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Meta-Analysis
. 2005 Oct 19;2005(4):CD001896.
doi: 10.1002/14651858.CD001896.pub2.

Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea

M L Proctor  1 , P M Latthe, C M Farquhar, K S Khan, N P Johnson
Affiliations
Meta-Analysis

Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea

M L Proctor et al. Cochrane Database Syst Rev. .

Abstract

Background: Dysmenorrhoea is the occurrence of painful menstrual cramps of uterine origin and is a very common gynaecological complaint with negative effect on a sufferer's quality of life. Medical therapy for dysmenorrhoea includes oral contraceptive pills (OCP) and nonsteroidal anti-inflammatory drugs (NSAIDs) which both act by suppressing prostaglandin levels. While these treatments are very successful there is still a 20 to 25% failure rate and surgery has been an option for such cases. Uterine nerve ablation (UNA) and presacral neurectomy (PSN) are two surgical treatments that have become increasingly utilised in recent years due to advances in laparoscopic procedures. These procedures both interrupt the majority of the cervical sensory pain nerve fibres. Observational studies have supported the use of these procedures for primary dysmenorrhoea. However, both operations only partially interrupt the cervical sensory nerve fibres in the pelvic area and, therefore, this type of surgery may not always benefit women with dysmenorrhoea.

Objectives: To assess the effectiveness of surgical interruption of pelvic nerve pathways as treatment for primary and secondary dysmenorrhoea, and to determine the most effective surgical treatment.

Search strategy: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 9 June 2004), CENTRAL (The Cochrane Library Issue 2, 2004), MEDLINE (1966 to Nov 2003), EMBASE (1980 to Nov 2003), and CINAHL (1982 to Oct 2003). Attempts were also made to identify trials from the metaRegister of Controlled Trials and the citation lists of review articles and included trials. In most cases the first or corresponding author of each included trial was contacted for additional information.

Selection criteria: The inclusion criteria were randomised comparisons of surgical techniques of interruption of the pelvic nerve pathways (using both open and laparoscopic procedures) for the treatment of primary and secondary dysmenorrhoea. The main outcome measures were pain relief and adverse effects.

Data collection and analysis: Eleven randomised controlled trials (RCTs) were identified that initially appeared to fulfil the inclusion criteria for this review. Two trials were subsequently excluded (Garcia Leon 2003; Sutton 1991). Of the remaining nine trials, eight were included in the meta-analysis. The results of one trial were included in the text of the review for discussion because the data were not available in a form that allowed them to be combined in the meta-analysis. Five trials investigated laparoscopic uterine nerve ablation (LUNA), two trials laparoscopic presacral neurectomy (LPSN) and two open presacral neurectomy (PSN).

Main results: For the treatment of primary dysmenorrhoea there was some evidence of the effectiveness of laparoscopic uterine nerve ablation (LUNA) when compared to a control or no treatment. The comparison between LUNA and laparoscopic presacral neurectomy (LPSN) for primary dysmenorrhoea showed no significant difference in pain relief in the short term; however, long-term LPSN was shown to be significantly more effective than LUNA. For the treatment of secondary dysmenorrhoea six identified RCTs addressed endometriosis and one included women with uterine myomas. The treatment of LUNA combined with surgical treatment of endometrial implants versus surgical treatment of endometriosis alone showed that the addition of LUNA did not aid pain relief. For PSN combined with endometriosis treatment versus endometriosis treatment alone there was an overall difference in pain relief although the data suggests this may be specific to laparoscopy and for midline abdominal pain only. Adverse events were significantly more common for presacral neurectomy; however, the majority were complications such as constipation, which may spontaneously improve.

Authors' conclusions: There is insufficient evidence to recommend the use of nerve interruption in the management of dysmenorrhoea, regardless of cause. Future methodologically sound and sufficiently powered RCTs should be undertaken.

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Conflict of interest statement

Dr C Farquhar and Dr N Johnson are investigators in a randomised controlled trial of laparoscopic uterine nerve ablation (LUNA), which was funded by a grant from the Princess of Wales Memorial Trust and administered by the Mercia Barnes Fund of the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) (NZ branch) (Johnson 2004). Dr P Latthe is the Clinical Research Fellow and Mr KS Khan is the principal investigator on a LUNA trial funded by WellBeing, Royal College of Obstetrics and Gynaecology (RCOG), UK (CF/371) (Latthe 2003).

Figures

1
1
Sensory afferent nerve supply of the female pelvic organs. C = afferent nerve supply of cervix (illustrated on right side of diagram); O = afferent nerve supply of ovary (illustrated on left side of diagram); U = afferent nerve supply of uterus (illustrated on right side of diagram); P = parasympathetic nerve; S = sympathetic nerve. Copyright approval for reproduction of this figure has been kindly granted by Blackwell Science, publisher of Gynaecological Endoscopy (Johnson 2000).
1.1
1.1. Analysis
Comparison 1 LUNA versus control, Outcome 1 Pain relief ‐ up to 6 months.
1.2
1.2. Analysis
Comparison 1 LUNA versus control, Outcome 2 Pain relief ‐ up to 12 months.
1.4
1.4. Analysis
Comparison 1 LUNA versus control, Outcome 4 Pain relief up to 36 months.
2.1
2.1. Analysis
Comparison 2 PSN versus control, Outcome 1 Pain relief ‐ up to 6 months.
2.2
2.2. Analysis
Comparison 2 PSN versus control, Outcome 2 Pain relief ‐ up to 12 months.
2.3
2.3. Analysis
Comparison 2 PSN versus control, Outcome 3 Adverse effects.
3.1
3.1. Analysis
Comparison 3 LUNA versus LPSN, Outcome 1 Pain relief ‐ up to 6 months.
3.2
3.2. Analysis
Comparison 3 LUNA versus LPSN, Outcome 2 Pain relief ‐ up to 12 months.
3.3
3.3. Analysis
Comparison 3 LUNA versus LPSN, Outcome 3 Adverse effects.
See this image and copyright information in PMC

Update of

References

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References to studies excluded from this review

Garcia Leon 2003 {published data only}
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