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Chronic Pelvic Pain
Take home points
1. Chronic pelvic pain is a difficult problem to manage, and the longer the duration of the problem the longer it would take to deal with it.
2. Patients’ perception of pain should be believed and addressed with utmost respect, even in the absence of any identifiable pathology. An integral part of the pain syndrome is the discrepancy between what is actually felt, and what is reported.
3. The attitude of the clinician during the initial consultation has a strong bearing on the response of the patient and her future management. A rapport should be established between the chronic pelvic pain team and patients. Efforts should be made to encourage them to ask questions without restrictions. Patients should feel heard and understood.
4. Endometriosis, irritable bowel syndrome, and interstitial cystitis are the three most common causes of chronic pelvic pain either separately or in combinations. This would explain the need for the combined efforts of a multidisciplinary team to deal with these problems.
5. A psychological element is usually involved either as a cause or an effect, and should be addressed accordingly to help with the patients’ recovery. Patients concerns regarding fertility issues and the possibility of cancer should be addressed professionally and not brushed a side. Thorough explanations are needed, as most of these patients had some unqualified statements from other sources, mainly the Internet.
6. Adult onset progressive dysmenorrhoea and deep dyspareunia are more likely to have a pelvic pathological origin. However, teenage girls with chronic pelvic pain should not be neglected, as they are not immune against endometriosis.
7. Doctors should set attainable outcome targets with their patients. Pain control and improved quality of life might be more realistic than a complete cure.
8. Objective criteria should be used for patients’ assessment, and for auditing outcome of treatment. This should include pain calendars and pain questionnaire with an objective pain scoring system.
9. Specific criteria should be set for using invasive investigations especially diagnostic laparoscopy.
10. As many patients with endometriosis have no chronic pelvic pain, the mere presence of endometriosis does not prove causation of symptoms.
11. 33-85% of patients with chronic pelvic pain might have interstitial cystitis which should not be neglected as a diagnostic entity in the gynaecology clinic. Lack of urinary symptoms should not exclude the diagnosis.
12. Irritable bowel syndrome symptoms have been reported in 40 - 80% of women with chronic pelvic pain. This might be a falsely high figure as diagnostic laparoscopy could offer a different diagnosis in some of these cases especially bowel involvement with endometriosis.
13. 40-50% of patients with chronic pelvic pain were reported to have had physical or sexual abuse at one time or another during their lives.
14. Musculoskeletal and myofascial causes of pelvic pain should not be ignored and the services of a trained physiotherapist are most important in dealing with them.
15. Early intervention, when indicated, is very important to prevent the development of the chronic pelvic pain syndrome.
16. Neuropathic pain could complicate other known pathological entities, and would interfere with treatment outcome if not specifically addressed.
17. Liberal use of antidepressants, neuroleptics and local anaesthetic injections, when necessary, should replace the use of the non-effective NSAIDs for the treatment of chronic pelvic pain syndrome.
18. Narcotics should be avoided as much as possible to avoid the possibility of addiction, but drugs with low dependence tendency like tramadol could be used, when necessary.
19. As with all other types of medication, the risk and benefit of all drugs should be weighed for each individual case.
20. Irrespective of causes or treatment outcome, a good line of communication should be kept with the patient, her family, and General Practitioner.
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