- Email: [email protected]
Chronic pelvic pain: Sailing between the “ Scylla” and the “ Charybdis”
International Congress Series 1279 (2005) 90 – 98
www.ics-elsevier.com
Chronic pelvic pain: Sailing between the b ScyllaQ and the b CharybdisQ A.A.W. PetersT Leiden University Medical Center, PO box 9600, 2300 RC Leiden, The Netherlands
Abstract. An integrated approach to patients with CPP seems most appropriate. When the complaints exist more than 6 months and the history, pelvic examination and ultrasound do not show any serious pathologic findings, there is no reason that a serous disease stays un-recognized. A routine laparoscopy is not indicated; it may give rise to hope with the patient and a reflex to do surgical interventions with the laparoscopist. Adhesions are more often the result of previous surgery performed on indication CPP than the cause of the complaint. Adhesiolysis is seldom necessary and only when ileus problems are arising an exception can be made. An integrated approach in which all the factors that can be responsible for the CPP are involved has to be offered to the patient from the start, preferable already by the General Practitioner. It seems most likely that women with CPP has to be offered the same treatment as women with other chronic pain syndromes, with the difference that gender specific problems related to the genitals and procreation and sexuality are more prominent. D 2005 Published by Elsevier B.V. Keywords: Psychosomatic gynaecology; Gender specific medicine; Chronic pelvic pain; Somatization; Integral approach of chronic pelvic pain
1. Introduction The number of studies on chronic or recurrent pelvic pain in women, bears no relation to the frequency of this complaint. Chronic pelvic pain (CPP) is very common in women in the reproductive age group and it is one of the most common gynaecological complaints, estimated to compromise almost 10% of outpatient gynaecological referrals [1]. Despite the high incidence, the pathogenesis of CPP is poorly understood. CPP causes
T Tel.: +31 71 526 3348. E-mail address: [email protected]. 0531-5131/ D 2005 Published by Elsevier B.V. doi:10.1016/j.ics.2005.02.087
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disability and distress and results in significant costs to health services, estimated at over $880 million in the USA [2]. Howard claims in his review that over 40% of all diagnostic and therapeutic laparoscopies are performed for chronic pelvic pain. In this review, he also reports that there is a tendency for an increase of laparoscopies done for CPP due to either an increase in the prevalence of CPP or due to the awareness that in women with CPP the physical examination is not a good predictor of laparoscopic findings [3]. CPP is often labelled bthe disease with 20 different namesQ, but many names have been added the last decennium. Unfortunately, it tends to be managed using even more different treatment methods, often with little or no improvement, sometimes even aggravating the complaints and giving rise to even more disability. It seems that the woman with chronic or recurrent pelvic pain presents a continuing clinical challenge. The fruitless research for somatic disease often results to visits to many different consultants. Various diagnoses are very popular such as: Qchronic cystitisQ, binterstitial cystitisQ, burethral syndromeQ, birritable bowel syndromeQ, bpelvic laxityQ or bpelvic pain syndromeQ. These diagnoses do not lead to a better understanding of the problem and do not result in a successful treatment in most of these women. Because the results of surgical and pharmaceutical treatment are poor, the psychosocial aspects of chronic pelvic pain have gained more attention lately [4]. Pain, as defined by the International Association for the study of Pain, is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in those terms [5]. This definition in mind the model of Loesser can be useful to understand the complexity of chronic pain, and the patient with CPP should be considered as bchronic pain patientQ. He recognizes in his model 4 different domains: (1) nociception, (2) pain perception, (3) pain suffering, (4) pain-behaviour; each with their specific physiological, somatic and psychological significance [6]. Since pain is perceived in the mind, the experience of pain will inevitable be affected by the sufferer’s environment, both physical and psychological, such as the presence of other illness, levels of stress and coping with these, social support or beliefs about the pain. Thus, in the assessment of patients with chronic pain, it is imperative to the individual as a whole, and not to dichotomise pain as either organic or psychological with the problem of somatic fixation or psychosocial fixation [7]. The most used definition of CPP is: pain in the lower abdomen or pelvis of more than 6 months duration, occurring continuously or intermittently for at least 2 days per week and not exclusively related the menstrual cycle or intercourse. 2. Diagnoses and treatment Many different consultants are involved in the treatment of women with CPP. It is depending on related complaints, provoking factors or localisation of the pain and time frame and luxating moments if they are referred to the gynaecologist, urologist, gastroenterologist or orthopaedic surgeon. They tend to do a lot of investigations with the risks of detecting abnormalities with no relation to the complaint or no other consequences. Sometimes, medical or surgical interventions are planned and performed more for the assurance of the patient and the doctor than for the benefit of the patient.
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Referral to a psychologist or psychiatrist after negative findings or disappointing results after medical or surgical treatment are often not well accepted by the patients and felt as denial and frustrating. A survey of the literature on somatic and psychological aspects of chronic pelvic pain indicates that many aspects have not received as much attention as they deserve. The neurophysiologic aspects and general concepts that are needed to understand pain and pain sensations deserve a more central place in research and patient care. For the review of gynaecological, urological, gastro-intestinal and other somatic causes of CPP, it becomes clear that CPP does not constitute a single, well-defined category of problems, nor does it appear that a single well-defined course of action is the most appropriate way to deal with this symptom. Theories on causation and treatment of CPP are often inadequately substantiated with change findings determining much of our current thinking about this condition. The tendency among gynaecologists to select a surgical approach to the problem appears to be related to the values and specific functions that are attributed to the organs that can be removed. There is a tendency to limit the importance of the internal genital organs to their reproductive function, and thus to consider them largely superfluous, when that function has been fulfilled. This may explain the fact that hysterectomy is the most frequently applied surgical treatment next to adhesiolysis and that those surgical approaches to women with CPP are applied more frequently by gynaecologists than by other medical specialists. Inadequate substantiation of hypothesis and theories concerning CPP is not limited to its somatic aspects. Also psychological and psychosocial theories are often heavily biased and prone to single-mindedness (bIf you have a hammer, everything looks like a nailQ). Methods for objective evaluation and scoring of pain are imperative, such as the Visual Analogue Scale. But even better is the Mc Gill pain questionnaire as it is more suitable for investigating the multidimensional character of CPP, measuring the sensoric, affective, evaluative and temporal aspects of pain [8] (Table 1). Considering the arguments mentioned before, there is often no causal relation between the findings and the CPP. Restrain is important to start all kind of treatment without proper evidence. Table 1 Most common somatic causes of CPP Gynaecological
Non- gynaecological
Endometriosis Adhesions Fibroids Ovarian cysts Chronic Pelvic Inflammatory Disease (PID) Uterine prolaps/pelvic laxity Retroversion/ flexion of the uterus Pelvic congestion Abdominal wall and pelvic floor dysfunctions
Irritable bowel syndrome (IBS) Chronic constipation (slow transit syndrome) Chronic bowel disease Diverticulosis Colon or rectal tumour Chronic cystitis Interstitial cystitis Urethral syndrome Myofascial and abdominal wall trigger points/muscular–skeletal pain Nerve entrapment syndrome Lower back and sacro-iliacal joint dysfunctions
Remnant ovary syndrome Residual ovary syndrome
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2.1. Psychosocial and psychiatric factors In a meta-analysis of 22 studies, different groups of women with CPP were compared with each other on different psychopathological variables and sexual and physical abuse experiences in the past. Distinction was made on the basis of pathological findings with gynaecological examination or laparoscopy. The women with CPP were also compared with women with other chronic pain syndromes or women without pain [9]. Some of the conclusions of this meta-analysis are: – There is more psychopathology in the total group of women with CPP than in a comparable group of women without pain. – The prevalence of psychopathology – especially depressive and fobic disorder – is the same in women with CPP as in women with other pain disorders. – There is no difference in psychopathology between women with a somatic pathology found and women with no abnormalities on examination. – Women with CPP without obvious pathology have more other unexplained pain complaints than women without pain. All women with CPP have more unexplained complaints than women without pain. – Women with CPP without obvious pathology were more convinced that they had a serious disease than women with a supposed cause for their complaint. – Women with CPP (and other forms of chronic pain) were more often victim of sexual and physical violence. The above conclusions show that psychological aspects are playing an important role in CPP as in other pain disorders. 2.2. Laparoscopy In the approach of women with CPP, many diagnostics are often involved. Physical examination is not very specific. Lundberg concluded from a study of 95 patients with pelvic pain that there was a poor correlation between pelvic examination and the existence of pelvic disease [10]. Most of the time, ultrasound is included in the examination. Fibroids and ovarian cysts may be detected, although their relation with the complaint may be unclear and a surgical reflex inevitable. A pain calendar and diary are essential and give some ideas about the different aspects of the pain and the provoking factors and reactions on the prescribed treatment. Some blood tests may be necessary as is the Chlamydia DNA. Most controversial is the routine diagnostic laparoscopy. It is nearly always used in the assessment procedures of chronic CPP, the usefulness is disputable for the assessment of the somatic pathology, as the real cause of the CPP. However, there are some uncontrolled studies, which report pain reduction after a diagnostic laparoscopy, without other medical intervention than just blookingQ [11]. Attention should be paid, when analysing these data, to inclusion and diagnostic criteria for the study groups and to the laparoscopic techniques, especially where double of multiple puncture techniques are used to ensure adequate vision [12]. Reviewed 1194 charts of consecutive patients, who had a diagnostic laparoscopy for pelvic pain. He found that 63% of the patients that had a normal pelvic examination prior to the laparoscopy showed abnormal findings on the diagnostic
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laparoscopy, whereas 17.5% of the patients that had abnormal pelvic examination showed normal findings on laparoscopy. Levitan concluded that patients with pelvic pain that had pathologic underlying conditions experienced more severe pain compared to patients without a pathologic condition, thus suggesting a relationship between the presence of pathology and pain [13]. A study performed by Kretsch showed that 83% of the patients with pelvic pain showed some kind of pathology of which 38% of the patients showed adhesion formation. Kretsch followed very detailed inclusion criteria, which might explain the high percentage of pathology found. Although this study dealt with only 50 patients, it was a prospective study and even included a control group [14]. Stout reported that the localization of the pain was concomitant with the localization of the adhesions in 97% of the patients, although extent of adhesion formation or severity of the pain showed no relation [15]. One should compare the abovementioned percentages found in women with CPP with the percentage of pathology found in asymptomatic women. Kretsch, for example, found 29% pathology with a control group of asymptomatic women having a sterilization. Trimbos recorded laparoscopic findings in 200 asymptomatic women having a sterilization. In 26% of these women, abnormalities were found including 14 of pelvic adhesions [16]. Rapkin found a percentage of 39% adhesions with laparoscopy of which 12% showed CPP. In this study group, 26% of the adhesions were found with the patients that had pain. Howard summarizes all these cumulative data from the different studies and concludes that laparoscopy in patients with CPP reveals a detectable pathologic condition in 61% of the patients. 25% of these pathologic conditions are adhesions. In women without CPP, a pathologic condition was detectable in 28%, of which adhesions accounted for 17%. He concluded that women without CPP have a significant incidence of abnormal laparoscopic findings but that women with CPP have twice the incidence of laparoscopically detected pathology. In our view, it seems of greater importance to see what a routine laparoscopy can add to the information obtained by history, pelvic examination and ultrasound. Of course adhesions can be found more frequently in women with CPP realizing that this group had very often previous surgery. All other pathologic finding can be diagnosed otherwise. The babnormalQ findings at laparoscopy often induce further somatic fixation by surgery again suiting the whish of the patient and appealing to the surgical reflex of the gynaecologist. Our conclusion is that routine laparoscopy should not be performed with women with CPP and only on indication after informing the patient that there is reasonable doubt about the relation between the possible findings and her complaint. 2.3. Treatment The Cochrane Library [17] reported only 6 randomised controlled trials on the treatment of CPP of which 4 were of good methodological quality. The results of these four studies are: prostagen was associated with a reduction of pain during treatment [18]; a session of counselling supported by ultrasound scanning was associated with reduced pain and improvement in mood [19]; a multidisciplinary approach was beneficial for some outcome measures [20] and adhesiolysis was not associated with an improved outcome apart from where adhesions were severe [21]. Data regarding the long- term efficacy of treatment procedures for CPP are not available, but estimates of failure to bring about relief are high.
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Especially the adhesiolysis, which still very often performed by laparotomy or laparoscopy needs some further attention. Most studies dealing with adhesiolysis address infertility or adhesion reformation. Howard has made a review in which he summarizes the studies on adhesiolysis. Many authors conclude that there is an substantial positive benefit of adhesiolysis on pelvic pain. Percentages of improvement vary from 67% [22] – his follow-up period was only 4 months – 84% [23] – follow-up 1 to 5 years – to 89% [24]. When analysing these data, one should take into account that in many of the studies the evaluation of pain was not blinded, no control groups were included and follow-up times differed significantly. Steege also found a positive effect of adhesiolysis in a prospective study of 30 women. An improvement of 75% was found at 6 to 12 months after surgery in the women without a chronic pelvic pain syndrome. In women with a chronic pain syndrome, 40% improvement was achieved. Seven patients had initial relief but a return of pain within 3 to 5 months, thereby stressing the importance of longer follow-up intervals. Because we could not confirm the results of the literature in our clinic and were very dissatisfied with our results, we performed a randomised clinical trial in 48 women with stage II to IV pelvic adhesions. Surgical treatment (adhesiolysis) was compared to a nonsurgery group. Nine to 12 months after adhesiolysis, no significant differences were found between the two groups with regard to pelvic pain. A subgroup of women with severe, vascularized and dense adhesions involving the bowel (stage IV) had significantly less pain after adhesiolysis [25]. Laparoscopic adhesiolysis is sometimes thought to be superior to adhesiolysis by means of laparotomy. The Operative Laparoscopy Study Group, who found that adhesion reformation is a frequent occurrence after operative laparoscopy, could not confirm this theory [26]. Recently, the results of a multicentre trial in the Netherlands more or less confirmed the earlier results in a prospective randomised trial [27]. 3. Placebo effects Psychological effects have frequently been discussed in relation with CPP and laparoscopy in CPP. The reassurance derived from the results with laparoscopy might contribute to the beneficial effect so that prejudiced conclusions are drawn. Peters suggest postponement of the assessment of the results to more than 12 months at least after treatment due to the influence of the placebo effect, which seldom last longer [28]. Baker performed a study in 60 patients with CPP that had laparoscopy that excluded obvious pelvic pathology. At a 6 month follow-up period, 58% reported that they were pain free and 39% reported that their pain had diminished. Baker concluded that treatment of pelvic pain should concentrate on the small minority of patients whose symptoms remain 6 months after laparoscopy [29]. Recent research with the help of f (functional) MRI is giving scientific prove for the placebo phenomenon. The therapeutic effect of a medicine could be improved by the suggestion to the patient that it really works. On f MRI with those patients, who were reassures about the efficacy of the treatment, there was a marked decrease of activity in orbito-frontal cortex. (the are where the pain stimuli are perceived) [30].The conclusion of all bevidenceQ at this moment: there is no reason to treat
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women with CPP different from women with other chronic pain syndromes, unless the treatment is aimed at the underlying cause, such as hormonal treatment with endometriosis or complaints related to the menstrual cycle. Surgery is seldom indicated as is a routine laparoscopy with the understanding that: bCertain operations are effective depending upon an appropriate mental state of the patient and the surgeonQ [31]. 4. Integral approach of women with CPP A literature survey of so-named holistic approaches to CPP reveals a discrepancy between opinions and research data, the latter being largely absent. It is obvious, however, that such wholesome approaches to the problem involve far more than a multidisciplinary or psychosomatic approach. The most crucial ingredient appears to be that all potential mechanisms are given equal and simultaneous attention. Within that approach, there is a wide diversity of specific treatments. In an integrated approach, equal attention is devoted to somatic, psychological, dietary, environmental and physiotherapeutic factors in contrast with the standard approach in which a somatic cause had to be excluded first. In this group, laparoscopy is performed routinely. In a prospective randomised trial, both approaches were compared. The conclusion was: an integrated care is likely to be more effective than the standard approach. A possible explanation of this finding might be that the risk of somatic fixation is less with the integrated approach. Other factors that seem important are the diminished impairments from the pain and the adventitious distress. The attention to factors other than somatic is also more easily accepted by the patients than after an extensive and fruitless hunt for somatic abnormalities. Of course, organic abnormalities remain important and should not be overlooked, but if carefully taken history and an expert pelvic examination are negative, it is doubtful whether invasive measures such as laparoscopy have any additional information to offer [28]. Since the outcome of this trial in the department of Gynaecology a bChronic Pelvic Pain TeamQ is functioning, in which all the mentioned disciplines are represented. If no rational treatment can be suggested to the patient she is often offered bCognitive Behaviour TreatmentQ in groups. The cause of the pain is no longer the target of the efforts and interventions but the pain itself. A symptom–response model can be helpful in supporting the patients, according to following schema.
Physical symptom Interpretation Response Cognitiveemotional consequences
Behavioural consequences
Physical consequences
Social consequences
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5. Conclusions An integrated approach to patients with CPP seems most appropriate. When the complaints exists more than 6 months and the history, pelvic examination and ultrasound do not show any serious pathologic findings there is no reason that a serous disease stays un-recognized. A routine laparoscopy is not indicated; it may give rise to hope with the patient and a reflex to do surgical interventions with the laparoscopist. Adhesions are more often the result of previous surgery performed on indication CPP than the cause of the complaint. Adhesiolysis is seldom necessary and only when ileus problems are arising an exception can be made. An integrated approach in which all the factors that can be responsible for the CPP are involved has to be offered to the patient from the start, preferable already by the General Practitioner. It seems most likely that women with CPP have to be offered the same treatment as women with other chronic pain syndromes, with the difference that gender specific problems related to the genitals and procreation and sexuality are more prominent. References [1] R.C. Reiter, A profile of women with chronic pelvic pain, Clin. Obstet. Gynecol. 33 (1990) 130. [2] S.D. Matthias, et al., Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates, Obstet. Gynecol. l87 (1996) 321. [3] F.M. Howard, The role of laparoscopy in chronic pelvic pain: promise and pitfalls, Obstet. Gynecol. Surv. 48 (1993) 357. [4] Pearce, et al., Pelvic pain—a common gynaecological problem, J. Psychosom. Obstet. Gynecol. 1 (1982) 12. [5] IASP, Classification of chronic pain, Pain (Suppl. 3) (1986) 217. [6] J.D. Loesser, A definition of pain, Medicine 7 (1980) 3. [7] V.M. Grace, Mind/body dualism in medicine: the case of chronic pelvic pain without organic pathology, Int. J. Health Sci. 28 (1998) 127. [8] A.A.W. Peters, Chronisch buikpijn bij vrouwen, een integrale benadering – bChronic pelvic pain, an integral approachQ. Thesis Leiden (1990). [9] L.P.A. McGowan, et al., Chronic pelvic pain: a meta-analytic review, Psychol. Health 13 (1998) 1153. [10] W.I. Lundberg, et al., Laparoscopy in the evaluation of pelvic pain, Obstet. Gynecol. 42 (1973) 872. [11] F.M. Howard, The role of laparoscopy in chronic pelvic pain: promise and pitfalls, Obstet. Gynecol. Surv. 48 (1993) 357. [12] R.G. Cunanana, et al., Laparocopic findings in patients with pelvic pain, Am. J. Obstet. 146 (1983) 589. [13] Z. Levitan, et al., The value of laparoscopy in women with chronic pelvic pain and a normal pelvis, Int. J. Gynecol. Obstet. 23 (1985) 71. [14] A.J. Kretsch, et al., Laparoscopy in 100 women with chronic pelvic pain, Obstet. Gynecol. 164 (1991) 672. [15] A.L. Stout, et al., Relationship of laparoscopic findings to self-report of pelvic pain, Am. J. Obstet. Gynecol. 164 (1991) 73. [16] J.B. Trimbos, et al., Findings in 200 consecutive asymptomatic women, having a laparoscopic sterilization, Arch. Gynecol. Obstet. 247 (1990) 121. [17] R.W. Stones, J. Mountfield, Management of chronic pelvic pain in women (Cochrane Review), The Cochrane Library, Issue, vol. 2, Update Software, Oxford, 1998, Updated quarterly. [18] C.M. Farquhar, et al., Randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion, Br. J. Obstet. Gynaecol. 96 (1989) 1153. [19] A.F.F. Ghaly, The psychological and physical benefits of pelvic ultrasonography in patients with chronic pelvic pain and negative laparoscopy. A random allocation trial, J. Obstet. Gynaecol. 14 (1994) 269. [20] A.A.W. Peters, et al., A randomised clinical trial to compare two different approaches in women with chronic pelvic pain, Obstet. Gynecol. 77 (1991) 740.
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[21] A.A.W. Peters, et al., A randomised clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain, Br. J. Obstet. Gynaecol. 99 (1992) 59. [22] J.F. Daniell, Laparoscopic enterolysis for chronic abdominal pain, J. Gynecol. Surg. 6 (1989) 61. [23] C. Sutton, et al., Laser laparoscopic adhesiolysis, J. Gynecol. Surg. 6 (1990) 155. [24] D.P. Goldstein, et al., Laparoscopy in the diagnosis and management of pelvic pain in adolescents, J. Reprod. Med. 24 (1980) 251. [25] Peters, 1992. [26] Operative Laparoscopy Study Group, Postoperative adhesion development after operative lapaproscopy: evaluation at early second- look procedures, Fertil. Steril. 55 (1991) 700. [27] D.J. Swank, et al., Laparoscopic adhesiolysis in patients with chronic abdominal pain. A blinded randomised controlled multicentre trial, Lancet 361 (2003) 12 – 47. [28] Peters, 1991. [29] P.N. Baker, et al., The resolution of chronic pelvic pain after normal laparoscopic findings, Am. J. Obstet. Gynecol. (1992) 835. [30] T.D. Wager, et al., Placebo induced changes in MRI in the anticipation and experience of pain, Science 303 (2004) 1162. [31] L. Beecher, The Autobiography, The John Harvard Library, Cambridge, 1961.
www.ics-elsevier.com
Chronic pelvic pain: Sailing between the b ScyllaQ and the b CharybdisQ A.A.W. PetersT Leiden University Medical Center, PO box 9600, 2300 RC Leiden, The Netherlands
Abstract. An integrated approach to patients with CPP seems most appropriate. When the complaints exist more than 6 months and the history, pelvic examination and ultrasound do not show any serious pathologic findings, there is no reason that a serous disease stays un-recognized. A routine laparoscopy is not indicated; it may give rise to hope with the patient and a reflex to do surgical interventions with the laparoscopist. Adhesions are more often the result of previous surgery performed on indication CPP than the cause of the complaint. Adhesiolysis is seldom necessary and only when ileus problems are arising an exception can be made. An integrated approach in which all the factors that can be responsible for the CPP are involved has to be offered to the patient from the start, preferable already by the General Practitioner. It seems most likely that women with CPP has to be offered the same treatment as women with other chronic pain syndromes, with the difference that gender specific problems related to the genitals and procreation and sexuality are more prominent. D 2005 Published by Elsevier B.V. Keywords: Psychosomatic gynaecology; Gender specific medicine; Chronic pelvic pain; Somatization; Integral approach of chronic pelvic pain
1. Introduction The number of studies on chronic or recurrent pelvic pain in women, bears no relation to the frequency of this complaint. Chronic pelvic pain (CPP) is very common in women in the reproductive age group and it is one of the most common gynaecological complaints, estimated to compromise almost 10% of outpatient gynaecological referrals [1]. Despite the high incidence, the pathogenesis of CPP is poorly understood. CPP causes
T Tel.: +31 71 526 3348. E-mail address: [email protected]. 0531-5131/ D 2005 Published by Elsevier B.V. doi:10.1016/j.ics.2005.02.087
A.A.W. Peters / International Congress Series 1279 (2005) 90–98
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disability and distress and results in significant costs to health services, estimated at over $880 million in the USA [2]. Howard claims in his review that over 40% of all diagnostic and therapeutic laparoscopies are performed for chronic pelvic pain. In this review, he also reports that there is a tendency for an increase of laparoscopies done for CPP due to either an increase in the prevalence of CPP or due to the awareness that in women with CPP the physical examination is not a good predictor of laparoscopic findings [3]. CPP is often labelled bthe disease with 20 different namesQ, but many names have been added the last decennium. Unfortunately, it tends to be managed using even more different treatment methods, often with little or no improvement, sometimes even aggravating the complaints and giving rise to even more disability. It seems that the woman with chronic or recurrent pelvic pain presents a continuing clinical challenge. The fruitless research for somatic disease often results to visits to many different consultants. Various diagnoses are very popular such as: Qchronic cystitisQ, binterstitial cystitisQ, burethral syndromeQ, birritable bowel syndromeQ, bpelvic laxityQ or bpelvic pain syndromeQ. These diagnoses do not lead to a better understanding of the problem and do not result in a successful treatment in most of these women. Because the results of surgical and pharmaceutical treatment are poor, the psychosocial aspects of chronic pelvic pain have gained more attention lately [4]. Pain, as defined by the International Association for the study of Pain, is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in those terms [5]. This definition in mind the model of Loesser can be useful to understand the complexity of chronic pain, and the patient with CPP should be considered as bchronic pain patientQ. He recognizes in his model 4 different domains: (1) nociception, (2) pain perception, (3) pain suffering, (4) pain-behaviour; each with their specific physiological, somatic and psychological significance [6]. Since pain is perceived in the mind, the experience of pain will inevitable be affected by the sufferer’s environment, both physical and psychological, such as the presence of other illness, levels of stress and coping with these, social support or beliefs about the pain. Thus, in the assessment of patients with chronic pain, it is imperative to the individual as a whole, and not to dichotomise pain as either organic or psychological with the problem of somatic fixation or psychosocial fixation [7]. The most used definition of CPP is: pain in the lower abdomen or pelvis of more than 6 months duration, occurring continuously or intermittently for at least 2 days per week and not exclusively related the menstrual cycle or intercourse. 2. Diagnoses and treatment Many different consultants are involved in the treatment of women with CPP. It is depending on related complaints, provoking factors or localisation of the pain and time frame and luxating moments if they are referred to the gynaecologist, urologist, gastroenterologist or orthopaedic surgeon. They tend to do a lot of investigations with the risks of detecting abnormalities with no relation to the complaint or no other consequences. Sometimes, medical or surgical interventions are planned and performed more for the assurance of the patient and the doctor than for the benefit of the patient.
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Referral to a psychologist or psychiatrist after negative findings or disappointing results after medical or surgical treatment are often not well accepted by the patients and felt as denial and frustrating. A survey of the literature on somatic and psychological aspects of chronic pelvic pain indicates that many aspects have not received as much attention as they deserve. The neurophysiologic aspects and general concepts that are needed to understand pain and pain sensations deserve a more central place in research and patient care. For the review of gynaecological, urological, gastro-intestinal and other somatic causes of CPP, it becomes clear that CPP does not constitute a single, well-defined category of problems, nor does it appear that a single well-defined course of action is the most appropriate way to deal with this symptom. Theories on causation and treatment of CPP are often inadequately substantiated with change findings determining much of our current thinking about this condition. The tendency among gynaecologists to select a surgical approach to the problem appears to be related to the values and specific functions that are attributed to the organs that can be removed. There is a tendency to limit the importance of the internal genital organs to their reproductive function, and thus to consider them largely superfluous, when that function has been fulfilled. This may explain the fact that hysterectomy is the most frequently applied surgical treatment next to adhesiolysis and that those surgical approaches to women with CPP are applied more frequently by gynaecologists than by other medical specialists. Inadequate substantiation of hypothesis and theories concerning CPP is not limited to its somatic aspects. Also psychological and psychosocial theories are often heavily biased and prone to single-mindedness (bIf you have a hammer, everything looks like a nailQ). Methods for objective evaluation and scoring of pain are imperative, such as the Visual Analogue Scale. But even better is the Mc Gill pain questionnaire as it is more suitable for investigating the multidimensional character of CPP, measuring the sensoric, affective, evaluative and temporal aspects of pain [8] (Table 1). Considering the arguments mentioned before, there is often no causal relation between the findings and the CPP. Restrain is important to start all kind of treatment without proper evidence. Table 1 Most common somatic causes of CPP Gynaecological
Non- gynaecological
Endometriosis Adhesions Fibroids Ovarian cysts Chronic Pelvic Inflammatory Disease (PID) Uterine prolaps/pelvic laxity Retroversion/ flexion of the uterus Pelvic congestion Abdominal wall and pelvic floor dysfunctions
Irritable bowel syndrome (IBS) Chronic constipation (slow transit syndrome) Chronic bowel disease Diverticulosis Colon or rectal tumour Chronic cystitis Interstitial cystitis Urethral syndrome Myofascial and abdominal wall trigger points/muscular–skeletal pain Nerve entrapment syndrome Lower back and sacro-iliacal joint dysfunctions
Remnant ovary syndrome Residual ovary syndrome
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2.1. Psychosocial and psychiatric factors In a meta-analysis of 22 studies, different groups of women with CPP were compared with each other on different psychopathological variables and sexual and physical abuse experiences in the past. Distinction was made on the basis of pathological findings with gynaecological examination or laparoscopy. The women with CPP were also compared with women with other chronic pain syndromes or women without pain [9]. Some of the conclusions of this meta-analysis are: – There is more psychopathology in the total group of women with CPP than in a comparable group of women without pain. – The prevalence of psychopathology – especially depressive and fobic disorder – is the same in women with CPP as in women with other pain disorders. – There is no difference in psychopathology between women with a somatic pathology found and women with no abnormalities on examination. – Women with CPP without obvious pathology have more other unexplained pain complaints than women without pain. All women with CPP have more unexplained complaints than women without pain. – Women with CPP without obvious pathology were more convinced that they had a serious disease than women with a supposed cause for their complaint. – Women with CPP (and other forms of chronic pain) were more often victim of sexual and physical violence. The above conclusions show that psychological aspects are playing an important role in CPP as in other pain disorders. 2.2. Laparoscopy In the approach of women with CPP, many diagnostics are often involved. Physical examination is not very specific. Lundberg concluded from a study of 95 patients with pelvic pain that there was a poor correlation between pelvic examination and the existence of pelvic disease [10]. Most of the time, ultrasound is included in the examination. Fibroids and ovarian cysts may be detected, although their relation with the complaint may be unclear and a surgical reflex inevitable. A pain calendar and diary are essential and give some ideas about the different aspects of the pain and the provoking factors and reactions on the prescribed treatment. Some blood tests may be necessary as is the Chlamydia DNA. Most controversial is the routine diagnostic laparoscopy. It is nearly always used in the assessment procedures of chronic CPP, the usefulness is disputable for the assessment of the somatic pathology, as the real cause of the CPP. However, there are some uncontrolled studies, which report pain reduction after a diagnostic laparoscopy, without other medical intervention than just blookingQ [11]. Attention should be paid, when analysing these data, to inclusion and diagnostic criteria for the study groups and to the laparoscopic techniques, especially where double of multiple puncture techniques are used to ensure adequate vision [12]. Reviewed 1194 charts of consecutive patients, who had a diagnostic laparoscopy for pelvic pain. He found that 63% of the patients that had a normal pelvic examination prior to the laparoscopy showed abnormal findings on the diagnostic
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laparoscopy, whereas 17.5% of the patients that had abnormal pelvic examination showed normal findings on laparoscopy. Levitan concluded that patients with pelvic pain that had pathologic underlying conditions experienced more severe pain compared to patients without a pathologic condition, thus suggesting a relationship between the presence of pathology and pain [13]. A study performed by Kretsch showed that 83% of the patients with pelvic pain showed some kind of pathology of which 38% of the patients showed adhesion formation. Kretsch followed very detailed inclusion criteria, which might explain the high percentage of pathology found. Although this study dealt with only 50 patients, it was a prospective study and even included a control group [14]. Stout reported that the localization of the pain was concomitant with the localization of the adhesions in 97% of the patients, although extent of adhesion formation or severity of the pain showed no relation [15]. One should compare the abovementioned percentages found in women with CPP with the percentage of pathology found in asymptomatic women. Kretsch, for example, found 29% pathology with a control group of asymptomatic women having a sterilization. Trimbos recorded laparoscopic findings in 200 asymptomatic women having a sterilization. In 26% of these women, abnormalities were found including 14 of pelvic adhesions [16]. Rapkin found a percentage of 39% adhesions with laparoscopy of which 12% showed CPP. In this study group, 26% of the adhesions were found with the patients that had pain. Howard summarizes all these cumulative data from the different studies and concludes that laparoscopy in patients with CPP reveals a detectable pathologic condition in 61% of the patients. 25% of these pathologic conditions are adhesions. In women without CPP, a pathologic condition was detectable in 28%, of which adhesions accounted for 17%. He concluded that women without CPP have a significant incidence of abnormal laparoscopic findings but that women with CPP have twice the incidence of laparoscopically detected pathology. In our view, it seems of greater importance to see what a routine laparoscopy can add to the information obtained by history, pelvic examination and ultrasound. Of course adhesions can be found more frequently in women with CPP realizing that this group had very often previous surgery. All other pathologic finding can be diagnosed otherwise. The babnormalQ findings at laparoscopy often induce further somatic fixation by surgery again suiting the whish of the patient and appealing to the surgical reflex of the gynaecologist. Our conclusion is that routine laparoscopy should not be performed with women with CPP and only on indication after informing the patient that there is reasonable doubt about the relation between the possible findings and her complaint. 2.3. Treatment The Cochrane Library [17] reported only 6 randomised controlled trials on the treatment of CPP of which 4 were of good methodological quality. The results of these four studies are: prostagen was associated with a reduction of pain during treatment [18]; a session of counselling supported by ultrasound scanning was associated with reduced pain and improvement in mood [19]; a multidisciplinary approach was beneficial for some outcome measures [20] and adhesiolysis was not associated with an improved outcome apart from where adhesions were severe [21]. Data regarding the long- term efficacy of treatment procedures for CPP are not available, but estimates of failure to bring about relief are high.
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Especially the adhesiolysis, which still very often performed by laparotomy or laparoscopy needs some further attention. Most studies dealing with adhesiolysis address infertility or adhesion reformation. Howard has made a review in which he summarizes the studies on adhesiolysis. Many authors conclude that there is an substantial positive benefit of adhesiolysis on pelvic pain. Percentages of improvement vary from 67% [22] – his follow-up period was only 4 months – 84% [23] – follow-up 1 to 5 years – to 89% [24]. When analysing these data, one should take into account that in many of the studies the evaluation of pain was not blinded, no control groups were included and follow-up times differed significantly. Steege also found a positive effect of adhesiolysis in a prospective study of 30 women. An improvement of 75% was found at 6 to 12 months after surgery in the women without a chronic pelvic pain syndrome. In women with a chronic pain syndrome, 40% improvement was achieved. Seven patients had initial relief but a return of pain within 3 to 5 months, thereby stressing the importance of longer follow-up intervals. Because we could not confirm the results of the literature in our clinic and were very dissatisfied with our results, we performed a randomised clinical trial in 48 women with stage II to IV pelvic adhesions. Surgical treatment (adhesiolysis) was compared to a nonsurgery group. Nine to 12 months after adhesiolysis, no significant differences were found between the two groups with regard to pelvic pain. A subgroup of women with severe, vascularized and dense adhesions involving the bowel (stage IV) had significantly less pain after adhesiolysis [25]. Laparoscopic adhesiolysis is sometimes thought to be superior to adhesiolysis by means of laparotomy. The Operative Laparoscopy Study Group, who found that adhesion reformation is a frequent occurrence after operative laparoscopy, could not confirm this theory [26]. Recently, the results of a multicentre trial in the Netherlands more or less confirmed the earlier results in a prospective randomised trial [27]. 3. Placebo effects Psychological effects have frequently been discussed in relation with CPP and laparoscopy in CPP. The reassurance derived from the results with laparoscopy might contribute to the beneficial effect so that prejudiced conclusions are drawn. Peters suggest postponement of the assessment of the results to more than 12 months at least after treatment due to the influence of the placebo effect, which seldom last longer [28]. Baker performed a study in 60 patients with CPP that had laparoscopy that excluded obvious pelvic pathology. At a 6 month follow-up period, 58% reported that they were pain free and 39% reported that their pain had diminished. Baker concluded that treatment of pelvic pain should concentrate on the small minority of patients whose symptoms remain 6 months after laparoscopy [29]. Recent research with the help of f (functional) MRI is giving scientific prove for the placebo phenomenon. The therapeutic effect of a medicine could be improved by the suggestion to the patient that it really works. On f MRI with those patients, who were reassures about the efficacy of the treatment, there was a marked decrease of activity in orbito-frontal cortex. (the are where the pain stimuli are perceived) [30].The conclusion of all bevidenceQ at this moment: there is no reason to treat
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women with CPP different from women with other chronic pain syndromes, unless the treatment is aimed at the underlying cause, such as hormonal treatment with endometriosis or complaints related to the menstrual cycle. Surgery is seldom indicated as is a routine laparoscopy with the understanding that: bCertain operations are effective depending upon an appropriate mental state of the patient and the surgeonQ [31]. 4. Integral approach of women with CPP A literature survey of so-named holistic approaches to CPP reveals a discrepancy between opinions and research data, the latter being largely absent. It is obvious, however, that such wholesome approaches to the problem involve far more than a multidisciplinary or psychosomatic approach. The most crucial ingredient appears to be that all potential mechanisms are given equal and simultaneous attention. Within that approach, there is a wide diversity of specific treatments. In an integrated approach, equal attention is devoted to somatic, psychological, dietary, environmental and physiotherapeutic factors in contrast with the standard approach in which a somatic cause had to be excluded first. In this group, laparoscopy is performed routinely. In a prospective randomised trial, both approaches were compared. The conclusion was: an integrated care is likely to be more effective than the standard approach. A possible explanation of this finding might be that the risk of somatic fixation is less with the integrated approach. Other factors that seem important are the diminished impairments from the pain and the adventitious distress. The attention to factors other than somatic is also more easily accepted by the patients than after an extensive and fruitless hunt for somatic abnormalities. Of course, organic abnormalities remain important and should not be overlooked, but if carefully taken history and an expert pelvic examination are negative, it is doubtful whether invasive measures such as laparoscopy have any additional information to offer [28]. Since the outcome of this trial in the department of Gynaecology a bChronic Pelvic Pain TeamQ is functioning, in which all the mentioned disciplines are represented. If no rational treatment can be suggested to the patient she is often offered bCognitive Behaviour TreatmentQ in groups. The cause of the pain is no longer the target of the efforts and interventions but the pain itself. A symptom–response model can be helpful in supporting the patients, according to following schema.
Physical symptom Interpretation Response Cognitiveemotional consequences
Behavioural consequences
Physical consequences
Social consequences
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5. Conclusions An integrated approach to patients with CPP seems most appropriate. When the complaints exists more than 6 months and the history, pelvic examination and ultrasound do not show any serious pathologic findings there is no reason that a serous disease stays un-recognized. A routine laparoscopy is not indicated; it may give rise to hope with the patient and a reflex to do surgical interventions with the laparoscopist. Adhesions are more often the result of previous surgery performed on indication CPP than the cause of the complaint. Adhesiolysis is seldom necessary and only when ileus problems are arising an exception can be made. An integrated approach in which all the factors that can be responsible for the CPP are involved has to be offered to the patient from the start, preferable already by the General Practitioner. It seems most likely that women with CPP have to be offered the same treatment as women with other chronic pain syndromes, with the difference that gender specific problems related to the genitals and procreation and sexuality are more prominent. References [1] R.C. Reiter, A profile of women with chronic pelvic pain, Clin. Obstet. Gynecol. 33 (1990) 130. [2] S.D. Matthias, et al., Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates, Obstet. Gynecol. l87 (1996) 321. [3] F.M. Howard, The role of laparoscopy in chronic pelvic pain: promise and pitfalls, Obstet. Gynecol. Surv. 48 (1993) 357. [4] Pearce, et al., Pelvic pain—a common gynaecological problem, J. Psychosom. Obstet. Gynecol. 1 (1982) 12. [5] IASP, Classification of chronic pain, Pain (Suppl. 3) (1986) 217. [6] J.D. Loesser, A definition of pain, Medicine 7 (1980) 3. [7] V.M. Grace, Mind/body dualism in medicine: the case of chronic pelvic pain without organic pathology, Int. J. Health Sci. 28 (1998) 127. [8] A.A.W. Peters, Chronisch buikpijn bij vrouwen, een integrale benadering – bChronic pelvic pain, an integral approachQ. Thesis Leiden (1990). [9] L.P.A. McGowan, et al., Chronic pelvic pain: a meta-analytic review, Psychol. Health 13 (1998) 1153. [10] W.I. Lundberg, et al., Laparoscopy in the evaluation of pelvic pain, Obstet. Gynecol. 42 (1973) 872. [11] F.M. Howard, The role of laparoscopy in chronic pelvic pain: promise and pitfalls, Obstet. Gynecol. Surv. 48 (1993) 357. [12] R.G. Cunanana, et al., Laparocopic findings in patients with pelvic pain, Am. J. Obstet. 146 (1983) 589. [13] Z. Levitan, et al., The value of laparoscopy in women with chronic pelvic pain and a normal pelvis, Int. J. Gynecol. Obstet. 23 (1985) 71. [14] A.J. Kretsch, et al., Laparoscopy in 100 women with chronic pelvic pain, Obstet. Gynecol. 164 (1991) 672. [15] A.L. Stout, et al., Relationship of laparoscopic findings to self-report of pelvic pain, Am. J. Obstet. Gynecol. 164 (1991) 73. [16] J.B. Trimbos, et al., Findings in 200 consecutive asymptomatic women, having a laparoscopic sterilization, Arch. Gynecol. Obstet. 247 (1990) 121. [17] R.W. Stones, J. Mountfield, Management of chronic pelvic pain in women (Cochrane Review), The Cochrane Library, Issue, vol. 2, Update Software, Oxford, 1998, Updated quarterly. [18] C.M. Farquhar, et al., Randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion, Br. J. Obstet. Gynaecol. 96 (1989) 1153. [19] A.F.F. Ghaly, The psychological and physical benefits of pelvic ultrasonography in patients with chronic pelvic pain and negative laparoscopy. A random allocation trial, J. Obstet. Gynaecol. 14 (1994) 269. [20] A.A.W. Peters, et al., A randomised clinical trial to compare two different approaches in women with chronic pelvic pain, Obstet. Gynecol. 77 (1991) 740.
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[21] A.A.W. Peters, et al., A randomised clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain, Br. J. Obstet. Gynaecol. 99 (1992) 59. [22] J.F. Daniell, Laparoscopic enterolysis for chronic abdominal pain, J. Gynecol. Surg. 6 (1989) 61. [23] C. Sutton, et al., Laser laparoscopic adhesiolysis, J. Gynecol. Surg. 6 (1990) 155. [24] D.P. Goldstein, et al., Laparoscopy in the diagnosis and management of pelvic pain in adolescents, J. Reprod. Med. 24 (1980) 251. [25] Peters, 1992. [26] Operative Laparoscopy Study Group, Postoperative adhesion development after operative lapaproscopy: evaluation at early second- look procedures, Fertil. Steril. 55 (1991) 700. [27] D.J. Swank, et al., Laparoscopic adhesiolysis in patients with chronic abdominal pain. A blinded randomised controlled multicentre trial, Lancet 361 (2003) 12 – 47. [28] Peters, 1991. [29] P.N. Baker, et al., The resolution of chronic pelvic pain after normal laparoscopic findings, Am. J. Obstet. Gynecol. (1992) 835. [30] T.D. Wager, et al., Placebo induced changes in MRI in the anticipation and experience of pain, Science 303 (2004) 1162. [31] L. Beecher, The Autobiography, The John Harvard Library, Cambridge, 1961.