The 2013 EAU Guidelines on Chronic Pelvic Pain: Is Management of Chronic Pelvic Pain a Habit,a Philosophy,or a Science? 10 Years of Development

Context

Progress in the science of pain has led pain specialists to move away from an organ-centred understanding of pain located in the pelvis to an understanding based on the mechanism of pain and integrating, as far as possible, psychological, social, and sexual dimensions of the problem. This change is reflected in all areas, from taxonomy through treatment. However, deciding what is adequate investigation to rule out treatable disease before moving to this way of engaging with the patient experiencing pain is a complex process, informed by pain expertise as much as by organ-based medical knowledge.

Objective

To summarise the evolving changes in the management of patients with chronic pelvic pain by referring to the 2012 version of the European Association of Urology (EAU) guidelines on chronic pelvic pain.

Evidence acquisition

The working panel highlights some of the most important aspects of the management of patients with chronic pelvic pain emerging in recent years in the context of the EAU guidelines on chronic pelvic pain. The guidelines were completely updated in 2012 based on a systematic review of the literature from online databases from 1995 to 2011. According to this review, levels of evidence and grades of recommendation were added to the text. A full version of the guidelines is available at the EAU office or Web site (www.uroweb.org).

Evidence synthesis

The previously mentioned issues are explored in this paper, which refers throughout to dilemmas for the physician and treatment team as well as to the need to inform and engage the patient in a collaborative empirical approach to pain relief and rehabilitation. These issues are exemplified in two case histories.

Conclusions

Chronic pelvic pain persisting after appropriate treatment requires a different approach focussing on pain. This approach integrates the medical, psychosocial, and sexual elements of care to engage the patient in a collaborative journey towards self-management.     

Pelvic packing or angiography: Competitive or complementary?

Pelvic angiography is an established technique that has evolved into a highly effective means of controlling arterial pelvic haemorrhage. The current dominant paradigm for haemodynamically unstable patients with pelvic fractures is angiographic management combined with mechanical stabilisation of the pelvis. However, an effective rapid screening tool for arterial bleeding in pelvic fracture patients has yet to be identified. There is also no precise way to determine the major source of bleeding responsible for haemodynamic instability. In many pelvic fracture patients, bleeding is from venous lacerations which are not effectively treated with angiography to fractured bony surfaces. Modern pelvic packing consists of time-saving and minimally invasive techniques which appear to result in effective control of the haemorrhage via tamponade. This review article focuses on the recent body of knowledge on angiography and pelvic packing. We propose the optimal role for each modality in trauma centres.     

The Painful Knee: Arthroscopy or MR Imaging?

While neither arthroscopy nor magnetic resonance (MR) imaging is perfect, both can delineate pathologic changes in the knee with reasonable accuracy. The greatest advantage of MR imaging is that it is noninvasive and can be used to detect pathologic changes both inside and outside the synovial cavity. Arthroscopy has the distinct advantage of allowing definitive treatment at the time of diagnosis in most cases, but carries with it the potential risks associated with any invasive diagnostic technique. Both modalities are expensive, and their judicious use is therefore dictated, especially in this era of cost containment. The decision to use one or both studies is best made by the orthopaedic surgeon.     

Renal Transplantation in Patients With “Valve Bladder”: Is Bladder Augmentation Necessary?

Introduction

Posterior urethral valve is a common cause of renal failure in children. This disorder often results in small bladder and low compliance, which frequently requires bladder augmentation. Herein, we report our experience in 5 children with “valve bladder” who underwent renal transplantation without preliminary bladder enlargement.

Materials and Methods

Thirteen children with valve bladder undergoing renal transplantation were considered candidates for bladder augmentation. All had oligoanuria at transplantation. In 8 children, bladder augmentation was performed before renal transplantation; in the remaining 5, the decision was postponed until after transplantation. These children underwent transplantation with a ureteral reimplant, and a suprapubic catheter was in place for 2 months. Periodically, renal function, bladder capacity, and compliance were assessed, and renal ultrasonography was performed.

Results

At 1-, 2-, 4-, and 6-month follow-up, the 5 children who did not undergo bladder augmentation demonstrated normal renal function, with improved bladder capacity and absence of hydronephrosis. No significant difference was evident between the 2 groups (augmented vs nonaugmented) insofar as renal function, bladder capacity, or hydronephrosis. After transplantation, bladder augmentation was not deemed necessary in any of the 5 children because of complete restoration of clinical and urodynamic parameters.

Conclusion

Renal transplantation can be performed safely without preemptive bladder augmentation. Ureteral reimplantation is recommended, even in patients with small valve bladders. The decision about the need for bladder augmentation should be made only after normal diuresis is restored.     

Editorial Commentary: The Gain in Pain After Hip Arthroscopic Surgery: What Is Clinically Relevant,and Is Pain Related to Function in Patients With Femoroacetabular Impingement Syndrome?

Hip arthroscopic surgery improves patient-reported outcomes in patients with femoroacetabular impingement syndrome and/or hip chondropathy. The minimal clinically important change on a pain visual analog scale has now been calculated in this patient group, and the pain level 1 year after surgery has been related to function. Next step: identifying what causes pain and decreased function 1 year after surgery.     

Advancements in the Management of Urologic Chronic Pelvic Pain: What is New and What Do We Know?

Prostatitis is one of the most common urologic diagnoses in men of all ages. The etiology of this problem remains poorly understood. No uniform solitary treatment is known for chronic prostatitis. As a result, a multimodal approach is most likely to demonstrate benefit for this disease. Various treatment modalities have included the use of both pharmacologic and nonpharmacologic treatments. In addition, multiple interventional techniques including the injection of botulinum toxin, transurethral needle ablation of the prostate, microwave thermotherapy, neuromodulation, and, most recently, extracorporeal shockwave therapy have been utilized with varying degrees of benefit.     

Editorial Commentary: Do Patients With Femoroacetabular Impingement Syndrome Already Show Hip Muscle Atrophy?

Muscle atrophy, fatty degeneration, and strength deficits of the hip abductors, flexors, and even external rotators are well-known clinical and radiologic findings in patients with advanced hip osteoarthritis. More recently, in the context of prearthritic hip diseases, the role of hip muscle function in femoroacetabular impingement syndrome (FAIS) has gained greater focus for hip surgeons. Several studies have shown that patients with FAIS present with activation deficits of the hip muscles, which may result in hip muscle weakness. Nevertheless, previous studies have yet to determine whether young and mainly active patients with FAIS already show hip muscle atrophy. Future research is required to further characterize hip muscle function in patients with FAIS. Of particular interest is the investigation of whether both qualitative (muscle fatty degeneration) and quantitative (muscle atrophy) morphologic alterations of the hip muscles are present in patients with FAIS, as well as whether these alterations are sex specific and/or related to the underlying hip morphology.     

Hyaluronic Acid: An Effective Alternative Treatment of Interstitial Cystitis,Recurrent Urinary Tract Infections,and Hemorrhagic Cystitis?

OBJECTIVES: Hyaluronic acid is a protective barrier of the urothelium. A damaged glycosaminoglycan layer may increase the possibility of bacterial adherence and infection. This damage is proposed to be a causative factor in the development of interstitial cystitis, common urinary tract infections, and hemorrhagic cystitis due to posthematopoietic stem cell transplantation. The aim of this article was to review the available data regarding the use of hyaluronic acid as an alternative treatment of the above-mentioned conditions. METHODS: Articles relevant to our review that were archived by September 2006 were retrieved from PubMed. RESULTS: Nine relevant studies were identified and evaluated. Hyaluronic acid was administered intravesically at a dose of 40 mg every week for 4-6 wk; patients with noted improvement received two additional monthly doses. Short-term responses of patients with interstitial cystitis, hemorrhagic cystitis, and recurrent urinary tract infections were 30-73% (7 studies), 71% (1 study), and 100% (1 study), respectively. The treatment was well tolerated except for occasional development of bacterial cystitis. The cost of each intravesical installation of hyaluronic acid is 120 UK pounds (excluding the cost of the urinary catheterization). CONCLUSIONS: The available clinical data regarding the effectiveness of hyaluronic acid as a potential treatment of patients with interstitial cystitis, recurrent urinary tract infections, and hemorrhagic cystitis are limited. There is need for randomized controlled trials for further investigation of this important therapeutics question; these clinical trials should be disease-specific, blinded, and controlled, and of a sufficient number of patients. Until such studies are available, intravesical instillation of hyaluronic acid cannot be unquestionably endorsed for use for the aforementioned diseases.     

Does Native Combined Anteversion Influence Pain Onset in Patients With Dysplastic Hips?

Background

Combined anteversion is the sum of femoral and acetabular anteversion and represents their morphological relationship in the axial plane. Few studies have investigated the native combined anteversion in patients with symptomatic dysplastic hips.

Questions/purposes

We hypothesized the following: (1) dysplastic hips have two distinct populations, which differ from each other and from normal hips in their combined anteversion; and (2) these populations differ clinically in terms of correlation between age of onset of symptoms and amount of anteversion.

Methods

We measured radiographic parameters by CT of 100 dysplastic hips in 76 patients who were symptomatic enough to undergo periacetabular osteotomy and of 50 normal hips in 44 patients who had CT scans as part of preparation for computer-navigated TKAs; these patients had no visible hip arthritis or dysplasia and no hip symptoms. Dysplastic hips were divided into the anteversion (83 hips) and retroversion groups (17 hips) based on acetabular version. Age at pain onset was determined from their medical charts.

Results

Combined anteversion in the anteversion group was greater than that in the retroversion and control groups: 47° ± 12°, 30° ± 16°, and 36° ± 9°, respectively. In the anteversion group, combined anteversion (r = −0.49; 95% confidence interval [CI], −0.66 to −0.27; p < 0.001) and femoral anteversion (r = −0.41; 95% CI, −0.60 to −0.19; p < 0.001) were associated with an earlier age at pain onset; however, no such relationships were observed in the retroversion group. After controlling for relevant potential confounding variables, we found that combined anteversion (hazard ratio [HR], 1.04; 95% CI, 1.01–1.07; p = 0.006) and Sharp angle (HR, 1.10; 95% CI, 1.02–1.17; p = 0.008) were associated with an earlier age of pain onset in the anteversion group.

Conclusions

These results suggest that not only lateral coverage of the femoral head, but also axial joint morphology is important for the development of pain in the anteversion group. Optimal combined anteversion should be considered during periacetabular osteotomy.

Level of Evidence

Level IV, prognostic study.