Chronic Pelvic Pain: Which Approach? Surgical Versus Medical

Chronic pelvic pain is generally used to describe a condition of pelvic discomfort not solely associated with menstruation, of more than 6 month's duration, and of a severity sufficient to cause disability in some form. Chronic pelvic pain (CPP) is one of the most common problems in gynecology, accounting for approximately 1 of 10 outpatients visits. Forty percent of all laparoscopies are done for chronic pelvic pain. The responsibility for these women is challenging and often very frustrating to the clinician. In many aspects the complaints by their very nature are biased and difficult to quantify; the objective tests are often unsuitable and correlate poorly with symptoms; and patients are often apprehensive, depressed, and distrustful of the medical profession. Several likely etiologies may be unveiled, and the role each plays in the origin of the pain may be difficult to determine. Likewise, common therapies, both medical and surgical, may be associated with significant morbidity, and yet are often of limited or unproved benefit. A paradigm for workup of the CPP patient can be very helpful in fulfilling the treatment of this difficult problem.

APPRAISAL

A patient presenting with CPP would have to be defined as one who has experienced pain for 6 months or longer in its prevailing form. There are considered to be six common features for CPP: (1) altered family roles, (2)duration of 6 months or longer, (3) significantly impaired function at home or work; (4) incomplete relief with most treatments; (5) signs of depression, such as early morning awakening, weight loss, or anorexia; and (6) pain out of proportion to pathology. No one of these lineaments is an absolute prerequisite for the diagnosis for CPP, but when identified, they can be used as guidelines to strengthen the clinical impression. Rather, the diagnosis is made based on the overall clinical picture.

It is essential when evaluating the woman with CPP to consider the various known causes that may be contributing to the symptoms. For this purpose the Renaeer classification is of value. This scheme classifies etiologies of CPP as episodic and continuous. (Table 1) Due to the complexity of the carious CPP syndromes and their significant psychological component, thorough evaluation often requires a multidisciplinary approach with a gynecologist, mental health professional and possibly a gastroenterologist, urologist and anesthesiologist.

HISTORY AND PHYSICAL EXAMINATION

It is of upmost importance for a thorough history and physical examination to be undertaken. An open interview allows the patient to present her concerns and their interpretations. The chief complaint should be stated in the patients own words and exactly why she has sought are at the specific time. The description of pain should include its site, character, duration, fluctuations, and aggravating or alleviating factors including changes in relation to gastrointestinal and urinary functions. The questions or review of systems asked can evolve around the etiology of pelvic pain, whether gynecological, urological, gastrointestinal, musculoskeletal, biochemical, neurological or psychological (table 2). The menstrual history and the association of pain with each part of the menstrual cycle is crucial. A detailed history of past surgical procedures and medical ailments must be taken. The result of the treatment must be reviewed as to whether the medical treatment or surgery worsened or improved the pain.

A history of the illness may be augmented by measures quantifying the severity of pain and its effect on subsequent evaluations and assessment of the effects of therapy. The McGill Pain Questionnaires is composed of four parts designed to identify where the pain is located, how it changes over time, what it feels like qualitatively, and its intensity.

A complete physical examination should be performed. This should include a careful examination of each system with particular attention being made to the location of any pathology, the depth of the pain and the severity of the pain. In order to evaluate the patient’s pain, the standard pain stimulus, subjective pain may be assessed with a verbal rating scale using descriptive categories (no pain >severe pain) or numbers. Also effective are several available visual analog and graphic rating scales. Therefore a scale of 0 to 10 (10 being the worst) is obtained from the patient with a notation as to whether the pain was elicited superficially or deeply. A grade deployment of information can be helpful for comparison and future reference. (table 2) A similar process of grading can be applied to the vaginal examination while the speculum is in place. Touching various quadrants of the vagina with a "Q" tip may be able to map out the location and severity. Not only should a bimanual examination be performed but a rectal-vaginal examination should be instituted especially for diagnosing endometriosis or a frozen pelvis. Occasionally, local anesthesia can be injected into the area at the time of the examination to see if the pain will be ameliorated.. This is especially helpful in evaluation dysmenorrhea with injection of the utero-sacral ligaments as a pre-operative evaluation for a LUNA or Presacral-neurectomy.

ANCILLARY STUDIES

The necessity of further studies depends on the findings at the initial physical examination. A complete blood count with differential should be done in patients with recent worsening symptoms of abdominal or pelvic pain. A routine urinalysis is extremely important to rule out urological problems of CPP. Cultures of urine should be limited to those cases where standard treatment of the urinary tract infection fails. Other pertinent studies used to help identify the etiology of CPP include GC, CT and Chlamydia cultures or titers, wet preps of the vagina, ultrasound, MRI, CT scan, office hysteroscopy, endometrial biopsy or microlaparoscopy under conscious sedation local anesthesia.

The conscious sedation local anesthetic micro-laparoscopy can be very beneficial in pain mapping. It is somewhat counter productive to put a patient to sleep to determine the location of the pain when under local anesthesia the exact location can be determined. Pathologic findings are typically observed in more than 50% of laparoscopies. 5 Table 3 lists the laparoscopic findings reported by Howard. Thirty-nine percent had no visible pathology, 28 % had endometriosis and 25% had adhesions. The remaining 8% was divided amongst several other pathologies. What was extremely interesting is the 39% with no pathology. It would certainly be cost effective if all the laparoscopies for pelvic pain were performed under local anesthesia in a minor procedure room rather than in a operating suite. Both endometriosis and pelvic adhesions are known as potential causes of CPP. Howard found that these two abnormalities are found in 61% of women with and 28% of women without CPP. The use of contrast ultrasound has been very beneficial and relatively inexpensive method to evaluate the endometrial cavity. The choice of any one of these studies should be carefully weighed against the chances that the study may not be of any help in the diagnosis. We must be sensitive to the cost of medical care and use only those studies that are warranted.

Medical Management

Medical therapy being readily available is the first choice for the treatment of CPP. This initial therapy poses little or not acute risk and is very beneficial when the etiology of the pain may be psychological or psychosomatic. The medical therapy may be directly related to the relief of pain or to treatment of the underlying disorder. For instance, dysmenorrhea should first be treated with analgesics such as NSAIDs. Should this regime not work, the next best treatment is the use of oral conceptives. The value of NSAIDs has been established in 51 trials involving 1649 women. The use of this category of medication was associated with significant pain relief in 71% of patients. Placebo response was observed in 15% of patients. Pelvic pain, even in the absence of positive chlymadia cultures, should be treated with 10 days of doxycycline that is actually less expensive that the laboratory studies.

Since endometriosis may account for one third of the patient with CPP, the treatment with various medical therapies can be very cost effective. However, the empirical treatment with GnRH analogs or Danazol has been controversial. However, in the presence of typical nodules, symptoms of dysmenorrhea, pelvic pain, and dyspareunia, the diagnosis is extremely likely without an endoscopic procedure. If one can eliminate other non surgical, non-gynecological etiologies with ultrasound, etc., an empirical treatment many be indicated. Waller has shown that patients with known endometriosis stage I and II, the relief of pain without surgery using 6 months of GnRH agonist was over 53% after five years. If there is no relief of the pain within the first three months, the possibility of adhesions must be entertained. Other medications including danazol, continuous oral contraceptives, medroxyprogesterone and megesrol acetate have all been reported to be beneficial for the treatment of many patients with endometriosis. However, in most series, the pain returned 6 months after treatment to the same level as that documented before treatment.

Pelvic congestion syndrome with venous congestion has been found as an etiology for CPP in some patients. These patients usually experience deep dyspareunia and deep, dull pain exacerbated by postural changes. The treatment of PCS should first be aimed at the treatment of any chronic cervicitis. I have found that chronic cervicitis will increase the vascularity of the uterus manifested by the "four poster" sign with decrease run-off on uterine phlebography. Those patients without chronic cervicitis, the use of dihydroergotalmine and medroxyprogesterone have proven to be somewhat helpful. In one series, significant improvement of pain was observed in 73% of patients treated with medroxyprogesterone acetate 50 mg/day. In contrast, the placebo and placebo plus psychotherapy had 38% and 29% relief of pain respectively.

Initially, any patient with pelvic pain should be tried on a course of NSAIDs. These non-steriodal agents will many times help the pain and in some instances the pain may not recur. When chronic pain is associated with terminal illnesses, opioids are obviously indicated. The use of local anesthesia for treated trigger points on the skin may be very helpful in treating some types of pelvic pain. The use of electrical stimulation of nerves as with the transcutaneous electrical nerve stimulation instruments (TENS) has been proven to be very helpful. However, the use of these modalities would be limited to cyclic, repeated and predictable pain such as dysmenorrhea.

Surgical Treatment

Surgical Treatment is primarily used either to remove the pathology causing CPP or interrupting the nerves that transmit the pain impulses. In the last several years, the goals for surgical treatment have been primarily that of endoscopic treatment over laparotomy and hysterectomy. The minimally invasive techniques are not only less painful, but obviously cost effective, less invasive, and associated with faster recovery. The diagnosis of CPP is even better served by local anesthesia conscious sedation microlaparoscopy. This even less invasive technique can be a useful tool in the diagnosis and minimal surgical treatment of CPP. It is obvious that one cannot diagnose CPP under general anesthesia when it would be preferred to have the patient be awake and tell you where the pain is located. This is the distinct advantage of conscious sedation local anesthesia microlaparoscopy. The smaller laparoscopes require smaller trocars thereby decreasing the likelihood of injury to normal tissues upon insertion. Adhesiolysis is very appropriate when the adhesions are extensive and their location correlates with the location of CPP. This is the main reason for pain mapping with microlaparoscopy. There has been a significant amount of controversy as the likelihood of adhesion causing pelvic pain. Peter et al did demonstrate a significant long-term improvement 9 to 12 months after surgery in patients with severe vascular, and dense adhesions involving the bowel. However, after treating the adhesions, measures must be taken to prevent the recurrence. Meticulous handling of tissue, impeccable hemostasis, the liberal use of irrigation and the application of barrier grafts such as Interceede or Gortex can be very effective. However the most effective method of decreasing adhesions is the liberal use of the "second Look"; laparoscope. Because of the expense, this procedure has become more difficult to have approved in a managed health care environment. To solve this problem, others as well as myself, have used a Tenckoft dialysis catheter at the time of the extensive adhesiolysis. The catheter is inserted in the umbilicus after the surgery, cut off a few centimeters beneath the peritoneal surface and the outside taped to the abdomen. In one week, the patient is brought back into the office, the catheter is used to insufflate carbon dioxide and the patient has a second look laparoscopy with a 3mm microlaparoscope. Those patients who have recurrent adhesions that are extensive, are justified to be brought back for a procedure in the operating room.. Those with minimal adhesions can easily be lysed using local anesthesia. Those patients with no significant adhesions, would have been spared a general anesthetic laparoscopy by having a microlaparoscopy being performed

The treatment of the most common cause of CPP, endometriosis, can in most cases be treated laparoscopically. There are many studies that reveal the significance of surgical treatment of endometriosis. It is recommended that patients with suspected endometriosis have a bowel preparation prior to their surgery. Rectal probes and vaginal probes can be used to delineate theses structures when dissecting out the cul-de-sac of Douglas. It is usually best to resect all the deep lesions and vaporize the superficial ones. Those cases with extensive bowel involvement may require a laparotomy should bowel resection be necessary. Obvious regard for the ureters, bladder greater vessels and bowel must always be considered. The ovaries are the most likely structures to require adhesion prevention since the capsule is the least vascular structure in the pelvis. The need for hemostasis is critical as well as the need not to use sutures to close the ovary.

Myomectomy has become a questionable treatment for CPP. The myomas may cause pressure especially on the bladder and rectum. It is critical that the myoma be considered to be causing CPP before removing the tumor. Without the concomitant association of bleeding, the myomas are rarely a cause of CPP. Intracavitary and submucous myomas are best removed by hysteroscopy while intramural fibroids should be removed by laparotomy especially if the patient is considering pregnancy in the future. Other ways of treating these intramural fibroids would be a minilap to close the myometrium after a laparoscopic excision. In many instances, however, the time it takes to remove the myoma and potential risks, may make a simple laparotomy a better treatment for these tumors.

Adnexal masses are a cause of CPP when they are involved with adhesions. Rarely, unless the mass is very large will it cause CPP by itself. Those that are deemed a cause of CPP can usually be removed at laparoscopy. The liberal use of "bags" can prevent the spill of malignant tumors.

The two procedures suggested for the treatment of interrupting the nerve supply to the pelvis are the LUNA procedure and presacral neurectomy. The LUNA procedure, of previously called laser neurectomy, has met with less success because of the development of collateral nerve regeneration and incomplete severing of the sensory nerves. There is approximately as 50% recurrence of dysmenorrhea after LUNA within two years of the procedure. However, with presacral neurectomy the likelihood of long term relief of midline dysmenorrhea is about 85% in most reported series. There are many excellent prospective studies that have documented these data. The ability to perform this procedure by laparoscopy has made the treatment of intractable dysmenorrhea very effective. The skill of the surgeon is the main concern in the treatment of intractable dysmenorrhea by laparoscopy.

Summary

Chronic pelvic pain has always been a difficult problem for gynecologist in the past. It is extremely important for one to consider all other etiologies before reverting to surgery. At the same time one must consider the expense of unnecessary studies as well as the cost of consultants necessary to diagnose the etiology of CPP. Ultimately, laparoscopy or even better, conscious sedation local anesthetic microlaparoscopy may be the best tool to diagnosis patients with CPP. In this way only those patients with demonstrable pathology will have to be taken to the operating room for definitive surgical therapy. This local anesthetic microlaparoscopy will direct the attention toward the right treatment if there are no surgical pathologies found.

Table 1

Classification of Chronic Pelvic Pain

Episodic Chronic Pain Continuous Chronic Pain

Dyspareunia Adhesions

Mittleschmerz Chronic infection

Primary dysmenorrhea Residual ovary syndrome

Secondary dysmenorrhea Pelvic tumors

Adenomyosis Genital prolapse

Endometriosis Endometriosis

Chronic pain without pathology

Pelvic congestion syndrome


Table 2

Etiology of Pelvic Pain

* Gynecological

* Urological

* Gastrointestinal

* Musculoskeletal

* Biochemical

* Neurological

* Psychosocial


Table 3

Laparoscopic Findings in 1,318 Women with Chronic Pelvic Pain

No visible pathology 39% (516)

Endometriosis 28% (364)

Adhesion 25% (331)

Chronic PID 6% (85)

Ovarian cysts 3% (39)

Pelvic varicosities <1% (5)

Leiomyomata <1% (10)

Other 4% (57)