Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

12. Chronic Pelvic Pain in Women
165
Neuroablative techniques can be performed surgically by transecting
specific nerve or nerve bundles or percutaneously by injecting sclerosing
agents. These procedures are typically reserved for women with
refractory pain where the distribution is aligned within an identifiable
nerve or nerve plexus. Nevertheless, the role for surgical management of
pain that is likely neurosensory in origin remains limited. Laparoscopic
uterosacral nerve ablation (LUNA) has been described as a technique
that interrupts pain conduction to the uterus, but is of limited to no use
for managing pain of gynecologic origin. Presacral neurectomy (PSN) is
a procedure that excises a segment of sympathetic nerve bundles at the
level of the superior hypogastric plexus. When used as a surgical
adjuvant in the setting of endometriosis, PSN may add a component of
relief to those with midline pain [ 29 ].
Hysterectomy clearly represents one of the more aggressive surgical
maneuvers used to treat CPP, but as a stand- alone procedure it may
result in failure for many women not properly evaluated for the likely
cause of pain. Endometriosis- associated pain, refractory to conservative
surgical measures, pain associated with menstrual bleeding, and pain
suspected to be of uterine origin may provide women relief from their
symptoms. If performed hastily, hysterectomy has the potential to
worsen or induce new pain symptoms as a result of surgical trauma.
Prior to considering hysterectomy, alternatives as discussed above
should first be considered.
Vaginal Cuff Pain
Just as neuropathic pain can develop following an abdominal incision
[ 30 ], the vaginal cuff can be a source of pain following hysterectomy
[ 31 ]. Vaginal cuff pain usually presents as new dyspareunia
following hysterectomy, whereas dyspareunia that was present before
and remains after surgery is more likely related to other factors such as
pelvic floor tension myalgia. The character of discomfort from vaginal
cuff pain is often burning, stinging, or simply sharp, radiating pain when
contact is made. Cuff pain is diagnosed by tenderness elicited with careful
cotton-swab palpation along the length of the cuff. In evaluating
post-hysterectomy dyspareunia, moving directly to a bimanual exam can
provide confusing information, as it can be difficult to distinguish if pain
is arising from the cuff itself or pathology beyond the cuff, such as an
adherent ovary. Treatment follows in-line with other neuropathic modalities
with systemic medications such as tricyclic antidepressants or