CASE REPORT
The Significance of Cutaneous Allodynia in a Woman With Chronic Pelvic Pain

https://doi.org/10.1016/S1701-2163(15)30201-2Get rights and content

Abstract

Background

This is a case report of sensory assessment in a woman with severe chronic pelvic pain following uterine artery embolization, and a discussion of a commonly observed sensory manifestation (allodynia) associated with chronic pelvic pain due to gynaecological conditions. Allodynia, as a common sensory abnormality can be readily detected at the bedside and represents the development of pain sensitization. Emergence of abdominal and perineal allodynia (assessed by cotton swap stroking and/or questionnaire) is associated with the development of the clinical features of sensitization: continuous pelvic pain, muscle tenderness, and reduced pressure pain thresholds.

Case

A uterine artery embolization was performed on a 42-year-old woman to treat a postpartum hemorrhage. The woman experienced severe pain immediately following the procedure, and it had persisted for one year when she was referred for chronic unrelenting pain. She was found to have extensive allodynia, myofascial dysfunction, and reduced pain thresholds. A hysterectomy was undertaken. As the pain persisted, botulinum toxin was administered to the lower abdomen in the region of reduced pain thresholds. Partial resolution of pain, physical limitation, and allodynia resolved one year after the hysterectomy and shortly after the injections of four tender regions of the anterior cutaneous nerves with 2.5 and 5.0 IU of botulinum toxin.

Conclusion

Testing for allodynia is a validated bedside test for pain sensitization. A clinical trial of botulinum toxin is indicated for the management of chronic pelvic pain associated with allodynia and pain sensitization.

Résumé

Contexte

Cet exposé de cas présente une évaluation sensorielle menée chez une femme qui a connu de graves douleurs pelviennes chroniques à la suite d’une embolisation des artères utérines et traite d’une manifestation sensorielle courante (allodynie) qui est associée à des douleurs pelviennes chroniques attribuables à des troubles gynécologiques. L’allodynie (en tant qu’anomalie sensorielle courante) peut facilement être détectée au chevet de la patiente et représente le développement d’une sensibilisation douloureuse. L’apparition d’une allodynie abdominale et périnéale (déterminée par effleurement au moyen d’un écouvillon et/ou par l’administration d’un questionnaire) est associée à celle des caractéristiques cliniques de la sensibilisation : douleur pelvienne continuelle, endolorissement musculaire et baisse des seuils de la douleur provoquée par une pression.

Cas

Cet exposé de cas présente une évaluation sensorielle menée chez une femme qui a connu de graves douleurs pelviennes chroniques à la suite d’une embolisation des artères utérines et traite d’une manifestation sensorielle courante (allodynie) qui est associée à des douleurs pelviennes chroniques attribuables à des troubles gynécologiques. L’allodynie (en tant qu’anomalie sensorielle courante) peut facilement être détectée au chevet de la patiente et représente le développement d’une sensibilisation douloureuse. L’apparition d’une allodynie abdominale et périnéale (déterminée par effleurement au moyen d’un écouvillon et/ou par l’administration d’un questionnaire) est associée à celle des caractéristiques cliniques de la sensibilisation : douleur pelvienne continuelle, endolorissement musculaire et baisse des seuils de la douleur provoquée par une pression.

Conclusion

Le dépistage de l’allodynie constitue un test dont la tenue au chevet a été validée pour ce qui est de la sensibilisation douloureuse. La tenue d’un essai clinique portant sur l’utilisation de toxine botulinique pour la prise en charge de la douleur pelvienne chronique qui est associée à l’allodynie et à la sensibilisation douloureuse s’avère indiquée.

Section snippets

INTRODUCTION

The International Association for the Study of Pain (IASP) has defined allodynia as "pain in response to a non-nociceptive stimulus."1,2 Allodynia is a relatively common clinically observed phenomenon that is identifiable among many women with chronic pelvic pain. It is said to be present when a test stimulus, such as gentle brushing of the skin, provokes a sensation of pain, and it has a long history in clinical practice.3., 4., 5. The term should be used only when it is known that the test

THE CASE

A 42-year-old woman, gravida 1, para 1, presented with continuous abdominal and pelvic pain that had begun immediately after uterine artery embolization for postpartum hemorrhage two years previously. She had had a postpartum hemorrhage following vaginal delivery and her management included administration of carboprost, three units of red blood cells, and two units of fresh frozen plasma. When bleeding continued, bilateral uterine artery embolization was performed using trisacryl-gelatin

DISCUSSION

The patient described here developed pain as a consequence of uterine artery embolization and an inflammatory reaction to the embolic material, rather than to the commonly reported ischemic etiology. Her chronic pain was associated with extensive abdominal cutaneous allodynia and reduced pressure thresholds for provoking pain. Less than one year after hysterectomy, and within weeks of botulinum toxin injection, the patient's pain, allodynia, and tenderness had dramatically decreased.

This case

CONCLUSION

A woman with chronic pelvic pain following abdominal hysterectomy and uterine artery embolization was shown to have marked abdominal wall cutaneous allodynia. The relief of the patient's symptoms following botulinum toxin injection into identified trigger spots suggests the need for a formal clinical trial.

ACKNOWLEDGEMENTS

The woman whose story is told in this case report has provided written consent for its publication.

REFERENCES (13)

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Competing Interests: None declared.

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Copyright © 2015 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.