Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study

OBJECTIVE: To assess the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP). DESIGN: Prospective cohort study. Setting Gynaecology Department, UK District General Hospital. POPULATION: Forty-three women diagnosed with CPP. METHODS: The cohort was followed up for 18-24 months after diagnosis and treatment based on conscious pain mapping. MAIN OUTCOME MEASURES: Improvement of pain assessed by using visual analogue scale (VAS) pain scores at 6-month follow up. RESULTS: Thirty-nine women had successful conscious pain mapping. Pelvic pathology was identified in 18, pelvic congestion in 13 and 8 women had normal pelvic organs. In 35 women (90%), conscious pain mapping identified the cause of pain. Five out of eight women (63%) who were judged to have a normal pelvis had positive findings at pain mapping. VAS scores fell significantly from pre-treatment to post-treatment values at 6-month follow up (P < 0.01). Overall, 26 women (74%) felt that their symptoms had improved after treatment based on findings at pain mapping. However, we concluded that pain mapping only contributed to the diagnosis and treatment in seven women (27%), who may not have received appropriate diagnosis and treatment if they had a laparoscopy under general anaesthetic. Conclusions CONSCIOUS: pain mapping is a useful additional investigation in the management of women with CPP. It can be employed in women with a negative laparoscopy or with visible pathology where the conventional treatment has failed.     

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.     

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.     

Lack of Data-driven Treatment Guidelines and Wide Variation in Management of Chronic Pelvic Pain in Adolescents and Young Adults

Study ObjectiveCurrent literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers.Design and SettingWe completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2016.ParticipantsWe included AYA patients aged 9-25 years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded.Interventions and Main Outcome MeasuresTrends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics.ResultsA total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital.ConclusionThere is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.     

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.     

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.     

Sexual behavior and findings on laparoscopy or laparotomy in women with severe chronic pelvic pain

OBJECTIVE: To identify features of sexual behavior in women with and without chronic pelvic pain. STUDY DESIGN: A group of 41 women with chronic pelvic pain of more than 6 months' duration and scheduled to undergo laparoscopy or laparotomy were surveyed to obtain information on their sexual activity. The results were compared with a control group of 86 women of similar age and socioeconomic status who underwent planned tubal ligation for permanent contraception. RESULTS: Women with pelvic pain initiated sexual relations at a later age and had a higher rate of dyspareunia than women in the control group. There were no significant differences between groups in any other characteristics of sexual behavior. CONCLUSION: Dyspareunia, the only feature of sexual relations that differed significantly between women with and without chronic pelvic pain, should be accorded greater attention as a painful symptom and not be dismissed as simply a type of sexual dysfunction.     

The value of laparoscopy in women with chronic pelvic pain and a "normal pelvis"

During the period January 1976--December 1982 laparoscopy was performed on 186 women complaining of pelvic pain of at least 6 months' duration. In all these cases, the routine pelvic examination and other medical and laboratory tests were negative. Laparoscopy revealed pelvic pathology in only 8.2%: in the vast majority (91.8%) entirely normal pelvic organs were seen. Evidence from the literature is compiling as to the psychogenic origin of most cases of chronic pelvic pain. Recently, it has been shown that laparoscopically negative pelvic pain can be relieved or abolished by psychological intervention. Since pathological findings on laparoscopy are of very low percentage and since the pain is psychogenic in most cases, the value of routine laparoscopy in chronic pelvic pain is very low. We propose that all women with chronic pelvic pain and normal pelvic examination should undergo psychological assessment and treatment if necessary. Laparoscopy should then be reserved for only those cases who show no amelioration on psychological intervention. Our estimation is that this approach would reduce the rate of laparoscopies performed for chronic pelvic pain by about 90%.     

Endometriosis in premenarcheal girls who do not have an associated obstructive anomaly

OBJECTIVE: To identify endometriosis as a cause of chronic pelvic pain in premenarcheal girls without an obstructive anomaly of the reproductive tract. DESIGN: A case series. SETTING: Tertiary-care academic pediatric hospital. PATIENT(S): Five premenarcheal girls with chronic (>6 months) pelvic pain and negative gastrointestinal workup. INTERVENTION(S): Laparoscopic biopsies and resection, laser and/or cautery of all visible lesions. MAIN OUTCOME MEASURE(S): Visual presence of endometriosis and decrease in pelvic pain after destruction of lesions. RESULT(S): All subjects had laparoscopy with the identification of clear, red, and/or white lesions consistent with endometriosis based on the standard American Society for Reproductive Medicine Classification of Endometriosis. Postoperatively, all of the girls had marked improvement of their pelvic pain based on self-reported pain scales. Two of the subjects had subsequent repeat laparoscopies 6 and 8 years after their initial surgery, which revealed pathology-proven endometriosis. CONCLUSION(S): Endometriosis should be part of the differential diagnosis of chronic pelvic/lower abdominal pain in premenarcheal girls. The presence of lesions visibly consistent with endometriosis in premenarcheal girls without an obstructive anomaly supports the concept that some cases of endometriosis may result from an etiology other than retrograde menses.     

New Diagnosis of Endometriosis is Less Common in Women over Age Forty Presenting with Pelvic Pain

Study ObjectiveTo investigate the incidence of new diagnosis of endometriosis in women at or above the age of 40 who present with previously undiagnosed pelvic pain and no previous surgical or sonographic evidence of endometriosis to a tertiary care clinic specializing in pelvic pain and endometriosis.DesignRetrospective cohort study (on the basis of the Strengthening the Reporting of Observational Studies in Epidemiology guidelines) of the incidence of laparoscopically proven endometriosis in women presenting with previously undiagnosed pelvic pain on the basis of age category (age <40 years or ≥40 years). Adjusted odds ratios and 95% confidence intervals were calculated using a multivariable logistic regression model.SettingPelvic pain focused gynecology clinic at a tertiary care hospital.PatientsPremenopausal women between 18 to 51 years who presented with pelvic pain and were booked for laparoscopy for the diagnosis and the possible treatment of endometriosis between the years 2012 to 2016. Patients who had had previous laparoscopy and those who had sonographic evidence of endometriosis were excluded from the study.InterventionsLaparoscopic visual evaluation and treatment was carried out in all patients by specialized gynecologists focusing on endometriosis surgery.Measurements and Main resultsPresence or absence of visualized endometriosis at laparoscopy. We evaluated 174 women who met the inclusion criteria. Endometriosis was diagnosed in 35% (19/55) of patients aged 40 years and above and in 67% (80/119) of patients below the age of 40 years. Odds ratio adjusted for body mass index and parity was 2.38 (1.09-5.00; p = .03). When assessed as a continuous curvilinear variable without division to age categories, age was significant even in the more comprehensive model including more potential confounders. Secondary outcome analysis demonstrated that deep infiltrating endometriosis was diagnosed in 5% (3/55) of the women at or above 40 years and in 8% (10/119) of women below 40 years (p = .76). In addition, a curvilinear relationship was found with age, and there was also a lower incidence of endometriosis of 50% (19/38) in the youngest cohort of women aged 18 to 25 years.ConclusionThe likelihood of a new diagnosis of endometriosis in women with pelvic pain, no previous laparoscopy and a normal sonogram in our referral center was lower in women aged 40 and above. Careful counseling and consideration of the risks and yield of surgery is recommended before performing a laparoscopy for investigation of pelvic pain in this age group.     

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.     

Surgical treatment of endometriosis

In this review, the pitfalls that still exist with the surgical treatment of endometriosisassociatedpelvic pain have been discussed and the best evidence regarding various aspects of surgical techniques have been reviewed. When laparoscopy is performed to evaluate a woman with pelvic pain symptoms, it is important she be counseled that the primary function of the surgery is to confirm the presence (and allow surgical treatment) of endometriosis, and that it is not the penultimate diagnostic modality for her pelvic pain. There are many etiologies of pelvic pain that present with symptoms resembling those of endometriosis-associated pelvic pain that are not diagnosable with laparoscopy, such as interstitial cystitis and irritable bowel syndrome. It is unfortunate that many women are left with the belief that if a laparoscopy fails to provide a diagnosis of a pain generator, then it means there are no diagnoses other than that the “pain is in her head,” often disparagingly termed “supratentorial” byclinicians. In fact, the pain-related diagnoses that are amenable to and possibly require a laparoscopy are quite limited, a group of diagnoses that this author terms the “dirty dozen” because there are just 12, and only the first 4 have good evidence to clearly associate them with chronic pelvic pain:1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic)9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian.I would argue that diagnostic laparoscopy in modern gynecology has a limited, if any role, and that when laparoscopy is planned for women with chronic pelvic pain, it should be with a very high suspicion of a diagnosis and with plans to treat the disease operatively. In this era, a negative diagnostic laparoscopy should be a rare event.     

Long-term follow-up after laparoscopic treatment for endometriosis: multivariate analysis of predictive factors for recurrence of endometriotic lesions and pain

Objective

To investigate factors that might influence the recurrence of both painful symptoms and endometriotic lesions following laparoscopic treatment of endometriosis.

Study design

Retrospective cohort study in a University teaching hospital. We reviewed data from patients referred for laparoscopy between March 1993 and November 2007. We selected women who were followed up throughout Transvaginal-ultrasound (TV-US) after a first conservative laparoscopy for endometriosis. After laparoscopy, all patients were followed up according to an internal protocol: a standard gynaecologic examination, the assessment of painful symptoms and a TV-US scan that were repeated at 3, 6, and 12 months, and subsequently on a yearly basis. Sixteen factors were assessed by univariable and multivariable Cox proportional hazards models to evaluate their associations with recurrence of endometriotic lesions and pain related-endometriosis.

Results

401 women were enrolled. A total of 154 (38.4%) experienced moderate or severe pain after laparoscopy; endometriotic lesions were observed by TV-US in 74 (18.4%) patients. In the multivariable model, age at menarche, severity of chronic pelvic pain (CPP) and dysmenorrhoea prior to surgery were significant risk factors for recurrence/occurrence of pain. Age at the first laparoscopy, stage of disease, pre-operative severity of CPP, and pregnancy were predictive factors of the recurrence for such lesions.

Conclusion

The severity of CPP prior to the first laparoscopy showed the only significant factor in the overall prediction of recurrence of pain and endometriotic lesions. Patients with severe CPP at the time of their first surgery might represent a sub-group of women with a more aggressive form of endometriosis.     

Autoamputation of the Fallopian Tube after Chronic Adnexal Torsion

Autoamputation of the adnexa, although very rare, can either be congenital or acquired. For affected women it can have future fertility implications. Although in some women it is asymptomatic, in most cases a history of acute followed by chronic pelvic pain can be elicited. This is a case of autoamputation of a fallopian tube after chronic adnexal torsion. We suggest that all patients of reproductive age with acute lower abdominal pain should have a pelvic ultrasound scan and, if symptoms persist, early recourse to laparoscopy. Misdiagnosis can lead to ovarian damage, loss of tubal function, infertility, or chronic pelvic pain.     

Pelvic vein thrombosis as a cause of acute pelvic pain

BACKGROUND: Pelvic vein thrombosis may occur in nonpuerperal patients with hypercoagulable conditions and have significant sequelae. The purpose of this report is to describe a nonpuerperal woman with factor V Leiden mutation who developed acute pelvic pain secondary to pelvic varix thrombosis.CASE: A multiparous woman, status post-bilateral tubal interruption, presented with acute onset of severe left-sided pelvic pain 5–6 weeks from the onset of her last menstrual period. A pelvic computed tomography scan showed left pelvic varix thrombosis. Hematologic studies were consistent with heterozygous factor V Leiden mutation. The patient was treated with heparin and warfarin, and had complete resolution of her pain.CONCLUSION: Pelvic vein thrombosis may cause acute pelvic pain in nonpuerperal women, especially those with primary hypercoagulopathies. This should be included in the differential diagnosis of acute pelvic pain in reproductive-age women.     

Laparoscopic diagnosis of acute lower abdominal pain in women of reproductive age.

OBJECTIVES: To compare the accuracy of laparoscopy performed within 24 h of admission and the conventional method based on clinical observation in the etiological diagnosis of non-specific acute lower abdominal pain (NSLAP) in women of reproductive age. METHODS: A total of 110 patients who met the selection criteria and were seen from November 1997 to June 2000 at the Instituto Materno Infantil, a referral hospital for maternal and perinatal care in Bogotá, were randomly divided into two groups. The effectiveness of each method was evaluated according to number of diagnoses reached, length of in-patient stay before diagnosis, complications, and diagnostic accuracy when compared with a standard given by microbiological and histopathological findings as well as clinical course. RESULTS: The early laparoscopy group did not experience more accurate diagnoses (85% vs. 79%, P=0.61) or a greater number of complications (11% vs. 9%, P=0.48), although the patients' stay was shorter (1.3 vs. 2.3 days, P=0.008) than the stay of the conventional-diagnosis group. Sensitivity analysis showed more accurate judgements with laparoscopy in four of the five NSLAP causes, but only in two of the cases did this greater accuracy have clinical significance. CONCLUSIONS: Early laparoscopy did not show a clear benefit in women with NSLAP.     

Sexual Satisfaction and Frequency of Orgasm in Women With Chronic Pelvic Pain due to Endometriosis

BackgroundDyspareunia, one of the main symptoms of the chronic gynecological pelvic pain disorder endometriosis, may interfere with the likelihood of reaching an orgasm, yet for women with dyspareunia, no data on orgasm rates in different sexual activities are available.AimThe aim of this study was to evaluate the ability to reach an orgasm and its association with sexual satisfaction during different sexual activities in women with a chronic pelvic pain disorder and in healthy control women.MethodsA set of questionnaires including the brief index of sexual functioning and global sexual functioning was used to evaluate sexuality in women affected with endometriosis (n = 434) and a nonaffected control group (n = 434) recruited in German-speaking countries.OutcomesThe primary outcome measure of this study was the orgasm rate during different types of sexual activities.ResultsOnly the ability to have an orgasm during sexual intercourse (P = .002) but not during masturbation (P = .509) or partnered noncoital sexual activities (P = .229) is affected by endometriosis. Dyspareunia was associated with a reduced ability to experience an orgasm during intercourse for endometriosis patients (P = .020) and control women (P = .006). The ability to orgasm during noncoital sexual activities (P = .006) and sexual intercourse (P = .038) was associated with a higher sexual satisfaction in women with endometriosis. For controls, only the ability to achieve an orgasm with sexual intercourse was associated with sexual satisfaction (P = .038).Clinical implicationsSexual counselling as part of medical support could help couples living with chronic pelvic pain of the female partner integrate noncoital sexual activities in their sex lives, leading to fewer sex-related problems and higher sexual desire and satisfaction.Strengths and limitationsThis study is the first to examine different ways of achieving an orgasm and sexual satisfaction in a large group of women with endometriosis and a matched control group. The breadth of the questionnaire allowed a differentiated analysis of factors influencing the likelihood of achieving an orgasm and overall sexual satisfaction. The one limitation is that the length and the intimate nature of the questionnaire possibly resulted in reluctance to answer this part of the questionnaire.ConclusionPartnered noncoital sexual activities may represent an alternative to reach orgasm for women with endometriosis-related chronic pelvic pain or anorgasmia during sexual intercourse.Hämmerli S, Kohl-Schwartz A, Imesch P, et al. Sexual Satisfaction and Frequency of Orgasm in Women With Chronic Pelvic Pain due to Endometriosis. J Sex Med 2020;17:2417–2426.     

Dyspareunia: a difficult symptom in gynaecological practice

Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse. It is a symptom that can have a significant impact on women's health, relationships and quality of life. There are multiple different causes for it, including both organic and psychosexual components. Despite the high prevalence of sexual pain, estimated to between 3 and 18% worldwide, few guidelines exist for its evaluation and management. Adequate assessment requires a comprehensive sexual history, a systematic and thorough examination of the lower genital tract to rule out anatomical causes and an exploration of potential psychosexual causes. Further investigations may include swabs and a pelvic ultrasound scan. In some cases a diagnostic laparoscopy may be required if there is evidence of endometriosis or utero-vaginal pathology that does not respond to conservative management. This article considers the diagnosis and investigation of women complaining of dyspareunia.