Current Concepts in the Evaluation and Management of a Common Gynecologic Problem

Definitions:

• Chronic pelvic pain: Pelvic pain lasting six months or more
• Chronic pelvic pain syndrome: Chronic pelvic pain that impairs daily function. Depression, altered family roles, and a history of multiple unsuccessful treatments are not uncommon.

Introduction:
Chronic pelvic pain affects a large number of women, and is not often optimally treated within a single specialty. It is responsible for approximately 40% of laparoscopies and 10-15% of hysterectomies in this country. In one survey of 5300 women, more than 16% noted chronic pelvic pain. In many cases, patients are evaluated by different physicians and undergo multiple operations without success. In these cases a multidisciplinary approach is appropriate. While chronic pain may not always be curable, it can be managed so that patients attain normal or near-normal levels of function. Endometriosis and adhesive disease are responsible for many cases of chronic pelvic pain in women, but a significant number of patients have no obvious etiology for their pain at the time of laparoscopy. Many of the latter women are inappropriately diagnosed with "pelvic congestion syndrome" or "somatization."

Physiology and Anatomy:
Pelvic pain is a poorly understood phenomenon. Acute pain is a protective mechanism that alerts the CNS to impending peripheral injury. Descartes originally maintained that pain was a simple signal from peripheral pain neurons to the brain (the "Somatic Theory." Eventually it became clear that pain is much more complex. The "Gate Theory" proposes that peripheral nociceptive signals can be modulated by neurotransmitters that can be linked with mood states. These neurotransmitters include serotonin and endorphins. The "gateway" to pain may be opened by depressive states as opposed to direct tissue irritation. Indeed, affective disorders are not uncommon after several months of pain. Chronic pain is thus interrelated to the patient's behavior and can result in severe debilitation, as opposed to the positive aspects of acute pain. A third theory, the "Diathesis-Stress" model, proposes that some patients are at increased risk of experiencing chronic pain due to preexisting vulnerabilities that may be acquired. This might explain why a disproportionate number of chronic pelvic pain patients report histories of sexual abuse, although it may also be that abused women are more likely to seek out physicians and report chronic pain that might have occurred regardless of previous trauma.

The pelvic viscera receive neurons from both the sympathetic (thoracolumbar) and parasympathetic (craniosacral) systems. The corpus, cervix and proximal fallopian tubes transmit pain through sympathetic fibers that arise from T10-L1. These fibers include neurons that are part of the uterosacral ligaments, and eventually coalesce into the superior hypogastric plexus (presacral nerve). It should be noted that the presacral nerve does not receive fibers from the ovaries and lateral pelvic structures, which is why a presacral neurectomy is applicable only to midline pain. The lateral pelvis transmits pain via parasympathetic neurons ("Nervi Erigentes") arising from S2-S4. The presacral nerve divides into the hypogastric nerves that eventually form the inferior hypogastric plexus, and this plexus subdivides into vesical, middle rectal and uterovaginal (Frankenhauser's) plexuses. Frankenhauser's plexus lies just lateral to the uterosacral ligaments and medial to the uterine arteries, and receives pain sensations only from the corpus and vagina. Unlike presacral neurectomy, which can affect bladder and rectal function, transection of Frankenhauser's plexus during a laparoscopic uterosacral nerve division should not result in constipation or bladder distention.

Approach to the Patient:
Women with chronic pelvic pain present unique challenges to the clinician. Unlike many gynecologic conditions that are relatively treatable, chronic pelvic pain may not be cured in a large number of patients. This is ultimately unsatisfying for both the patient and physician. In some cases, physicians may become frustrated and ascribe the patient's pain to psychiatric disease. Many women are also told that they "have to live with their pain."
It is unacceptable to tell a patient that they must tolerate chronic pain and that nothing more can be done. It is also inappropriate to make patients feel that their pain is imaginary and "in their heads." A better approach is one in which the patient is informed that while their chronic pelvic pain may not be cured, it can be managed. An analogy can be made with diabetics who (short of a pancreas transplant) are not cured of their disease but can live relatively normal lives with appropriate medical care. The chronic pain patient should also be told that their pain is real, even when our limited medical science has failed to elucidate the etiology of that pain. Pain IS perception, and no simple objective test exists to quantitate pelvic pain. Patients should be informed, however, that psychiatric support is available to them, not because they are "crazy" but because all patients with chronic disease can benefit from supportive counseling and appropriate psychiatric intervention.

Ultimately, many chronic pain patients benefit from sensitive physicians who are willing to spend the time necessary to alleviate what is often a significant threat to the patient's quality of life. In many cases a multidisciplinary effort produces the best results.

Patient Evaluation:
As with any patient, a detailed history is of primary importance to determining management. One should inquire about any associated symptoms, with particular emphasis on GU, GI and psychosocial complaints. Any previous treatment should be detailed, and any pathology and operative reports examined. Clinicians must inquire about a history of sexual and mental abuse. A pain questionnaire is very useful as a means of collecting patient data.
The physical exam differs a bit from the classic bimanual exam. After a careful abdominal examination, one should initially palpate the pelvic structures with one hand on the lower abdomen, avoiding the use of the other hand until later in the exam. By keeping one's hands separate, it is possible to avoid the painful compression of pelvic structures between the examiner's hands that can give an erroneous picture of the patient's symptoms. All painful areas should thus be recorded. Abdominal wall pain may be distinguished from visceral pain by the classic maneuver of having the patient tense their abdominal muscles. If the pain increases, it may be ascribed to an abdominal wall process, whereas visceral pain will decrease with abdominal muscle tensing. Rectal sphincter pain can be assessed with the insertion of one finger into the anal verge. Finally, a bimanual exam may be done, with the most tender areas palpated last. Uterosacral nodularity may be assessed via a rectovaginal examination.
Ancillary tests may include a pregnancy test, CBC, cervical cultures and ultrasound, although the latter is often of limited value. CA-125 can predict infiltrating endometriosis with a sensitivity of 87% and a specificity of 83%, but is an unproven adjunct. Similarly, contrast-enhanced fat-saturated MRI has shown some value in detecting small endometriotic implants but may not be any more useful than conventional laparoscopy.
If bladder or GI symptoms are present, consultation with urology or gastroenterology is appropriate.

Conscious pain mapping is becoming more prevalent. This is a laparoscopic technique in which the patient is sedated but can respond to questions during surgery that allows the gynecologist to better correlate operative findings with symptoms. It can help to distinguish abdominal wall pain from gynecologic pain, and may facilitate identification of vague endometriotic lesions. In some cases, the patient may pinpoint painful areas in the pelvis that do not correlate with overt pathology. The utility of conscious pain mapping, which uses microlaparoscopic techniques and can be done in an office setting, is still debatable but appears promising.

Medical Treatment:

• NSAIDS: Especially useful for inflammatory conditions such as dysmenorrhea. Use is limited by gastric irritation, and occasional renal and hematological complications. NSAIDS work best when dosed on a "round the clock" basis rather than "prn."
• Opioids: Effective for short-term use. Longer therapy durations are limited by tachyphylaxis and side effects such as constipation. While narcotics are acceptable for cancer patients and acute pain therapy, their role in treatment of chronic pelvic pain is at best controversial, and supportive prospective randomized trials do not exist. Of particular note is the drug tramadol (Ultram) which is both analgesic and antidepressant in its actions (but also lowers the seizure threshold). Drug "contracts" between the physician and patient is an attempt to provide some control over the patient's use (and abuse) of narcotics.
• Hormonal Modulators: OCP's, progestins (e.g. MPA @ 50-100 mg/day), GnRH-a
• Miscellaneous: Tricyclic antidepressants (e.g. Elavil), SSRI's (e.g. Zoloft), anticonvulsants for neuropathic pain, capsaicin

Surgical Treatment:

• Adhesiolysis: Kligman, et. al demonstrated nerve fibers within adhesions in 10 of 17 patients, although there was no correlation with the presence of pelvic pain. Nonetheless, clinical experience has demonstrated pain relief in many women after a thorough lysis of adhesions.
• Excision of Endometriosis: Laser and cautery methods do not adequately treat deeply infiltrating endometriosis (often >5mm invasive), whereas excision allows for therapeutic removal of lesions and corroborative histology. Excision of endometriotic lesions is generally with higher fertility rates than medical treatment with hormonal modulators. Hormonal modulation, however, can be very successful in place of surgery for alleviating pelvic pain. There is no proven benefit to adjuvant medical therapy after extensive laparoscopic resection of endometriosis, and it may decrease fertility rates as well.
• Uterine Denervation: Presacral neurectomy (PSN) may be accomplished via laparotomy or laparoscopy. Many series report success rates around 75%, but this is variable depending upon the thoroughness of resection. PSN has been associated with catastrophic hemorrhage from the middle sacral vessels. It should be noted, however, that the presacral nerve is anterior to the vessels and can be safely mobilized so long as the surgeon does not stray posteriorly into the sacral promontory. Patients should be apprised of potential long-term constipation and urinary retention.

Uterosacral nerve division (LUNA) is accomplished more readily than PSN, but may be much less effective long-term. Because only the uterovaginal portion of the inferior hypogastric plexus is affected, bladder and bowel symptoms are avoided. However, like PSN, individual variations in technique affect efficacy rates, and the lack of uniformity has clouded study results. Some surgeons divide the uterosacral ligaments with either laser or scissors; other practitioners resect much if not all of the ligaments and even make attempts at isolating Frankenhauser's plexus itself. Some studies report excellent effectiveness but these involve small patient populations. If patients have endometriosis, it is possible that success may be influenced more by the resection of endometriosis than by concurrent LUNA. Ureteral injury has been reported in expert hands.
All uterine denervation procedures fail to treat lateral pain, and are only indicated in patients who suffer central uterine pain. Furthermore, a presacral nerve block can result in similar pain relief as PSN without the attendant surgical morbidity (although respiratory failure and death are potential risks)

• Hysterectomy: When the uterus is believed to be the source of chronic pelvic pain, hysterectomy is often proposed to ameliorate pelvic pain. Unfortunately, it fails to relieve chronic pelvic pain about 25% of the time. In the case of endometriosis, the ovaries may be preserved with only a 3% recurrence of cyclic pain. HRT is also appropriate if castration is performed as only 10% of patients will have continued endometriosis symptoms. When oöphorectomy is performed, care must be taken to remove all ovarian tissue to prevent ovarian remnant syndrome.
• Uterine Suspension: Once widely used for a multitude of gynecologic and nongynecologic conditions, there is little to justify its routine use. Occasional patients with symptoms attributable to an incarcerated uterus may benefit but this is largely anecdotal. Some surgeons believe that uterine suspension may prevent substantial ovarian adhesions after conservative surgery for endometriosis; again, this is unproven.
• Appendectomy: In patients with chronic RLQ pain, the appendix is often abnormal and serious consideration should be given to its removal at laparoscopy. Appendiceal endometriosis has been found in 3-5% of women with endometriosis, and fecaliths can also produce chronic pain without full-blown appendicitis.

Additional Treatment Options:

• Nerve Blockade
• TENS
• Biofeedback
• Complementary Alternative Medicine

Multidisciplinary Approach:

Every patient with chronic pelvic pain is different. Some present initially to a gynecologist and may receive definitive laparoscopic and/or medical treatment. Unfortunately, a great number of women are not helped by their initial provider and they typically migrate from one physician to the next in search of pain relief. It is not uncommon for such a patient to have seen 4 or more providers and receive several laparoscopies and laparotomies. By this time, a true pain syndrome exists in which there is a great degree of interference with daily activities. Further surgery is unlikely to benefit this patient, who is often dismissed as mentally impaired.
In these seemingly intractable cases, one specialist is not adequate to remedy a chronic pain syndrome, and this is where a multidisciplinary effort is helpful. The patient can be seen jointly by gynecology, anesthesiology, psychiatry and additional specialties who then combine their resources to manage the patient's chronic pain syndrome. The goal is not always to "cure" pain so much as to allow the patient to function more normally and have a better quality of life. While often <50% effective in effecting long-term pain relief, pain centers generally achieve better results than those seen with efforts within a single specialty

Questions:
1) The concept that a previous traumatic experience may predispose a person to chronic pain is consistent with which theory of pain?

a) Somatic
b) Diathesis-Stress
c) Gate
d) Neural Hypothesis of Vantz

2) The following structures have sensory nerve fibers that comprise part of the superior hypogastric plexus except:

a) bladder
b) ovary
c) uterine corpus
d) rectum

3) Appropriate responses to a chronic pain patient who has undergone 5 negative laparoscopies include all of the following except:

a) Empiric treatment with Elavil
b) Conscious pain mapping
c) Pain Center referral
d) Being frank with the patient by informing her that she will have to live with the pain

4) Pain due to deep, infiltrative endometriosis may be treated most effectively with:

a) Laparoscopic excision of implants
b) Nd-YAG laser fulgeration of implants
c) CO2 laser fulgeration of implants with uterosacral ligament ablation
d) Modified Gilliam suspension