Fred M. Howard

Chronic pelvic pain.

Chronic pelvic pain is a common and significant disorder of women. It is estimated to have a prevalence of 3.8% in women. Often the etiology of chronic pelvic pain is not clear, as there are many disorders of the reproductive tract, gastrointestinal system, urological organs, musculoskeletal system, and psychoneurological system that may be associated with chronic pelvic pain. The history and physical examination are crucial in evaluating a woman with chronic pelvic pain and must address all of the possible systems potentially involved in chronic pelvic pain, not just the reproductive system. Laboratory and imaging studies should be selectively utilized, as should laparoscopy. Conscious laparoscopic pain mapping has been proposed as a way to improve information derived from laparoscopic evaluations. Treatment of chronic pelvic pain may consist of two approaches. One is to treat chronic pain itself as a diagnosis, and the other is to treat diseases or disorders that might be a cause of or a contributor to chronic pelvic pain. These two approaches are not mutually exclusive, and in many patients effective therapy is best achieved by using both approaches. Treatment of chronic pain as well as treatment of four of the more common disorders associated with chronic pelvic pain (endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis) are discussed in this review.

The Role of Laparoscopy in Chronic Pelvic Pain: Promise and Pitfalls

Published studies relating to the usefulness of diagnostic and operative laparoscopy in women with chronic pelvic pain (CPP) were reviewed. This revealed that approximately 40 per cent of all laparoscopies were done for CPP. However, the definition of CPP was found to be nebulous and inconsistent, and that muddled definitive conclusions about patient diagnoses and treatments. The following definition of CPP was proposed: nonmenstrual pain of 3 or more months duration that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. A survey of published reports showed laparoscopically diagnosable abnormalities in 61 per cent of patients, compared with abnormalities in 28 per cent of women without CPP. Studies in adolescents were also reviewed and showed that adolescents with CPP also had significant laparoscopically diagnosed abnormalities, with 78 per cent showing some pathology, especially endometriosis (40 per cent). Endometriosis, pelvic adhesions, chronic pelvic inflammatory disease, and ovarian cysts were the diagnoses most commonly made via laparoscopy in CPP patients. The potential roles of each of these abnormalities in CPP were discussed, as well as the results of laparoscopic treatment of each disease. Laparoscopy was also found to have a limited role in women with CPP after hysterectomy or bilateral salpingo-oophorectomy, with usefulness in diagnosing and treating adhesions and residual ovary syndrome, although its role in ovarian remnant syndrome was uncertain. Overall, the data showed that less than 50 per cent of women with CPP were helped by diagnostic and operative laparoscopy, stressing the need for both physicians and patients to recognize that laparoscopy is neither the ultimate evaluation nor the panacea for CPP.

Gynaecological and obstetrical morbidity in women with type I von Willebrand disease: results of a patient survey.

Type 1 von Willebrand disease (vWD) is generally regarded clinically as ‘mild’ and the obstetrical–gynaecological features have not been fully described. We administered a patient questionnaire and provider survey of the medical and quality of life aspects of childbirth and menstruation to 99 type 1 vWD patients and compared the patients presently menstruating (n=81) to a cohort of 150 menstruating females in the general population. The following measurements had a statistically higher proportion in the vWD group: number of tampons/towels used for a typical menstrual cycle (P=0.002); percentage reporting that clothes are stained by menses (P = 0.001); past or present history of anaemia (P = 0.001); childbirth‐related bleeding (P=0.001); and childbirth‐related bleeding necessitating RBC transfusion (P=0.002). Quality of life assessment of the impact of menses in both of the above cohorts was measured by a Likert scale using seven quality of life parameters. Compared to the control group, the vWD patients had a significantly higher score, with P‐values of < 0.0001 for each parameter. Hormonal interventions for menorrhagia in the vWD patients were ≤ 50% effective. Menorrhagia resulted in red blood cell transfusions in 6% of patients, dilatation and curettage in 17% and hysterectomy in 13%. Despite the common connotation of type 1 vWD as clinically ‘mild’, childbirth and the monthly challenge to haemostasis presented by menstruation result in a substantial degree of morbidity in females with type 1 vWD. These results support the rationale for ongoing international efforts to increase awareness of vWD as a cause for menorrhagia and to improve the quality of life in females with known vWD.

Antecedent Nonbladder Syndromes in Case-Control Study of Interstitial Cystitis/Painful Bladder Syndrome

OBJECTIVES Probing for clues to the pathogenesis of interstitial cystitis/painful bladder syndrome (IC/PBS), we sought antecedent nonbladder syndromes that distinguished incident IC/PBS cases from matched controls. METHODS Female incident IC/PBS cases were recruited nationally, and their IC/PBS onset date (index date) was established. The controls were recruited by national random digit dialing and matched to the cases by sex, age, region, and interval between the (assigned) index date and interview. The prevalence of 24 nonbladder syndromes before the index date was assessed, 7 by multiple methods. RESULTS The cases with IC/PBS had greater antecedent prevalence of 11 syndromes, and 243 of 313 cases (78%) vs 145 of 313 controls (45%) had multiple syndromes (P < .001). Fibromyalgia-chronic widespread pain (FM-CWP), chronic fatigue syndrome, sicca syndrome, and irritable bowel syndrome were associated with each other by pairwise and factor analyses using numerous assumptions. Cases with FM-CWP, chronic fatigue syndrome, sicca syndrome, and/or irritable bowel syndrome (n = 141, 45%) were more likely to have other syndromes (ie, migraine, chronic pelvic pain, depression, and allergy). Three other syndrome clusters were identified; each was associated with this FM-CWP cluster. CONCLUSIONS Eleven antecedent syndromes were more often diagnosed in those with IC/PBS, and most syndromes appeared in clusters. The most prominent cluster comprised FM-CWP, chronic fatigue syndrome, sicca syndrome, and irritable bowel syndrome; most of the other syndromes and identified clusters were associated with it. Among the hypotheses generated was that some patients with IC/PBS have a systemic syndrome and not one confined to the bladder.

Endometriosis and Mechanisms of Pelvic Pain

Endometriosis remains an enigmatic disorder in that the cause, the natural history, and the precise mechanisms by which it causes pain are not completely understood. The pain symptoms most commonly attributed to endometriosis are dysmenorrhea, dyspareunia, and chronic pelvic pain. Pain may be due to nociceptive, inflammatory, or neuropathic mechanisms, and there is evidence that all 3 of these mechanisms are relevant to endometriosis-associated pelvic pain. It is proposed that the clinically observed inconsistencies of the relationships of endometriosis severity and the presence or severity of pain are likely due to variable roles of different pain mechanisms in endometriosis. A better understanding of the roles of nociceptive, inflammatory, and neuropathic pain in endometriosis is likely to improve the treatment of women with endometriosis-associated pelvic pain.

Oral desipramine and topical lidocaine for vulvodynia: a randomized controlled trial.

OBJECTIVE: To estimate the efficacy of common treatments for vulvodynia: topical lidocaine monotherapy, oral desipramine monotherapy, and lidocaine-desipramine combined therapy. METHODS: A 12-week randomized, double-blinded, placebo-controlled trial was conducted on 133 vulvodynia-afflicted women assigned to four treatment arms: placebo tablets–placebo cream, desipramine tablets–placebo cream, placebo tablets–lidocaine cream, and desipramine tablets–lidocaine cream. The tampon test was selected as primary end point using a modified intention-to-treat analysis. Twelve secondary end points were also examined. At completion of the 12-week randomized phase, women were examined “open label” through 52 weeks postrandomization. RESULTS: All treatment arms reported substantial tampon-test pain reduction: 33% reduction placebo cream–placebo tablet, 20% reduction lidocaine cream–placebo tablet, 24% reduction placebo cream–desipramine tablet, and 36% reduction lidocaine cream–desipramine tablet. Compared with placebo, we found no significant difference in tampon-test pain reduction with desipramine (t=0.90; P=.37) or lidocaine (t=1.27; P=.21). Of the remaining 12 outcome measures, only the Index of Sexual Satisfaction, improved with desipramine compared with placebo (t=-2.81; P=.006). During the open-label phase, women undergoing vestibulectomy surgery reported significantly improved pain as measured by cotton swab test and the McGill Pain Scale compared with nonsurgical alternatives. CONCLUSION: Oral desipramine and topical lidocaine, as monotherapy or in combination, failed to reduce vulvodynia pain more than placebo. Placebo or placebo-independent effects are behind the substantial pain improvement seen in all treatment allocations. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00276068. LEVEL OF EVIDENCE: I

Office prenatal formula advertising and its effect on breast-feeding patterns

Objective To compare the effect of formula company–produced materials about infant feeding to breast-feeding promotion materials without formula advertising on breast-feeding initiation and duration. Methods Five hundred forty-seven pregnant women were randomized to receive either formula company (commercial; n = 277) or specially designed (research; n = 270) educational packs about infant feeding at their first prenatal visit. Feeding method was determined at delivery. Breast-feeding duration of the 294 women who chose to breast-feed was ascertained at 2, 6, 12, and 24 weeks. Survival analyses were used to evaluate continuous outcomes, and χ2 and logistic regression analyses were used to evaluate discrete outcomes. Results Breast-feeding initiation (relative risk [RR] 0.93, 95% confidence interval [CI] 0.61, 1.43) and duration after 2 weeks (hazard ratio 1.19, 95% CI 0.86, 1.64) were not affected. Women in the commercial group were more likely to cease breast-feeding before hospital discharge (RR 5.80, 95% CI 1.25, 54.01) and before 2 weeks (adjusted odds ratio [OR] 1.91, 95% CI 1.02, 3.55). In subgroup analyses, women with uncertain goals for breast-feeding or goals of 12 weeks or less experienced shortened exclusive (hazard ratio 1.53, 95% CI 1.06, 2.21), full (hazard ratio 1.70, 95% CI 1.18, 2.48), and overall (hazard ratio 1.75, 95% CI 1.16, 2.64) breast-feeding duration when exposed to the commercial intervention. Conclusion Although breast-feeding initiation and long-term duration were not affected, exposure to formula promotion materials increased significantly breast-feeding cessation in the first 2 weeks. Additionally, among women with uncertain goals or breast-feeding goals of 12 weeks or less, exclusive, full, and overall breast-feeding duration were shortened. Educational materials about infant feeding should support unequivocally breast-feeding as optimal nutrition for infants; formula promotion products should be eliminated from prenatal settings.

THE ROLE OF LAPAROSCOPY IN THE EVALUATION OF CHRONIC PELVIC PAIN : PITFALLS WITH A NEGATIVE LAPAROSCOPY

Laparoscopic findings are negative in anywhere from 10% to 90% of women with chronic pelvic pain. When this occurs a woman is often told one or more of the following: (1) nothing is wrong; (2) the pain is in her head and she should see a psychiatrist; (3) she should have a neurolytic procedure, such as uterine nerve transection or presacral neurectomy; (4) the only thing that is left to do is a hysterectomy; or (5) nothing can be done and she must learn to live with the pain. Usually these statements are inappropriate, often stemming from the mistaken belief that laparoscopy represents the definitive diagnostic end point in the evaluation of a woman with chronic pelvic pain. It is important that gynecologists appreciate that laparoscopy is only one of many possible methods of evaluation and recognize its diagnostic limitations and pitfalls.

Conscious pain mapping by laparoscopy in women with chronic pelvic pain

Objective To evaluate the findings and outcomes of laparoscopic conscious pain mapping in women with unsuccessfully treated chronic pelvic pain. Methods Fifty consecutive women with at least one prior procedure for chronic pelvic pain had conscious pain mapping. Operative findings and clinical outcomes were documented. Preoperative and postoperative pain levels were evaluated using visual analog scales. Results Conscious pain mapping was successful in 35 cases (70%). Twenty-nine patients had 42 specific positive sites, and six patients had diffuse visceroperitoneal pelvic tenderness. Adhesions and endometriosis accounted for 45% of positive lesions or sites. About half of women with endometriosis or adhesions mapped pain specifically to those lesions. For endometriosis, histologic but not visual diagnosis predicted positive mapping. Specific viscera accounted for 36% of positively mapped sites. Diagnoses of chronic visceral pain syndrome were suggested by the findings in 16 (46%) patients whose mapping was successful. Mean ± standard deviation visual analog scale pain levels were 8.7 ± 1.2 preoperatively and 5.5 ± 3.7 postoperatively. Twenty-two women (44%) had decreased pain postoperatively and eight (16%) were pain-free. Conclusion Conscious pain mapping can be done with reasonable success in women with prior surgical evaluations and treatments for chronic pelvic pain. Chronic visceral pain syndrome, adhesions, and endometriosis were the most common diagnoses.

The role of laparoscopy in the chronic pelvic pain patient.

Introduction Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective and individuals describe pain based on their experience of actual or potential tissue injury or damage. Universally it is the unpleasantness of the bodily sensation that characterizes pain, and this makes pain an emotional experience, not just a sensory experience. The definition of pain avoids tying pain to the stimulus. This perspective of pain is important to the gynecologists’ understanding of the role of laparoscopy, in which specific pathology is being sought to explain the presence and the severity of the patient’s pain. There is not a generally accepted definition of chronic pelvic pain. Most but not all authors have used duration of 6 or more months as the major criterion of the definition of chronicity. Specifying only duration allows for significant ambiguity. Does this include cyclic pain (dysmenorrhea), intermittent pain (dyspareunia), or noncyclic pain? The concern about inconsistencies in defining chronic pelvic pain is not pedantic, but has clinical relevance. In reviewing any research on the causes or treatments of chronic pelvic pain, it is crucial that one know what definition was used. A proposed working definition of chronic pelvic pain is noncyclic pain of 6 or more months’ duration that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks, and is of sufficient severity as to cause functional disability or lead to medical care. Chronic pelvic pain is a significant problem and is far more common than generally recognized. For example, a U.S. study conducted by the Gallup Organization found that 15% of women aged 18 to 50 years have chronic pelvic pain and a U.K. study found that chronic pelvic pain has a prevalence similar to that of asthma, back pain, and migraine in women aged 18 to 49 years. There Correspondence: Fred M. Howard, MD, University of Rochester, School of Medicine and Dentistry, Rochester, NY 14642 E-mail: fred_howard@urmc.rochester.edu CLINICAL OBSTETRICS AND GYNECOLOGY Volume 46, Number 4, 749–766