Management of chronic primary pelvic pain syndromes

Management of chronic pelvic pain (CPP) remains a huge challenge for care providers and a major burden for healthcare systems. Treating chronic pain that has no obvious cause warrants an understanding of the difficulties in managing these conditions. Chronic pain has recently been accepted as a disease in its own right by the World Health Organization, with chronic pain without obvious cause being classified as chronic primary pain. Despite innumerable treatments that have been proposed and tried to date for CPP, unimodal therapeutic options are mostly unsuccessful, especially in unselected individuals. In contrast, individualised multimodal management of CPP seems the most promising approach and may lead to an acceptable situation for a large proportion of patients. In the present review, the interdisciplinary and interprofessional European Association of Urology Chronic Pelvic Pain Guideline Group gives a contemporary overview of the most important concepts to successfully diagnose and treat this challenging disease.     

Role of psychology in pain management

Br J Anaesth 2001; 87: 144–152     

精神心理学干预在慢性疼痛治疗中的应用研究进展

越来越多的研究关注精神心理学参与慢性疼痛的治疗,在临床中不断有报道提出慢性疼痛复合心理干预有效,并能综合的改善患者的生活质量.常见慢性疼痛的心理学干预包括心理药理学干预与心理行为学干预,均对慢性疼痛的改善有效.     

Similar prevalence but different characteristics of pain in kidney transplant recipients and chronic hemodialysis patients

Masajtis‐Zagajewska A, Pietrasik P, Krawczyk J, Krakowska M, Jarz?bski T, Pietrasiewicz B, Zbróg Z, Nowicki M. Similar prevalence but different characteristics of pain in kidney transplant recipients and chronic hemodialysis patients.
Clin Transplant 2011: 25: E144–E151. © 2010 John Wiley & Sons A/S. Abstract: Background: Chronic pain is frequent in both hemodialysis (HD) patients and kidney transplant (KTx) recipients but its detailed characteristics have never been thoroughly investigated. Aim: To compare prevalence of pain, its locations and characteristics, and analgesics use in chronic HD and KTx patients. Methods: A cross‐sectional comparative study in 164 HD patients and 114 stable deceased donor KTx recipients. All participants completed the modified McGill Pain Questionnaire. Results: Overall, 63% of HD patients and 62% of KTx patients reported pain. Fifty‐four percent of HD patients and 67% of KTx patients indicated more than one location of pain. Severe pain was more common in HD patients, and prevalence of pain‐associated symptoms from major body systems was higher in HD patients. Pain in both groups was mostly local, paroxysmal and/or chronic. Fifteen percent of HD patients and 37% of KTx patients with chronic pain were not receiving pain relief drugs. The general feeling of illness was lower in KTx than HD patients (4.54 ± 2.1 vs. 5.6 ± 0.7; p < 0.0001); however, in the former group, it was systematically increasing with the time after transplantation. Conclusions: A successful kidney transplantation does not lead to a significant reduction in the prevalence of pain when compared to chronic HD patients. Pain relief medications are underused in KTx patients.     

塞来昔布治疗ⅢA型前列腺炎的临床评估

目的 :评价环氧合酶 2抑制剂塞来昔布治疗炎症性 (ⅢA型 )慢性非细菌性前列腺炎 /慢性盆腔疼痛综合征(CP/CPPS)的有效性及安全性。　方法 :6 4例ⅢA型CP/CPPS患者随机均分为两组 :A组口服塞来昔布 2 0 0mg ,1次 /d ;B组口服塞来昔布 2 0 0mg,2次 /d。两组疗程均为 6周 ,其间每两周检测前列腺按摩液 (EPS)中白细胞计数及进行慢性前列腺炎症状评分 (CPSI) ,比较其变化趋势及治疗前后的差异。　结果 :A、B两组服药后EPS中白细胞计数及CPSI总评分逐渐下降 ,治疗 6周后A、B两组平均EPS白细胞计数与治疗前相比分别下降 4 6 .2 %和 6 9.4 % ,平均CPSI总评分分别下降 5 .6分和 8.3分。B组两项指标下降比率均大于A组 (P均 <0 .0 5 )。两组治疗期间均无严重不良事件发生。　结论 :塞来昔布治疗ⅢA型CP/CPPS有效、安全 ;2 0 0mg ,2次 /d为较优剂量。     

慢性胰腺炎疼痛的发生机制及处理对策

疼痛是慢性胰腺炎病人的主要症状之一,反复发作的顽固性疼痛使病人痛苦不堪,极大地降低了病人的生活质量。然而,人们对于慢性胰腺炎疼痛原因的研究甚少,治疗水平更是参差不齐。21世纪以来,随着分子生物学和胰腺外科的深入发展,慢性胰腺炎的多重疼痛机制逐渐被人们所认识。药物、内镜、手术等多元化治疗方案已成为临床医生处理慢性胰腺炎疼痛的重要手段。     

The future role of the anaesthesiologist in pain management

Background: Relieving pain during and after surgery and trauma has always been a basic duty of anaesthesiologists. With their skills and expertise in regional analgesia and pharmacological analgesia, anaesthesiologists have improved management of severe cancer pain. Will there be a place for anaesthesiologists in multidisciplinary pain clinics managing chronic non‐cancer pain patients in the future? Methods: This is a personal review of the development of pain management as a growing part of the responsibilities of anaesthesiologists during the past three decades and the importance of continued involvement of anaesthesiologists in this interesting and challenging aspect of clinical medicine. Results and conclusions: Optimal management of pain during and after surgery is a prerequisite for successful short‐ and long‐term rehabilitation after surgery. After surgery, reducing dynamic pain with prolonged optimal epidural analgesia and regional blocks facilitates mobilization and reduces chronic pain. The expertise of well‐trained anaesthesiologists in skilfully using regional analgesia and pharmacological pain relief continues to be in demand in palliative care. Some interventional techniques are useful in relieving chronic non‐cancer pain in selected patients. Well‐trained anaesthesiologist‐pain clinicians can perform interventional treatments safely. No doubt, anaesthesiologists will continue to have important roles in pain management in the future.     

Virtual reality for acute and chronic pain management in adult patients: a narrative review

Virtual reality is a computer-generated environment that immerses the user in an interactive artificial world. This ability to distract from reality has been utilised for the purposes of providing pain relief from noxious stimuli. As technology rapidly matures, there is potential for anaesthetists and pain physicians to incorporate virtual reality devices as non-pharmacological therapy in a multimodal pain management strategy. This systematic narrative review evaluates clinical studies that used virtual reality in adult patients for management of acute and chronic pain. A literature search found 690 citations, out of which 18 studies satisfied the inclusion criteria. Studies were assessed for quality using the Jadad and Nottingham-Ottawa Scales. Agreement on scores between independent assessors was 0.87 (95%CI 0.73–0.94). Studies investigated virtual reality use: intra-operatively; for labour analgesia; for wound dressing changes; and in multiple chronic pain conditions. Twelve studies showed reduced pain scores in acute or chronic pain with virtual reality therapy, five studies showed no superiority to control treatment arms and in one study, the virtual reality exposure group had a worsening of acute pain scores. Studies were heterogeneous in: methods; patient population; and type of virtual reality used. These limitations suggest the evidence-base in adult patients is currently immature and more rigorous studies are required to validate the use of virtual reality as a non-pharmacological adjunct in multimodal pain management.     

Causes,prevention, and surgical treatment of postherniorrhaphy neuropathic inguinodynia: Triple neurectomy with proximal end implantation

The recommended surgical treatment for chronic neuropathic pain after herniorrhaphy has been a two-stage operation including: (a) ilioinguinal and iliohypogastric neurectomies through an inguinal approach and (b) genital nerve neurectomy through a flank approach. Two hundred twenty-five patients underwent triple neurectomies with proximal end implantation to treat chronic postherniorrhaphy neuralgia. Four patients reported no improvement. Eighty percent of patients recovered completely, and 15% had transient insignificant pain with no functional impairment. These results are comparable to the results of the two-stage operation. Simultaneous neurectomy of the ilioinguinal, iliohypogastric, and genital nerves without mobilization of the spermatic cord is an effective one-stage procedure to treat postherniorrhaphy neuralgia. It can be performed under local anesthesia and avoids testicular complications. Proximal end implantation of the nerves prevents adherence of the cut ends to the aponeurotic structures of the groin, which can result in recurrence of the pain. A one-stage surgical procedure resecting all three nerves from an anterior approach avoids a second operation through the flank and successfully treats chronic neuralgia.This paper was presented at the meeting of the American Hernia Society in Orlando, Fla. USA, on February 2004     

Breakthrough pain in opioid-treated chronic non-malignant pain patients referred to a multidisciplinary pain centre: a preliminary study

BACKGROUND: Breakthrough pain (BTP) has not formerly been discussed as such in chronic non-malignant pain patients referred to pain centres and clinics. The purpose of the study was to investigate the prevalence, characteristics and mechanisms of BTP in opioid-treated chronic non-malignant pain patients referred to a pain centre and to assess the short-term effects of pain treatment. METHODS: Patients were assessed at referral (T(0)) and after a treatment period of 3 months (T(3)) using the visual analogue scale (VAS) of the brief pain inventory (BPI) within somatic nociceptive, neuropathic and/or visceral pain conditions, the mini mental state examination (MMSE) and the hospital anxiety and depression scale (HADS). The main treatment intervention from T(0) to T(3) was to convert short-acting oral opioids to long-acting oral opioids and to discontinue on demand and parenteral use of opioids. RESULTS: Thirty-three patients were assessed at T(0) and 27 at T(3). The prevalence of BTP declined significantly from T(0) (90%) to T(3) (70.4%). Worst, least, average and current pain intensities as well as duration of BTP were significantly reduced from T(0) to T(3.) The majority of BTPs were exacerbation of background pain assumed to be of the same pain mechanisms. High average pain intensity (BPI) was significantly associated with high scores for both anxiety and depression (HADS). CONCLUSION: BTP in chronic non-malignant pain patients seems to be surprisingly frequent and severe. Stabilizing the opioid regimen seems to reduce pain intensity in general as well as the intensity and duration of BTP. Average pain intensity was associated with anxiety and depression.     

Chronic pain management after surgery

Chronic post-surgical pain is a common problem affecting between 2% and 10% of adults after surgery and a significant health burden. The development of chronic post-surgical pain involves multiple mechanisms including peripheral and central sensitization and nerve injury, thought to be the most significant factor. There are many risk factors including preoperative pain, chemotherapy/radiotherapy, surgical, psychological and genetic factors. The prevention of chronic post-surgical pain is challenging but progress is being made in identifying at risk groups, improved surgical technique and preventative analgesia including regional analgesia. Accurate diagnosis is essential for proper management, including identification of neuropathic pain. Management involves identifying any surgically or medically treatable cause, followed by pharmacological, psychological, physical and interventional management. It is essential for all clinicians involved in the care of surgical patients to have an awareness of chronic post-surgical pain, its prevention, diagnosis and treatment.     

慢性前列腺炎/慢性骨盆疼痛综合征治疗新进展

慢性前列腺炎(CP)尤其是慢性前列腺炎/慢性骨盆疼痛综合征(CP/CPPS)(Ⅲ型)的发病机制至今尚不完全清楚,人群发病率可达2.5%~16.0%,为50岁以下男性最常见的泌尿外科疾病。20世纪90年代以来,在美国国立卫生研究院慢性前列腺炎协作研究网(NIH-CPCRN)、国际前列腺炎协作网(IPCN)等国际研究机构的协调下,各国研究者对CP的病因、诊断、治疗等诸方面进行了较以往更大规模的深入研究。CPPS是CP中最常见的也是疗效最差的一种类型,本文综述了近几年来CP/CPPS治疗新进展,探讨了其目前治疗所面临的主要问题及可能的原因,并对CP/CPPS治疗的前景予以展望。     

Factors Associated with the Development of Chronic Pain after Surgery for Breast Cancer: A Prospective Cohort from a Tertiary Center in the United States

Chronic pain has been shown to affect up to 60% of patients undergoing surgery for breast cancer. Besides younger age, other risk factors for the development of chronic pain have not been consistent in previous studies. The objective of the current investigation was to detect the prevalence and risk factors for the development of chronic pain after breast cancer surgery by examining a patient population from a tertiary cancer center in the United States. The study was a prospective observational cohort study. Subjects were evaluated at least 6 months after the surgical procedure. Subjects responded to the modified short form Brief pain inventory and the short form McGill pain questionnaire to identify and characterize pain. Demographic, surgery, cancer treatment, and perioperative characteristics were recorded. Propensity matching regression analysis were used to examine risk factors associated with the development of chronic pain. 300 patients were included in the study. 110 reported the presence of chronic pain. Subjects with chronic pain reported median (interquartile range [IQR]) rating of worst pain in the last 24 hours of 4 (2–5) and a median (IQR) rating on average pain in the last 24 hours of 3 (1–4) on a 0–10 numeric rating scale. Independent risk factors associated with the development of chronic pain were age, OR (95% CI) of 0.95 (0.93–0.98) and axillary lymph node dissection, 7.7 (4.3–13.9) but not radiation therapy, 1.05(0.56–1.95). After propensity matching for confounding covariates, radiation was still not associated with the development of chronic pain. Chronic pain after mastectomy continues to have a high prevalence in breast cancer patients. Younger age and axillary lymph node dissection but not radiation therapy are risk factors for the development of chronic pain. Preventive strategies to minimize the development of chronic pain are highly desirable.     

Chronic pain after surgery

Br J Anaesth 2001; 87: 88–98     

Applications of Drug Anesthesia in Control Chronic Pain

Surgery is one of the major causes of chronic pain in patients that have undergone any kind of surgeries. These complain are not only associated with major surgeries; even common minor surgeries like hernia repair have a significant risk of chronic pain. The development of chronic postsurgical pain (CPSP) depends on the type of surgical technique used. Furthermore, changes in the central nervous system have been associated with the development of persistent and chronic pain after surgical trauma and nerve injury. Anesthesia agents that block the mechanisms stimulating the process of central sensitization may be efficient in reducing the incidence of CPSP and finally psychosocial factors have been reported to be an important factor in the progression of chronic pain and as such should be addressed as part of perioperative care. The purpose of this mini-review is to give a comprehensive summary of the application of anesthesia drugs to reduce or control chronic pain during or after surgery.     

An update on the management of chronic pelvic pain in women

Chronic pelvic pain represents a major public health problem for women and impacts significantly on their quality of life. Yet it is under-researched and a challenge to manage. Women who suffer from chronic pelvic pain frequently describe their healthcare journey as long, via a variety of specialists and frustrating, with their pain often dismissed. Aetiological factors and associations are best conceptualised using the ‘three P’s’ model of predisposing, precipitating and perpetuating factors. This integrates the numerous biological, psychological and social contributors to the complex, multifactorial nature of chronic pelvic pain. Overall management involves analgesia, hormonal therapies, physiotherapy, psychological approaches and lifestyle advice, which like other chronic pain conditions relies on a multidisciplinary team approach delivered by professionals experienced and trained in managing chronic pelvic pain.     

Predictors of quality of life and pain in chronic prostatitis/chronic pelvic pain syndrome: findings from the National Institutes of Health Chronic Prostatitis Cohort Study

OBJECTIVES: To examine the cross-sectional relationship of age, urinary and depressive symptoms and partner status on pain intensity and quality of life (QoL) in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). PATIENTS AND METHODS: In all, 463 men enrolled in the National Institutes of Health (NIH) Chronic Prostatitis Cohort Study from seven clinical centres (six in the USA and one in Canada) reported baseline screening symptoms using the NIH Chronic Prostatitis Symptom Index (CPSI). The CPSI provides scores for pain, urinary symptoms and QoL. In addition, a demographic profile, including age and partner (living with another) status, and a depressive symptom score were obtained. Regression modelling of QoL, adjusting for between-centre variability, examined the unique effects of age, partner status, urological symptoms, depressive symptoms and pain. RESULTS: Urinary scores, depressive symptoms and pain intensity scores significantly predicted QoL for patients with CP/CPPS (higher CPSI QoL scores indicated more impairment; median 8.0, range 0-12). On average, for every 1-point increase in urinary scores, there was a corresponding increase in QoL score of 0.118 points (P = 0.001); for every 1-point increase in pain intensity score, there was a corresponding increase in QoL score of 0.722 points (P < 0.001); and for every 1-point decrease in depressive symptoms (lower scores equal poorer mood), the QoL score increased (poorer quality of life) by 0.381 points (P < 0.001). Age and partner status did not significantly contribute to poorer QoL. Urinary scores and depressive symptoms were significant predictors (P < 0.001) of pain in patients with CP/CPPS. CONCLUSIONS: These data show that depressive symptoms and pain intensity significantly predict a poorer QoL in patients with CP/CPPS, and that these effects are independent of partner status, age and urinary status. In particular, pain intensity was the most robust predictor of a poorer QoL. Further data relating pain and psychological factors to CP/CPPS are highly recommended, to aid in determining specific factors for pain and its impact on QoL. These data are essential if empirically guided efforts to manage pain are to progress.