Urogynecological Complex Chronic Pain 

Novel Approach with Double Bipolar Radiofrecuency for Intraurethral and intravaginal woman disorders. (NABIUR- RF Protocol)

Authors: 

Ernesto Delgado Cidranes MD, PHD   (a)

Zuramis Estrada Blanco MD  (b)

a   IUGA SIG NeuroAnesthesiologist, Pain Management, Department of 

     Neuroanesthesiologist of CIMEG MADRID, Advanced Pain Management Center 

     Madrid, Spain

b  IUGA SIG Urogynecologist  Department of Urogynecology of CIMEG MADRID,  

     Advanced Aesthetic and Urogynecologica Center, Madrid, Spain 

Abstract:

Objetive: The purpose of this study was verify the effectiveness of the use of double bipolar radiofrequency in the control of urethritis and trigonitis in  three patients with complex chronic pain syndromes of the pelvic floor.

Methods: Three women were analyzed and studied for inclusion in the study and treatment. These are very complex cases with no resolution with previous treatments.

Previous studies were carried out, incontinence test, evaluation of pain scales, quality of life test, advanced echographic analysis such as elastography, low flow Doppler and 3D / 4D volumetric study of the urethral and vaginal area to be treated. Studies of flowmetry, cystoscopy, urethrocystography and analysis before and after with functional magnetic resonance were performed. We used the Pulstrode catheter at the urethral level and the bipolar radiofrequency Votiva Inmode for the treatment and vaginal approach.

Results: The three complex patients with severe pain above 7 on the analogue visual scale for pain decreased their pain by more than 4 points in the first 15 days after treatment. Two of them a month no longer present pain and only one pain was assessed in 2. The degree of satisfaction after the procedure was 100% for its clear improvement, absence of complications and improvement in quality of life.

Conclusions: 100% of patients improved in pain control, general satisfaction and improvement of quality of life. His level of frustration improved and limitations in social activities.

Introduction:

Gynecologic and urologic etiologiesare the sources of pelvic pain for many individuals

Among the chronic cystic diseases the most frequent is chronic urethrotigonitis (or urethral syndrome) and interstitial cystitis, the latter being the most serious. The first description of interstitial cystitis in women was made by Hunner in 1914 who referred to this condition as ulcerative cystitis because it described a certain type of erosion of the bladder mucosa accompanying these patients. Other authors have called it parenchymal cystitis and «neurotic bladder». [1]

Trigonitis is an inflammation of the bladder epithelium in the inner zone of the urinary bladder between the beginning of the urethra and the ureteral meatus, of diverse origin. Sometimes it starts after an inflammation and / or infection, although often the cause can not be determined. [2]

The most characteristic symptom is pain during urination, with the urgency to urinate and the feeling of not emptying the bladder as often as possible, with up to 60 trips to the bathroom in one day. It is a recurrent chronic disease, difficult treatment, complex and long-lasting. Classically it has been treated with instillations of various chemical substances, usually silver salts of officinal concentration (nitrate, protein, etc.) [3] administered by the specialist in a serial way. These substances act on the bladder mucosa producing a chemical peel, forcing a superficial cellular desquamation with stimulation of epithelial regeneration. This pathological condition is greatly influenced by stress, coming to be considered psychosomatic and as such has some seasonal behavior and great tendency to relapse. The treatment must be carried out by the specialist doctor (urologist, urogynecologist, pain expert), who will try to identify the causative agent of the crisis. Supportive psychotherapy should be performed in each session. [ 4,5,6]

This chronic inflammatory pathological vesical picture that is characterized clinically by irritative symptoms similar to classic but persistent acute cystitis. There is dysuria, frequency, hypogastric pain, dyspareunia, etc. It is a very variable clinical picture and occurs especially in women of the third and fourth decade of life; In the most serious cases there is a decrease in bladder capacity that leads to a disabling situation. It usually presents without urinary infection, although in some cases it can complicate the situation. [7]

The fundamental examination is cystoscopy, with or without anesthesia, depending on the severity of the case, which will provide information about bladder capacity and the presence of lesions of the bladder mucosa, such as redness and / or chronic inflammation lesions. In mild cases of urethral syndrome, chronic granulomatous and sometimes desquamative inflammation of the trigone and bladder neck can be seen. Sometimes there are pseudopolyps in the bladder neck that are edematous manifestations of this inflammation. Reuter describes, from the endoscopic point of view, glandular, follicular, granulomatous and cystic lesions. There are also, but in a more exceptional way, vesical leukoplakias, which are chronic fibrous and proliferative inflammations; these can even be pretumoral. [8]

Material and Method: 

Three women were analyzed and studied for inclusion in the study and treatment. These are very complex cases with no resolution with previous treatments. 

NABIUR- RF Protocol was applicate (Non ablative Bipolar urethral radiofrecuency with pulstrode Catheter ) and VOTIVA, Forma V treatment with Inmode Technology. ( Figure 1)

Previous studies were carried out, incontinence test, evaluation of pain scales, quality of life test, advanced echographic analysis such as elastography, low flow Doppler and 3D / 4D volumetric study of the urethral and vaginal area to be treated. Studies of flowmetry, urethrocystography and analysis before and after with functional magnetic resonance were performed. We used the Pulstrode catheter at the urethral level and the bipolar radiofrequency Votiva Inmode for the treatment and vaginal approach. (Figure 2, 3 )

Figure 1 

We show the technique used. Above you can observe the Pulstrode catheter that we introduce into the urethra, trigone and bladder and below you can observe the VOTIVA Inmode hand piece [ figure 3] for intravaginal bipolar radiofrequency treatment.

Multifunctional Pulstrode catheter for the application of bipolar pulsed RF ( PBRF) in the urethral space with safety and efficacy. 4 Fr Electrocatheter, Length 39 cm. Channel to infuse solutions. 3 active electrodes, Tª control at distal end, Radiological Control and  3D/4D Advanced Ultrasound. We use non-ablative pulsed bipolar radiofrequency with temperature control until 42,5 degrees. 

Figure 2

Real-time viewing of the Pulstrode catheter. Its correct localization is possible in the different target through advanced ultrasound and through X-rays, even with the possibility of using contrast for its work channels.

Figure 3

VOTIVA Forma V, hand piece, Bipolar radiofrecuency for intravaginal approach 

And Catheter Pulstrode 

Result: 

The three complex patients with severe pain above 7 on the analogic visual scale for pain decreased their pain by more than 4 points in the first 15 days after treatment. Two of them a month no longer present pain and only one pain was assessed in 2. The degree of satisfaction after the procedure was 100% for its clear improvement, absence of complications and improvement in quality of life.

Elastographic changes were detected in all patients. The degree of quantitative and qualitative elasticity was measured before, during and after treatment and during follow-up. [ Figure 4] Tissue retraction and better elasticity recovery were confirmed by improving angiogenesis. We do not observe complications or sequelae in subsequent explorations with magnetic resonances. 

Figure 4 

In the image you can observe the elastographic change; step from a state of diminution of the tissue elasticity (red color) to another state of greater retraction and hardness (blue color)

Conclusions: 

100% of patients improved in pain control, general satisfaction and improvement of quality of life. His level of frustration improved and limitations in social activities.

Recommendation:

We recommend continuing to increase the number of cases to use this technique since it is safe, easy to perform and represents an alternative, a new tool that improves the quality of life of our patients.

Bibliography:

  1. Qureshi AA, Tenenbaum MM, Myckatyn TM. Nonsurgical vulvovaginal rejuvenation with radiofrequency and laser devices: a literature review and comprehensive update for aesthetic surgeons.Aesthet Surg J. 2018;38:302
  2. Nygaard I, Barber MD, Burgio KL, et al. ; Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300:1311. [PMC free article] [PubMed] [Google Scholar]
  3. Griffiths A, Watermeyer S, Sidhu K, et al. Female genital tract morbidity and sexual function following vaginal delivery or lower segment caesarean section. J Obstet Gynaecol. 2006;26:645. [PubMed] [Google Scholar]
  4. Krychman ML. Vaginal laxity issues, answers and implications for female sexual function. J Sex Med. 2016;13:1445. [PubMed] [Google Scholar]
  5. Alinsod RM. Transcutaneous temperature controlled radiofrequency for atrophic vaginitis and dyspareunia. J Minim Invasive Gynecol. 2015;22(suppl):S226. [PubMed] [Google Scholar]
  6. Tadir Y, Gaspar A, Lev-Sagie A, et al. Light and energy based therapeutics for genitourinary syndrome of menopause: consensus and controversies. Lasers Surg Med. 2017;49:137. [PMC free article] [PubMed] [Google Scholar]
  7.  Griffiths A, Watermeyer S, Sidhu K, et al. Female genital tract morbidity and sexual function following vaginal delivery or lower segment caesarean section. J Obstet Gynaecol. 2006;26:645. [PubMed] [Google Scholar]
  8. ASoP Surgeons. Plastic Surgery Statistics Report 2016. 2016. Available at: https://www.plasticsurgery.org/documents/News/Statistics/2016/plastic-surgery-statistics-full-report-2016.pdf. Accessed 3 September 2018.