Chronic pelvic pain: A meta-analytic review

'I have no life and neither do the ones watching me suffer': women's experiences of transvaginal mesh implant surgery

Objective: Many women are affected by pelvic floor disorders, such as stress urinary incontinence and pelvic organ prolapse. In recent years, these disorders have been treated with transvaginal mesh implant surgeries involving the vaginal insertion of woven netting. We explored women's experiences of transvaginal mesh implant surgery through a biopsychosocial lens. Design: We analysed women's submissions to an Australian Parliament Senate Inquiry on transvaginal mesh implant surgery using thematic analysis. Main Outcome Methods: One-hundred and fifty-three publicly available submissions detailing women's experiences of transvaginal mesh implant surgery to an Australian Parliament Senate Inquiry were analysed. Adverse and positive accounts were eligible for inclusion. Results: We generated nine themes in three categories relating to the Biopsychosocial Model: Physical Health - comprising three themes; Psychological Health - comprising two themes; and Social Wellbeing - comprising four themes. Physical, psychological and social experiences interacted, resulting in reduced quality of life for women. Conclusion: Most women who made submissions to an Australian government inquiry about transvaginal mesh implant surgery described devastating impacts on physical, psychological, and social wellbeing. We provide recommendations to guide psychologists in assisting women with adverse transvaginal mesh-related outcomes. Further research should explore women's long-term experiences of the various transvaginal mesh procedures.

Cultural aspects of pain: A study of Indian Asian women in the UK

OBJECTIVES

Culture and ethnicity are acknowledged as important factors in the context of the biopsychosocial model. They may contribute to explaining the experience of pain, therapeutic encounters within healthcare, and the strategies that individuals use to cope with pain. The present study explored these issues in a sample of Indian Asian women in the UK.

METHODS

Based on a phenomenological approach, 17 women participated in five semi-structured group interviews. Data were analysed using qualitative content analysis, so as to identify core themes and subthemes inductively from the data.

RESULTS

Six themes were identified: meaning of pain; personal experience of pain; causes of pain; coping strategies; family and friends; experience of healthcare. Pain was conceptualized in both physical and mental terms, and its experience was explained largely in terms of functional consequences. The causes of pain offered suggested externalized beliefs, relating to events in participants' lives, rather than being expressed in biomedical terms. Alongside culture-specific therapies, the women spoke of coping strategies based on rest and activity. Although satisfaction with healthcare appeared to be high overall, problems due to communication - sometimes related to a language barrier - were voiced by some participants.

CONCLUSIONS

Greater attention to cultural aspects of the pain experience may assist health professionals in communicating with and managing patients with pain from ethnic minority backgrounds.

Child Sexual Abuse and Intimate Partner Violence Victimization in Adulthood: Sex-Differences in the Mediating Influence of Age of Sexual Initiation

Child sexual abuse is a major public health concern in the United States with devastating sequelae. Although the relationship between child sexual abuse and intimate partner violence victimization in adulthood is known, little is known about the mediating influence of the age of sexual initiation on the association, or whether sex differences exist. Using data from waves I, III, and IV of the National Longitudinal Study of Adolescent to Adult Health (N = 1,163), we aimed to examine the mediating influence of age of sexual initiation on the association between child sexual abuse and intimate partner violence victimization in adulthood and identify sex differences. Findings reveal that in female survivors, age of sexual initiation partially mediated the association between child sexual abuse and physical intimate partner violence victimization in adulthood. In male survivors, no mediational effect was observed. Public health practitioners should be aware of sex differences in the effect of early sexual initiation on intimate partner violence victimization in adulthood among child sexual abuse survivors.

Symptom onset and the socially sanctioned pathway: the example of diet

Theories of symptom perception do not explain symptom onset, nor why symptoms vary according to culture and time. This article attempts to explain cultural, temporal and individual variation in symptoms, and presents a new three-stage model of symptom onset. First, it is argued that tensions relating to issues of conflict and control arise as an individual interfaces with their social world and that this requires communication. Second, it is suggested that symptoms are embedded with culturally specific meanings which offer up a socially sanctioned pathway as a forum for communication. Third, if this pathway is appraised as personally relevant, the symptoms offered by the pathway will be adopted as the forum for communication. The resulting symptoms are therefore both culturally and personally meaningful. This model is derived from an analysis of the literature on diet, but is also offered as a means to understand the onset of other common symptoms.

Evaluation of the frequency and the association of sexual pain and chronic headaches

BACKGROUND

Sexual pain and chronic headaches are both complex conditions with associated high disability. Little research has examined whether there is a relationship between the 2. The aim of this survey-based study was to explore the frequency of sexual pain in a population of women being treated for chronic headache. Peripheral aims included exploring the number of patients receiving treatment for sexual pain and the association between sexual pain and libido, and history of abuse.

METHODS

Patients presenting to an ambulatory chronic headache clinic were administered a short 10-item survey.

RESULTS

Forty-four percent of patients reported that they had pelvic region or genital pain brought on by sexual activity. Only half of these patients had ever discussed their pelvic pain with a health care provider, and 31% of these patients had not received treatment. Almost all patients would be interested in treatment if available. Seventy-five percent of patients indicated a change in libido.

CONCLUSION

Chronic headaches and sexual pain are both conditions that have a significant impact on patients and the health care system, and they do coexist. More research is needed to look at the relationship between these conditions in addition to epidemiology, symptomatology, evaluation, and treatments.

Psychological factors and chronic pelvic pain in women: a comparative study with women with chronic migraine headaches

Chronic pelvic pain (CPP) is often attributed to psychogenic causation. To determine if women with CPP possess a unique psychological profile, this study examined the comparative pain experience, psychological functioning, and marital/sexual satisfaction of women with either CPP or chronic migraine headache (CH). Patients with CPP reported greater dissatisfaction with their marriage and greater sexual dysfunction. No differences were obtained for ratings of depression, anxiety, mood factors, or additional personality traits. These data suggest that, in general, when psychological disorders are observed in CPP patients, they most likely reflect the effects of chronic pain rather than be causative to it.

Presence of mental imagery associated with chronic pelvic pain: a pilot study

OBJECTIVE

To ascertain whether a small sample of patients with chronic pelvic pain experienced any pain-related cognitions in the form of mental images.

PATIENTS

Ten women with chronic pelvic pain consecutively referred from a tertiary referral center by the physicians in charge of their treatment.

OUTCOME MEASURES

An interview was used to determine the presence, emotional valence, content, and impact of cognitions about pain in the form of mental images and verbal thoughts. The Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), Spontaneous Use of Imagery Scale (SUIS), and Hospital Anxiety and Depression Scale (HADS) were completed.

RESULTS

In a population of patients with a prolonged duration of pain and high distress, all patients reported experiencing cognitions about pain in the form of mental images. For each patient, the most significant image was both negative in valence and intrusive. The associated emotional-behavioral pattern could be described within a cognitive behavioral therapy framework. Eight patients also reported coping imagery.

CONCLUSION

Negative pain-related cognitions in the form of intrusive mental imagery were reported by women with chronic pelvic pain. Targeting such imagery has led to interesting treatment innovation in the emotional disorders. Thus, imagery, hitherto neglected in pain phenomenology, could provide a novel target for cognitive behavioral therapy in chronic pain. These exciting yet preliminary results require replication and extension in a broader population of patients with chronic pain.

‘How do you explain a pain that can't be seen?’: The narratives of women with chronic pelvic pain and their disengagement with the diagnostic cycle

OBJECTIVES

Chronic pelvic pain (CPP) has an adverse effect on women's quality of life. Research has suggested that many women become dissatisfied with their care and withdraw from seeking help despite continuing symptoms. The aim of this study was to explore the processes which lead to disengagement and to understand the psychosocial processes that affect this group of women.

DESIGN

A qualitative narrative approach was used, guided by phenomenological-hermeneutic tradition, and informed by the philosophy of Paul Ricoeur.

METHOD

Thirty-two women with CPP were asked to write their stories about their illness trajectories. These written stories served as data which were analysed thematically according to narrative theory.

RESULTS

In the search for validation and recognition women engaged in the diagnostic cycle. Many women do not complete this cycle, become stuck at a certain point, or re-enter the cycle repeatedly. They can only opt out if the problem is resolved or by choosing to disengage with medical care.

CONCLUSIONS

While the medical consultation was a dominant theme, a complex interaction of factors was required to initiate disengagement. The dualistic nature of the diagnostic process prohibits women from telling their stories. Women were left feeling disempowered and in limbo, and they were at a loss as to how to manage their pain.

Is chronic pelvic pain a comfortable diagnosis for primary care practitioners: a qualitative study

Background

Chronic pelvic pain (CPP) has a prevalence similar to asthma and chronic back pain, but little is known about how general practitioners (GPs) and practice nurses manage women with this problem. A clearer understanding of current management is necessary to develop appropriate strategies, in keeping with current health care policy, for the supported self-management of patients with long term conditions. The aim of this study was to explore GPs' and practice nurses' understanding and perspectives on the management of chronic pelvic pain.

Methods

Data were collected using semi-structured interviews with a purposive sample of 21 GPs and 20 practice nurses, in three primary care trusts in the North West of England. Data were analysed using the principles of Framework analysis.

Results

Analysis suggests that women who present with CPP pose a challenge to GPs and practice nurses. CPP is not necessarily recognized as a diagnostic label and making the diagnosis was achieved only by exclusion. This contrasts with the relative acceptability of labels such as irritable bowel syndrome (IBS). GPs expressed elements of therapeutic nihilism about the condition. Despite practice nurses taking on increasing responsibilities for the management of patients with long term conditions, respondents did not feel that CPP was an area that they were comfortable in managing.

Conclusions

The study demonstrates an educational/training need for both GPs and practice nurses. GPs described a number of skills and clinical competencies which could be harnessed to develop a more targeted management strategy. There is potential to develop facilitated self- management for use in this patient group, given that this approach has been successful in patients with similar conditions such as IBS.

A cognitive behavioural based assessment of women with chronic pelvic pain

From population-based surveys, chronic pelvic pain (CPP) in women is a common condition with a spectrum of associated disability and distress. Those seen by gynaecologists in a referral setting often have substantial impairment of function and mood disturbance. Because in most cases, the aetiology of CPP cannot be explained and the range of effective interventions remains limited, treatment of CPP might easily result in a sense of frustration not only for the patient but also for the gynaecologist. To avoid this situation in clinical practice, a structured assessment of women suffering from CPP using a cognitive behavioural model, is suggested. This type of assessment provides information about the impact of CPP on a particular patient's daily life. It also facilitates referral for pain management. Future studies are needed to show further evidence of benefit of this approach for women with CPP.

The prevalence of child sexual abuse in community and student samples: a meta-analysis

BACKGROUND

Studies conducted internationally confirm that child sexual abuse is a much more widespread problem than previously thought, with even the lowest prevalence rates including a large number of victims that need to be taken into account.

OBJECTIVE

To carry out a meta-analysis of the prevalence of child sexual abuse in order to establish an overall international figure.

METHODS

Studies were retrieved from various electronic databases. The measure of interest was the prevalence of abuse reported in each article, these values being combined via a random effects model. A detailed analysis was conducted of the effects of various moderator variables.

RESULTS

Sixty-five articles covering 22 countries were included. The analysis showed that 7.9% of men (7.4% without outliers) and 19.7% of women (19.2% without outliers) had suffered some form of sexual abuse prior to the age of eighteen.

CONCLUSIONS

The results of the present meta-analysis indicate that child sexual abuse is a serious problem in the countries analysed.

Chronic pelvic pain: aetiology and therapy

Chronic pelvic pain (CPP) is a common condition in women and rates of consultation for CPP in general practice are similar to those for asthma and migraine. US and UK population-based studies, together with data from UK hospital settings demonstrate a substantial impact of CPP on health-related quality of life. In this review, we will examine the current evidence on the aetiology and management of CPP, focussing on the randomised controlled trials (RCTs) that are available to date. CPP is a heterogeneous condition and causation is often unclear. There are associations with specific pathological processes but a barrier to understanding is that many studies have data that are not comparable. In the community setting, as many as 60% of women with CPP have not received a specific diagnosis and up to 20% have not undergone any investigation. The factor most commonly associated with CPP in the community is irritable bowel syndrome, although in a tertiary setting with laparoscopy, pathology associated with CPP in ascending order of frequency is endometriosis (33%), adhesions (24%) and 'no pathology' (35%). Current RCT evidence provides some support for the use of ultrasound scanning as an aid to counselling and reassurance, progestogen (medroxyprogesterone acetate) or goserelin for pelvic congestion and a multidisciplinary approach to assessment and treatment. Adhesiolysis is not shown to be of benefit other than in women with extensive adhesions. While studied in relation to dysmenorrhoea rather than CPP, the short term results for presacral neurectomy (PSN) and laparoscopic utero-sacral nerve ablation (LUNA) seem to be similar, although PSN has better results in the long term. Selective serotonin reuptake inhibitor (SSRI) antidepressants have not been shown to be of benefit in CPP. Most of these conclusions are based on the outcome of single randomised trials and therefore need replication.

Coping with emotions and abuse history in women with chronic pelvic pain

OBJECTIVE

The purpose of this study was to investigate whether past abuse and the tendency to repress or suppress unwanted thoughts and emotions contribute to the experience of pain in patients with chronic pelvic pain (CPP).

METHODS

A group of CPP patients without endometriosis and a group with endometriosis were compared with a pain-free control group. Participants completed measures of pain, emotional repression, suppression of unwanted thoughts and emotions, and past abuse history.

RESULTS

Both CPP groups were more likely to be emotional suppressors when compared with the control group and reported significantly higher levels of thought suppression and abuse. Endometriosis patients were also more likely to be repressors of emotions when compared with controls. Suppression but not repression was related to higher levels of abuse and pain.

CONCLUSION

Suppression of unwanted thoughts and emotions and past abuse distinguishes CPP patients from healthy controls. Assisting patients to express distressing emotions may impact on pain levels.

Psychological factors associated with perception of experimental pain in vulvar vestibulitis syndrome

This study assessed the association between pain perception and psychological variables in women with vulvar vestibulitis syndrome (VVS) by comparing 28 VVS women with 50 healthy women. We assessed non genital systemic pain perception with quantitative sensory testing by administering experimental pain stimuli to the forearm. The VVS women demonstrated a lower pain threshold and a higher magnitude estimation of pain, combined with a higher trait anxiety, increased somatization, and a lower body image. Among the VVS women, nonvaginal pain catastrophizing was significantly related to reported pain during coitus. A cluster analysis revealed four subtypes of VVS women, as characterized by levels of pain and personality variables. I suggest implications for the assessment and treatment of women suffering from painful coitus.

Chronic pelvic pain in New Zealand: prevalence, pain severity, diagnoses and use of the health services

Chronic pelvic pain (CPP) in women is often debilitating and isolating. Problems with diagnosis continue to make CPP one of the most perplexing conditions in gynaecology, and one of the most difficult to treat.

OBJECTIVES

This paper reports the findings of a population-based study in New Zealand in 2001 designed to investigate the prevalence of chronic pelvic pain in women between the ages of 18 and 50. Chronic pelvic pain was defined as pain that is neither associated with the menstrual cycle nor sexual activity. The prevalence of dysmenorrhoea and dyspareunia was also sought. It further aimed to examine pain severity, diagnoses, and the use of the health services as these facets of CPP affect different groups of women within New Zealand.

METHODS

A random sample of 2261 was generated from the New Zealand Electoral Roll, and a postal questionnaire was administered during 2001. The response rate was 66% (adjusted for non-receivers), giving a study group of 1,160 respondents.

RESULTS

The three-month CPP prevalence rate was 25.4% (95% CI 22.8-27.9). Half of those women reporting CPP (47.7%) remained undiagnosed. The three-month prevalence of dysmenorrhoea was 55.2%, and dyspareunia 19.7%. Recent or past consulters of health services for CPP contained a higher proportion of women with a high pain burden than those not consulting health services. Only one-third of New Zealand women (34%) reported no form of chronic pelvic pain (i.e. no CPP, dysmenorrhoea or dyspareunia). These prevalence rates indicate that CPP should receive greater public education and clinical attention.

Multivariate Genetic Analysis of Chronic Pelvic Pain and Associated Phenotypes

Chronic pelvic pain (CPP) is a common condition in women that is difficult to diagnose. Although heritability estimates have been published for some conditions potentially underlying pelvic pain, the heritability of CPP itself has never been investigated. Using data from 623 MZ and 377 DZ female twin pairs aged 29-50 from an Australian twin cohort, we found an increased CPP concordance among MZs compared to DZs, with tetrachoric correlations of 0.43 (95% CI: 0.26-0.58) and 0.11 (95% CI: -0.16-0.38), respectively. This corresponded to a heritability of 0.41 (95% CI: 0.25-0.56). Lack of correlations with environmental indicators suggested that violation of the equal environments assumption was not responsible for this effect. Multivariate Cholesky decomposition models incorporating CPP and significantly correlated phenotypes showed that the entire CPP heritability could be explained by genetic variance underlying endometriosis (38%), dysmenorrhoea (23%), fibroids (24%), and somatic distress (15%), the latter a possible indicator of increased nociception. CPP itself is unlikely to be a useful independent phenotype to conduct genetic aetiological studies; contributing conditions such as endometriosis and variation in nociception are likely to provide more useful phenotypes.

Evidence for associations among somatoform dissociation, psychological dissociation and reported trauma in patients with chronic pelvic pain

This study investigates somatoform as well as psychological dissociation, somatization and reported trauma among patients with chronic pelvic pain (CPP). Women with CPP (n = 52) who were newly referred to a gynecology department, or whose pain had resisted treatment, completed standardized self-report questionnaires and received a structured interview for DSM-IV dissociative disorders. The prevalence of dissociative disorders in the sample was very low. As hypothesized, self-reported somatoform dissociation was positively correlated with self-reported psychological dissociation and features of DSM-IV dissociative disorders; women who reported more serious psychic trauma, in particular sexual and physical abuse, experienced more somatoform and psychological dissociation than women reporting less trauma, or no trauma at all; and the association of somatoform dissociation and reported trauma was stronger than the association of psychological dissociation and trauma. Physical abuse/life threat posed by a person predicted somatoform dissociation best. The results are consistent with findings among psychiatric patients, and, therefore, strengthen the thesis that somatoform dissociation, (features of) dissociative disorder, and reported trauma are strongly intercorrelated phenomena.

Chronic pelvic pain in the community--symptoms, investigations, and diagnoses

OBJECTIVES

This study was undertaken to investigate the overlap between chronic pelvic pain, dysmenorrhea, dyspareunia, irritable bowel syndrome, and genitourinary symptoms in the community and also to examine associated investigations and diagnoses.

STUDY DESIGN

A postal questionnaire was used to survey 3916 women aged 18 through 49 randomly selected from the Oxfordshire Health Authority Register. The number of responders was 2304 (74% of 3106 questionnaire recipients). Chronic pelvic pain was described as recurrent or constant pelvic pain of > or =6 months' duration unrelated to periods, intercourse, or pregnancy. Case patients (n = 483) were subgrouped as follows: (1) chronic pelvic pain only, (2) chronic pelvic pain and irritable bowel syndrome, (3) chronic pelvic pain and genitourinary symptoms, and (4) chronic pelvic pain, genitourinary symptoms, and irritable bowel syndrome.

RESULTS

Half the women with chronic pelvic pain also had either genitourinary symptoms or irritable bowel syndrome, or both. Prevalences of dysmenorrhea and dyspareunia were higher among women with chronic pelvic pain (81% and 41%, respectively) than among women without chronic pelvic pain (58% and 14%, respectively); rates did not differ among the chronic pelvic pain subgroups. Irritable bowel syndrome and stress were the most common diagnoses received by patients with chronic pelvic pain, but 50% had never received a diagnosis.

CONCLUSIONS

There is substantial overlap between chronic pelvic pain and other abdominal symptoms in the community. Despite a high prevalence of chronic pelvic pain, many women have never had the condition diagnosed.

Causes of chronic pelvic pain

Chronic pelvic pain (CPP) is a common and debilitating condition, and yet remarkably little is known about what causes the pain. In this chapter we present a model of CPP which emphasizes the multifactorial nature of the problem. A range of physical causes are discussed, including endometriosis, pelvic inflammatory disease (PID), adhesions, irritable bowel syndrome, interstitial cystitis, musculo-skeletal factors and nerve-related pain. The role of the nervous system in the genesis and moderation of pain is explored. The importance of psychological factors is discussed, both as a primary cause of pain and as a factor which affects the pain experience. As with other chronic syndromes, the biopsychosocial model offers a way of integrating physical causes of pain with psychological and social factors.