Chronic gynaecological pain: Insights into how to tackle long-term despair

Summary

It is important to make a profound change in the way we think about chronic pelvic pain. The notion that endometriosis is the sole cause of chronic pelvic pain is wrong; it delays correct diagnosis and leads to unrealistic expectations about treatment success. It is an outdated view perpetuated by many gynaecologists who are selective in their focus. Negative laparoscopy with persistent symptoms deserves as much, if not more attention and care. The key to managing a complex disease like chronic pelvic pain is to see it as a condition that cannot be cured but can be managed successfully. This idea is like the successful treatment of diabetes and hypertension, other chronic conditions which can be controlled. From the outset, a multimodal and a multidisciplinary approach is required.

Chronic pelvic pain

Lets first define what we are talking about. Chronic pelvic pain is non-cyclic or cyclical pain lasting more than 3 months located in the anatomical area of the pelvis, the anterior abdominal wall below the navel, the perineum, the genital area, the lumbosacral region, or the hip. It has a severity that causes functional disability or leads women to seek medical attention. The patients cannot exercise, have sleep disorders, experience difficulty enjoying free time, suffer poor socialization, have to put up with difficulties in mobility, find it hard to concentrate mentally, are negatively impacted on their quality of life, and their sexual enjoyment is enormously reduced. 

Acute pain is undeniably different from chronic pain. Acute pain is a symptom of tissue damage often associated with underlying disease. Chronic pain is by itself a diagnosis that needs recognition as a disease in its own right, with or without any additional pathology observed. At least 116 million adults in the United States suffer from chronic pain. This number is higher than the number of patients who have high blood pressure, diabetes mellitus, and cancer combined. Therefore, chronic pain has immense effects not only on the quality of life of sufferers but also on the health system and care delivery,

Focussing on diagnosing a single component of this condition, such as endometriosis or pelvic adhesions, for targeting treatment is unlikely to be successful in chronic cases. Given an understanding of chronic pelvic pain neuropathology, it is obvious that the above traditional approach is bound to fail; the condition needs to be addressed comprehensively with a multidisciplinary and multimodal approach from the outset. The key is to recognise the complex nature of the disease from the outset. The absence of positive clinical findings does not mean that one should minimize the meaning of the pain suffered by the patients. In these cases, a normal physical examination does not rule out the possibility of pelvic pathology.

Why does it matter?

Many ask the question: Why worry about a condition that does not kill? This silly viewpoint undermines the sufferer. Let's look at what is the actual dimension of the problem: The impact that chronic pelvic pain has is prominent. Approximately a third of all gynaecological outpatient visits, a quarter of all gynaecological emergency visits, and almost half of all gynaecological laparoscopies are performed for diagnoses related to chronic pelvic pain. Furthermore, nearly two-thirds of patients live without an accurate diagnosis or adequate treatment. No wonder it contributes to three-quarters of gynaecological disability and incapacity in the United States. It is estimated to generate in the United States a medical cost of approximately $1.2 billion a year and labour productivity losses of more than $15 billion a year with an inability to work fully for a majority of the sufferers

Endometriosis

Let's put endometriosis in perspective. It is clear that endometriosis is an important and frequent diagnosis. But, it is also known that pain can persist even after medical and surgical treatment. Not all chronic pelvic pain sufferers have endometriosis and not all endometriosis patients have pain. The severity of pain and the stage of endometriosis are not correlated. Minimal and mild endometriosis tends to be more painful than severe or deep infiltrative endometriosis. As many as a third of asymptomatic tubal ligation patients may incidentally be found to have endometriosis. 

Failure to cure the pain associated with endometriosis is linked to having intervened after making a wrong diagnosis, incomplete or insufficient treatments, or overlooking treatment of other contributing diagnoses. The diagnosis of endometriosis overlaps with several other painful pathologies. Endometriosis and painful bladder, the evil twin's syndrome, is one of many such combinations. Irritable bowel and myalgia due to pelvic floor tension also frequently co-exist with endometriosis. When endometriosis is suspected, diagnostic work should be comprehensive, including a systematic search for all other visceral or somatic causes of pain. Visual diagnosis of endometriosis should always be backed by tissue diagnosis confirmation at laparoscopy.

Beyond endometriosis

There is more than endometriosis that is worthy of attention. Women should be managed on the basis that there are multiple pain generators. The modern theories of chronic pain should be understood. When a primary pain generator persists and produces a prolonged painful stimuli, a neurological phenomenon is triggered that causes abnormal pain processing and inadequate central and peripheral responses. Secondary pain is then generated. Endometriosis, but also myofascial syndrome, fibromyalgia, irritable bowel syndrome, musculoskeletal causes, pelvic floor dysfunction, painful bladder syndrome, and peripheral neuropathies all are linked up in this way.

The exact mechanisms involved in the pathophysiology of chronic pain remain under investigation. However, it is believed that acute and long-term changes occur in both the central and peripheral nervous systems. Women who suffer chronic pain are victims of the vicious circle of pain-disability-pain. Among the various pain mechanisms involved are neuronal hyperexcitability, allodynia (pain with stimuli that are not painful in normal people) and hyperalgesia (pain more severe than that actually generated by a painful stimulus). There is the development of cross-talk in the pain pathways of the pelvic organs. Painful signals from the main organs of the pelvis, such as bladder, colon, rectum, and uterus overlap in way that focus on a single organ for directing therapy makes no sense. Given the implications of central and peripheral nerve sensitization in chronic pain, control of symptoms requires a broad, not narrow focus.

Conclusion

Given the current understanding of the neuropathy of pain, and the failure of single organ focussed traditional therapy, an integrated approach to treatment has the best chance of a successful outcome in chronic pelvic pain. The goal should be to educate the sufferer, to comprehensively diagnose her condition, to engage her in shared decision-making, to treat each of the multiple pain generators, and to target improving her life quality.

Author: Professor Khalid Khan