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Chronic pelvic pain
February 1996, Vol 3, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
Editorial
Chronic Pelvic Pain Anthony A. Luciano, M.D. Chronic pelvic pain is a common medical problem with significant social, psychologic, and economic implications. It accounts for 10% of all gynecologic referrals, 1 40% of laparoscopies, 2 and 12% of hysterectomies3performed in the United States. With the highest frequency in young adult women at the peak of their productivity (mean age 30 yrs), chronic pelvic pain is associated with long-term suffering and disability, often leading to marital discord and divorce, loss of employment, and numerous medical and surgical interventions that are frequently unsuccessful and occasionally compounded by untoward effects and complications. The annual medical cost of the disorder is estimated to exceed $2 billion. Chronic pain differs from acute pain not only in duration but also in behavioral, psychologic, and physiologic manifestations. Over the roughly 6 months when the transition from acute to chronic pain occurs, the relief provided by various treatments progressively diminishes both in degree and duration. As the pain becomes chronic, other organ systems may manifest progressive symptomatology, including irritable bowel, urinary bladder dysfunction, diminished sexual interest and response, and low back and pelvic floor pain syndromes. As the physical disability and
emotional distress progress over time, the patient's role at work, in the family and in society is altered as support progressively erodes. Eventually, pain becomes the most important problem for both the woman and her family. Hence, the urgent expectation of the physician to cure it. Classic Cartesian teaching assumes that pain is the direct result of pathologic processes. The injured tissue activates neurosensory fibers that register pain sensation to a degree that corresponds to the severity of the pathology. "Real" pain is associated with observable pathology. In the absence of identifiable tissue injury, the pain must be spurious or psychogenic. Although the Cartesian model may hold true for acute pain, it does not apply for most cases for chronic pelvic pain, in which a somatic etiology is identified in less than 50% of patients, and when it is, it may not account for the symptoms. This lack of correlation between the severity of symptoms and objective pathologic findings is a frequent source of exasperation and frustration for both the woman and the physician. The assumption that in the absence of somatic pathology the disorder must be psychogenic is equally frustrating and not supported by scientific evidence. Although depression may be a consequence, especially
From the Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, and Center for Fertility and Reproductive Endocrinology, New Britain General Hospital, New Britain, Connecticut.
193
Editorial
in individuals with a personal or family history of depression, little evidence suggests that chronic pain may result from or be due to preexisting depression. 4 To understand better the multifaceted problem of chronic pelvic pain, the gate control theory of pain was proposed, which takes into account the influence that psychologic and social characteristics have on the perception of nociceptive stimuli. This model suggests that incoming peripheral pain stimuli may be modulated (censored, heightened, even exaggerated) by messages from other sources, such as afferent input from cutaneous and deep somatic structures, endogenous opioid and nonopioid analgesic systems, and several central excitatory and inhibitory influences from the brain stem, hypothalamus, and cortex.5,6These gates, or modulators, exert a significant influence on the ultimate perception of pain. The injured athlete who feels no pain while competing, the painful anticipation of the dentist's drill, and the exacerbation of headaches by even the slightest noise are clear examples of the significant effect that peripheral and central modulators have on the perception of nociceptive stimuli. The gate theory provides a physiologic basis for the influence that somatic and psychogenic factors have on each other. Anxiety, depression, physical activity, mental concentration, marital discord, and the like may increase or decrease the perception of pain. Conversely, chronic somatic nociception may deplete the descending central nervous system modulators of pain (e.g., endogenous opioids), and this depletion may biochemically lead to depression. Thus potential mechanisms for depression can be postulated, and neurophysiologic evidence exists to support both. v,8 The clinical relevance of current pain theories is that diagnosis and treatment must integrate many influences--the patient's personality and affect, cultural influences, stress, organic changes that may trigger nociceptive signals, sensory thresholds or gates, and the patient's cognition about pain. For chronic pain no clear distinction can be made between psychologic and physical causes, nor are attempts to make such a distinction useful. Rather than trying to establish organic versus functional etiologies, it is more useful to ask regarding each patient if she has any physical disease or abnormality that requires medical or surgical treatment, and if she is experiencing social or psychologic distress that requires treatment. To the second question, the answer is usually yes, and appropriate referral should be instituted unless the primary care
physician or gynecologist can provide the necessary emotional support and care. To answer the first question, the clinician assumes the role of diagnostician, looking for objective pathologic processes through medical history, physical examination, laboratory tests, and imaging, and a diagnostic laparoscopy to rule out or treat any pelvic pathology. The review article by Duleba et al published in this issue elegantly outlines the diagnostic approach and correctly emphasizes the importance of laparoscopy in the patient's evaluation and management. In more than 50% of laparoscopies, pathologic findings are observed, frequently, endometriosis and pelvic adhesions. Whether the pathology is actually responsible for the patient's symptoms is a more difficult and more important issue, and frequently leads to repeated unsuccessful therapies and surgical interventions. The recent resurgence of laparoscopy under local anesthesia using small (<2 mm) endoscopic instruments allows for safer and less traumatic access to the peritoneal cavity. More important, however, by performing laparoscopy under local anesthesia, with the patient awake and responsive, the surgeon may be able to determine whether or not a given lesion is responsible for or contributing to her symptoms. Accurate pain mapping and correlating observed pathology with the presence or absence of symptomatology are best accomplished by microendoscopy under local anesthesia, and give us a much better understanding of the pathophysiology of pelvic pain and a better chance to improve our therapeutic efficacy for this problem. Women suffering from chronic pelvic pain are a heterogeneous group, and the possible diagnoses, besides chronic pelvic pain, are numerous and varied. Occasionally a gynecologist may be the first to evaluate the patient and may be able to make a single diagnosis with a curative treatment. More often, the pain is of long standing, with numerous diagnoses and treatments. Thus a number of contributing factors may require evaluation, and the gynecologist may have to serve as the organizer of a multidisciplinary team for the patient's management. For example, bladder irritability, irritable bowel syndrome, poor posture, and emotional stresses may all be contributing factors, with the need for simultaneous urologic, gastroenterologic, physical therapy, and psychologic treatment. In planning treatment it is useful to stress the differentiation between acute and chronic pain, both
194
February 1996, Vol 3, No. 2
TheJournal of the American Association of Gynecologic Laparoscopists
psychologically and physiologically, and to recognize chronic pelvic pain as a diagnosis in itself, rather than as a symptom. With the current incomplete understanding of the disorder, it is necessary to accept that in many patients it must be managed rather than cured. Again, this is best accomplished with a multifaceted, biophysical approach. Even multidisciplinary chronic pain centers are usually unsuccessful, however, since less than 50% o f women treated in these highly specialized clinics experience long-term relief. So what can the physician offer after the analgesics, the surgical interventions, the behavioral modification programs, the hypnosis, and the antidepressants and anxiolytics have failed? The physician must resort to a more humanistic role, best examplified by the story of a little girl who was late coming home from school because she had stopped to help her friend whose tricycle was broken. "But you cannot fix tricycles," said her mother. "I know," said the girl, "but he needed me to help him cry." Chronic pelvic pain is a complex, multifactoral problem that challenges even the most astute diagnostician and stifles even the most resourceful therapeutic facility. It is rarely cured, it is occasionally improved, but it can usually be managed. In their excellent article, Duleba et al describe the nature of the problem, outline a comprehensive diagnostic evaluation, and describe an exhaustive list of therapeutic options available to cure, improve, or manage the
disorder. It is important to remember, however, that even if we cannot fix it, we can always help. References
1. Reiter RC: A profile of women with chronic pelvic pain. Clin Obstet Gynecol 33:117-118, 1990 2. Howard FM: The role of laparoscopy in the evaluation of chronic pelvic pain: Promise and pitfall. Obstet Gynecol Surv 48:10-46, 1993 3. Reiter RC: Chronic pelvic pain: Forward. Clin Obstet Gynecol 33:117-118, 1990 4. Rosenthal RH: Psychology of chronic pelvic pain. Obstet Gynecol Clin North Am 20:627-642, 1993 5. Turk DC, Melzack R: Handbook of PainAssessment. New York, Guilford Press, 1992 6. Rapkin AJ: Neuroanatomy, neurophysiology, and neuropharmacology of pelvic pain. Clin Obstet Gynecol 33:119-126, 1990 7. Walker EA, Sullivan MD, Stenchever MA: Use of antidepressants in the management of women with chronic pelvic pain. Obstet Gynecol Clin North Am 20:743-751, 1993 8. Steege JF: Assessment and treatment of chroriic pelvic pain. In Te Linde's Operative Gynecology, Updates, 7th ed. Edited by JD Thompson, JA Rock. Philadelphia, JB Lippincott, 1992, pp 1-10
195
The Journal of the American Association of Gynecologic Laparoscopists
Editorial
Chronic Pelvic Pain Anthony A. Luciano, M.D. Chronic pelvic pain is a common medical problem with significant social, psychologic, and economic implications. It accounts for 10% of all gynecologic referrals, 1 40% of laparoscopies, 2 and 12% of hysterectomies3performed in the United States. With the highest frequency in young adult women at the peak of their productivity (mean age 30 yrs), chronic pelvic pain is associated with long-term suffering and disability, often leading to marital discord and divorce, loss of employment, and numerous medical and surgical interventions that are frequently unsuccessful and occasionally compounded by untoward effects and complications. The annual medical cost of the disorder is estimated to exceed $2 billion. Chronic pain differs from acute pain not only in duration but also in behavioral, psychologic, and physiologic manifestations. Over the roughly 6 months when the transition from acute to chronic pain occurs, the relief provided by various treatments progressively diminishes both in degree and duration. As the pain becomes chronic, other organ systems may manifest progressive symptomatology, including irritable bowel, urinary bladder dysfunction, diminished sexual interest and response, and low back and pelvic floor pain syndromes. As the physical disability and
emotional distress progress over time, the patient's role at work, in the family and in society is altered as support progressively erodes. Eventually, pain becomes the most important problem for both the woman and her family. Hence, the urgent expectation of the physician to cure it. Classic Cartesian teaching assumes that pain is the direct result of pathologic processes. The injured tissue activates neurosensory fibers that register pain sensation to a degree that corresponds to the severity of the pathology. "Real" pain is associated with observable pathology. In the absence of identifiable tissue injury, the pain must be spurious or psychogenic. Although the Cartesian model may hold true for acute pain, it does not apply for most cases for chronic pelvic pain, in which a somatic etiology is identified in less than 50% of patients, and when it is, it may not account for the symptoms. This lack of correlation between the severity of symptoms and objective pathologic findings is a frequent source of exasperation and frustration for both the woman and the physician. The assumption that in the absence of somatic pathology the disorder must be psychogenic is equally frustrating and not supported by scientific evidence. Although depression may be a consequence, especially
From the Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, and Center for Fertility and Reproductive Endocrinology, New Britain General Hospital, New Britain, Connecticut.
193
Editorial
in individuals with a personal or family history of depression, little evidence suggests that chronic pain may result from or be due to preexisting depression. 4 To understand better the multifaceted problem of chronic pelvic pain, the gate control theory of pain was proposed, which takes into account the influence that psychologic and social characteristics have on the perception of nociceptive stimuli. This model suggests that incoming peripheral pain stimuli may be modulated (censored, heightened, even exaggerated) by messages from other sources, such as afferent input from cutaneous and deep somatic structures, endogenous opioid and nonopioid analgesic systems, and several central excitatory and inhibitory influences from the brain stem, hypothalamus, and cortex.5,6These gates, or modulators, exert a significant influence on the ultimate perception of pain. The injured athlete who feels no pain while competing, the painful anticipation of the dentist's drill, and the exacerbation of headaches by even the slightest noise are clear examples of the significant effect that peripheral and central modulators have on the perception of nociceptive stimuli. The gate theory provides a physiologic basis for the influence that somatic and psychogenic factors have on each other. Anxiety, depression, physical activity, mental concentration, marital discord, and the like may increase or decrease the perception of pain. Conversely, chronic somatic nociception may deplete the descending central nervous system modulators of pain (e.g., endogenous opioids), and this depletion may biochemically lead to depression. Thus potential mechanisms for depression can be postulated, and neurophysiologic evidence exists to support both. v,8 The clinical relevance of current pain theories is that diagnosis and treatment must integrate many influences--the patient's personality and affect, cultural influences, stress, organic changes that may trigger nociceptive signals, sensory thresholds or gates, and the patient's cognition about pain. For chronic pain no clear distinction can be made between psychologic and physical causes, nor are attempts to make such a distinction useful. Rather than trying to establish organic versus functional etiologies, it is more useful to ask regarding each patient if she has any physical disease or abnormality that requires medical or surgical treatment, and if she is experiencing social or psychologic distress that requires treatment. To the second question, the answer is usually yes, and appropriate referral should be instituted unless the primary care
physician or gynecologist can provide the necessary emotional support and care. To answer the first question, the clinician assumes the role of diagnostician, looking for objective pathologic processes through medical history, physical examination, laboratory tests, and imaging, and a diagnostic laparoscopy to rule out or treat any pelvic pathology. The review article by Duleba et al published in this issue elegantly outlines the diagnostic approach and correctly emphasizes the importance of laparoscopy in the patient's evaluation and management. In more than 50% of laparoscopies, pathologic findings are observed, frequently, endometriosis and pelvic adhesions. Whether the pathology is actually responsible for the patient's symptoms is a more difficult and more important issue, and frequently leads to repeated unsuccessful therapies and surgical interventions. The recent resurgence of laparoscopy under local anesthesia using small (<2 mm) endoscopic instruments allows for safer and less traumatic access to the peritoneal cavity. More important, however, by performing laparoscopy under local anesthesia, with the patient awake and responsive, the surgeon may be able to determine whether or not a given lesion is responsible for or contributing to her symptoms. Accurate pain mapping and correlating observed pathology with the presence or absence of symptomatology are best accomplished by microendoscopy under local anesthesia, and give us a much better understanding of the pathophysiology of pelvic pain and a better chance to improve our therapeutic efficacy for this problem. Women suffering from chronic pelvic pain are a heterogeneous group, and the possible diagnoses, besides chronic pelvic pain, are numerous and varied. Occasionally a gynecologist may be the first to evaluate the patient and may be able to make a single diagnosis with a curative treatment. More often, the pain is of long standing, with numerous diagnoses and treatments. Thus a number of contributing factors may require evaluation, and the gynecologist may have to serve as the organizer of a multidisciplinary team for the patient's management. For example, bladder irritability, irritable bowel syndrome, poor posture, and emotional stresses may all be contributing factors, with the need for simultaneous urologic, gastroenterologic, physical therapy, and psychologic treatment. In planning treatment it is useful to stress the differentiation between acute and chronic pain, both
194
February 1996, Vol 3, No. 2
TheJournal of the American Association of Gynecologic Laparoscopists
psychologically and physiologically, and to recognize chronic pelvic pain as a diagnosis in itself, rather than as a symptom. With the current incomplete understanding of the disorder, it is necessary to accept that in many patients it must be managed rather than cured. Again, this is best accomplished with a multifaceted, biophysical approach. Even multidisciplinary chronic pain centers are usually unsuccessful, however, since less than 50% o f women treated in these highly specialized clinics experience long-term relief. So what can the physician offer after the analgesics, the surgical interventions, the behavioral modification programs, the hypnosis, and the antidepressants and anxiolytics have failed? The physician must resort to a more humanistic role, best examplified by the story of a little girl who was late coming home from school because she had stopped to help her friend whose tricycle was broken. "But you cannot fix tricycles," said her mother. "I know," said the girl, "but he needed me to help him cry." Chronic pelvic pain is a complex, multifactoral problem that challenges even the most astute diagnostician and stifles even the most resourceful therapeutic facility. It is rarely cured, it is occasionally improved, but it can usually be managed. In their excellent article, Duleba et al describe the nature of the problem, outline a comprehensive diagnostic evaluation, and describe an exhaustive list of therapeutic options available to cure, improve, or manage the
disorder. It is important to remember, however, that even if we cannot fix it, we can always help. References
1. Reiter RC: A profile of women with chronic pelvic pain. Clin Obstet Gynecol 33:117-118, 1990 2. Howard FM: The role of laparoscopy in the evaluation of chronic pelvic pain: Promise and pitfall. Obstet Gynecol Surv 48:10-46, 1993 3. Reiter RC: Chronic pelvic pain: Forward. Clin Obstet Gynecol 33:117-118, 1990 4. Rosenthal RH: Psychology of chronic pelvic pain. Obstet Gynecol Clin North Am 20:627-642, 1993 5. Turk DC, Melzack R: Handbook of PainAssessment. New York, Guilford Press, 1992 6. Rapkin AJ: Neuroanatomy, neurophysiology, and neuropharmacology of pelvic pain. Clin Obstet Gynecol 33:119-126, 1990 7. Walker EA, Sullivan MD, Stenchever MA: Use of antidepressants in the management of women with chronic pelvic pain. Obstet Gynecol Clin North Am 20:743-751, 1993 8. Steege JF: Assessment and treatment of chroriic pelvic pain. In Te Linde's Operative Gynecology, Updates, 7th ed. Edited by JD Thompson, JA Rock. Philadelphia, JB Lippincott, 1992, pp 1-10
195