Medical and surgical management of chronic pelvic pain

Chronic pelvic pain is common and is estimated to affect over one million women in the UK. It may be a symptom of a number of different conditions and is often multifactorial in nature, caused by a combination of physical, psychological and social factors. For many women, a primary cause cannot be identified. This can make both diagnosis and management difficult. Gynaecological causes of chronic pelvic pain include endometriosis, chronic pelvic inflammatory disease and adhesions. The gynaecologist must also consider non-gynaecological causes of pain related to the gastrointestinal, urinary, neurological, musculoskeletal and psychological systems if satisfactory management of the woman's pain is to be achieved.This review addresses the approach to diagnosis and management of women presenting with chronic pelvic pain. It details specific disease management but also seeks to encourage a holistic approach to all women with chronic pelvic pain, whether or not a primary diagnosis is established.     

Medical and surgical management of chronic pelvic pain

Chronic pelvic pain is common and is estimated to affect over one million women in the UK. It may be a symptom of a number of different conditions and is often multifactorial in nature, caused by a combination of physical, psychological and social factors. For many women, a primary cause cannot be identified. This can make both diagnosis and management difficult. Gynaecological causes of chronic pelvic pain include endometriosis, chronic pelvic inflammatory disease and adhesions. The gynaecologist must also consider non-gynaecological causes of pain related to the gastrointestinal, urinary, neurological, musculoskeletal and psychological systems if satisfactory management of the woman's pain is to be achieved.This review addresses the approach to diagnosis and management of women presenting with chronic pelvic pain. It details specific disease management but also seeks to encourage a holistic approach to all women with chronic pelvic pain, whether or not a primary diagnosis is established.     

Cesarean section as a cause of chronic pelvic pain.

OBJECTIVE: To determine if the history of cesarean section was associated with chronic pelvic pain, independent of the presence of other conditions such as pelvic adhesions, endometriosis, sequelae of pelvic inflammatory disease, leiomyoma and pelvic varices. METHODS: Retrospective case-control study conducted on 199 patients consecutively admitted from January 1998 to January 2000, 116 of them submitted to laparoscopy for the diagnosis of chronic pelvic pain and 83 asymptomatic patients submitted to tubal ligation by laparoscopy. A logistic regression analysis was used to verify the association between chronic pelvic pain and the history of previous cesarean section. RESULTS: In women with chronic pelvic pain, a history of cesarean section was observed in 67.2% of cases, adhesions in 51.7%, endometriosis in 33.6%, sequelae of pelvic inflammatory disease in 31.9%, leiomyoma in 6.9% and pelvic varices in 11.2%. In asymptomatic women, a history of cesarean section was observed in 38.5%, adhesions in 24.1%, endometriosis in 9.6%, sequelae of pelvic inflammatory disease in 4.8%, leiomyoma in 7.2% and pelvic varices in 3.6%. In a logistic model, chronic pelvic pain was associated with a history of cesarean section (O.R.=3.7), as well as with endometriosis (O.R.=8.5), sequelae of pelvic inflammatory disease (O.R.=10.5). CONCLUSIONS: In the present study cesarean section was associated with chronic pelvic pain. This fact may be the cause of a public health problem in the coming years, due to the raised rates of cesarean section in Brazilian women.     

Menstrual symptoms in women with pelvic endometriosis

OBJECTIVE--To investigate menstrual symptoms in relation to pelvic pathology. DESIGN--A prospective questionnaire-based study. SETTING--Aberdeen Royal Infirmary, Scotland. SUBJECTS--1250 questionnaires were sent out prior to planned admission and 1200 women (96%) brought the completed questionnaires. They comprised 598 women undergoing laparoscopic sterilization, 312 having laparoscopy because of infertility, 156 having laparoscopy because of chronic pelvic pain and 134 women undergoing abdominal hysterectomy for dysfunctional uterine bleeding. MAIN OUTCOME MEASURES--The occurrence of dysmenorrhoea, menorrhagia, menstrual regularity, premenstrual spotting, deep dyspareunia and pelvic pain in women with either endometriosis and post infective pelvic adhesions or a normal pelvis. RESULTS--Menorrhagia, menstrual irregularity and premenstrual spotting occurred with equal frequency in all groups. Deep dyspareunia, pain after intercourse and recurrent pain unrelated to menstruation or coitus was more common in women with endometriosis and those with post infective pelvic adhesions than in those with a normal pelvis. Dysmenorrhoea appears to be more prevalent among women having endometriosis. CONCLUSIONS--Menstrual symptoms, while raising a high index of suspicion for endometriosis, are not entirely reliable as indicators of disease. Dysmenorrhoea is the most common reported symptom in endometriosis sufferers. Diagnostic laparoscopy should be considered before institution of treatment in women complaining of pelvic pain and menstrual symptoms.     

Future directions in endometriosis research

Future research in endometriosis must focus on pathogenesis studies in the baboon model, the early interactions between endometrial and peritoneal cells in the pelvic cavity at the time of menstruation, and potential differences between eutopic endometrium and myometrium in women with and without endometriosis. More integration is needed between the areas of epidemiology and genetics. Pelvic inflammation in women with endometriosis could be the target for new diagnostic and therapeutic approaches. Important questions remain regarding the relationship between endometriosis and environmental factors. Systemic and extrapelvic manifestations of endometriosis must be analyzed carefully, and better tools are needed to measure quality of life in women with chronic pain caused by endometriosis. Most current evidence supports a causal relationship between endometriosis and subfertility, and the spontaneous progressive nature of endometriosis has been demonstrated in 30% to 60% of patients. Recurrence of endometriosis after classic medical and surgical therapy is a major and underestimated problem, especially in women with advanced disease. Integrated clinical and research teams are needed that combine expert medical, surgical, and holistic care with state-of-the-art research expertise in immunology, endocrinology, and genetics to discover new diagnostic methods and medical treatments for endometriosis.     

A double-blind randomised controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain

OBJECTIVE: To determine the effectiveness of laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain in women with endometriosis and women with no laparoscopic evidence of endometriosis. DESIGN: A prospective double-blind randomised controlled trial (RCT). SETTING: Single-centre, secondary-level gynaecology outpatient service and tertiary-level pelvic pain and endometriosis outpatient service in Auckland, New Zealand. POPULATION: One hundred and twenty-three women undergoing laparoscopy for investigation and management of chronic pelvic pain, 56 with no laparoscopic evidence of endometriosis and 67 with endometriosis. METHODS: Women were randomised from the two populations, firstly those with no evidence of endometriosis and secondly those undergoing laparoscopic surgical treatment for endometriosis, to receive LUNA or no LUNA. Participant and assessor blinding was employed. Follow up for pain outcomes was undertaken at 24 hours, 3 months and 12 months. MAIN OUTCOME MEASURES: Changes in non-menstrual pelvic pain, dysmenorrhoea, deep dyspareunia and dyschezia were assessed primarily by whether there was a decrease in visual analogue score for these types of pain of 50% or more from baseline and additionally whether there was a significantly different change in median visual analogue score. The numbers requiring further surgery or starting a new medical treatment for pelvic pain and complications were also measured. RESULTS: There was a significant reduction in dysmenorrhoea at 12 month follow up in women with chronic pelvic pain in the absence of endometriosis who underwent LUNA (median change in visual analogue scale (VAS) from baseline -4.8 versus-0.8 (P= 0.039), 42.1%versus 14.3% experiencing a successful treatment defined as a 50% or greater reduction in visual analogue pain scale for dysmenorrhoea (P= 0.045). There was no significant difference in non-menstrual pelvic pain, deep dyspareunia or dyschezia in women with no endometriosis undergoing LUNA versus no LUNA. The addition of LUNA to laparoscopic surgical treatment of endometriosis was not associated with a significant difference in any pain outcomes. CONCLUSIONS: LUNA is effective for dysmenorrhoea in the absence of endometriosis, although there is no evidence of effectiveness of LUNA for non-dysmenorrhoeic chronic pelvic pain or for any type of chronic pelvic pain related to endometriosis.     

Is endometriosis really associated with pain?

To address the contrasting findings regarding how pain is related to endometriosis, the relationship between pain and stage of endometriosis was dissected differently by the chief complaint to eliminate selection biases. A total of 1,092 women with endometriosis were classified into two groups depending on their chief complaint, i.e., infertility (infertility group; n = 476) or pain (pain group; n = 616). The correlations between disease stage and various types of pain were analyzed differently in each group. The frequencies of chronic pelvic pain and dyspareunia increased with disease stage either in the infertility group, in the pain group or in the aggregate. On the other hand, no significant relation between the severity of dysmenorrhea and disease stage was observed in the aggregate. Interestingly, a parallel increase in the severity of dysmenorrhea with disease stage was observed in the infertility group, but not in the pain group. In view of selection biases involved in analyzing endometriosis associated with pain, these results could be seen to support the contention that chronic pelvic pain, dyspareunia and dysmenorrhea are in fact related to the extent of endometriosis.     

Chronic pelvic pain

Chronic pelvic pain is a common and significant disorder of women. It is estimated to have a prevalence of 3.8% in women. Often the etiology of chronic pelvic pain is not clear, as there are many disorders of the reproductive tract, gastrointestinal system, urological organs, musculoskeletal system, and psychoneurological system that may be associated with chronic pelvic pain. The history and physical examination are crucial in evaluating a woman with chronic pelvic pain and must address all of the possible systems potentially involved in chronic pelvic pain, not just the reproductive system. Laboratory and imaging studies should be selectively utilized, as should laparoscopy. Conscious laparoscopic pain mapping has been proposed as a way to improve information derived from laparoscopic evaluations. Treatment of chronic pelvic pain may consist of two approaches. One is to treat chronic pain itself as a diagnosis, and the other is to treat diseases or disorders that might be a cause of or a contributor to chronic pelvic pain. These two approaches are not mutually exclusive, and in many patients effective therapy is best achieved by using both approaches. Treatment of chronic pain as well as treatment of four of the more common disorders associated with chronic pelvic pain (endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis) are discussed in this review.     

Depression in women with endometriosis with and without chronic pelvic pain

AIM: The aim of the study is to compare the prevalence of depression in women surgically diagnosed with endometriosis according to the presence or absence of pelvic pain. METHODS: This cross-sectional prospective study evaluated 100 women receiving care at the Outpatients' Clinic for Endometriosis, Department of Obstetrics and Gynecology, Universidade Estadual de Campinas (UNICAMP), Campinas, S?o Paulo, Brazil, equally divided into two groups: one suffering from chronic pelvic pain and the other pain-free. The Beck Depression Inventory was used in order to measure depression. RESULTS: Depression was detected in 86 and 38% of the women with and without chronic pelvic pain, respectively. Complaints of depression, such as somatic concerns, work inhibition, dissatisfaction, and sadness, were observed at a significantly higher rate in the group with pain. A sensation of failure was the only variable observed more frequently in the pain-free group. CONCLUSIONS: Depression is highly prevalent in women with endometriosis, especially those with pelvic pain. Careful evaluation can identify women with depression who may benefit from treatment.     

Revisiting the association between endometriosis and bipolar disorder

ObjectiveWe sought to study the association between endometriosis and bipolar disorder.MethodsUsing the Structured Clinical Interview for DSM-IV Axis I Disorders, the prevalence of bipolar disorder was compared in 27 patients with endometriosis and 12 women with pelvic pain not related to endometriosis who were seen at a specialty gynaecology clinic for women with chronic pelvic pain.ResultsA significantly greater proportion of women in the endometriosis group were found to have bipolar disorder and a poorer quality of life than women with pelvic pain not related to endometriosis.ConclusionThere may be an association between endometriosis and bipolar disorder An optimal approach to managing endometriosis should include evaluation and treatment of psychiatric comorbidity, particularly bipolar disorder.     

CA-125 in menstrual discharge in patients with chronic pelvic pain.

CA-125 levels in menstrual discharge were determined in 55 patients with chronic pelvic pain to evaluate whether this test would be useful in differentiating between pelvic pain due to endometriosis and other causes. Of the 28 women with endometriosis, 25 (89%) had CA-125 concentration greater than or equal to 72,000 units/ml. The frequencies of elevated levels in Stage I, Stage II and Stages III/IV were 85.7, 85.7 and 92.8%, respectively. When used for the detection of endometriosis, the test had a sensitivity of 89.3% and a specificity of 96.3%. These results suggest that CA-125 in menstrual discharge may be helpful in the evaluation of women with chronic pelvic pain.     

Laparoscopic mobilization of the rectosigmoid and excision of the obliterated cul-de-sac

STUDY OBJECTIVE: To evaluate the feasibility and surgical and clinical outcomes of laparoscopic excision of anterior recto-sigmoid wall endometriosis and en bloc dissection of the obliterated cul-de-sac. DESIGN: Retrospective cohort (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Eighty-one women with infertility and/or chronic pelvic pain. Intervention. Laparoscopic excision of all endometrial implants and uterosacral ligaments, and dissection of the cul-de-sac using a horseshoe-shaped approach to mobilize, but not resect, the rectosigmoid. MEASUREMENTS AND MAIN OUTCOMES: Eleven women (24%) had endometriomas. Cumulative pregnancy rates in 34 women with primary infertility and 12 with secondary infertility were 62% and 42%, respectively. Eighty-eight percent of 61 women with pain reported significant improvement of symptoms. CONCLUSION: Laparoscopic excision of cul-de-sac and rectovaginal endometriosis by this approach is feasible and safe when performed by an experienced surgeon, and results in high rates of cumulative pregnancy and relief of pain. Some patient variables may give higher rates of success for pregnancy than others.     

Endometriosis and the primary care consultation

OBJECTIVES: Endometriosis is a long term, disabling condition, and a common cause of chronic pelvic pain. Symptomatic disease is usually characterised by pelvic and abdominal pain, lower back pain, and dyspareunia, all of which may be severe and debilitating. Yet the time between onset of symptoms and diagnosis is frequently a number of years, and many women report negative experience within the primary care setting. This paper explores the experience of women with endometriosis in the primary care setting. STUDY DESIGN: A qualitative research design was considered appropriate to elicit the experience of endometriosis and the impact on women's lives. Semi-structured interviews were conducted with 30 women who suffer with endometriosis. The sample was recruited via a dedicated endometriosis clinic in the English Midlands, and participants had all been diagnosed laparoscopically with endometriosis. RESULTS: Participants described diverse experiences within the primary care setting. Although some women reported a positive relationship with their general practitioner, over half had had negative experiences, which they felt had contributed to delays in them receiving a diagnosis of endometriosis. CONCLUSION: The delay in diagnosis can be reduced and perceived attitudes of general practitioners towards women presenting with endometriosis can be improved by being alert to certain symptomology, and by detailed and sensitive history taking.     

Efficacy of laparoscopic excision of visually diagnosed peritoneal endometriosis in the treatment of chronic pelvic pain

OBJECTIVE: To determine the efficacy of laparoscopic excision of visually diagnosed endometriosis in the treatment of chronic pelvic pain. STUDY DESIGN: Sixty-two women with chronic pelvic pain and who underwent laparoscopic excision of visually diagnosed peritoneal lesions suggestive of endometriosis returned postal questionnaires. The main outcomes measures were change in pelvic pain symptoms measured on a continuous and ordinal scale and patient satisfaction following treatment. Secondary outcomes were quality of life, time off work and use of health service resources. RESULTS: 42/62 (68%) women with an average follow up time of 13 months (range 6-38 months) returned completed outcome questionnaires. The mean amount of pelvic pain was reduced following surgery compared to immediately prior to treatment, regardless of the nature of the pain (P<0.05). Overall, 67% (95% CI 50-80%) of women reported improvement in pain symptoms and 71% (95% CI 55-84%) were satisfied with the results of treatment. Satisfaction with treatment was comparable whether the visual diagnosis of peritoneal endometriosis was confirmed histologically or not (62% versus 64%, P=1.0). CONCLUSION: Laparoscopic excision of visually diagnosed endometriosis appears to be efficacious in the treatment of women with chronic pelvic pain. The launch of a long-term randomised controlled trial to confirm these provisional results is now required.     

Relations entre endométriose et algie pelvienne chronique : quel est le niveau de preuve ?

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic microbleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the subperitoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as “location indicating pain”. A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic.     

Conscious pain mapping by laparoscopy in women with chronic pelvic pain

OBJECTIVE: To evaluate the findings and outcomes of laparoscopic conscious pain mapping in women with unsuccessfully treated chronic pelvic pain. METHODS: Fifty consecutive women with at least one prior procedure for chronic pelvic pain had conscious pain mapping. Operative findings and clinical outcomes were documented. Preoperative and postoperative pain levels were evaluated using visual analog scales. RESULTS: Conscious pain mapping was successful in 35 cases (70%). Twenty-nine patients had 42 specific positive sites, and six patients had diffuse visceroperitoneal pelvic tenderness. Adhesions and endometriosis accounted for 45% of positive lesions or sites. About half of women with endometriosis or adhesions mapped pain specifically to those lesions. For endometriosis, histologic but not visual diagnosis predicted positive mapping. Specific viscera accounted for 36% of positively mapped sites. Diagnoses of chronic visceral pain syndrome were suggested by the findings in 16 (46%) patients whose mapping was successful. Mean +/- standard deviation visual analog scale pain levels were 8.7 +/- 1.2 preoperatively and 5.5 +/- 3.7 postoperatively. Twenty-two women (44%) had decreased pain postoperatively and eight (16%) were pain-free. CONCLUSION: Conscious pain mapping can be done with reasonable success in women with prior surgical evaluations and treatments for chronic pelvic pain. Chronic visceral pain syndrome, adhesions, and endometriosis were the most common diagnoses.     

Deep and superficial endometriotic disease: the response to radical laparoscopic excision in the treatment of chronic pelvic pain

A cohort of 108 women with chronic pelvic pain underwent a laparoscopy, and a diagnosis of endometriosis was made in 88 (81%). Pre-operative and 2 years post-operative pain scores, using a ranked ordinal scale, were calculated for 44 women with complete pelvic organs (50%) and full data sets. Endometriosis was diagnosed on the basis of histological confirmation of the presence of glands and stroma in excised specimens and endometriosis classified by the American Society of Reproductive Medicine r-ASRM or by the presence of superficial or deep disease. The r-ASRM was a poor predictor of pain relief following surgery, and women with superficial disease did not respond well (in terms of appreciable, reduced pain) to surgical treatment, but good pain relief was seen with some women with nodular or infiltrating (‘deep’) disease. Women were also asked to complete a General Health Questionnaire. This showed an appreciable degree of depressive morbidity, which improved over the time of the study. Severity of initial global pain scores did not equate to the severity of endometriosis as categorised by either the r-ASRM score or the type of disease. This small study suggests that surgical therapy does not reduce pain scores in superficial endometriosis but is valuable in the treatment of deep or infiltrating disease. Longer-term follow-up of a larger cohort is necessary to evaluate further the value of surgery in this disease and to be further able to develop more accurate predictions of the outcome of surgical intervention in terms of pain relief.     

Pain in endometriosis: effectiveness of medical and surgical management

PURPOSE OF REVIEW: Endometriosis is a common cause of chronic pelvic pain and has a detrimental effect on the quality of life for women affected with the condition. It is also clear that early diagnosis with prompt effective management does not always occur. This review will discuss the medical and surgical treatment options and support conclusions with randomized double blind placebo-controlled studies where possible. RECENT FINDINGS: Assessment of the pelvic pain associated with endometriosis can be categorized according to its relation to the menstrual cycle. Dysmenorrhoea and ovulatory pain occur with cyclical changes, as compared with chronic non-cyclic pain and deep dyspareunia. Dyskesia and urinary pain may have a relation to the menstrual cycle. The severity of pain symptoms, as well as the effect on the woman's quality of life, should be quantified. The preoperative symptoms can be compared with the operative findings and the stage of endometriosis according to the revised American Fertility Score. SUMMARY: Review of the current literature demonstrates that a combined medical and conservative surgical approach is beneficial for most women with endometriosis associated pelvic pain.     

Impact of endometriosis on quality of life and mental health: pelvic pain makes the difference

Abstract

Introduction: No prior study of endometriosis has investigated the psychological impact of having asymptomatic endometriosis versus endometriosis with pelvic pain in a systematic way. This study aimed at examining the impact of endometriosis on quality of life, anxiety and depression by comparing asymptomatic endometriosis, endometriosis with pelvic pain, and healthy, pain-free controls. The psychological impact of different types of endometriosis pain was also tested.

Methods: One hundred and ten patients with surgically diagnosed endometriosis (78 with pelvic pain and 32 without pain symptoms) and 61 healthy controls completed two psychometric tests assessing quality of life, anxiety and depression. Endometriosis participants indicated on a numerical rating scale the intensity of four types of pain (dysmenorrhea, dyspareunia, non-menstrual pelvic pain and dyschezia).

Results: Endometriosis patients with pelvic pain had poorer quality of life and mental health as compared with those with asymptomatic endometriosis and the healthy controls. No significant differences were found between asymptomatic endometriosis and the control group. Dysmenorrhea had significant effects only on physical quality of life; non-menstrual pelvic pain affected all the variables; no significant effects were found for dyspareunia and dyschezia.

Conclusions: Pain significantly affects women’s experience of endometriosis. The medical treatment of endometriosis with pain may not be sufficient and psychological intervention is recommended.     

Endometriosis and Mechanisms of Pelvic Pain

Endometriosis remains an enigmatic disorder in that the cause, the natural history, and the precise mechanisms by which it causes pain are not completely understood. The pain symptoms most commonly attributed to endometriosis are dysmenorrhea, dyspareunia, and chronic pelvic pain. Pain may be due to nociceptive, inflammatory, or neuropathic mechanisms, and there is evidence that all 3 of these mechanisms are relevant to endometriosis-associated pelvic pain. It is proposed that the clinically observed inconsistencies of the relationships of endometriosis severity and the presence or severity of pain are likely due to variable roles of different pain mechanisms in endometriosis. A better understanding of the roles of nociceptive, inflammatory, and neuropathic pain in endometriosis is likely to improve the treatment of women with endometriosis-associated pelvic pain.