ABSTRACT
The pathogenesis and medical management of primary dysmenorrhea was discussed in Chapter 23. Surgical treatment of primary dysmenorrhea is rarely indicated, but when it is deemed necessary, conservative surgical treatment is interruption of nociceptive pathways from the uterus. The nociceptive innervation of the uterus runs primarily with the autonomic sympathetic nerves (T10-L2) (Figure 45.1). Cutting the sympathetic nerves promotes vasodilation, interrupts sensory input from the uterus, and often relieves dysmenorrhea. Presacral neurectomy consists of transection of the sympathetic nerves of the superior hypogastric plexus at the sacral promontory (Video 45.1). It has an efficacy of about 75% in relieving midline dysmenorrhea. Uterine nerve ablation (or laparoscopic uterine nerve ablation-LUNA) is performed by transecting the uterosacral ligaments (Figure 45.2). While LUNA may be more easily performed than a presacral neurectomy, data from randomized clinical trials (RCTs)
show that it is in effective, both for the treatment of primary dysmenorrhea,1 and for any other type of pelvic pain, including endometriosis-associated pelvic pain.2-4
Presacral neurectomy for dysmenorrhea was first reported by Jaboulay and by Ruggi.5,6 Black, based on a review of 72 articles published from 1936 to 1963, plus his own cases, estimated that 75%–85% of women had relief of dysmenorrhea after presacral neurectomy.7 These data, like most regarding presacral neurectomy, were observational. Chen et al. reported a clinical trial of 68 women with primary dysmenorrhea randomized to either laparoscopic presacral neurectomy or laparoscopic uterine nerve ablation that showed, at 12 months, presacral neurectomy had an efficacy 82% compared to 51% with uterine nerve ablation.8 There are no RCTs evaluating the efficacy of presacral neurectomy for the treatment of primary dysmenorrhea, only for secondary dysmenorrhea associated with endometriosis.9-12 Thus the role of presacral neurectomy for primary dysmenorrhea is limited in current practice.
