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Resolution of chronic pelvic pain after laparoscopic lysis of adhesions
Resolution of chronic pelvic pain after laparoscopic lysis of adhesions John F. Steege, MD, and Anna L. Stout, PhD Durham, North Carolina Thirty women undergoing laparoscopic lysis of adhesions for the treatment of chronic pelvic pain were prospectively evaluated for the presence of a chronic pain syndrome. At follow-up, of those with chronic pain syndrome (10), four (40%) reported continued improvement or resolution of pain during daily activities or dyspareunia, whereas of those without chronic pain syndrome (20), 15 (75%) were better (p = 0.06). When these two complaints are evaluated individually, both pain during daily activities (p < 0.05) and dyspareunia (p < 0.05) are more likely to improve after lysis of adhesions in women without chronic pain syndrome. Prognosis was not related to the number of previous operations, adhesion score, or other physical parameters. Laparoscopic lysis of adhesions is generally worthwhile in the treatment of chronic pelvic pain, although the presence of psychosocial compromise warrants preoperative evaluation and concomitant treatment. (AM J OSSTET GVNECOL 1991 ;165:278-83.)
Key words: Chronic pelvic pain, adhesions, operative laparoscopy Of all operative laparoscopy procedures performed in the United States, about 40% are done for the evaluation and treatment of pelvic pain. I In approximately 30% to 50% of chronic pain cases, pelvic adhesions are found;·' although their relationship to pain is uncertain}· 6 We recently reported that the location of pain correlates well with the location of the pathologic condition (usually adhesions or endometriosis),7 although the available clinical studies do not demonstrate a quantitative relationship between adhesions and chronic pelvic pain.7. s Studies of other chronic pain problems such as low back pain have similarly failed in the attempt to quantitatively associate pain with a pathologic condition. 9 Together with other observations,lo these studies point out the inadequacies of the Cartesian theory of pain perception, which hypothesizes unique pain fibers and holds that pain is proportional to tissue damage. Newer theories of pain perception such as the gate control theory and cognitive models include the influences of culture, psychologic conditioning, cognitions, affect, and stress." Considering these complexities, it should perhaps not be surprising that attempts to find enough pathologic conditions to explain chronic clinical pain have routinely been frustrating. Clearly, some patients get negative or nociceptive input of substantial degree From the Department of Obstetrics and Gynecology and the Medical Psychology Division, Department of Psychiatry, Duke University Medical Center. Presented as Official Guest at the Fifty-third Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, January 27-30, 1991. R eprint requests: John F. Steege, MD, Box 3263, Duke University Medical Center, Durham, NC 27710. 6/6/30392
278
from their illnesses but never develop the affective, behavioral, and cognitive hallmarks of what we have called a chronic pain syndrome. 12 When these behavioral and psychologic changes do occur, to what degree is it useful to treat conditions, such as pelvic adhesions, that rarely affect general physical health? This study of laparoscopic lysis of adhesions assesses outcome in terms of relief of daily pain and dyspareunia and examines the relationship between pain relief and the preoperative diagnosis of a chronic pain syndrome. Methods Thirty-four women aged 18 to 70 years (mean, 34.9 ± 9.9 years) were evaluated in a teritiary care medical center for chronic, constant pelvic pain of ?6 months' duration. Consecutive patients who ultimately proved to have pelvic adhesions at laparoscopy were included in the present study. All women submitted documentation of previous medical care, including surgical procedures, and completed detailed clinical interviews and physical examinations. Of the 30 women reached for follow-up evaluation, one had previously had unilateral salpingo-oophorectomy, whereas 19 had undergone hysterectomy, 10 with bilateral and five with unilateral salpingo-oophorectomy. At their first visit patients rated dysmenorrhea, dyspareunia, and pain during daily activities on a numerical scale of 0 to 10, with the anchors of 0 being "no pain" and 1 being the "worst pain I can imagine." The following parameters of the pain were then scored by the clinician as present or absent: (1) pain duration of ~6 months, (2) incomplete relief by previous treatments (e.g., analgesics, prior operations), (3) impaired
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Table I. Adhesion scores and pain ratings in patients with and without chronic pain syndrome
No. Adhesion score Pain during daily activities Preoperative rating Postoperative rating Postoperative courset Improved Unchanged Improved, then pain returned Dyspareunia Preoperative rating Postoperative rating Postoperative courset Improved Cured Unchanged Worse Daily pain and lor d yspareunia:!: Improved Not improved
*p <
With chronic pain syndrome
Without chronic pain syndrome
10 6.3 ± 4.2
20 7.5 ± 3.3
Total
30 7.0 ± 3.57
8.56 ± 1.42 (n = 9) 6.56 ± 2.79*
7.63 ± 1.83 (n = 16) 2.44 ± 2.97*
7.96 ± 1.96 (N = 25) 3.92 ± 3.56
3/ 9 (33 %) 3/ 9 (33 %) 3/9 (33 %)
11 / 16 (69 %) 1/ 16 (6%)
14 / 25 (56%) 3/25 (12%) 8/25 (32%)
7.67 ± 1.97 (n = 6) 6.4 ± 2.70*
8.5 ± 1.6 (n = 14) 2.5 ± 2.53*
4fl6 (25%)
5114 (36%) 7114 (50%)
2/6 (33%)
0
3/ 6 (50 %) 1/ 6 (17 %)
2 / 14 (14%)
4 6
15 5
8.25 ± 1.71 (N = 20) 3.52 ± 3.06 7 / 20 7 / 20 5 / 20 1/ 20
(35%) (35%) (25 %) (5 %)
19 11
0.05.
tp < 0.05, combining all nonimproved categories. :!:p = 0.06.
physical function (work, recreation, etc.), (4) at least one vegetative sign of depression (sleep disturbance aside from being awakened by pain, loss of appetite, or psychomotor retardation), and (5) altered family roles. The last category included child care and household responsibilities, financial decision making, and emotional involvement with and support of other family members. Women were designated as having a chronic pain syndrome if four or more of these characteristics were present. All the women underwent operative video laparoscopy while they were under general anesthesia, using a carbon dioxide laser, scissors, hydrodissection, and blunt dissection to lyse adhesions. At the termination of each procedure, Interceed (Johnson & Johnson, Newark, N.J.) adhesion barrier was placed over areas of dissection along the pelvic sidewalls and moistened with 4 to 6 ml of heparin, 1000 U / ml. Patients returned for follow-up examinations at 1 month and again at intervals ranging from 6 to 12 months (mean, 8.2). At follow-up all patients either scored pain during a structured clinical interview or completed a questionnaire including the same rating scale items. Before tabulation of the clinical data on pain severity and chronic pain syndrome classification, all videotapes of the laparoscopic procedures were reviewed and adhesions were scored in the following areas: (1) right ovary, (2) right tube, (3) left ovary, (4) left tube, (5) omentum, (6) large bowel, (7) small bowel, (8) pelvic sidewalls, and (9) cul-de-sac. The severity of adhesions was rated as follows: 0, none ; 1, filmy; 2, dense or
vascular; and 3, dense and vascular. Dense was defined as opaque, and vascular as bleeding on laser dissection or, in the judgment of the operator, necessitating electrocoagulation before severing with scissors or laser. A total adhesion score was then calculated by summing scores across all nine areas evaluated. Adhesion location was compared with pain location, with reported pain characterized as right, left, central, or any combination of these areas. Patients were then categorized by the presence or absence of chronic pain syndrome, and the resulting two groups were compared across demographic variables, adhesion scores, and clinical outcome at 6 to 12 months (mean, 8 .2) after surgery. Categoric variables were compared with the X2 test or Fisher's exact statistic and continuous variables with the Student t test and Pearson's r; p < 0.05 was used as the level of significance. Results
Ten patients had a chronic pain syndrome and 20 patients did not. By virtue of the inclusion criteria for the study, all patients fulfilled the first two criteria for a chronic pain syndrome (duration of ~6 months, incomplete relief by previous treatments). In addition, 19 had impaired physical function, nine had at least one vegetative sign of depression , and seven acknowledged significant changes in their roles within the family. Of the 30 patients completing evaluation, 25 had had laparotomy (mean ± SD, 1.55 ± 1.27; range, 1 to 4),
280
Steege and Stout
August 1991
Am
10 9 8 en 7 c ~ 6
a: 5 c
.
4
3 2 1 0
0
2
3
4
5
7
6
8
9
10
11
Time Since Surgery, Months
Fig. 1. Time of return of pain during daily activities after
laparoscopic lysis of adhesions (n
=
8).
and 10 had had laparoscopy (mean :J:: SD,0.52 :J:: 0.83; range, 1 to 3). Patients with chronic pain syndrome more often had prior operations (laparotomy, 1.9 vs 1.36; laparoscopy, 0.8 vs 0.36) and hysterectomy (80% vs 55%), but neither of these differences reached statistical significance in this sample. Patients with and without chronic pain syndrome had similar preoperative ratings of dyspareunia and pain during daily activities, as well as similar adhesion scores (Table I). Because of the paucity of women with chronic pain syndrome and intact uteri (n = 2), the effects of laparoscopic lysis of adhesions on dysmenorrhea could not be compared between the two groups. Pain location overlapped with the location of adhesions in 90% of patients; both were scored by dividing the pelvis in thirds (right, left, and middle). Preoperative ratings of dyspareunia and pain during daily activities did not correlate with adhesion scores in the study as a whole or in the patients with or without chronic pain syndrome. SmaIl- or large-bowel adhesions were equally prevalent in the group with (80%) and without (70%) chronic pain syndrome. Five patients had dyspareunia only, whereas 25 had pain during daily activities; 15 of these also had dyspareunia (Table I). Of the 25 patients with chronic pain during daily activities, 14 (56%) had either complete resolution of pain (n = 9, 36%) or at least 50% reduction of pain (n = 5, 20%) at follow-up. Seven (28%) had initial improvement, with pain returning to >50% of preoperative levels within 2 to 5 months of the operation (Fig. I), and four (16%) had no improvement (Table I). The return of pain after transient relief was associated with bowel adhesions at the trend level (P = 0.19). Fourteen of 20 patients (70.0%) with deep dyspareunia had either complete resolution (n = 7, 50.0%) or improved >50% (n = 7, 50.0%) after operative laparoscopy (Table I). In some cases resolution of dyspareunia was apparently hindered by concomitant vaginal factors of tightness and deficient lubrica-
J Obstet Gynecol
tion. In women with both dyspareunia and pain during daily activities, the postoperative courses of both symptoms were similar, i.e., either both improved or both persistent in all cases. Patients without chronic pain syndrome were significantly more likely to have prolonged relief of pain during daily activities (p < 0.05) and relief of dyspareunia (p < 0.05) (Table I). When results with daily pain and dyspareunia are combined, these patients were more likely (at the strong trend level, p = 0.06) than women with chronic pain syndrome to obtain good results. Relief of dyspareunia and pain during daily activities was not related to adhesion score in the whole group or in the subgroups with or without chronic pain syndrome. Comment
Models of pain perception have grown more complicated with time, in part as a response to the need for a better model to explain the complexities of chronic pain syndromes. The ancient Cartesian theory, which postulated the existence of neurons having the single function of carrying pain signals to the brain, has given way to the gate control theory" and to cognitive-behavioral models.'" These models integrate the influences of personality, affect, organic changes, sensory thresholds, and cognitions about pain and its causes in a manner that avoids clear demarcation between psychologic and physical causes for pain but rather recognizes their intricate and interdependent relationships. This study suggests that lysis of pelvic adhesions may indeed be a useful procedure in many circumstances. Pain associated with adhesions is less often relieved when accompanied by a chronic pain syndrome, i.e., diminished physical activity, vegetative signs of depression (usually sleep disturbance), and substantial alteration of the patient's role in the family. The results are most consistent with a model of pain perception that integrates physical and psychologic factors. Our study replicates our previous finding 7 that the anatomic site of the pathologic condition often matches well with the reported location of pain but that the intensity of pain does not correlate with the amount of disease present. Similar findings have been noted in the case of endometriosis.' 1 In short-term follow-up the majority (88% in this study) will report relief of pain. About one fourth will note return of pain within 3 to 5 months, emphasizing the need for long-term monitoring. Women in this study with chronic pain syndrome, more often than those without, tended (at trend level) to have pain return after transient relief. The clinical dilemma after pain returns becomes whether to pursue further lysis of adhesions or to follow other therapeutic avenues. These results support the approach that any evidence
Laparoscopic adhesion lysis for pain
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for elements of a chronic pain syndrome should prompt application of nonsurgical therapies, regardless of whether further lysis of adhesions is performed. Several investigators have pointed out that pelvic abnormalities in general 5 • 15 and adhesions in particular" may be no more prevalent in women with pain than in those who are pain free. The degree and location of adhesions in these comparative studies are not specified. The comparison populations in this latter studt were possibly self-selected as pain free, i.e., sufficiently comfortable to allow pursuit of infertility treatment, and hence were not a valid comparison sample. These studies imply that, like endometriosis, pelvic adhesions apparently do not always cause pain but are a source of nociceptive signals in many cases. This study suggests that adhesions involving large or small bowel may play a more significant role in pelvic pain than adhesions in other areas, especially in terms of the chance of recurrence of pain after laparoscopic lysis of adhesions. Many studies have evaluated the impact of lysis of adhesions on fertility, but only a few l 6-18 have examined the role of this procedure for pain relief. In primary care settings, the proportion of patients helped by lysis of adhesions may be as high as 84%,17 and, even in the case of severe adhesions with many preceding operations, the majority may be helped. 16 The precise role of psychosocial factors in chronic pelvic pain is uncertain. In the apparent effort to avoid confounding variables, many studies examining the psychologic profile of the pelvic pain patient have focused on "laparoscopy negative" women or compared the psychologic profiles of women with and without organic findings. Such studies have emphasized the role of psychosocial factors such as a distressed or multiproblem family of origin, sexual abuse, marital discord, and psychiatric diagnoses such as depression, anxiety, and personality disorders. 15, 19 These factors no doubt play substantial roles in many patients. We postulate that a person with such difficulties may be ill equipped to cope with the uncomfortable somatic sensations accompanying any disease process and perhaps especially vulnerable to impairment when the disease involves a body area (the reproductive or sexual system) that may have been the target of abuse. However, the observation that these factors may complicate the presentation of symptoms in the presence of organic disease does not demand the conclusion that the organic disease is of no significance. These data support the notion that lysis of adhesions is useful but should be accompanied by additional psychologic evaluation and treatment in these women displaying vegetative signs of depression or significant alteration of family roles. Further clinical studies are needed to clarify subtypes of patients with chronic pelvic pain, to understand the role for lysis of adhesions in women with significant psychosocial risk
281
factors, and to better understand the types of nonsurgical therapies most likely to be effective. REFERENCES 1. Peterson HB, Hulka JF, PhillipsJM. American Association of Gynecologic Laparoscopists' 1988 membership survey on operative laparoscopy. J Reprod Med 1990;35:587-9. 2. Kresch AJ, Seifer DB, Sachs LB, et al. Laparoscopy in the evaluation of pelvic pain. Obstet Gynecol 1973;64:672-4. 3. Lundberg WI, Wall JE, Matthews ]E. Laparoscopy in the evaluation of pelvic pain. Obstet Gynecol 1973;42:872-6. 4. Cunanan RF, Courey NG, Lippes J. Laparoscopic findings in patients with pelvic pain. AM] OBSTET GYNECOL 1983;46:589-91. 5. Stovall TG, Elder RF, Ling FW. Predictors of pelvic adhesions. J Reprod Med 19S9;34:345-S. 6. Rapkin AJ. Adhesions and pelvic pain: a retrospective study. Obstet GynecoI19S6;6S:13-5. 7. Stout AL, Steege,JF. Relationship oflaparoscopic findings to self-report of pelvic pain. AMJ OBSTET GYNECOL 1991; 164:73-9. S. Diamond MP, Daniell JF, Johns DA, et al. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Ferti! Steril 1991; 55:700-4. 9. Sternbach RA, ed: The psychology of pain. 2nd ed. New York: Raven Press, 19S5:1-24. 10. Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: CV Mosby, 1976. 11. Melzack R. Neurophysiological foundations of pain. In: Sternbach RA, ed. The psychology of pain, 2nd ed. New York: Raven Press, 19S6: 1-24. 12. Steege]F. Chronic pelvic pain. Washington DC: American College of Obstetricians and Gynecologists. June 19S9; technical bulletin no 129. 13. Rudy TE, Kerns RD, Turk DC. Chronic pain and depression: toward a cognitive-behavioral mediation model. Pain 19S8;35:129-40. 14. Fidele L, Arcaini L, Parazzini F, Candiani GB, Bianchi S. Stage and localization of pelvic endometriosis and pain. Fertil Steril 1990;53: 155-S. 15. Walker E, Katon W, Harrop-Griffiths], Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am] Psychiatry 1985;145:75-80. 16. Daniell JF. Laparoscopic enterolysis for chronic abdominal pain.] Gynecol Surg 19S9;5:61-6. 17. Sutton C, MacDonald R. Laser laparoscopic adhesiolysis. ] Gynecol Surg 1990;6:155-9. IS. Chan CLK, Wood C. Pelvic adhesiolysis-the assessment of symptom relief by 100 patients. Aust NZ Obstet Gynaecol 1985;25:295-8. 19. Gross R], Doerr H, Caldirola D, Guzinski GM, Ripley HS. Borderline syndrome and incest in chronic pelvic pain patients. Int] Psychiatry Med 1980-1981; 10:79-96.
Editors' note: This manuscript was revised after these discussions were presented.
Discussion DR. ROBERT B. ALBEE, JR.,
Atlanta, Georgia (Official Guest). Pelvic pain that has no explanation is one of the most frustrating problems that the gynecologist faces. However, even more exasperating is the failure of pelvic pain to respond to the appropriate and thorough treatment of pelvic pathologic conditions. Drs. Steege and Stout have presented a prospective comparison of consecutive patients undergoing lapa-
282 Steege and Stout
roscopy for pelvic adhesions. Three preoperatively evaluated parameters are then used to isolate a subgroup of patients whose successful resolution of pain is different and less than the remainder. In the study group all patients had pain for ;:::6 months and none had complete relief of pain from previous medical or surgical treatment. The preoperatively evaluated parameters were as follows: (1) the presence of impaired physical function (work, recreation, etc.), (2) the presence of vegetative signs of depression (sleep disturbance aside from being awakened by pain, loss of appetite, psychomotor retardation), and (3) the presence of alteration of family roles. The findings suggest that in patients with prolonged pain and previous treatment failure, there may still be good reason to try to eradicate residual adhesions; however, if two of the three above-listed conditions are present (i.e., chronic pain syndrome), the chances of long-term relief from pain are less than if those conditions are not present. This information is going to come as no surprise to clinicians, yet there is almost nothing in the literature that prospectively evaluates these specific variables. The authors concluded that psychologic treatment should be used in addition to the surgical lysis of adhesions if patients have diminished physical activity and vegetative signs of depression or significantly altered family roles. I believe it also would be appropriate to counsel these individuals before operation regarding their reduced relative success compared with the group without chronic pain syndrome. This would give each individual the opportunity to reconsider any other factors that may be related to their pain. It also more appropriately defines the chances of long-term success. Drs. Steege and Stout do not specify the types of psychologic treatment being used or recommended in these patients. Typically behavioral modification, counseling, group therapy, and drug therapy (such as anxiolytics and antidepressants) all have been used. In virtually all of these treatment avenues, definitive treatment depends on the individual's ability to acknowledge and assess all factors contributing to the pain. Thus, as the authors have recommended, we must not pass up this opportunity to encourage each patient to seek further evaluation and treatment of the other factors involved. I would like to ask the authors if it is safe to assume that they have excluded from this study group all patients who were found to have any concomitant pelvic disease in addition to adhesions? I think it is important to point out that the validity of their conclusioins would certainly be affected by the presence of endometriosis, myomas, ovarian cysts, etc., because the prevalence of other diseases was not indicated in the two study groups. If other diseases were excluded, I would like to ask to what extent an effort was made to rule out the presence of what is being referred to as microscopic endometriosis?l.2
August 1991 Am J Obstet Gynecol
REFERENCES 1. Redwine DB. Is "microscopic" peritoneal endometriosis visible? Ferti! Steril 1988;50:665-6. 2. Redwine DB. Peritoneal blood painting: an aid in the diagnosis of endometriosis. AM ] OBSTET GYNECOL 1989; 161 :865-6. DR. DOROTHY E. MITCHELL-LEEF, Atlanta, Georgia. You discussed the fact that you have encountered adhesions. What are you using for the prevention of further adhesions, and are you considering repeat laparoscopy in those patients who experience a return of pain? DR. J. GREG JOHNSON, Greenville, South Carolina. What is the role of uterosacral ablation in the control of pain in a patient with an intact uterus? DR. WALLACEC. NUNLEY,JR., Charlotte, North Carolina. In the six of 10 patients with chronic pelvic pain syndrome who did not respond over the long term, did you offer referrals or psychologic evaluation, and if so, would you share information as to their subsequent course? DR. JAROSLAV F. HULI{A, Chapel Hill, North Carolina. Dr. Steege is to be congratulated for pointing out the transient nature of some of the cures that we have relied on for the management of pain. His illustration showing a I-month cure and a six-month recurrence is important in our reevaluating the literature about the efficacy of pain medication and surgery. I want to ask a question about the efficacy of psychiatric therapy. Given that the patients do not respond to surgery, what is your experience about the efficacy of psychotherapy; in other words, how can we help these patients? DR. STEEGE (Closing). As I mentioned, we did use the Interceed adhesion barrier as a part of our standard procedure. I don't mean to say that I am convinced that it is the be-all and end-all of adhesion prevention. I think that it should be evaluated and used laparoscopically, as opposed to generalizing from its use during laparotomy, because laparotomy in itself predisposes to adhesion recurrence far more than does laparoscopy. In laparoscpic reports available so far, there is a reduction of adhesion formation by 50% to 60%, regardless of what kind of operative technique is used. Whether you use Hyskon or Interceed, the results are similar. The use of uterosacral ablation applies primarily to dysmenorrhea. I don't think its use applies to chronic pelvic pain. Nineteen of 30 patients in our series had hysterectomy. Of those who had pain, seldom was it totally central pain, and that is because these are patients with adhesions only. Although there were some with adhesions to the fundus of the uterus, most of them had adhesions involving the adnexa and bowel. Seventy-five percent of the total group had adhesions involving the large bowel, small bowel, or both. I believe that uterosacral ablation is useful only for central pelvic pain. The nerve supply of the adnexa and the pelvic sidewalls doesn't go through the uterosacral ligaments. The follow-up of nonresponders is difficult because they are relatively few and because they are a very
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heterogeneous group in terms of their social situations and their psychiatric histories. I should mention that one obvious thing missing in this article is any assessment of whether sexual abuse, during either childhood or adult life, had been a part of their history. I think that many of you are aware of recent studies showing that in women experiencing chronic pelvic pain, defined in a very similar way-2:6 months-about 60% had been sexually abused at some point in lIfe'. The question then becomes, "Is there a predisposing factor that makes a person vulnerable to whatever nociceptive signals come from whatever pelvic abnormality there is, or is there a current, important active ingredient that needs to be addressed?" I think that question is far from settled. Clinically, when I get that history, I have a hard time knowing quite what to do with it, on the basis of not knowing how it connects to the symptoms and having seen discouraging results in the psychotherapeutic treatment of those who have been victims of sexual abuse. Nonresponder follow-up is a far more difficult question to ariswer and involves much more complex levels of assessment. I think our results with those have been very mixed. We do use antidepressants, psychotherapy, inpatient psychiatric hospitalization, and a variety of different treatments. Again, it is very difficult to generate homogeneous groups to evaluate results. There are several articles in the literature that talk about psychotherapy or behavioral therapy for the
Laparoscopic adhesion lysis for pain
283
treatment of chronic pelvic pain. One was done at a military facility in which a chronic pain clinic was the ultimate referral for anyone with 'chronic pain. They demonstrated that the frequency of hysterectomy could be drastically reduced by such referral. The problem in applying this to general practice is that people in the military system are a captive audience. They do not have the option for private medical care, short of paying for it themselves and going outside the system to have a hysterectomy. I think that in many of our populations if we say, "You don't really need a hysterectomy," many will simply walk out and find someone else who will perform a hysterectomy. Therefore I am not sure the results of the military study apply. Individual psychotherapy, in the sense of a typical psychodynamically oriented approach, is less likely to be useful. What is more likely to be useful, generalizing from work with chronic pain in other areas such as back pain, headache pain, etc. , is a more behaviororiented program that takes a more rehabilitative approach, maximizing what positive elements in the person's life are left, approaching the roles within the family that may have changed, looking at the role of the husband and the children, etc., in the perpetuation of the ' chronic pain syndrome. Thus the burden of responsibility is basically taken away from the symptom bearer and the family system is examined. I think that is more likely than individual psychodynamically oriented psychotherapy to be effective.
Key words: Chronic pelvic pain, adhesions, operative laparoscopy Of all operative laparoscopy procedures performed in the United States, about 40% are done for the evaluation and treatment of pelvic pain. I In approximately 30% to 50% of chronic pain cases, pelvic adhesions are found;·' although their relationship to pain is uncertain}· 6 We recently reported that the location of pain correlates well with the location of the pathologic condition (usually adhesions or endometriosis),7 although the available clinical studies do not demonstrate a quantitative relationship between adhesions and chronic pelvic pain.7. s Studies of other chronic pain problems such as low back pain have similarly failed in the attempt to quantitatively associate pain with a pathologic condition. 9 Together with other observations,lo these studies point out the inadequacies of the Cartesian theory of pain perception, which hypothesizes unique pain fibers and holds that pain is proportional to tissue damage. Newer theories of pain perception such as the gate control theory and cognitive models include the influences of culture, psychologic conditioning, cognitions, affect, and stress." Considering these complexities, it should perhaps not be surprising that attempts to find enough pathologic conditions to explain chronic clinical pain have routinely been frustrating. Clearly, some patients get negative or nociceptive input of substantial degree From the Department of Obstetrics and Gynecology and the Medical Psychology Division, Department of Psychiatry, Duke University Medical Center. Presented as Official Guest at the Fifty-third Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, January 27-30, 1991. R eprint requests: John F. Steege, MD, Box 3263, Duke University Medical Center, Durham, NC 27710. 6/6/30392
278
from their illnesses but never develop the affective, behavioral, and cognitive hallmarks of what we have called a chronic pain syndrome. 12 When these behavioral and psychologic changes do occur, to what degree is it useful to treat conditions, such as pelvic adhesions, that rarely affect general physical health? This study of laparoscopic lysis of adhesions assesses outcome in terms of relief of daily pain and dyspareunia and examines the relationship between pain relief and the preoperative diagnosis of a chronic pain syndrome. Methods Thirty-four women aged 18 to 70 years (mean, 34.9 ± 9.9 years) were evaluated in a teritiary care medical center for chronic, constant pelvic pain of ?6 months' duration. Consecutive patients who ultimately proved to have pelvic adhesions at laparoscopy were included in the present study. All women submitted documentation of previous medical care, including surgical procedures, and completed detailed clinical interviews and physical examinations. Of the 30 women reached for follow-up evaluation, one had previously had unilateral salpingo-oophorectomy, whereas 19 had undergone hysterectomy, 10 with bilateral and five with unilateral salpingo-oophorectomy. At their first visit patients rated dysmenorrhea, dyspareunia, and pain during daily activities on a numerical scale of 0 to 10, with the anchors of 0 being "no pain" and 1 being the "worst pain I can imagine." The following parameters of the pain were then scored by the clinician as present or absent: (1) pain duration of ~6 months, (2) incomplete relief by previous treatments (e.g., analgesics, prior operations), (3) impaired
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Table I. Adhesion scores and pain ratings in patients with and without chronic pain syndrome
No. Adhesion score Pain during daily activities Preoperative rating Postoperative rating Postoperative courset Improved Unchanged Improved, then pain returned Dyspareunia Preoperative rating Postoperative rating Postoperative courset Improved Cured Unchanged Worse Daily pain and lor d yspareunia:!: Improved Not improved
*p <
With chronic pain syndrome
Without chronic pain syndrome
10 6.3 ± 4.2
20 7.5 ± 3.3
Total
30 7.0 ± 3.57
8.56 ± 1.42 (n = 9) 6.56 ± 2.79*
7.63 ± 1.83 (n = 16) 2.44 ± 2.97*
7.96 ± 1.96 (N = 25) 3.92 ± 3.56
3/ 9 (33 %) 3/ 9 (33 %) 3/9 (33 %)
11 / 16 (69 %) 1/ 16 (6%)
14 / 25 (56%) 3/25 (12%) 8/25 (32%)
7.67 ± 1.97 (n = 6) 6.4 ± 2.70*
8.5 ± 1.6 (n = 14) 2.5 ± 2.53*
4fl6 (25%)
5114 (36%) 7114 (50%)
2/6 (33%)
0
3/ 6 (50 %) 1/ 6 (17 %)
2 / 14 (14%)
4 6
15 5
8.25 ± 1.71 (N = 20) 3.52 ± 3.06 7 / 20 7 / 20 5 / 20 1/ 20
(35%) (35%) (25 %) (5 %)
19 11
0.05.
tp < 0.05, combining all nonimproved categories. :!:p = 0.06.
physical function (work, recreation, etc.), (4) at least one vegetative sign of depression (sleep disturbance aside from being awakened by pain, loss of appetite, or psychomotor retardation), and (5) altered family roles. The last category included child care and household responsibilities, financial decision making, and emotional involvement with and support of other family members. Women were designated as having a chronic pain syndrome if four or more of these characteristics were present. All the women underwent operative video laparoscopy while they were under general anesthesia, using a carbon dioxide laser, scissors, hydrodissection, and blunt dissection to lyse adhesions. At the termination of each procedure, Interceed (Johnson & Johnson, Newark, N.J.) adhesion barrier was placed over areas of dissection along the pelvic sidewalls and moistened with 4 to 6 ml of heparin, 1000 U / ml. Patients returned for follow-up examinations at 1 month and again at intervals ranging from 6 to 12 months (mean, 8.2). At follow-up all patients either scored pain during a structured clinical interview or completed a questionnaire including the same rating scale items. Before tabulation of the clinical data on pain severity and chronic pain syndrome classification, all videotapes of the laparoscopic procedures were reviewed and adhesions were scored in the following areas: (1) right ovary, (2) right tube, (3) left ovary, (4) left tube, (5) omentum, (6) large bowel, (7) small bowel, (8) pelvic sidewalls, and (9) cul-de-sac. The severity of adhesions was rated as follows: 0, none ; 1, filmy; 2, dense or
vascular; and 3, dense and vascular. Dense was defined as opaque, and vascular as bleeding on laser dissection or, in the judgment of the operator, necessitating electrocoagulation before severing with scissors or laser. A total adhesion score was then calculated by summing scores across all nine areas evaluated. Adhesion location was compared with pain location, with reported pain characterized as right, left, central, or any combination of these areas. Patients were then categorized by the presence or absence of chronic pain syndrome, and the resulting two groups were compared across demographic variables, adhesion scores, and clinical outcome at 6 to 12 months (mean, 8 .2) after surgery. Categoric variables were compared with the X2 test or Fisher's exact statistic and continuous variables with the Student t test and Pearson's r; p < 0.05 was used as the level of significance. Results
Ten patients had a chronic pain syndrome and 20 patients did not. By virtue of the inclusion criteria for the study, all patients fulfilled the first two criteria for a chronic pain syndrome (duration of ~6 months, incomplete relief by previous treatments). In addition, 19 had impaired physical function, nine had at least one vegetative sign of depression , and seven acknowledged significant changes in their roles within the family. Of the 30 patients completing evaluation, 25 had had laparotomy (mean ± SD, 1.55 ± 1.27; range, 1 to 4),
280
Steege and Stout
August 1991
Am
10 9 8 en 7 c ~ 6
a: 5 c
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4
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Time Since Surgery, Months
Fig. 1. Time of return of pain during daily activities after
laparoscopic lysis of adhesions (n
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8).
and 10 had had laparoscopy (mean :J:: SD,0.52 :J:: 0.83; range, 1 to 3). Patients with chronic pain syndrome more often had prior operations (laparotomy, 1.9 vs 1.36; laparoscopy, 0.8 vs 0.36) and hysterectomy (80% vs 55%), but neither of these differences reached statistical significance in this sample. Patients with and without chronic pain syndrome had similar preoperative ratings of dyspareunia and pain during daily activities, as well as similar adhesion scores (Table I). Because of the paucity of women with chronic pain syndrome and intact uteri (n = 2), the effects of laparoscopic lysis of adhesions on dysmenorrhea could not be compared between the two groups. Pain location overlapped with the location of adhesions in 90% of patients; both were scored by dividing the pelvis in thirds (right, left, and middle). Preoperative ratings of dyspareunia and pain during daily activities did not correlate with adhesion scores in the study as a whole or in the patients with or without chronic pain syndrome. SmaIl- or large-bowel adhesions were equally prevalent in the group with (80%) and without (70%) chronic pain syndrome. Five patients had dyspareunia only, whereas 25 had pain during daily activities; 15 of these also had dyspareunia (Table I). Of the 25 patients with chronic pain during daily activities, 14 (56%) had either complete resolution of pain (n = 9, 36%) or at least 50% reduction of pain (n = 5, 20%) at follow-up. Seven (28%) had initial improvement, with pain returning to >50% of preoperative levels within 2 to 5 months of the operation (Fig. I), and four (16%) had no improvement (Table I). The return of pain after transient relief was associated with bowel adhesions at the trend level (P = 0.19). Fourteen of 20 patients (70.0%) with deep dyspareunia had either complete resolution (n = 7, 50.0%) or improved >50% (n = 7, 50.0%) after operative laparoscopy (Table I). In some cases resolution of dyspareunia was apparently hindered by concomitant vaginal factors of tightness and deficient lubrica-
J Obstet Gynecol
tion. In women with both dyspareunia and pain during daily activities, the postoperative courses of both symptoms were similar, i.e., either both improved or both persistent in all cases. Patients without chronic pain syndrome were significantly more likely to have prolonged relief of pain during daily activities (p < 0.05) and relief of dyspareunia (p < 0.05) (Table I). When results with daily pain and dyspareunia are combined, these patients were more likely (at the strong trend level, p = 0.06) than women with chronic pain syndrome to obtain good results. Relief of dyspareunia and pain during daily activities was not related to adhesion score in the whole group or in the subgroups with or without chronic pain syndrome. Comment
Models of pain perception have grown more complicated with time, in part as a response to the need for a better model to explain the complexities of chronic pain syndromes. The ancient Cartesian theory, which postulated the existence of neurons having the single function of carrying pain signals to the brain, has given way to the gate control theory" and to cognitive-behavioral models.'" These models integrate the influences of personality, affect, organic changes, sensory thresholds, and cognitions about pain and its causes in a manner that avoids clear demarcation between psychologic and physical causes for pain but rather recognizes their intricate and interdependent relationships. This study suggests that lysis of pelvic adhesions may indeed be a useful procedure in many circumstances. Pain associated with adhesions is less often relieved when accompanied by a chronic pain syndrome, i.e., diminished physical activity, vegetative signs of depression (usually sleep disturbance), and substantial alteration of the patient's role in the family. The results are most consistent with a model of pain perception that integrates physical and psychologic factors. Our study replicates our previous finding 7 that the anatomic site of the pathologic condition often matches well with the reported location of pain but that the intensity of pain does not correlate with the amount of disease present. Similar findings have been noted in the case of endometriosis.' 1 In short-term follow-up the majority (88% in this study) will report relief of pain. About one fourth will note return of pain within 3 to 5 months, emphasizing the need for long-term monitoring. Women in this study with chronic pain syndrome, more often than those without, tended (at trend level) to have pain return after transient relief. The clinical dilemma after pain returns becomes whether to pursue further lysis of adhesions or to follow other therapeutic avenues. These results support the approach that any evidence
Laparoscopic adhesion lysis for pain
Volume 165 Number 2
for elements of a chronic pain syndrome should prompt application of nonsurgical therapies, regardless of whether further lysis of adhesions is performed. Several investigators have pointed out that pelvic abnormalities in general 5 • 15 and adhesions in particular" may be no more prevalent in women with pain than in those who are pain free. The degree and location of adhesions in these comparative studies are not specified. The comparison populations in this latter studt were possibly self-selected as pain free, i.e., sufficiently comfortable to allow pursuit of infertility treatment, and hence were not a valid comparison sample. These studies imply that, like endometriosis, pelvic adhesions apparently do not always cause pain but are a source of nociceptive signals in many cases. This study suggests that adhesions involving large or small bowel may play a more significant role in pelvic pain than adhesions in other areas, especially in terms of the chance of recurrence of pain after laparoscopic lysis of adhesions. Many studies have evaluated the impact of lysis of adhesions on fertility, but only a few l 6-18 have examined the role of this procedure for pain relief. In primary care settings, the proportion of patients helped by lysis of adhesions may be as high as 84%,17 and, even in the case of severe adhesions with many preceding operations, the majority may be helped. 16 The precise role of psychosocial factors in chronic pelvic pain is uncertain. In the apparent effort to avoid confounding variables, many studies examining the psychologic profile of the pelvic pain patient have focused on "laparoscopy negative" women or compared the psychologic profiles of women with and without organic findings. Such studies have emphasized the role of psychosocial factors such as a distressed or multiproblem family of origin, sexual abuse, marital discord, and psychiatric diagnoses such as depression, anxiety, and personality disorders. 15, 19 These factors no doubt play substantial roles in many patients. We postulate that a person with such difficulties may be ill equipped to cope with the uncomfortable somatic sensations accompanying any disease process and perhaps especially vulnerable to impairment when the disease involves a body area (the reproductive or sexual system) that may have been the target of abuse. However, the observation that these factors may complicate the presentation of symptoms in the presence of organic disease does not demand the conclusion that the organic disease is of no significance. These data support the notion that lysis of adhesions is useful but should be accompanied by additional psychologic evaluation and treatment in these women displaying vegetative signs of depression or significant alteration of family roles. Further clinical studies are needed to clarify subtypes of patients with chronic pelvic pain, to understand the role for lysis of adhesions in women with significant psychosocial risk
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factors, and to better understand the types of nonsurgical therapies most likely to be effective. REFERENCES 1. Peterson HB, Hulka JF, PhillipsJM. American Association of Gynecologic Laparoscopists' 1988 membership survey on operative laparoscopy. J Reprod Med 1990;35:587-9. 2. Kresch AJ, Seifer DB, Sachs LB, et al. Laparoscopy in the evaluation of pelvic pain. Obstet Gynecol 1973;64:672-4. 3. Lundberg WI, Wall JE, Matthews ]E. Laparoscopy in the evaluation of pelvic pain. Obstet Gynecol 1973;42:872-6. 4. Cunanan RF, Courey NG, Lippes J. Laparoscopic findings in patients with pelvic pain. AM] OBSTET GYNECOL 1983;46:589-91. 5. Stovall TG, Elder RF, Ling FW. Predictors of pelvic adhesions. J Reprod Med 19S9;34:345-S. 6. Rapkin AJ. Adhesions and pelvic pain: a retrospective study. Obstet GynecoI19S6;6S:13-5. 7. Stout AL, Steege,JF. Relationship oflaparoscopic findings to self-report of pelvic pain. AMJ OBSTET GYNECOL 1991; 164:73-9. S. Diamond MP, Daniell JF, Johns DA, et al. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Ferti! Steril 1991; 55:700-4. 9. Sternbach RA, ed: The psychology of pain. 2nd ed. New York: Raven Press, 19S5:1-24. 10. Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: CV Mosby, 1976. 11. Melzack R. Neurophysiological foundations of pain. In: Sternbach RA, ed. The psychology of pain, 2nd ed. New York: Raven Press, 19S6: 1-24. 12. Steege]F. Chronic pelvic pain. Washington DC: American College of Obstetricians and Gynecologists. June 19S9; technical bulletin no 129. 13. Rudy TE, Kerns RD, Turk DC. Chronic pain and depression: toward a cognitive-behavioral mediation model. Pain 19S8;35:129-40. 14. Fidele L, Arcaini L, Parazzini F, Candiani GB, Bianchi S. Stage and localization of pelvic endometriosis and pain. Fertil Steril 1990;53: 155-S. 15. Walker E, Katon W, Harrop-Griffiths], Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am] Psychiatry 1985;145:75-80. 16. Daniell JF. Laparoscopic enterolysis for chronic abdominal pain.] Gynecol Surg 19S9;5:61-6. 17. Sutton C, MacDonald R. Laser laparoscopic adhesiolysis. ] Gynecol Surg 1990;6:155-9. IS. Chan CLK, Wood C. Pelvic adhesiolysis-the assessment of symptom relief by 100 patients. Aust NZ Obstet Gynaecol 1985;25:295-8. 19. Gross R], Doerr H, Caldirola D, Guzinski GM, Ripley HS. Borderline syndrome and incest in chronic pelvic pain patients. Int] Psychiatry Med 1980-1981; 10:79-96.
Editors' note: This manuscript was revised after these discussions were presented.
Discussion DR. ROBERT B. ALBEE, JR.,
Atlanta, Georgia (Official Guest). Pelvic pain that has no explanation is one of the most frustrating problems that the gynecologist faces. However, even more exasperating is the failure of pelvic pain to respond to the appropriate and thorough treatment of pelvic pathologic conditions. Drs. Steege and Stout have presented a prospective comparison of consecutive patients undergoing lapa-
282 Steege and Stout
roscopy for pelvic adhesions. Three preoperatively evaluated parameters are then used to isolate a subgroup of patients whose successful resolution of pain is different and less than the remainder. In the study group all patients had pain for ;:::6 months and none had complete relief of pain from previous medical or surgical treatment. The preoperatively evaluated parameters were as follows: (1) the presence of impaired physical function (work, recreation, etc.), (2) the presence of vegetative signs of depression (sleep disturbance aside from being awakened by pain, loss of appetite, psychomotor retardation), and (3) the presence of alteration of family roles. The findings suggest that in patients with prolonged pain and previous treatment failure, there may still be good reason to try to eradicate residual adhesions; however, if two of the three above-listed conditions are present (i.e., chronic pain syndrome), the chances of long-term relief from pain are less than if those conditions are not present. This information is going to come as no surprise to clinicians, yet there is almost nothing in the literature that prospectively evaluates these specific variables. The authors concluded that psychologic treatment should be used in addition to the surgical lysis of adhesions if patients have diminished physical activity and vegetative signs of depression or significantly altered family roles. I believe it also would be appropriate to counsel these individuals before operation regarding their reduced relative success compared with the group without chronic pain syndrome. This would give each individual the opportunity to reconsider any other factors that may be related to their pain. It also more appropriately defines the chances of long-term success. Drs. Steege and Stout do not specify the types of psychologic treatment being used or recommended in these patients. Typically behavioral modification, counseling, group therapy, and drug therapy (such as anxiolytics and antidepressants) all have been used. In virtually all of these treatment avenues, definitive treatment depends on the individual's ability to acknowledge and assess all factors contributing to the pain. Thus, as the authors have recommended, we must not pass up this opportunity to encourage each patient to seek further evaluation and treatment of the other factors involved. I would like to ask the authors if it is safe to assume that they have excluded from this study group all patients who were found to have any concomitant pelvic disease in addition to adhesions? I think it is important to point out that the validity of their conclusioins would certainly be affected by the presence of endometriosis, myomas, ovarian cysts, etc., because the prevalence of other diseases was not indicated in the two study groups. If other diseases were excluded, I would like to ask to what extent an effort was made to rule out the presence of what is being referred to as microscopic endometriosis?l.2
August 1991 Am J Obstet Gynecol
REFERENCES 1. Redwine DB. Is "microscopic" peritoneal endometriosis visible? Ferti! Steril 1988;50:665-6. 2. Redwine DB. Peritoneal blood painting: an aid in the diagnosis of endometriosis. AM ] OBSTET GYNECOL 1989; 161 :865-6. DR. DOROTHY E. MITCHELL-LEEF, Atlanta, Georgia. You discussed the fact that you have encountered adhesions. What are you using for the prevention of further adhesions, and are you considering repeat laparoscopy in those patients who experience a return of pain? DR. J. GREG JOHNSON, Greenville, South Carolina. What is the role of uterosacral ablation in the control of pain in a patient with an intact uterus? DR. WALLACEC. NUNLEY,JR., Charlotte, North Carolina. In the six of 10 patients with chronic pelvic pain syndrome who did not respond over the long term, did you offer referrals or psychologic evaluation, and if so, would you share information as to their subsequent course? DR. JAROSLAV F. HULI{A, Chapel Hill, North Carolina. Dr. Steege is to be congratulated for pointing out the transient nature of some of the cures that we have relied on for the management of pain. His illustration showing a I-month cure and a six-month recurrence is important in our reevaluating the literature about the efficacy of pain medication and surgery. I want to ask a question about the efficacy of psychiatric therapy. Given that the patients do not respond to surgery, what is your experience about the efficacy of psychotherapy; in other words, how can we help these patients? DR. STEEGE (Closing). As I mentioned, we did use the Interceed adhesion barrier as a part of our standard procedure. I don't mean to say that I am convinced that it is the be-all and end-all of adhesion prevention. I think that it should be evaluated and used laparoscopically, as opposed to generalizing from its use during laparotomy, because laparotomy in itself predisposes to adhesion recurrence far more than does laparoscopy. In laparoscpic reports available so far, there is a reduction of adhesion formation by 50% to 60%, regardless of what kind of operative technique is used. Whether you use Hyskon or Interceed, the results are similar. The use of uterosacral ablation applies primarily to dysmenorrhea. I don't think its use applies to chronic pelvic pain. Nineteen of 30 patients in our series had hysterectomy. Of those who had pain, seldom was it totally central pain, and that is because these are patients with adhesions only. Although there were some with adhesions to the fundus of the uterus, most of them had adhesions involving the adnexa and bowel. Seventy-five percent of the total group had adhesions involving the large bowel, small bowel, or both. I believe that uterosacral ablation is useful only for central pelvic pain. The nerve supply of the adnexa and the pelvic sidewalls doesn't go through the uterosacral ligaments. The follow-up of nonresponders is difficult because they are relatively few and because they are a very
Volume 165 Number 2
heterogeneous group in terms of their social situations and their psychiatric histories. I should mention that one obvious thing missing in this article is any assessment of whether sexual abuse, during either childhood or adult life, had been a part of their history. I think that many of you are aware of recent studies showing that in women experiencing chronic pelvic pain, defined in a very similar way-2:6 months-about 60% had been sexually abused at some point in lIfe'. The question then becomes, "Is there a predisposing factor that makes a person vulnerable to whatever nociceptive signals come from whatever pelvic abnormality there is, or is there a current, important active ingredient that needs to be addressed?" I think that question is far from settled. Clinically, when I get that history, I have a hard time knowing quite what to do with it, on the basis of not knowing how it connects to the symptoms and having seen discouraging results in the psychotherapeutic treatment of those who have been victims of sexual abuse. Nonresponder follow-up is a far more difficult question to ariswer and involves much more complex levels of assessment. I think our results with those have been very mixed. We do use antidepressants, psychotherapy, inpatient psychiatric hospitalization, and a variety of different treatments. Again, it is very difficult to generate homogeneous groups to evaluate results. There are several articles in the literature that talk about psychotherapy or behavioral therapy for the
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treatment of chronic pelvic pain. One was done at a military facility in which a chronic pain clinic was the ultimate referral for anyone with 'chronic pain. They demonstrated that the frequency of hysterectomy could be drastically reduced by such referral. The problem in applying this to general practice is that people in the military system are a captive audience. They do not have the option for private medical care, short of paying for it themselves and going outside the system to have a hysterectomy. I think that in many of our populations if we say, "You don't really need a hysterectomy," many will simply walk out and find someone else who will perform a hysterectomy. Therefore I am not sure the results of the military study apply. Individual psychotherapy, in the sense of a typical psychodynamically oriented approach, is less likely to be useful. What is more likely to be useful, generalizing from work with chronic pain in other areas such as back pain, headache pain, etc. , is a more behaviororiented program that takes a more rehabilitative approach, maximizing what positive elements in the person's life are left, approaching the roles within the family that may have changed, looking at the role of the husband and the children, etc., in the perpetuation of the ' chronic pain syndrome. Thus the burden of responsibility is basically taken away from the symptom bearer and the family system is examined. I think that is more likely than individual psychodynamically oriented psychotherapy to be effective.