Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study

Anatomical landmarks of the intra-pelvic side-wall as sources of pain in women with and without pregnancy-related chronic pelvic pain after childbirth: a descriptive study

Background

Chronic pelvic pain (CPP) affects 15–24% of women and can have a devastating impact on quality of life. Laparoscopy is often used in the investigation, although in one third of the examinations there is no visible pathology and the women may be dismissed without further investigation. Also, the contribution of skeletal, muscular, periosteal and ligamentous tissues to CPP remains to be further elucidated. The objective of the present study was to compare pain intensity provoked from anatomical landmarks of the intra-pelvic side-wall in women with pregnancy-related CPP after childbirth and women without such pain.

Methods

This is a descriptive study of 36 non-randomly selected parous women with CPP after childbirth and 29 likewise selected parous women after childbirth without CPP. Pain was determined by questionnaire and clinical examination. The primary outcome measure was reported pain intensity provoked on 13 anatomical landmarks of the intra-pelvic side-wall. All women reported their perceived pain intensity for each anatomical landmark on Likert scales and an individual sum score was calculated.

Results

Women with chronic pelvic pain were older than women without CPP. At several intra-pelvic landmarks high intensity pain was provoked in women with CPP compared with less intense pain provoked at fewer landmarks in women without low back or pelvic pain (p < 0.0001). The average sum of pain intensity scores was about 4 times higher in women with CPP (1.3) as compared with those without low back or pelvic pain (0.3), p < 0.0001. This association remained when adjusting for the age difference between the pain groups in linear regression analysis. In addition, reported pain intensity at worst past week was independently associated with sum of pain intensity scores. The maximum individual sum of pain intensity scores among women without CPP was exceeded by that of 85% of the women with CPP.

Conclusions

Parous women with CPP after childbirth had a heightened pain intensity over 13 anatomical landmarks during pelvic examination compared with parous women without CPP. These results need to be confirmed in a larger cohort with different types of CPP.

Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review

Introduction

In the work‐up of patients with suspected pelvic congestion syndrome, venography is currently the gold standard. Yet if non‐invasive diagnostic tools are found to be accurate, invasive venography might no longer be indicated as necessary.

Material and methods

A literature search in Pubmed and EMBASE was performed from inception until 6 May 2017. Studies comparing non‐invasive diagnostic tools to a reference standard in the work‐up of patients with (suspected) pelvic congestion syndrome were included. Relevant data were extracted and methodological quality of individual included studies was assessed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool.

Results

Nine studies matched our inclusion criteria. Six studies compared ultrasonography to venography and three studies described a magnetic resonance imaging technique. In using transvaginal ultrasonography, the occurrence of a vein greater than five mm crossing the uterine body had a specificity of 91% (95% CI; 77–98%) and occurrence of pelvic varicoceles a sensitivity and specificity of 100% (95% CI; 89–100%) and 83–100% (95% CI; 66–93%), respectively. In transabdominal ultrasonography, reversed caudal flow in the ovarian vein accounted for a sensitivity of 100% (95% CI; 84–100%). Detection of pelvic congestion syndrome with magnetic resonance imaging techniques resulted in a sensitivity varying from 88 to 100%.

Conclusions

The sensitivity of ultrasonography and magnetic resonance imaging seem to be adequate, which indicates a role for both tests in an early stage of the diagnostic workup. However, due to methodological flaws and diversity in outcome parameters, more high standard research is necessary to establish a clear advice for clinical practice.

Referred pain patterns provoked on intra-pelvic structures among women with and without chronic pelvic pain: a descriptive study

Objectives

To describe referred pain patterns provoked from intra-pelvic structures in women with chronic pelvic pain (CPP) persisting after childbirth with the purpose to improve diagnostics and give implications for treatment.

Materials and Methods

In this descriptive and comparative study 36 parous women with CPP were recruited from a physiotherapy department waiting list and by advertisements in newspapers. A control group of 29 parous women without CPP was consecutively assessed for eligibility from a midwifery surgery. Inclusion criterion for CPP was: moderate pain in the sacral region persisting at least six months after childbirth confirmed by pelvic pain provocation tests. Exclusion criteria in groups with and without CPP were: persistent back or pelvic pain with onset prior to pregnancy, previous back surgery and positive neurological signs. Pain was provoked by palpation of 13 predetermined intra-pelvic anatomical landmarks. The referred pain distribution was expressed in pain drawings and described in pain maps and calculated referred pain areas.

Results

Pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions, with or without pain referred down the ipsilateral leg. The average pain distribution area provoked by palpation of all 13 anatomical landmarks was 30.3 mm^² (19.2 to 53.7) in women with CPP as compared to 3.2 mm^² (1.0 to 5.1) in women without CPP, p< 0.0001.

Conclusions

Referred pain patterns provoked from intra-pelvic landmarks in women with CPP are consistent with sclerotomal sensory innervation. Magnification of referred pain patterns indicates allodynia and central sensitization. The results suggest that pain mapping can be used to evaluate and confirm the pain experience among women with CPP and contribute to diagnosis.

Practical guide to laparoscopic pain mapping

Conscious laparoscopic pain mapping, a technique that has been described in the literature for more than a decade, can be a particularly helpful tool to assist with pelvic pain diagnosis and treatment decisions. Several factors, when optimized, increase the likelihood of a good outcome. Herein, we review the literature and address common questions about pain mapping including appropriate patient selection, standard technique, typical outcomes, and how the results might influence treatment.

Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach

Chronic pelvic pain (CPP), defined as non-cyclic pain of 6 or more months, is a frequent disorder that may negatively affect health-related quality of life. In women several causes are recognised, although in a not negligible proportion of patients a definite diagnosis cannot be made. Different neurophysiological mechanisms are involved in the pathophysiology of CPP. Pain may be classified as nociceptive or non-nociceptive. In the first case the symptom originates from stimulation of a pain-sensitive structure, whereas in the second pain is considered neuropatic or psychogenic. Patients history is crucial and is generally of utmost importance for a correct diagnosis, being sometimes more indicative than several diagnostic investigations. The main contributing factors in women with CPP can still be identified by history and physical examination in most cases. Many disorders of the reproductive tract, urological organs, gastrointestinal, musculoskeletal and psycho-neurological systems may be associated with CPP. Excluding endometriosis, the most frequent causes of CPP are: post-operative adhesions, pelvic varices, interstitial cystitis and irritable bowel syndrome. CPP is a symptom, not a disease, and rarely reflects a single pathologic process. Gaining women's trust and developing a strong patient-physician relationship is of utmost importance for the long-term outcome of care.

Relating new graduate nurse competence to frequency of use

The healthcare workplace can be a stress-laden environment for new graduates and job performance indicators are an important sign of developing confidence and expertise that will lead to improved patient outcomes. What is not evident from nursing studies is whether new graduate nurse competencies relate to the frequency of their use. This study sought to determine the relationship between perceived nursing competence and self-assessed frequency of use by new graduate nurses. Three cohorts (n = 116) of new graduate nurses undertaking year-long transition to graduate practice programs responded to a questionnaire that utilised the 2001 ANCI competencies and the Nurse Competency Scale and a Visual Analogue scale to self assess their perceived competence and the relative frequency of use for specific competence items. Results indicate that a relationship exists between perceived competence and frequency of use and that research competency scores are substantially lower than all other categories of competency. Implications for education and practice indicate that assessment of nurse competency for the new graduate nurse should focus on the development of generic nursing competencies rather than current expectation of advanced and workplace specific nurse competencies.

Treatment of chronic pelvic pain in men and women

Chronic pelvic pain syndrome (CPPS) is a common condition that is encountered by a variety of healthcare professionals. Unfortunately, physicians often misdiagnose this problem or recommend inappropriate and sometimes dangerous treatments that offer little hope of successful outcome. In addition, CPPS is typically a multifaceted disorder, simultaneously compromising psychological, peripheral nerve, autonomic, central nervous, visceral, connective tissue, hormonal and other systems. Thus, solo practitioners who may correctly diagnose CPSS are often ill-equipped to provide adequate comprehensive, multidisciplinary treatment. This article is intended as an overview of the most recent literature in support of various treatment modalities for chronic pelvic pain in men and women. We advocate a team-oriented approach in the treatment of CPPS, which employs the coordinated efforts of multiple practitioners, ideally in a subspecialty care setting.

Hysterectomy for treatment of pain associated with endometriosis

The literature was searched for endometriosis and hysterectomy on PubMed and the individual search engines of the Journal of Minimally Invasive Surgery, Fertility and Sterility, BJOG, Obstetrics and Gynecology, the American Journal of Obstetrics and Gynecology, and Human Reproduction. Eighty references of interest were identified and included in this review. Analysis of hysterectomy for pain associated with endometriosis is difficult for many reasons. These include a lack of differentiation of various forms of cyclic pain from other forms of non-cyclic pain, the retrospective nature of much of the literature, and a low specificity for identifying pain. Hysterectomy for chronic non-specified pelvic pain associated with endometriosis is a successful approach in many women. It can not be determined whether this is due to intermingling of patients with and without cyclic pain or if both of these respond equally well. Focused prospective research is needed to determine whether symptoms, signs, or laboratory findings might be useful in determining more specific response patterns.