Disclaimer: This guideline has been reaffirmed for use and approved by Board of The Society of Obstetricians and Gynaecologists of Canada. A revision is underway.
REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINENo. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
Section snippets
CHAPTER 1: PHYSIOLOGICAL ASPECTS OF CHRONIC PAIN
John F. Jarrell, MD, Calgary, AB
This consensus statement cannot provide a complete summary on the physiological aspects of pain, but the members of ttie consensus panel felt that a brief summary, particularly in relation to chronic pain, was warranted. Additional references are provided.1, 2, 3, 4
PERIPHERAL NERVES
Pain sensation begins with the stimulation of a nociceptor, or nerve ending, and resultant activation of a sensory nerve. A signal passes through the lightly myelinated A delta fibres, which are responsible for the appreciation of cold and mechanical stimuli that produce stinging, sharp, fast pain. Also stimulated are the C fibres, which are associated with mechanical and thermal stimuli and transmit warm pain. Specialized bodies are responsible for the appreciation of texture (1vfeissner's
CENTRAL NERVOUS SYSTEM
Stimuli travelling to the spinal cord pass through the cord's dorsal roots, which contain the nuclei of the sensory nerves from both the soma and the viscera. These nerves convey stimuli to the spinothalamic tract of the spinal cord through an important synapse governed by a complex array of neurotransmitter messages that involve the N-methylĀ D-aspartate (NMDA) receptor.56
When stimuli through the sensory nerves become very intense, a process called "winding up" can develop, generating a great
THERAPY
Therapy at the level of the cord is directed to the NMDA receptor. Novel neuroleptics, such as gabapentin, inhibit excessive stimulation of the secondary neurons in the spinal cord, as do carbamazepine, phenytoin, and clonazepam. Modulation of gamma-aminobutyric acid-receptors may be inhibited by electric stimulation.
Therapy directed at the central processes of central inhibition include the use of opiates that act on the dorsal horns of the spinal cord and agents that increase the inhibition
CHAPTER 2: SCOPE, DEFINITION, AND CAUSES OF CHRONIC PELVIC PAIN
Catherine Allaire, MD, Vancouver, BC
SCOPE
Chronic pelvic pain (CPP) in women is one of the most common and difficult problems encountered by health care providers. CPP accounts for about 1 in 10 outpatient gynaecology visits and is the indication for an estimated 15% to 40% of laparoscopies and 12% of hysterectomies in the United States.9 The true incidence and prevalence, as well as the socioeconomic impact, of the problem are unknown. In a Gallup poll of 5325 US women, 16% reported problems with pelvic pain: because of CPP, 11%
DEFINITION
Various definitions of CPP have been used, but most investigators consider a minimum duration of 6 months to define the pain as chronic. However, because of the delay in seeking help and then getting appropriate referrals, there has been a trend toward using 3 months instead. Either way, these cut-off points are arbitrary and lack empiric validation.
Chronic pain syndrome usually encompasses the following clinical characteristics11:
- ā¢
duration of 6 months or longer;
- ā¢
incomplete relief with most
- ā¢
CAUSES
There are many recognized causes of CPP; the Table 2.1 lists those that are common. Many gynaecologic pathological conditions (adhesions, endometriosis, etc.) are more frequent in women with CPP, but the development of a chronic pain syndrome is often multifactorial. Clinical evaluation must therefore be thorough from a medical, surgical, and psychological standpoint. Organic and physiological changes affecting the reproductive tract, surrounding viscera, and musculoskeletal system can coexist
CHAPTER 3: HISTORY-TAKING, PHYSICAL EXAMINATION, AND PSYCHOLOGICAL ASSESSMENT
Catherine Allaire, MD, Vancouver, BC Paul Taenzer, PhD, CPsych, Calgary, AB
HISTORY-TAKING
Nowhere is the history more important than in assessing patients with chronic pain. It is crucial to get a detailed chronologie history of the problem, with careful attention to aggravating and alleviating factors, as well as results of previous attempts at treatment. It is useful to get a sense of what the patient thinks is contributing to her pain, as often she will have insight into her condition and fears that need to be addressed. The clinician should elicit symptoms denoting possible
PHYSICAL EXAMINATION12
The physical examination of a patient with CPP is very different from a routine gynaecologic examination. It may be necessary to defer the examination to the second visit because of time or the patient's distress after recounting her history. It is important to convey to the patient that she will control the timing of the examination and may elect to terminate it at any time.
If the pain is intermittent, it is best to examine the patient when she is in pain. The goal of the examination is to
PSYCHOLOGICAL ASSESSMENT
Modern definitions of pain acknowledge both sensory and affective aspects of the experience. Furthermore, particularly when moderate or severe, CPP can have a negative impact on the woman's capacity to function in family, sexual, social, and occupational roles. This condition is called chronic pain syndrome. Thorough evaluation of the woman experiencing CPP must include an assessment of her emotional experience and other aspects of the chronic pain syndrome.
A psychosocial assessment conducted
CHAPTER 4: INVESTIGATIONS
Paul Martyn, MB, Calgary, AB
INTRODUCTION
After thorough history-taking and physical examination, specific diagnostic tests may be appropriate in patients with chronic pelvic pain (CPP). These may include complete blood count, culture of cervical swabs, and urinalysis.
DIAGNOSTIC IMAGING
Diagnostic imaging should be performed only when indicated by the history and physical findings.
Transvaginal ultrasonography is useful for evaluating pelvic masses and adenomyosis and is more sensitive than transabdominal scanning.20 When a mass is found in the pelvis, ultrasonography is effective in distinguishing cystic from solid lesions. Doppler studies evaluate the vascular characteristics of the lesion.
Magnetic resonance imaging (MRI) is useful for characterizing pelvic masses. It may be
DIAGNOSTIC LAPAROSCOPY
Laparoscopy is indicated in patients with CPP in whom a pelvic abnormality is suspected, the goal being to find and treat contributing conditions. A thorough clinical assessment may lead to avoidance of unnecessary surgical procedures.
Forty percent of diagnostic laparoscopies are done for CPP, and 40% of these reveal nothing abnormal. Of those revealing abnormalities, 85% show endometriosis or adhesions.24 Negative results of laparoscopy do not exclude disease or mean there is no organic basis
CHAPTER 5: SOURCES OF CHRONIC PELVIC PAIN
George A. Vilos, MD;1 Hassan Shenassa, MD;2 Basim Abu-Rafea, MD1
1London ON
20ttawa ON
Various abnormalities may lead to chronic pelvic pain (CPP); however, not all women with these conditions will exhibit CPP.
ENDOMETRIOSIS
A detailed consensus statement on endometriosis was published by the Society of Obstetricians and Gynaecologists of Canada (SOGC) in 1999.27
Endometriosis is a condition of unknown etiology and pathogenesis. It is defined clinically as the presence of endometrium outside of the endometrial cavity. Both endometrial glands and stroma have to be present for a histologic diagnosis of endometriosis.
Current etiologic theories suggest genetic and environmental interaction, as in many chronic
ENDOSALPINGIOSIS
Endosalpingiosis first described by Sampson45 in 1927, is the presence of ectopic fallopian tube-like ciliated epithelium without stroma. As with endometriosis, the histogenesis is unknown. Possible mechanisms include coelomic metaplasia or implantation of tubal epithelial tissue. The distribution and gross appearance of the lesions of endosalpingiosis are the same as those of endometriosis. Several case studies have reported that endosalpingiosis may be associated with CPP.
A prospective study
ADENOMYOSIS
Adenomyosis is a condition of unknown etiology and pathogenesis. It is defmed histologically as the presence of endometrial glands and stroma deep within the myometrium. The uterus is usually enlarged and diffusely boggy to palpation. The adenomyotic foci may be diffusely distributed or be well-localized, forming adenomyomas (nodules of hypertrophic myometrium and ectopic endometrium). The reported incidence of adenomyosis ranges from 5% to 70%.48 Most cases occur in parous women in the fourth
PELVIC PERITONEAL DEFECTS (POCKETS)
A defect, or a pocket, in the pelvic peritoneal floor was first illustrated by Sampson45 in 1927 as he was describing endometriotic implants in the peritoneal cavity. In 1981, Chatman58 reported peritoneal defects in 25 (4%) of 635 consecutive patients undergoing diagnostic laparoscopy, 75% for CPP and 25% for infertility, among whom endometriosis was found in 192 women (30%). The frequency of peritoneal defects in women with CPP was 7%. In 7 (28%) of the 25 women, the defect was the only
ADHESIONS
Intraperitoneal adhesions are caused mainly by surgery and to a lesser extent by endometriosis and abdominal and pelvic inflammation or infection.64 The fmancial impact of adhesions is enormous.65 In the United States, adhesiolysis was responsible for 303 836 hospitalizations during 1994, primarily for procedures on the digestive and female reproductive systems, which accounted for 846 415 days of inpatient care and $1.3 billion in hospitalization and surgeon expenditures.66
Adhesions are found
PELVIC INFLAMMATORY DISEASE (PID)
PID is a common condition that carries several long-term sequelae, one of which is CPP. CPP has been reported to occur in 18% to 33% of women after an episode of PID, regardless of mode of antibiotic therapy.7071 The corresponding figure was 5% in a control series of women who had never had PID.68 Although pelvic adhesions after PID are thought to be the cause of CPP, the exact etiology remains unknown. One study showed a reduction in physical and mental health among women with CPP after PID.72
OVARIAN CYSTS
Unilateral CPP is often attributed to ovarian cysts, if present. Chronic ovarian cysts, however, do not usually produce pain. Although small studies have shown successful treatment of CPP in patients with ovarian cysts,74 no randomized clinical trials have addressed this issue.
RESIDUAL OVARY SYNDROME (ROS)
ROS is characterized by either recurrent pelvic pain or a persistent pelvic mass after hysterectomy.75
One study reported an incidence of ROS of 2.8% (73 cases) after 2561 hysterectomies with preservation of one or both ovaries over a 20-year period.76 There was no correlation between unilateral or bilateral ovarian preservation and development of ROS. Indications for removal of one or both of the residual ovaries included CPP in 52 patients (2.0%), persistent asymptomatic pelvic mass in 18
OVARIAN REMNANT SYNDROME (ORS)
ORS is the persistence of functional ovarian tissue after the intended removal of the ovary. The true incidence of ORS is not known. The condition is often not suspected in women with CPP who have had oophorectomies.77 The syndrome arises from unintentional, incomplete dissection and removal of the ovary during a difficult or emergency oophorectomy or implantation and growth of displaced ovarian tissue in the abdomen or pelvic cavity during oophorectomy. The condition is often encountered in
PELVIC CONGESTION SYNDROME
For more than half a century, dilated pelvic veins have been observed in some women with CPP. Symptoms may include a dull aching pain as well as menstrual disorders. Vulvar varicosities may be associated. Pelvic venography, Doppler ultrasonography, and MRI have been used to diagnose pelvic congestion syndrome.80, 81, 82 A recent study of asymptomatic kidney donors showed a 38% incidence of pelvic congestion syndrome, diagnosed by MRI detection of dilated pelvic veins. Hysterectomy as a
POST-HYSTERECTOMY CPP
CPP has been listed as the principal preoperative indication for 10% to 12% of hysterectomies in the United States8384 and Canada.40 Stoval et al.85 evaluated 99 women with CPP of unknown etiology after excluding endometriosis and adhesions. Histopathologic analysis of surgical specimens revealed adenomyosis in 20% of patients, fibroids in 12%, and both in 2%. At an average follow-up of 22 months, 22% of the women reported persistent pelvic pain.
Hillis and colleagues84 reported on a prospective
POST-HYSTERECTOMY ENDOMETRIOSIS
Among women with a previous hysterectomy and BSO (for different conditions), when laparoscopy was performed because of CPP, endometriosis was found in 34%.86
PELVIC PAIN IN THE ABSENCE OF GENITAL PELVIC ORGANS
Behera and associates87 evaluated laparoscopically 115 women, 22 to 68 years old, with chronic pain after hysterectomy and BSO. Findings at laparoscopy were adhesions in 107 patients, adnexal remnants in 32 (ovarian in 26 and tubal in 6), abnormal appendix in 19, and abnormal peritoneum in 14. Four peritoneal biopsies revealed endometriosis. Six appendices showed disease: endometriosis in two, chronic inflammation in one, and obliterated lumen in three. Of the 104 patients who were followed up
UTERINE FIBROIDS
Uterine fibroids (leiomyomas) are benign monoclonal tumours derived from the smooth muscle of the uterus. These tumours may be due to genetic pleiomorphisms, with a genetic-environmental interaction. They may be submucosal, intramural, subserosa!, or pedunculated. A detailed clinical practice guideline on uterine myomas was published in the Journal if Obstetrics and GynaecoloJ!)I Canada in 2003.88 Although dysmenorrhea and pelvic pressure symptoms may be due to the fibroids, other conditions,
ADNEXAL TORSION
Adnexal torsion may produce pain by mechanical, hypoxic, or chemical tissue changes. Unilateral CPP is often attributed to ovarian cysts, if present. Chronic ovarian cysts, however, do not usually produce pain. Although small studies have shown successful treatment of CPP in patients with ovarian cysts,74 no randomized clinical trials have addressed this issue.
Recommendations Ā Hysterectomy for endometriosis or adenomyosis with ovarian conservation can be an acceptable alternative.
CHAPTER 6: UROLOGIC AND GASTROINTESTINAL CAUSES OF CHRONIC PELVIC PAIN
Louise Lapensee, MD, FRCSC
MontrƩal QC
Chronic pelvic pain (CPP) is a complex syndrome that involves biologic and psychosocial phenomena. This chapter will focus on urologic and gastrointestinal causes (Table 6.1), particularly the two most frequently found in women with CPP.
INTERSTITIAL CYSTITIS (IC)
IC is a poorly understood chronic inflammatory condition of the bladder whose study is complex and frustrating. Its causes are unknown, its pathophysiology remains uncertain, and the efficacy of treatment regimens is questionable. The prevalence ofiC in the United States is 10 to 67/100 000; women predominate 10 to 1.90, 91, 92 Possible causes include infection, lymphatic or vascular obstruction, immunologic deficiencies, glycosaminoglycan layer deficiency, presence of a toxic urogenous
IRRITABLE BOWEL SYNDROME (IBS)
IBS affects up to 15% of adults, twice as many women as men.107 Patients present with abdominal pain and discomfort, bloating, and disturbed bowel habits (diarrhea, constipation, or both). The multifactorial pathophysiology mcludes altered bowel motility, visceral hypersensitivity, and psychosocial factors.
SOGC CLINICALCHAPTER 7: MYOFASCJAL DYSFUNCTION
Robert Gerwin, MD1; Paul Martyn, MB BS2; John F. Jarrell, MD2
1Baltimore MD
2Calgary AB
INTRODUCTION
The diagnosis of myofascial abdominal and pelvic pain is commonly overlooked by the general gynaecologist. Reiter and Gambone120 reported on 122 patients with chronic pelvic pain (CPP) who had been referred to a multidisciplinary clinic after negative results of laparoscopy and underwent a thorough medical and psychological evaluation and followup for a minimum of 6 months after completion of therapy. Myofascial pain was the most common somatic diagnosis, accounting for 30% of such diagnoses.
PATHOPHYSIOLOGICAL ASPECTS
In the neuromuscular stage, muscle hyperactivity and irritability are sustained by mechanical and postural stressors and prolonged contraction of muscle. Injury or microtrauma releases free calcium within muscle. Conscious awareness of pain provokes muscle guarding and splinting. In the musculodystrophic stage, after sustained contractile activity the muscle attempts to adapt by increasing metabolic activity, which results in localized fibrosis.121
Travell and Simons122 defined a myofascial
MYOFASCIAL PELVIC PAIN
Hypertonus of the levator ani group of muscles (pelvic floor tension myalgia) produces pain poorly localized to the perivaginal and perirectal areas. Pain may also be felt in the abdominal lower quadrants, suprapubic areas, coccyx, and posterior thigh. Piriformis syndrome is a similar problem in the adjacent piriformis muscle. These disorders involve a high resting tone in the muscles and fascia that attach to the bony pelvis.
Interstitial cystitis (IC), vulvodynia, and urethral syndrome
TREATMENT OVERVIEW
Patient education on pelvic floor function is vital to successful physical therapy. Physiological quieting and general relaxation with the use of biofeedback are taught to patients.
Manual soft tissue release is essential to reduce pelvic floor resting tone and tension. Acupuncture may also be helpful.121
It is important to inactivate trigger points to restore muscle to its normal resting length before strengthening. Trigger points can be injected with local anesthetic, dry-needled, massaged, or
OFFICE APPROACH TO MYOFASCIAL SOURCES OF GYNAECOLOGIC PAIN
Gynaecologic pain, or pain of pelvic origin, can arise from visceral organs in the pelvis, the muscular body wall (including the abdomen and low back muscles), the muscles of the hip region and upper thigh, and the lumbosacral nerves (nerve roots and peripheral nerves). Visceral pain has a wide variety of causes, both pathological (e.g., those associated with tissue damage or inflammation) and nonpathological (e.g., distention or increased capsular pressure). Pain in muscles, whether those of
Injections
Inactivation of a trigger point by injection appears to result from the mechanical action of the needle at the trigger point, since it can be accomplished by dry needling without local anesthesia or the use of other materials. Local anesthesia is more comfortable for many patients and results in a longer-lasting reduction in trigger-point pain.126,127
A local twitch response or a report of referred pain indicates that the trigger zone has been entered. A small amount of anesthetic, usually 0.1
CHAPTER 8: MEDICAL THERAPY-EVIDENCE ON EFFECTIVENESS
Claude Fortin, MD; 1 Robert H. Lea, MD2
1MontrƩal QC
2Halifax NS
INTRODUCTION
In clinical practice, there are two approaches to the treatment of chronic pelvic pain (CPP). One is to treat the pain as a diagnosis and the other is to treat the disorders that cause or contribute to the pain.26 In many patients, effective medical therapy could be achieved by using both approaches.
Detailed treatment of CPP associated with endometriosis was outlined in the SOGC consensus guideline in 1999.27 A meta-analysis of interventions for CPP not associated with endometriosis, primary
ANALGESICS
These include acetylsalicylic acid, nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, narcotics, and medicinal marijuana. NSAIDs have been studied extensively in randomized controlled trials (RCTs) for dysmenorrhea and have proven efficacious.144,145 However, individual response varies widely, and it seems reasonable to try different compounds before abandoning or adding another therapy. Even if not specifically studied for noncyclic CPP, empiric use of NSAIDs is among the first-line
Oral Contraceptives (OCs)
Various low-dose OCs have proven successful in studies of the initial management of dysmenorrhea.150,151 These studies included patients not screened by laparoscopy, which suggests that patients with or without endometriosis were included. Only one report of an RCT of low-dose OCs for CPP and endometriosis has been published so far.151 In this 6-month trial comparing cyclic OCs with a gonadotropin-releasing hormone (GnRH) agonist in women with laparoscopically diagnosed endometriosis, OCs were
ANTIBIOTICS
The value of antibiotics in the management of CPP is controversial. Most US management algorithms include antibiotics, but these agents are of value only if criteria for PID are present. The US Centers for Disease Control recommends treating suspected PID, even if cervical cultures are negative, to prevent complications such as infertility.161
ANTIDEPRESSANTS
Antidepressants have been used to treat numerous chronic pain syndromes. However, some studies on tricyclic antiĀ depressants in women with CPP and normal results of laparoscopy have reported a decreased intensity and duration of pain.162 Since depression is more frequent in patients with CPP, antidepressant therapy and psychological support, in conjunction with other medical therapy, might improve clinical outcomes.162
NEUROLYTIC THERAPY
Neurolytic therapy may be done by injecting neurotoxic chemicals (phenol or alcohol) or using energy (heat, cold, or laser) in doses sufficient to destroy neural tissue. Although these therapies are most often used to treat a particular nerve dysfunction, they may also be used more centrally to try to decrease pain even if there is no specific diagnosis or specific nerve dysfunction.146
TREATMENT OF SPECIFIC DISORDERS
CPP often originates from a specific disorder. Interstitial cystltls, irritable bowel syndrome, adhesions, musculoskeletal diseases, endometriosis, and psychosocial problems are the most frequent. Most of these common diagnoses have been studied in reasonably good trials, and their treatment has been addressed elsewhere in this consensus guideline.
SUMMARY
Selection of a first-line medical therapeutic agent should be based on the nature of the pain, contraindications to medications, and desire for contraception. NSAIDs, OCs, or both should be tried early on, especially if the origin of the pain is suspected to be endometriotic. If therapy fails, second-line options, such as danazol, a progestin, or a GnRH agonist (with add-back therapy), have to be considered for a predetermined period. Empiric medical therapy could be cost-effective. If adequate
CHAPTER 9: SURGERY-EVIDENCE ON EFFECTIVENESS
Nicholas A. Leyland, BSc, MD, FRCSC, FSOGC;1 Hassan Shenassa, MD, FRCSC2
1Toronto ON
2Ottawa ON
SURGICAL MANAGEMENT OF PELVIC ADHESIONS
There is evidence from one Cochrane study163 that the surgical management of pelvic adhesions associated with endometriosis is effective in the management of pain for 6 months. The combined surgical approach of laparoscopic laser ablation, adhesiolysis, and uterine nerve ablation is likely to benefit patients with pelvic pain associated with minimal, mild, or moderate endometriosis. However, since only one trial was included in the analysis, this conclusion should be interpreted with caution.
PSNAND LUNA
Adjunctive laparoscopic surgical procedures, including PSN and LUNA, can be technically demanding but continue to have a role in the management of CPP.179
Any surgical management of pelvic pain requires an understanding of the autonomic innervation of the pelvis. The disruption of afferent neural signals from the pelvic organs can reduce the perception of pain caused by endometriosis and other disorders.180
A prospective comparison of PSN and LUNA indicated that they were equally efficacious in
CHAPTER 10: PSYCHOLOGICAL TREATMENT FOR CHRONIC PELVIC PAIN
Paul Taenzer, PhD, CPsych
Calgary AS
INTRODUCTION
Among the psychological treatments for chronic pain, cognitive-behavioural therapies (CBTs) are the most widely used and have the strongest empiric support.183 CBTs for chronic pain management address the multiple determinants of the chronic pain experience. This spectrum of treatment methods engages chronic pain sufferers in an exploration of their personal pain modulators. The treatment approach provides instruction in strategies and skills for controlling the modulators through the patient's
STRATEGIES
Treatment strategies included within the rubric of CBT include training in muscular relaxation, meditation, stress management techniques, recognizing and modifying negative or catastrophic cognitions or thoughts that amplify arousal and feelings of helplessness, lifestyle modification (including pacing of activities to avoid overexertion followed by exhaustion and physical de-conditioning), re-engagement in physically appropriate and personally fulftlling activities, and effective communication
CHAPTER 11: MULTIDISCIPLINARY CHRONIC PAIN MANAGEMENT
Paul Taenzer, PhD, CPsych
Calgary AB
DEFINITION
Multidisciplinary chronic pain management refers to assessment, treatment planning, and ongoing coordination of intervention provided by a team of health care providers from relevant medical specialties and allied health provider disciplines.
MANAGEMENT CENTRES
Multidisciplinary pain management is typically provided in a chronic pain clinic or centre wherein the providers are all located and routinely provide joint assessment and treatment services. A standardized classification of pain centres has been developed by the International Association for the Study of Pain. The four types of centres include modalityĀ oriented clinics, pain clinics, multidisciplinary pain clinics, and multidisciplinary pain centres. Modality-oriented clinics provide one or
SCOPE OF CARE
Multidisciplinary care is commonly tailored to the particular needs of the patient and may include a combination of medical and rehabilitative intervention focused on eliminating or modifying the biological pain generators, as well as psychological and psychosocial intervention focused on helping the client, and her important social and family contacts, adapt successfully to the changes in function and capacity engendered by the chronic pain state. Multidisciplinary pain centres extend their
OUTCOMES RESEARCH
Multidisciplinary chronic pain management has been the subject of extensive outcomes research for the past 25 years. Systematic reviews of this literature189-191 have confirmed the value of this treatment approach with regard to clinical outcomes for low back pain. A Cochrane systematic review of interventions for the treatment of CPP in women143 provided support for multidisciplinary management that was based on one randomized controlled trial.192 Systematic reviews of the economic outcomes of
CHAPTER 12: COMPLEMENTARY AND ALTERNATIVE MEDICINE
Susan Burgess, MD, Vancouver BC
INTRODUCTION
The pathogenesis of chronic pelvic pain (CPP) remains poorly understood, and, therefore, treatment is often unsatisfactory.194 Consequently, complementary and alternative medicine (CAM) is increasingly of interest to both patients and health care providers. The Cochrane Collaboration now has more than 1750 completed Cochrane reviews, of which more than 100 relate to CAM.195
However, the literature specifically relating to CPP and CAM is limited. As with the literature from allopathic sources,
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION AND ACUPUNCTURE
The Cochrane Collaboration has reviewed the use of TENS and acupuncture, when compared with one another, with placebo, with pharmacotherapy, and with no treatment.196 Nine RCTs were identified, and the review concluded that high-frequency TENS was effective in the treatment of dysmenorrhea. One methodologically sound trial of acupuncture also suggested benefit.199
A case report on a 23-year-old primigravida with CPP at 27 weeks gestation documented that acupuncture significantly reduced the
PLANTS AND' HERBAL AND DIETARY THERAPIES
Traditional healing provides for a large percentage of primary health care needs in many populations. One study screened plants used by South African Zulu traditional healers in the treatment of dysmenorrhea.203 Several plant extracts exhibited high inhibitory activity against cyclooxygenase and therefore the prostaglandin biosynthetic pathway responsible for painful uterine contractions.
The Cochrane Review of herbal and dietary therapies for primary and secondary dysmenorrhea204 suggested that
SUMMARY
CPP is a frustrating and disabling condition, with as yet unclear neuroendocrine etiology. A multidisciplinary approach to diagnosis and care is currently recommended.191 For visceral-peritoneal pain, acupuncture is beneficial. Musculoskeletal sources of pain respond to physiotherapy and biofeedback training. Somatic-myofascial pain has been reduced with massage, ultrasound stimulation, TENS, and, especially, trigger-point injection and dry-needling modalities. Grounding all treatment is the
CHAPTER 13: PATIENT PERSPECTIVES
John F. Jarrell, MD, Calgary AB
PATIENTS' NEEDS
A 2002 needs assessment survey by the Society of Obstetricians and Gynaecologists of Canada (SOGC) of subjects with chronic pelvic pain (CPP), undertaken using the principles of qualitative research, determined that the following were the most important needs of these patients:
- ā¢
the need for the health care professional to legitimize the pain,
- ā¢
the need for the patient to be heard during the patient contact visit,
- ā¢
the need for the patient to receive support in numerous forms, and
- ā¢
the need for the
- ā¢
A LOOK INTO THE FUTURE
In the future, a woman with CPP will be recognized as having a condition that requires rehabilitation and not solely acute care management. She will be managed by a team of individuals who are aware of the principles of multidisciplinary care, including a physiotherapist, a psychologist, a primary care physician, and a gynaecologist. Such an approach will be funded by the local hospital or regional health authority on the basis of its effectiveness and cost efficiency.
Emphasis will be placed on
CHAPTER 14: FUTURE DIRECTIONS
John F. Jarrell, MD, Calgary, AB
EDUCATION
A 2002 needs assessment survey by the Society of Obstetricians and Gynaecologists of Canada (SOGC) on the management of chronic pelvic pain (CPP) revealed a desire for more training in the recognition and management of CPP. SOGC members expressed the need to modify the approach to CPP and for help in diagnosing its causes.
The lack of knowledge in assessing CPP etiology is most evident in the identification of trigger points. The broad scope of CPP requires further education of medical students,
RESEARCH
Research is needed to identify psychoneurologic dysfunctions that are responsible for CPP so that we can adequately treat and possibly cure the condition.
Recommendations Ā The curriculum for professional development should be expanded to include theory and techniques in the management of myofascial dysfunction (A). Research into CPP should be encouraged, particularly in the areas of the impact of CPP on the use of health services, the pathophysiology of myofascial dysfunction, and
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2022, Disease-a-MonthCitation Excerpt :CPP can be seen in adolescent females and recurrent PID has been linked with over a 4-fold rise in chronic pelvic pain449. CPP is a complex condundrum that is difficult to manage and requires a multidisciplinary approach covering potentially both gynecologic and/or non-gynecologic causes of pain340, 450-454. Management options for PID are summarized in Table 6 and include the 2015 CDC STD treatment guidelines; indeed, a high management threshold is important for PID considering, as discussed in the last section, the potential complications of missed PID77, 255, 259, 345.
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate and tailored to their needs.
This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of all people - including transgender, gender non-binary, and intersex people - for whom the guideline may apply. We encourage healthcare providers to engage in respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate care. The values, beliefs and individual needs of each patient and their family should be sought and the final decision about the care and treatment options chosen by the patient should be respected.
Ā© 2018 Published by Elsevier Inc. on behalf of Society of Obstetricians and Gynaecologists of Canada.