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 (CPP) affects over 1 million women in the UK, with subsequent impact on ability to work and the economy. It is often debilitating and can be difficult to treat. Gynaecologists have traditionally focussed on the organ-specific approach to the diagnosis of pain. Endometriosis is common as is chronic pelvic inflammatory disease and adenomyosis. Some causes are non-gynaecological such as irritable bowel syndrome and interstitial cystitis. However, as many as 55% of women presenting with CPP will have no obvious underlying pathology following completion of all investigations.This review focuses on the appropriate investigations, diagnosis and management of women with identified pathological causes of pelvic pain. It also considers the holistic approach to the management of the woman with chronic pelvic pain syndrome. Careful prescribing, assessment, interaction and support from a multidisciplinary team are required.     

Significance of laparoscopy in the management of chronic pelvic pain

OBJECTIVE: Chronic pelvic pain is a complex disease and is far more common than generally recognized. STUDY DESIGN: Between 1 January 1979 and 31 December 2002 authors had performed 11,681 laparoscopic interventions. Among them, 1061 operations (9.08%) were done because of chronic pelvic pain. RESULTS: In 29.5% of these cases no anatomical abnormality was found. Analysis of data of laparoscopic operations performed from 1989 to 1990 and from 1998 to 1999 revealed that complaints dated back for a significantly longer period of time in patients presenting no obvious sign of pelvic anatomical anomaly when compared with those who had positive findings. In patients with positive pelvic findings laparotomy had previously been performed in a significantly higher number. When no apparent pelvic pathology was found medical history was also negative for ectopic pregnancy. Similarly, there were only three cases of previous adnexal operations. However, among patients with positive findings, medical history revealed 19 prior cases of ectopic pregnancy, 49 cases of previous adnexal operations, 82 appendectomy, and 26 cholecystectomy (p<0.01). Among patients with positive pelvic findings, diagnostic laparoscopy was immediately completed by adequate surgical treatment in the same session in more than two-third of cases. Most frequently this included adhesiolysis, ovarian cystectomy, uterosacral nerve ablation, electrocoagulation of areas of endometriosis, and ventrosuspension of the retroflected uterus. CONCLUSION: Based on our retrospective data analysis we believe that laparoscopy is an essential method for the diagnosis and management of chronic pelvic pain.     

Schistosoma mansoni pseudo-cyst as a cause of chronic pelvic pain

A case of mansoni schistosomiasis causing peritoneal inflammation and chronic iliac pain is reported. The patient complained of iliac pain for 6 months. Physical examination and sonographic evaluation found a tumor in the left iliac fosse. A pseudocyst was removed from the pelvic region. The histopathology confirmed the diagnosis of S. mansoni. This is a rare case of S. mansoni in the pelvic cavity.     

Chronic pelvic pain

Chronic pelvic pain is a major public health problem that impacts all areas of a woman's life. The diagnosis is frequently difficult and delayed with women often presenting to a variety of specialties and undergoing multiple investigations before a diagnosis is reached. Aetiology is frequently multifactorial with both precipitating and perpetuating factors. Optimal management is within a multidisciplinary team who can fully address the range of factors that may maintain pelvic pain.     

The management of endometriosis-related pelvic pain

Endometriosis is a common condition leading to debilitating pain in high numbers of women. Management of this pain is a complex process warranting an individualised approach. This review explores both medical and surgical management options for endometriosis, noting their evidence base and suitability for different presentation patterns. Discussion includes common techniques and some newer options, whilst pointing out the relative lack of good quality evidence in management strategies commonly employed. The paper goes on to discuss management of the complex patient who does not respond to standard methods. The paper provides a general overview and stepwise approach to care for this common but incapacitating disease.     

The role of laparoscopy in the management of pelvic pain in women of reproductive age

Objective: To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain.Data Identification: Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches.Conclusion(s): Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.     

Adolescent chronic pelvic pain

The presentation of chronic pelvic pain in the adolescent can at times be quite daunting. A careful and insightful approach to obtaining the history and physical examination must be implemented while maintaining an appreciation of the various stages of adolescent development. The etiologies can range from gynecologic to nongynecologic causes. The ability to render an early diagnosis and appropriate treatment in this population of patients can significantly improve future reproductive health outcomes. The following minireview will outline a systematic approach to the adolescent with chronic pelvic pain.     

Mast cells in chronic inflammation,pelvic pain and depression in women

Inflammatory and neuroinflammatory processes are increasingly recognized as critical pathophysiologic steps in the development of multiple chronic diseases and in the etiology of persistent pain and depression. Mast cells are immune cells now viewed as cellular sensors in inflammation and immunity. When stimulated, mast cells release an array of mediators to orchestrate an inflammatory response. These mediators can directly initiate tissue responses on resident cells, and may also regulate the activity of other immune cells, including central microglia. New evidence supports the involvement of peripheral and central mast cells in the development of pain processes as well as in the transition from acute, to chronic and neuropathic pain. That behavioral and endocrine states can increase the number and activation of peripheral and brain mast cells suggests that mast cells represent the immune cells that peripherally and centrally coordinate inflammatory processes in neuropsychiatric diseases such as depression and anxiety which are associated with chronic pelvic pain. Given that increasing evidence supports the activated mast cell as a director of common inflammatory pathways/mechanisms contributing to chronic and neuropathic pelvic pain and comorbid neuropsychiatric diseases, mast cells may be considered a viable target for the multifactorial management of both pain and depression.     

Forgotten needle--an unusual cause of chronic pelvic pain

Case report A case presented with chronic pelvic pain since a Fothergills repair 9 years back. Over the years she had received multiple courses of antibiotics and anti-inflammatory drugs to no avail.Results Thorough evaluation revealed the presence of a foreign body in the form of a surgical needle in the cervix.     

不同糖耐量状态肥胖儿童血清脂联素的变化及其临床意义

目的了解不同葡萄糖耐量状态的肥胖儿童血清脂联素水平，探讨其与年 龄、体重指数(BMI)、血脂、血糖及胰岛素水平的关系。 方法选择2002~2004年于广州市儿童医院初诊并住院诊治的肥胖儿童52例，分为36例糖耐量正常(NGT)肥胖组和16例糖耐量受损(IGT)肥胖组。测定两组肥胖儿童和41例年龄、性别匹配的正常儿童空腹血清脂联素、胆固醇(CHO)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL C)、血糖和胰岛素(FINS)，计算胰岛素抵抗指数(HOMA IR)。肥胖组儿童均做口服葡萄糖耐量试验(OGTT)，测定OGTT 2h血糖和胰岛素。 结果正常对照组、NGT肥胖组及IGT肥胖组血清脂联素水平依次降低，HOMA IR依次升高，且均有统计学意义；相关性分析显示肥胖儿童血清脂联素与TG、LDL C、FINS呈显著负相关(P<005)。 结论肥胖儿童血清脂联素水平降低，并与血脂、胰岛素抵抗密切相关；与NGT肥胖组相比，IGT肥胖组儿童的血清脂联素水平进一步降低。     

History of childhood maltreatment and symptoms of anxiety and depression in women with chronic pelvic pain

Objective: To determine the prevalence of physical, sexual and emotional abuse and physical and emotional neglect suffered by women with chronic pelvic pain (CPP) during childhood and whether these occurrences are associated with symptoms of pain, anxiety and depression.

Methods: A case–control study was conducted on 154 women older than 18?years, 77 of them healthy and 77 with CPP. A history of sexual, physical, and emotional abuse and physical and emotional neglect was determined using the Childhood Trauma Questionnaire (CTQ). Anxiety and depression symptoms were determined using the Hospital Anxiety and Depression (HAD) scale. Pain intensity was determined using a visual analog scale (VAS). The quantitative variables were compared by the Wilcoxon test, and the qualitative variables were compared by the Chi-square test or exact Fisher test when appropriate. Correlation between the CTQ, HAD and VAS scores was estimated by the Spearman’s p coefficient. Independent association of the variables with the presence of CPP was determined by logistic multiple regression analysis.

Results: The prevalence of childhood maltreatment was 77.9% and 64.9%, respectively, for women with CPP and healthy women (p?=?0.07). Emotional neglect was more frequent among women with CPP than among healthy women (58.4% versus 41.5%, p?=?0.04). There was a moderate correlation between anxiety and depression symptoms and CTQ scores for women with CPP. Unemployment (OR?=?4.15, 95% CI 1.73–9.94; OR_adj?= 3.30, 95% CI 1.26–8.55) was independently associated with the presence of CPP.

Conclusions: Women with CPP reported emotional neglect abuse more frequently than healthy women. There was a direct correlation between maltreatment scores and anxiety and depression scores. On the other hand, CPP was independently associated only with unemployment.