalaires de la region gluteale profonde, elle est — d’abord et avant tout — une chirurgie des troncs nerveux peripheriques et doit en satisfaire l’essence meme : redonner en toute securite leur liberte aux troncs nerveux que sont le nerf pudendal et ses branches tout au long de leur parcours dans les zones potentiellement conflictuelles.

Les douleurs pelviperineales chroniques sont caracterisees par leur chronicite (plus de six mois), l’absence de pathologie maligne et leur topographie. La douleur qui s’exprime au niveau de l’organe n’est pas toujours le temoin d’une maladie de l’organe mais c’est la qu’elle s’exprime, temoignant de dysfonction-nement de la regulation des messages douloureux du pelvis et du perinee, et debordent largement d’une systematisation organique ou neurologique. Les douleurs pelviperineales chroniques ne peuvent etre abordees qu’a travers un demembrement clinique reposant tout d’abord sur l’elimination des pathologies lesionnelles regionales. C’est la negativite des bilans et surtout les donnees de l’interrogatoire qui permettent d’analyser cette douleur et de mieux en apprehender les mecanismes physiopathologiques [1]. La neuromodulation nerveuse est utilisee regulierement en pelviperineologie pour la prise en charge de l’hyperactivite vesicale rebelle. La neuromodulation sacree a ete reconnue avec un marquage CE en Europe depuis 1994 et un marquage par la FDA aux Etats-Unis depuis 1997. La neuromodulation est egalement tres utilisee dans la prise en charge de la douleur chronique mais essentiellement en stimulation medullaire1. Actuellement, la neuromodulation n’est pas reconnue dans le traitement specifique des douleurs pelviennes chroniques. Le probleme pour l’interpretation des resultats est une grande disparite dans les criteres d’inclusion et de selection des patients, et des criteres de jugement et d’efficacite des traitements. Ce chapitre fait le point sur l’ensemble des neurostimulations en fonction des differents niveaux qui sont proposes et realises dans la prise en charge des douleurs pelviennes chroniques.

To assess the value of the voiding diary in the management of patients with bladder pain syndrome for predicting the presence or absence of cystoscopic abnormalities.From November 2009 to March 2011, 54 consecutive patients (39 women and 15 men) with bladder pain syndrome, as defined by the European Society for the Study of Interstitial Cystitis/Bladder Pain Syndrome (ESSIC) criteria, were prospectively enrolled in this two-centre study. All patients completed a home voiding diary on 3 consecutive days, which included analysis of voiding frequency, voided volume and severity of pre- and post-voiding pain. The variables were evaluated on a numeric pain scale (NPS). All patients then underwent standardized cystoscopy under anaesthesia. Patients were stratified into two groups: a group with or a group without cystoscopic abnormalities. Voiding diary variables were compared using Student's t-test.Cystoscopic abnormalities were found in 33 patients. The group of patients with cystoscopic abnormalities had significantly more severe frequency (P = 0.034), especially nocturnal frequency (P = 0.009), a significantly lower mean voiding volume and lower sd from the mean (P = 0.011 and P = 0.014), and a significantly lower mean post-voiding NPS score (P = 0.039).On analysis of the voiding diaries, we found that different patient profiles were associated with the cystoscopic appearance of the bladder. A clinical voiding score was proposed to predict the cystoscopic appearance of the bladder on the basis of the voiding diary in bladder pain syndrome but needs to be validated on an independent population.

Objectifs Le traitement de la nevralgie pudendale resistant au traitement medical est un traitement chirurgical avec une liberation chirurgicale du nerf pudendal du canal sous piriforme au canal d’Alcock par un abord transfessier qui est la voie d’abord de predilection. L’objectif de cette video est de montrer les points techniques d’un autre abord de liberation du nerf pudendal par chirurgie robot assistee. Methodes Nous presentons le cas d’une patiente operee d’une liberation du nerf pudendal droit pour un tableau douloureux neuropathique resistant au traitement medical. La patiente a ete operee par chirurgie robot-assistee avec le robot DaVinci S 4 bras ( intuitive surgical ) Resultats La patiente a ete installee en decubitus dorsal, les bras le long du corps. Un premier trocart etait positionne en sous-ombilical pour l’optique puis 2 trocarts robot de 8 mm a droite, 1 trocart de 8 mm a gauche, associe a 1 trocart pour l’assistant a gauche. Les temps de l’intervention ont ete : – incision du peritoine pour aborder la fosse obturatrice ; – incision de l’aponevrose pour reperer le ligament sacro-epineux ; – section du ligament sacro-epineux ; – liberation et section du canal d’Alcock ; – dissection et mobilisation du nerf pudendal ; – pas de fermeture du ligament et du peritoine. Conclusion La liberation chirurgicale du nerf pudendal avec section de la pince ligamentaire du ligament sacro-epineux, incision du canal d’Alcock et neurolyse est faisable par chirurgie robot-assistee.

Objectifs Les algies pelvi-perineales ont souvent une expression neuropathique et peuvent s’exprimer au niveau cutane dans quatre territoires bien differencies ( Figure 1 , Figure 2 ). Le Qutenza* (patch de capsaicine a 8 %) est un traitement topique des douleurs neuropathiques. L’objectif de notre etude prospective a ete d’evaluer l’utilisation du Qutenza* dans la prise en charge de patients souffrant de nevralgies pelvi-perineales. Methodes Soixante patients presentant des douleurs pelvi-perineales d’expression neuropathique ont recu un traitement topique par patch de capsaicine a haute concentration. Les patients ont ete evalues a 2 mois de la pose du Qutenza*. Le critere principal d’evaluation etait le PGI (Patient Global Improvement) avec 7 niveaux de reponse (1 - Enormement mieux, 2 - Beaucoup mieux, 3 - Un peu mieux, 4 - Aucun changement, 5 - Un peu empire, 6 - Beaucoup empire, 7 - Enormement empire). Les criteres secondaires etaient le pourcentage d’amelioration estime par le patient, l’intensite douloureuse (EN) et la duree maximale en position assise apres 18 h. Resultats Trente-cinq pour cent des 60 patients inclus ont estime etre ameliores d’au moins 30 %. Vingt-quatre pour cent ont estime etre beaucoup mieux qu’avant (PGI ≤ 2) avec 58 % d’amelioration en moyenne, une baisse de 3,4/10 points sur l’EN et une duree maximale assise augmentee de 54 minutes. Parmi les bons repondeurs, les patients souffrant de coccygodynies ont ete le plus souvent soulages avec 37 % de PGI ≤ 2 (n = 7) et une amelioration de la douleur de 63 % en moyenne. Conclusion Ces resultats ont mis en evidence l’interet du patch de capsaicine a haute concentration (Qutenza*) dans la strategie de prise en charge des patients souffrant de nevralgies pelvi-perineales et en particulier en cas de coccygodynies.

The objective of this prospective innovative treatment is to section the pain pathways carried by sympathetic lumbar rami communicantes to achieve lasting pain relief of refractory low back pain.From December 2005 to September 2008, nine patients were operated by bilateral section of rami communicantes for a refractory low back pain. As a diagnostic and predictive test, all patients had, before surgery, a local anaesthetic infiltration of the sympathetic trunk at L2 performed with computed tomography guidance. Surgery is indicated if the tests lead to a reduction in pain of at least 50 %. The procedure, using a retroperitoneal laparoscopic approach, consisted to identify the sympathetic trunk and to section all lumbar rami communicantes from L1 to L2.No intraoperative complications were observed. The mean postoperative follow-up was 29 ± 15 months. At the last follow-up, only 22 % (2/9) patients had an improvement of their low back pain with this surgery but with a minimal effect (30 and 50 % reduction of pain). An improvement of quality of life was observed in 33 % (3/9) of cases. Due to persistent pain, four patients had a spinal cord stimulation after this surgery.Section the pain pathways carried by sympathetic lumbar rami communicantes for refractory low back pain improved 22 % of patients at the last follow-up of 29 months.

BACKGROUND Schwannoma is a rare benign tumor of peripheral nerves arising from Schwann cells of the ubiquitous nerve sheath. OBJECTIVE To describe the operative steps and technical aspects of robotic laparoscopic resection of pelvic schwannoma. METHODS We describe 2 patients with pelvic schwannoma: a 34-year-old woman with schwannoma of the right lumbosacral trunk and a 58-year-old woman with schwannoma of a left S1 nerve. Pain was the main symptom in both patients. The diagnosis was confirmed by magnetic resonance imaging and nerve biopsies. Both patients were operated on by robotic laparoscopy. RESULTS Lesions were totally enucleated after incising the epineurium. After dissection of the schwannoma, the vascular pedicle and nerve fascicles involved were identified, coagulated, and then sectioned. The remaining fascicles of the nerve were preserved. The postoperative course was uneventful in both patients. With follow-up of 9 and 13 months, both patients obtained complete pain relief with no neurological sequelae. CONCLUSION Robotic laparoscopic resection of pelvic nerve tumors such as schwannomas is technically feasible.

Aims In some patients, with refractory chronic pelvic and perineal pain, pain and quality of life are barely alleviated despite optimal medical treatment, infiltrations and surgical release of the pudendal nerve. The management of these patients is complex, especially after failure of neuromodulation techniques (spinal cord stimulation. S3 nerve root stimulation and direct stimulation of the pudendal nerve). We report the first two cases illustrating the value of motor cortex stimulation (MCS), in this new indication. Methods The history, decision-making process, intraoperative findings and results of this technique are presented. The perineal cortical area was identified by intraoperative motor evoked potentials in the external anal sphincter, confirming its location in the primary motor cortex between the inferior and superior limb positions. As predictive value of repetitive transcranial magnetic stimulation (rTMS) in the identification of responders to MCS for pain is now established, we performed pre-operative rTMS sessions for both patients. Results The first patient was a 74-years-old woman who reported an 11-year history of left lateral perineal pain. The second patient was a 45-year-old woman who reported a 4-year history of perineal pain following hysterectomy with ovariectomy. After respectively 40 months and 19 months of follow up, both patients reported an improvement of pain ranging from 40 to 50%. Time to onset of pain on sitting was markedly improved from a few minutes to 90 minutes, and largely contributing to improvement of activities of daily living and of quality of life. Conclusion These two first cases suggest that motor cortex stimulation constitutes a new treatment for refractory pelvic and perineal pain, and should be considered after failure of conventional neuromodulation techniques, especially spinal cord stimulation. Neurourol. Urodynam. 32: 53–57, 2013. © 2012 Wiley Periodicals, Inc.

Si le pheochromocytome peut etre cliniquement asymptomatique, il peut dans de rares cas se preśenter comme une veritable urgence abdominale. Ces urgences sont le plus souvent secondaires a la necrose hemorragique de la tumeur ou a un saignement abondant dans l’espace retro-peritoneal. Les auteurs rapportent le cas d’un pheochromocytome revele par une rupture spontanee de rate. Le mecanisme physiopathologique de cette rupture est discute ainsi que l’abstention chirurgicale adoptee vis a vis du pheochromocytome au cours de cette chirurgie d’urgence. Dans un deuxieme temps les auteurs discutent de la discordance observee entre taux de catecholamines et stabilite hemodynamique au cours de la chirurgie d’exerese du pheochromocytome.

The incidence of pelvic pain after placement of a suburethral sling for incontinence ranges between 0% and 30%. The management of this chronic pain after suburethral sling placement is complex and to our knowledge no consensus has been reached. We evaluated the functional results after removal of the suburethral tape responsible for chronic pelvic pain.From November 2004 to August 2009, 32 patients undergoing removal of suburethral tape causing chronic pelvic and perineal pain at our department were prospectively followed. Patients were divided according to the type of suburethral sling into the transobturator tape group (15 patients) and the tension-free vaginal (retropubic) tape group (17 patients). In the TVT group tape removal was performed using transperitoneal laparoscopy in every patient. In the TOT group tape removal was performed via a transvaginal approach possibly associated with a unilateral or bilateral incision in the proximal part of the thigh. Pain was evaluated by a visual analogue scale from 0-no pain to 10-maximal pain.The surgical exploration of suburethral tape responsible for chronic, treatment refractory pelvic pain revealed in most cases an abnormal tape position or excessive tape traction. In the overall population tape removal provided improvement of pain (at least 50% improvement of the visual analogue scale score) in 68% with a mean followup of 10 months. Mean visual analogue scale score was 7.3 +/- 1.5 before surgery and 3.4 +/- 3 after surgery. However, recurrence of incontinence was observed in 22% of cases. No significant difference was demonstrated in terms of functional results according to the type of tape insertion.The surgical removal of suburethral tape improved pain in 68% of patients but with a risk of recurrence of urinary incontinence in 22%.

Objective Obturator neuralgia consists of pain radiating from the obturator nerve territory to the inner thigh. Methods We report a case of idiopathic obturator neuralgia resulting from compression of the obturator nerve in the obturator canal, causing a case of nerve entrapment syndrome. The pain was characterized by its localization in the inguinal region and anterointernal side of the thigh, going down to the internal side of the knee. It was worse when standing or in a monopodal stance. Walking caused pain and a limp. Results The diagnosis was confirmed by an analgesic block. The analgesic was infiltrated using a posterior approach and computer-assisted tomography, allowing the quality and specificity of the infiltration to be judged. Conclusion We describe, for the first time, a treatment of obturator neuralgia by a minimally invasive laparoscopic approach. This involved an obturator nerve neurolysis and section of the internal obturator muscle and the obturator membrane.