How to Cure Chronic Pelvic Pain

Endometriosis Bible & Violet Protocol

Being developed by Zoe Brown a nutrition specialist, health consultant and former endometriosis Endometriosis Bible And Violet Protocol is the latest endometriosis treatment that is claimed to be able to teach sufferers how to finally eliminate endometriosis forever. The e-guide contains 303 pages which cover all fundamental information about endometriosis that can helps you pinpoint the root causes of your endometriosis condition and abolish typical symptoms of this problem. The author reveals to every user a substance which has the possibility to eradicate the clutter of dead cells that is clogging the body in endometriosis without harming their living cells. Additionally, you will know about the dangers around your own home which just wait to fire up the endometriosis lesions. Thus, you will know how to avoid them forever. Continue reading...

Endometriosis Bible & Violet Protocol Summary

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Laparoscopic surgery for endometriosis

An early randomized comparison of laparoscopic surgery for mild or moderate endometriosis showed evidence of benefit. Sixty-three patients were randomized to laser ablation of endometriotic deposits and laparoscopic uterine nerve ablation, or expectant management (diagnostic laparoscopy alone). At 6 months, 62.5 of those in the laser laparoscopy group reported improvement or resolution of symptoms compared with 22.6 in the expectant group 34 . With regard to severe endometriosis treated by laparoscopic excision or delayed for 6 months, symptom relief was obtained by 16 20 (80 ) of those operated on versus versus 6 19 (32 ) of those in whom treatment was delayed 35 . Table 13.2 Odds ratios and 95 confidence intervals for factors associated with chronic noncyclical pelvic pain in women. Adapted from Latthe etal. 33 with permission from BMJ Publishing Group Ltd.

Background to perinealpelvic pain syndromes in males

Perineal pelvic pain in the male relates to either a well-defined pathology or one of the pain syndromes. Well-defined pathologies would include the cancers and infectious diseases that may produce pain the management of such pathologic process will not be discussed in this chapter as treatment of the primary cause is described in numerous texts and is the treatment of choice when possible. Historically the perineal pelvic pain syndromes were classified by a terminology that implied a pathologic process that could not be confirmed. For instance, testicular pain was referred to as chronic orchitis despite there being no evidence of infection or even inflammation. Other spurious terms used include chronic prostatitis for pain perceived to arise from the prostate and interstitial cystitis for pain perceived in the bladder. The European Association for Urology (EAU) modified the axial taxonomy of the International Association for the Study of Pain in 2003, publishing a pain syndrome...

Psychology and psychiatry in male perinealpelvic pain syndromes

Chronic pelvic perineal pain is associated with psychologic distress and sexual dysfunction in men. There is a complex interaction between the psychology, sexology, relationships and sociology of chronic pelvic pain. Patients who exhibit catastrophizing and who have poor pain-contingent resting and poor social support have poor outcomes from therapy.

Box 157 Pain treatment options endometriosis [7476

Pain treatment options echo those put forward for dysmenorrhea, with analgesic and neuroablative procedures viewed as temporizing or palliative (Box 15.7). In general, the medical management of endometriosis typically starts with hormonal treatments. Surgical treatment, often performed at the time of diagnostic laparoscopy, may consist of resection, fulguration or the laser ablation of identified sites of endometriosis. More severe disease may prompt more radical interventions which can include hysterectomy, bilateral salpingo-oophorectomy, appendectomy, and extensive resection of any suspicious lesions 74-76 .

Chronic prostatitischronic pelvic pain syndrome

Chronic prostatitis chronic pelvic pain syndrome (CP CPPS) is defined as pain attributed to the prostate in the absence of identifiable pathology and has often been referred to as prostatodynia. Hallmark features consist of persistent complaints of urinary urgency, dysuria, poor urinary flow, and perineal discomfort without evidence of bacteria or white blood cells in prostatic fluids. It serves as a male-specific corollary to interstitial cystitis in that it has similar symptomatology, is a diagnosis of exclusion, and has a presumed site of pain generation. Infectious, inflammatory, neurological, and referred gastro-enterological etiologies of the pain need to be ruled out. Cystoscopic findings of interstitial cystitis have been found in males with the diagnosis of prostatodynia.61 Wesselmann et al.98 have suggested that interstitial cystitis, CP CPPS (male), and vulvodynia (female) may all be variations of a generalized disorder of the epithelium of the urogenital sinus. To further...

Gynecologic cyclic pelvic pain

Dysmenorrhea or painful menses is the most common category of cyclic pelvic pain. It is a common disorder of the female reproductive tract and affects approximately 50 percent of menstruating women.11 Dysmenorrhea may be described as primary or secondary, depending on its etiology. Primary dysmenorrhea refers to pain with menses in the absence of an underlying pathology. Secondary dysmenorrhea refers to pain in the presence of an underlying disorder such as adenomyosis or endometriosis.

Urologic Causes Of Chronic Pelvic Pain

Many chronic pelvic pain cases are primary urinary tract disorders.100'101 The overlap in clinical presentation in part relates to the close development and anatomic relationship of the urinary and genital tracts. Urologic symptoms can stem from a primary gynecologic cause, including bladder and ureteral involvement of endome-triosis or external bladder compression with a uterine leiomyomata. The differential diagnosis in urologic causes of chronic pelvic pain should include the following.

Chronic Pelvic Pain Without Obvious Pathology

Pelvic pain without obvious pathology. This category is useful because it allows the assignment of a diagnosis in situations where the etiology of the pain, even after an exhaustive evolution, remains elusive. This diagnosis should not imply, however, that the pain is psychogenic in nature, yet unrecognized neurophysiologic or biochemical perturbations may in the future be identified in women with pelvic pain without obvious pathology. Dysmenor-rhea, for example, was thought to be a neurotic affectation until the discovery of prostaglandins. Furthermore, the multifactorial etiology of most unexplained chronic pain conditions is just beginning to be recognized.122 The management of pelvic pain without obvious pathology is similar to that of any enigmatic pain process multi-disciplinary management including pharmacological and psychological interventions, although specific studies are lacking.

Endometriosis

Endometriosis is one of the problems that affects women's reproductive health about which the least is known concerning etiology and pathophysiology. The overall incidence of endometriosis in white women of reproductive age is approximately 3 . The incidence rate increases in successive age groups through to the age of 44 years, but declines in women aged 45-49 years 56 . Per definition, endometriosis means the occurrence of endometrium in ectopic locations most commonly observed in visceral and parietal peritoneal surfaces. Despite intensive research, the pathophysiological mechanisms of endometriosis and endometriosis-associated reproductive failure remain incompletely understood. Painful inflammatory response and immunological reaction may be considered the body's first line of defense against the development of endometriosis 57,58 . Eicosanoids are involved in both of these defensive reactions of the body. Prostaglandins may play an important role in endometriotic pain. Their...

Structured clinical interview

The clinical interview is ideally suited to review the patient's pain complaints, onset of pain and relationship to trauma, prior medical and psychiatric history, prior alcohol and drug usage. It also reviews current marital and family environment, current functional level, disability status, motivational level to return to work, primary, secondary and tertiary gain issues, ability to sleep, and utilization of coping skills. Coping strategies that lead to less pain are the active ones, such as staying busy and distraction. The bad coping strategies that lead to more pain are the passive ones - restricting activities, dependency, wishful thinking, and catastro-phizing (seeing everything in a negative light). An additional area of investigation of the clinical interview, particularly with women presenting with chronic pelvic pain, is a history of childhood physical, emotional, or sexual abuse. Studies have shown a high rate of incidence of childhood abuse appearing later in adulthood as...

Magnetic resonance imaging

MR imaging depicts bone in less detail than does CT, but its advantage over CT is its ability to reveal the internal architecture of soft tissues, notably that of the brain, and of fibrous connective tissues. Moreover, it demonstrates cerebrospinal fluid and flowing blood without the need for contrast medium. Particularly useful is the ability of MR imaging to resolve edema, and cellular infiltrates such as those of leukemia and spreading tumors like endometriosis. These properties give MR imaging high sensitivity and high specificity, not only for common lesions, but also for exotic and rare lesions not visible by any other means.

Ascending tract conduction block

Spinal stimulation may produce a conduction blockade of ascending (e.g. spinothalamic) tract input. Studies indicate that lesioning of the fasciculus gracilus at T10 via midline myelotomy will abolish visceral pelvic pain from cancer.14 Furthermore, visceral nociceptive activity may preferentially utilize fasciculus gracilus dorsal column pathways that project to the ventral posterolateral thalamus instead of the spinothalamic tracts.15 Case series of spinal stimulation for patients with visceral pelvic pain have shown some efficacy.16

Effects of Perinatal Estrogen Exposure on Fertility and Cancer in Mice

Concerns have been raised regarding the reproductive and health hazards of chemicals in the environment that have potential endocrine disrupting effects. These concerns include increased incidences of breast, ovarian, and uterine cancer, endometriosis, fibroids, infertility, and early menopause in women in men, alterations in sex differentiation, decreased sperm concentrations, benign prostatic hyperplasia, prostatic cancer, testicular cancer, and reproductive problems have been suggested. Studies with the potent synthetic estrogen diethyl-stilbestrol (DES) have shown that exogenous estrogen exposure during critical stages of development results in permanent cellular and molecular alterations in the exposed organism. These alterations manifest themselves in the female and male as structural, functional, or long-term pathological changes including neoplasia. Although DES is a potent environmental estrogen, studying its effects at low dose levels in an experimental animal model offers a...

Pathophysiology of chronic pelvic and perineal pain in women

A classic clinical observation in women presenting with chronic pelvic pain is the poor correlation between identifiable pathologic processes, the chronicity and severity of pain and the impact of symptoms on quality of life. This is exemplified by endometriosis, a condition affecting women predominantly in the reproductive age group and characterized by the presence of endometrial glands and stroma outside the endome-trial cavity. The condition is thought to arise mainly by i mplantation of endometrial tissue following retrograde menstruation via the fallopian tubes 1 . It presents a clinical spectrum, with endometriotic deposits sometimes observed at laparoscopy in the absence of symptoms or tissue damage, through sub-fertility apparently associated with endometriosis but in the absence of pain, to chronic pain associated with disabling pain symptoms and often gross damage to the pelvic organs through abnormal invasion of endometriotic deposits into the pelvic tissues,...

Hormonal therapy for ovarian suppression

Progestogen (medroxyprogesterone acetate) was effective in reducing chronic pelvic pain after 4 months' treatment as reflected in pain scores (OR 2.64, 95 CI 1.33-5.25, n 146) and a self-rating scale (OR 6.81, 95 CI 1.83-25.3, n 44), but benefit was not sustained 9 months post treatment 40, 41 . Medroxyprogesterone acetate plus psychotherapy was effective in terms of pain scores (OR 3.94, 95 CI 1.2-12.96, n 43) but not in the self-rating scale at the

Presacral neurectomy and laparoscopic uterine nerve ablation

Presacral neurectomy (PSN) and laparoscopic uterine nerve ablation (LUNA) are both surgical procedures that involve the disruption of sensory nerve afferents that carry pain stimuli from the pelvis. In LUNA, the uterosacral ligaments are transsected close to their insertion at the cervix, thus interrupting part of the Lee-Frankenhauser nerve plexus. In PSN, the presacral nerve plexus is isolated and cut proximally and distally. Complications associated with LUNA are rare there have been isolated cases of uterine prolapse and bladder dysfunction. PSN has been associated with more serious complications such as hematoma formation, major vessel injury, constipation and bladder dysfunction, though these are rare in experienced hands. A number of studies have suggested benefit from LUNA and PSN for primary and secondary dysmenorrhea, including randomized trials 43, 44 . However, a large multicenter study examining the effectiveness of LUNA in pelvic pain (n 487) has recently finished, with...

Photographic reinforcement

A randomized comparison of pain outcomes following laparoscopy was undertaken to assess the potential benefit of showing laparoscopic images to patients as a method of photographic reinforcement of the explanation of normal findings at surgery 58 . Two hundred and thirty-five women undergoing diagnostic laparoscopy for the investigation of pelvic pain were randomized. Pain scores at 6 months were reported in 45 and 57 women in the intervention and control groups respectively. Pain scores and other measures were not significantly different but there was a trend towards less favorable outcomes in the photographic reinforcement group.

Authors recommendations

It is interesting to reflect on the presence of a number of surgical interventions in the list of effective treatments. The evidence suggests that these are valuable and their presence in a review of pain treatments perhaps extends the conceptual boundaries of the multidisciplinary approach. As emphasized by the French group who have pioneered surgery for puden-dal neuralgia, surgery needs to be undertaken along with other pain management interventions and not as a single modality. Again, women with endometriosis have often not received multidisciplinary pain interventions because they have been considered to have a gynaecologic condition amenable to surgery. In reality, they benefit substantially from the combination of appropriate surgery with other pain management modalities.

Visceral chronic pain mechanisms

A number of chronic perineal pelvic pain syndromes may involve chronic infection or inflammation that cannot be identified. The evidence that such pathologies cause chronic pain is hotly debated and there is a general trend away from diagnoses which imply undected infection or inflammation.

Interventions supported by evidence

Chronic perineal pelvic pain in men covers a diverse group of poorly understood conditions. In many cases the recommendations about treatments will arise from drawing parallels with the management of other conditions. The evidence presented below will primarily be for the pain syndromes (see above) as other well-described conditions have recognized clinical approaches for their management. To reach the diagnosis of a pain syndrome, organ-specific investigations by appropriate specialists (e.g. urologists) will have been undertaken to exclude the well-defined pathologies. There are several summaries of evidence-based treatment for male perineal pelvic pain and the following will draw upon these 12 . In all probability there are significant overlaps in the various perineal pelvic pain syndromes and as a consequence, in addition to review of the evidence for specific treatment options in defined pain syndromes, the evidence for generic treatments based on putative underlying mechanisms...

Secondary dysmenorrhea

Secondary dysmenorrhea most commonly arises when a woman is in her twenties or thirties, after years of less painful cycles. Elevated prostaglandins may also play a role in secondary dysmenorrhea but, by definition, concomitant pelvic pathology must also be present. Common causes include endometriosis (see below under Endometriosis), adenomyosis, endometrial polyps, endometritis, pelvic inflammatory disease, copper intrauterine devices (IUDs), ovarian cysts, congenital pelvic malformations, and cervical stenosis.

Tumors and cysts of the reproductive organs and salpingooophoritis

Salpingo-oophoritis pelvic inflammatory disease (PID) generally presents as an acute process. Chronic pelvic pain can develop secondary to subacute infections with chlamydia for example, or possibly related to past salpingo-oophoritis with large hydrosalpinges and adhesion formation, causing restriction of pelvic organs and stretching of the pelvic peritoneum or an inflammatory insult leading to chronic up-regulation of neural proces-sing.87 Diagnosis of acute PID is made by clinical criteria proposed by Sweet and Gibbs.88 Two of the three must be present lower abdominal pain as well as lower abdominal tenderness (with or without rebound), cervical motion tenderness, and adnexal tenderness. In addition, one of the following minor criteria must be present (1) temperature greater than 38 C, leukocytosis (> 10,500 white blood cells mm3) (2) culdocentesis fluid containing white cells and bacteria on Gram stain (3) presence of an inflammatory mass (4) elevated ESR (5) a Gram stain from...

Other Potential Untoward Effects

Nausea and vomiting occur in some women but often disappear with time and may be minimized by taking estrogens with food or just prior to sleeping. Breast fullness and tenderness and edema may occur, which may be diminished by lowering the dose. A more serious concern is that estrogens may cause severe migraine in some women. Estrogens also may reactivate or exacerbate endometriosis.

Antiprogestins And Progesteronereceptor Modulators

The antiprogestin, RU 38486 (often referred to as RU-486) or mifepristone, is available for the termination of pregnancy. Antiprogestins have several other potential applications, including uses as contraceptives, to induce labor, and to treat uterine leiomyomas, endometriosis, meningiomas, and breast cancer.

Trigger Point Injections

Eliminating the positive feedback arc.10 No RCTs specifically looked at chronic pelvic pain and trigger point injections. One small RCT compared trigger point injections in patients with myofascial syndrome with bupiva-caine 0.5 percent, etidocaine 1 percent, or saline. Subjective improvement was noted with the local anesthetic treatment over saline.146 II Slocumb10 III studied the response of 122 women with abdominal pelvic pain characterized by dermatome hypersensitivity and trigger points 89.3 percent reported relief or improvement in pain, such that no further therapy was required over the duration of the study (3-36 months). Further management of myofascial pain is described in Chapter 12, Diagnostic procedures in chronic pain. Botulinum toxin injections were effective in reducing pain in patients with myofascial pain syndrome but the difference in pain between the two modes was not significantly different.147 II

Local Anesthetic Nerve Blocks

In some cases, with multiple trigger points in the vaginal wall, back, and abdominal wall, a series of abdominal nerve, caudal, pudendal or epidural blocks may prove to be more fruitful in treating the pain than multiple trigger point injections.10 III Nerve blocks with local anesthetics may provide relief of neuralgia due to nerve injury. Prolonged partial pain relief may occur for weeks or months following one or more nerve blocks beyond the anticipated duration of the local anesthetic. The explanation for prolonged pain relief may be secondary to reduced capacity of the nerve to maintain repetitive impulses, decreased excitability of the nerve fiber, and systemic uptake of the anesthetic. Nerve blocks have also been used as a prerequisite for evaluating potential effectiveness prior to neurectomy.148 III Superior hypogastric plexus block by CT guidance and at the time of microlaparo-scopy may provide further evaluation and management in chronic pelvic pain.149'150 III CT guidance...

Evidence for efficacy

The use of laparoscopy is controversial, as nonsurgical management of chronic pelvic pain is successful in 65-90 percent of patients regardless of the presence of pathology. 10,47,143,158 The only RCT of the use of laparoscopy randomized women with CPP to one of two treatment modalities.143 II The standard approach in 49 patients involved routine laparoscopy. The other 57 patients underwent an integrated approach, including assessment of somatic, psychological, dietary, environmental, and physiotherapeutic factors. Laparoscopy was not routinely performed in this group.143 Of the 49 patients in the standard group, 65 percent had no abnormality, 5 percent had endometriosis, 18 percent had adhesions, and the remainder had myomata, ovarian cysts, or pelvic varices. The integrated approach was significantly more effective in the reduction of pelvic pain (75 versus 41 percent).143 The authors concluded that laparoscopy provided too little a benefit to warrant its routine use in the...

Psychological therapies

Psychological evaluation should be performed early in the evaluation of CPP. Stress reduction, relaxation, and behavioral therapies should also be addressed.143 II Assessment should evaluate the pain complaint, impact on life circumstances, controlling factors, and coping mechanisms. Issues often involve relationship dysfunction requiring family and marital therapy, presence of past or current physical or sexual abuse, and the negative effects on self-esteem and independence. Prolonged psychotherapy for these issues is generally not part of pain management but can be used in conjunction. No RCTs have assessed the effect of psychological approaches on chronic pelvic pain, however, a randomized trial of multidisciplinary management of CPP (which involves a component of psychological assessment and therapy) has demonstrated significant improvement in pain and well-being with the multi-disciplinary approach compared with standard gynecologic treatment. Standardized psychological testing...

Multidisciplinary pain management

Evaluation of somatic and psychological components of chronic pelvic pain by different health care specialists. One program utilizing cognitive-behavioral therapy, acupuncture, and tricyclic antidepressants was successful in reducing pain by at least 50 percent in 85 percent of the subjects.180 Other studies have suggested that similar results maybe obtained with a multidisciplinary team.143, 158,182,183,184 In a prospective randomized, controlled study, the multidisciplinary approach combining the traditional gynecologic treatment with psychological, dietary, and physical therapy input was found to be more effective than traditional gynecologic (medical and surgical) management of cure.143 II

Epidemiology of chronic pelvic and vulvalperineal pain in women

Population data on pain prevalence in women are available. A US-based telephone survey interviewed respondents aged 18-50 years 21 17,927 households were contacted, 5325 women agreed to participate, and of these 925 reported pelvic pain of at least 6 months' duration, including pain within the past 3 months. Having excluded those pregnant or post-menopausal and those with only cycle-related pain, 773 5263 (14.7 ) were identified as suffering from chronic pelvic pain. A British population survey used a postal sample of 2016 women randomly selected from the Oxfordshire Health Authority register of 141,400 women aged 18-49 years 22 . Chronic pelvic pain was defined as recurrent pain of at least 6 months' duration, unrelated to periods, intercourse or pregnancy. For the survey, a case was defined as a woman with chronic pelvic pain in the previous 3 months, and on this basis the prevalence was 483 2016 (24.0 ). There were significant associations between chronic pelvic pain and the...

Static magnetic therapy

The effects of wearing small magnets as therapy for chronic pelvic pain versus placebo were assessed 61 . No difference was seen following 2 weeks' treatment but some significant differences appeared at 4 weeks as assessed by the Pain Disability Index and the Clinical Global Impression Scale but not the McGill Pain Questionnaire. Analyzed in terms of weighted mean differences, the differences were nonsignificant and there was a substantial drop-out rate. The putative mechanism of action of this modality is unclear but some data from other settings have indicated benefit, such as therapy for diabetic neuropathic foot pain. It is suggested that magnetic fields modify the abnormal discharge of damaged C-fiber afferents 62 . The costs and benefits of different forms of endometriosis treatment have been reviewed 63 . In this condition there are choices to be made between hormonal therapy and surgery. Costs associated with surgery are heavily dependent on the capacity to undertake one-stop...

Hypogastric Plexus Block

Hypogastric Nerve Distribution

Hypogastric plexus block is located bilaterally in front of the anterolateral border of the lower 1 3 of L5 vertebral body. The ganglia are located in the retroperitoneum (Plancarte et al. 1997). Superior hypogastric plexus innervates the sympathetic structures of the lower abdominal and pelvic organs. Visceral pain is an important component in pelvic pain due to cancer. Pain relief from superior hypogastric plexus block is possible because afferent nerve fibers to the pelvic structures travel via sympathetic nerves and ganglia.

Saw Palmetto

Saw palmetto is used mainly for treatment of benign prostatic hyperplasia with free fatty acids and sterols being the main components (Hughes et al. 2004). Despite an uncertain mechanism, the literature does demonstrate antagonism at the androgen receptor for dihy-drotestosterone and 5a-reductase enzyme (Hughes et al. 2004). Though prostate size and prostate-specific antigen level are not decreased by saw palmetto, biopsies have demonstrated decreases in transitional zone epithelia in prostates of men treated with this agent compared to placebo (Hughes et al. 2004). When compared with finasteride, a 5a-reductase inhibitor, saw palmetto use resulted in fewer side effects and increased urine flow (Hughes et al. 2004). However, a study of patients with prostatitis chronic pelvic pain syndrome that evaluated the safety and efficacy of saw palmetto compared to finasteride reported that at the end of the investigation, more patients opted to continue finasteride treatment rather than saw...

Antidepressants

Several meta-analyses and evidence-based reviews suggest that antidepressants are useful in mitigating pain associated with neuropathy (Collins et al. 2000, Saarto and Wiffen 2007), headache (Tomkins et al. 2001), fibromyalgia (Arnold et al. 2000, O'Malley et al. 2000), and irritable bowel syndrome (Jackson et al. 2000, Lesbros-Pantoflickova et al. 2004). Although antidepressants are advocated for use in other chronic pain syndromes, e.g., rheumatologic pain conditions, chronic pelvic pain, interstitial cystitis, and oro-facial pain (Kelada and Jones 2007, Onghena and Van Houdenhove 1992, Reiter 1998), these assertions are not often based on a solid foundation of empirical work. In fact, in some of these conditions, e.g., chronic pelvic pain and interstitial cystitis, there are few randomized controlled trials with small sample sizes upon which such recommendations are based (Onghena and Van Houdenhove 1992, Sharav et al. 1987, Stones et al. 2007, Van Ophoven et al. 2004).

Basic Science

Human study to date on SCS for visceral pain is minimal. Khan et al. reported a case series of nine patients with chronic pancreatitis and other conditions which were improved with thoracic SCS.54 V Kapural and colleagues16 recently described a small series of patients with chronic visceral pelvic pain who were helped with SCS.16 V The use of selective stimulation of sacral roots for interstitial cystitis55 and the description of retrograde percutaneous approaches to the sacral roots56 has improved the technical access to stimulation. Visceral pain appears to be a promising area of future applications for stimulation techniques.

Future Perspectives

While this chapter focuses on the significant potential of inflammatory responses, foreign body reaction, and fibrous encapsulation as being principal barriers to the bioavailability, pharmacokinetics, pharmacodynamics, and metabolism of proteins and peptides released from implanted controlled-release systems, it must be clearly noted that these barriers have been overcome for a few systems and clinically successful implants have been achieved for the release of proteins and peptides. The most obvious example is the clinical use of leuprolide acetate sustained-release systems for treatment of prostate cancer and endometriosis. The clinical success of these systems clearly demonstrates that efficacious bioavailability, pharmacokinetics, pharmacodynamics, and metabolism can be achieved with implantable controlled-release systems.

Gynecological Pain

Gynecological disease is prevalent among hospitalized women with HIV. A study of 67 HIV-positive women inpatients revealed lower pelvic pain in 19 percent, and dyspareunia in 16 percent.60 Genital ulceration was found in 25 percent of these women. HSV genital ulceration is a frequent finding in HIV-seropositive women and, if present for more than four weeks, is AIDS defining. Other causes of genital ulceration include other sexually transmitted infections including syphilis and CMV. HIV-infected women have a higher incidence of cervical intraepithelial neoplasia (CIN) and invasive cervical cancer, an AIDS-defining disorder. HIV-positive women are also at an increased risk of developing other HPV-associated lesions including vulval intraepithelial neoplasia and possibly invasive vulval cancer.

The Fallopian tube

In rabbits, PGE2 and PGF2a accelerate ovum transport (reviewed in Gelety and Chaudhuri 5 ). In human tubal preparations, PGE2 inhibits the activity of the longitudinal and circular muscle layers, whereas PGF2a promotes propulsion activity 31, 32 , Additionally, PGE2 and PGF2a stimulated ciliary activity in vitro 33 . The activity of the Fallopian tube is further regulated by steroids. Estrogens increase tubal motility, which is accompanied by increased PGF2a production and PGF2a binding, whereas progesterone decreases PGF2a production and tubal motility 34, 35 . In endometriosis, there is an altered PGE2 PGF2a production pattern within the Fallopian tube which may play a role in the reduced fertility rate in these patients 36 .

Adhesiolysis

Overall, a meta-analysis showed that out of over 600 patients with pelvic pain, 76 would obtain relief from adhesiolysis. However, the two available RCT are not supportive. The outcome in women undergoing adhesiolysis via laparot-omy was not different to that in women who did not undergo surgery on any outcome measure (OR 1.54, 95 CI 0.81-2.93, n 148). However, the small subgroup with dense vascularized adhesions did show a significant benefit for surgery (OR for self-rating scale 16.59, 95 CI 2.16-127.2, n 15) 49 . Using a laparoscopic approach, 29 52 patients reported improvement following adhesiolysis compared to 20 48 controls (OR 1.75 for improvement, 95 CI 0.8-3.82) 50 .

Writing therapy

Weighted mean differences (95 CI) on the various subcategories of McGill Pain Questionnaire were sensory pain 0.07 (-0.31 to -0.45), affective pain -0.12 (-0.42 to -0.18) and evaluation pain -1.16 (-1.96 to -0.36). Women with higher baseline ambivalence about emotional expression appear to respond more positively to this intervention, thus showing a subgroup who may benefit specifically from this type of psychologic approach.

Ovarian pain

Chronic pain disorder that relates to the ovary is the ovarian remnant syndrome where a previous surgical resection of an ovary was incomplete. Characterized by pelvic and or flank pain that normally does not arise until several years after the original surgery, the pain may be cyclic in nature. It has been speculated that ovarian remnant syndrome may become more common due to techniques of laparoscopic surgery that increase the risk of leaving small portions of ovarian tissue in situ 77 . Work-up is similar to that for any painful adnexal mass, and treatment is typically surgical, with complete resection of remaining tissues. Therapies similar to those employed for dysmenor-rhea and endometriosis may have some benefit.

Adhesions

The laparoscopic demonstration of intra-abdominal adhesions in patients with abdominal pelvic pain is common (16-51 of patients). Two separate randomized trials 85, 86 suggest that unless adhesions are very dense and producing bowel obstruction, adhesiolysis appears unlikely to produce a reliable benefit. Attempts to control or prevent adhesions with the use of anti-inflammatory agents, peritoneal instillates or surgical barriers have not affected pain-related outcomes 87 . Medical treatments are otherwise empiric and supportive in nature with no clear evidence guiding the best practice.

EstradiolCDS

Among all CDSs, estradiol-CDS is in the most advanced investigation stage, and it is currently undergoing phase I and II clinical trials. Estrogens are lipophilic steroids that are not impeded in their entry to the central nervous system (CNS). They can readily penetrate the BBB and achieve high central levels after peripheral administration, but, unfortunately, estrogens are poorly retained within the brain. Therefore, to maintain therapeutically significant concentrations, frequent doses have to be administered. Constant peripheral exposure to estrogens has been related, however, to a number of pathological conditions including cancer, hypertension, and altered metabolism 106-109 . Because the CNS is the target site for many estrogenic actions, brain-targeted delivery may provide safer and more effective agents. Estrogen CDSs could be useful in reducing the secretion of luteinizing hormone-releasing hormone (LHRH) and, hence, in reducing the secretion of luteinizing hormone (LH) and...

Incidence

In the general female population, prevalence is estimated at approximately 10 percent and with infertile women it is 15-25 percent, and 28-74 percent of women undergoing diagnostic laparoscopy for CPP.27,28,29 In the past decade, the incidence has increased, perhaps reflecting delayed childbearing but also the increasing use of laparoscopy and greater awareness of subtle endometriotic lesions.30 Endometriosis may present in any age group (from adolescents to postmenopausal women on hormonal therapy), however most diagnoses are made in women in their thirties or forties.31 Endometriosis has been suggested by

Hernia

Although infrequent in the female population, the presence of an abdominal wall hernia in a patient with chronic pelvic pain should be included in the differential diagnoses.94 These include inguinal (indirect or direct), femoral, spigelian, incisional, and umbilical. Symptoms and signs include history of an abdominal or groin mass and pain or discomfort with an increase in intraabdominal pressure. Spigelian hernias result from a defect through the transversalis fascia, just lateral to rectus muscle at the level of the semicircular line of Douglas.95 Incisional hernias generally occur at fascial defects with vertical incisions. Other types of hernias include sciatic hernias secondary to atrophy of the piriformis muscle, which may include the ipsilateral ovary in its hernia sac, and vaginal hernias (cystocele, rectocele, and enter-ocele).96 Treatment of abdominal hernias includes surgical repair through the laparoscope or through a skin incision. Vaginal hernias are repaired surgically...

Symptoms

This is a symptom complex characterized by pelvic pain, urinary urgency, urinary frequency, and nocturia.104 Symptoms of dyspareunia and perimenstrual exacerbation with negative laboratory studies are consistent with both interstitial cystitis (IC) and urgency frequency syn-drome.105 The National Institutes of Health (NIH) Consensus Criteria from 1988 for the diagnosis of IC includes at least two of the following pain on bladder filling relieved by emptying pain in the suprapubic, pelvic, urethral, vaginal, or perineal region glomerulations on endoscopy or decreased compliance on cystometro-gram.106 Symptoms that do not meet IC criteria can be termed painful bladder syndrome'' and are probably a variant of interstitial cystitis.

Depression

Major depression and other dysthymic, panic, and somatization disorders have been associated with CPP of unknown etiology.131,132 Higher depression scores and family histories of affective disorder were described in women with CPP without pathology than in women with chronic pelvic pain and pathology as established by laparoscopy.131 Often, the depression preceded the onset of the pain however, no prospective or outcome studies have been performed.89,131132 A recent systematic review found depression to be correlated with pelvic pain with an OR of 2.59.133

Pharmacological

NSAIDs, narcotics, antidepressants, and anticonvulsants have been utilized in the treatment of CPP as in other types of chronic pain. NSAIDs are also widely used in patients with cyclic pelvic pain. They act as inhibitors of prostaglandin production and may also act on local cytokines. A Cochrane review14 I found that NSAIDs in patients with dysmenorrhea were significantly more effective than placebo for pain relief (OR 7.91). Another Cochrane review42 II found only one applicable RCT Only one RCT has looked at the effect of a selective serotonin reuptake inhibitor (SSRI) on pelvic pain139 II and found no significant difference between sertraline and placebo in the measures of pain and functional disability. CPP patients treated with gabapentin alone or in combination with amitriptyline was better than with ami-triptyline alone.140 Treatment of CPP with narcotics should include a narcotic contract between provider and patient as well as regularly scheduled appointments for follow-up....

Physical therapy

There are few randomized studies in the area of physical therapy and pelvic pain. One open randomized study found that distention of painful pelvic structures in women with CPP resulted in significant relief of pain and improvement in quality of life measures.142 II However, in the multidisciplinary approach of treatment for CPP, physical therapy is often incorporated in the management,143 especially in cases of myofascial syndrome. TENS and biofeedback are often used in conjunction by the physical therapist.144 A meta-analysis of seven randomized controlled trials found that high frequency TENS is more effective for pain relief than placebo.21 I Intravaginal TENS provides electrical stimulation to the pelvic floor muscles and is also available.145 III

Laparoscopy

Laparoscopy has an important role in the diagnosis and management of acute pelvic pain. Its exact role in the evaluation of patients with chronic pelvic pain is more controversial and limited.153 Of patients with CPP 14-77 percent have no obvious pathology and two-thirds of patients have findings of adhesions, which may or may not play a role in their pain.29,154 In a review on the use of laparoscopy in chronic pelvic pain, Howard4,155 found that CPP patients had approximately twice the incidence of pelvic pathology compared with the 28 percent incidence of pathology in the non-CPP population.

Indications

Prior to proceeding with laparoscopy, a thorough evaluation of the patient's pelvic pain should be carried out to exclude other nongynecologic etiologies of CPP, as outlined above under Gastroenterologic causes of chronic pelvic pain Urologic causes of chronic pelvic pain Musculoskeletal causes of chronic pelvic pain Neuropathic pain nerve entrapment or injury and Chronic pelvic pain without obvious pathology. An abnormal pelvic examination prior to laparoscopy is associated with pathology 70-90 percent of the time, and abnormal pathology is present in one-half of patients with normal preoperative pelvic examinations.4 During the operative procedure, specific attention should be directed at sites of increased tenderness on physical examination. Laparo-scopy should be performed when one believes it will help in the management surgical management of adhesions, endometriosis, or hernias 29,156 III for pain mapping. Under conscious sedation and local anesthesia, direct visualization by...

Hysterectomy

Thirty percent of patients presenting to pelvic pain clinics have already undergone hysterectomy without experiencing relief of pain.5 A decline in the incidence of hysterectomy for the indication of CPP from 16.3 to 5.8 percent was rated after the initiation of a multidisciplinary approach to the diagnosis and treatment of chronic pelvic pain.158 Additionally, preoperative pelvic pain is a major risk factor for postsurgical pain one year after hysterectomy.159

Evidence Of Efficacy

No RCTs have compared hysterectomy with no surgery in CPP patients. From the limited nonrandomized studies, one may estimate that one in four women will continue to have persistent pain following hysterectomy for CPP.160,161,162,163 III The success rate of hysterectomy for the treatment of CPP is better with cyclic pelvic pain. Stovall et al.,162 in a retrospective study of 99 women, and Hillis et al.163 in a prospective cohort of 308 women, noted a 77 and 74 percent response rate, respectively, in woman who underwent hysterectomy for CPP felt to be of uterine origin. At one-year follow-up, however, 25 percent of women in Stovall's group noted a persistence of worsening of pain. Hillis observed that persistent pain was associated with multiparity, prior history of PID, lack of pathology, and Medicare payer status.163 A retrospective study of 98 women with a history of CPP who underwent abdominal hysterectomy found that 96 of women reported improvement in pain and 87 were satisfied...

Progestin Products

The progestins are primarily used in oral contraceptive products and in hormone replacement regimens for women. They are also used to treat several gynecological disorders dysmenorrhea, endometriosis, amenorrhea, and dysfunctional uterine bleeding. Estrogens are given simultaneously in most of these situations.

Chronic pancreatitis

A system of stratification or subgroupings of patients by morphological or functional criteria has never been agreed upon.19 Differential diagnoses must include pancreatic cancer but also include peptic ulcer disease, irritable bowel syndrome, gallstones, and endometriosis. An initial first step in the management of pain in patients with chronic pancreatitis is the exclusion of complications that can be the cause of the pain such as pseudocysts or compression of adjacent visceral structures.24

Case Scenario

The pain from laparoscopic tubal ligation is usually of moderate intensity and Anita responds to further doses of opioid and ketorolac. She is discharged 2 days later. Three months after her surgery Anita is back to see you in the pain clinic. She has been referred to you by her primary care physician for the evaluation of a tender scar above the belly button. She tells you that the scar sometimes burns. She mentions that ever since the laparoscopic her surgery, she has been suffering from severe and unbearable colicky pelvic pain radiating to her lower back. The pain comes during her mid-menstrual cycle. Anita is convinced that it is related to her ovulation. Her primary care physician has tried various analgesics and antidepressants without any benefit. Anita is concerned that her relationship with Leonardo is on the verge of breaking up. On examination you find that she has a very tender mass in the left iliac fossa.

51 Tips for Dealing with Endometriosis

51 Tips for Dealing with Endometriosis

Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.

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