Epidemiology of chronic pelvic pain
The exact prevalence of chronic pelvic pain in different societies is difficult to ascertain because of the different diagnostic criteria used as mentioned before. However, despite these variations, no age group proved to be immune. A British study reported an annual prevalence rate of 38/1000, which was equivalent to the prevalence rate of asthma, migraine, and lower backache in that population. However, the monthly prevalence rates increased with age from 18.1/1000 in 15-20 years olds to 27.6/1000 in women older than 60 years. These authors excluded patients with dysmenorrhoea, dyspareunia and chronic inflammatory bowel disease; otherwise the figures would have been much higher. In clinical terms 10% of all gynaecological visits (3) and 10-20% of hysterectomies and 40% of all laparoscopies (4) were done for pelvic pain. The criteria used here were different, and the last author also excluded menstrual pain, but reduced the duration of the pain to 3 or more months. Furthermore, the severity of pain was introduced as another factor in the diagnostic criteria. Only patients who had bad pains which caused functional disability needing medical or surgical treatment were included. Considering all these variables, any figures given for the incidence or prevalence of chronic pelvic pain in adult women worldwide would not be comparable. Outside gynaecological services, gastroenterologists, urologists, colorectal surgeons and back pain specialists spend considerable time in their respective practices dealing with patients presenting with recurrent episodes of pain. Patients with psychological problems are more prone to develop chronic pelvic pain, and history of sexual or physical abuse has been reported in 40-50% of the cases (5-9). Other factors include personality, marital and childhood disorders as well as depression and anxiety state. Racial and familial factors might also have some impact. Literature from the United States showed more prevalence of the condition in African Americans than among Asian Americans or Caucasians. Unfortunately, dealing with these patients in real life is far from ideal as 60% of them were not referred for specialist care, and 28% never received a diagnosis, 3-4 years after their first consultation based on a UK Primary Care Database study involving 136 general practices. Stone discussed the attitude of general practitioners, gynaecologists and patients as related to this problem. General practitioner’s had difficulty in dealing with patients who had no definite diagnosis and needed long and repeated consultations. As well, they were aware of a general lack of interest by gynaecologists to deal with this problem, and had difficulty in finding the right specialist for the job. On the other hand, gynaecologists usually focus on physical pathology and were reluctant to raise psychological issues with their patients. Furthermore, time restrictions in their busy clinics usually restricted their ability to give the necessary time needed by these patients. As for patients, they expected to have long frequent consultations with detailed explanations, continuity of care, and most important a diagnosis to explain their sufferings. This was not a unique problem in Britain, as the American Endometriosis Society released almost similar disturbing findings in 2002 which proved the common lack of structured care to deal with this problem. Most likely this would be the usual pattern in many parts of the world as well. Accordingly, dedicated multidisciplinary teams are needed for the proper diagnosis, management, and follow up of patients with this complex problem. Furthermore, the following general principles should be adopted by all professionals involved with these patients:
• Listen to the patient, show interest in her problems, and provide good explanations when possible. It has been shown that a patient’s impression of her first consultation and how the physician was sympathetic to her cause had great bearing in her recovery.
• Note should be taken of the entire patient’s previous medical and surgical history. The indications for pervious surgery, exact findings and pathology diagnosed, as well as the procedure performed should be ascertained.
• Always think of different causes rather than one cause for chronic pelvic pain. Identifying and treating a single pathology is unlikely to be successful. Always try to identify all pain generators, and deal with them in a total pain management plan. This entails treating the underlying conditions as well as controlling the pain itself with the appropriate means.
• Try to find and assess the magnitude of any predisposing or associated psychological factors which might have an important bearing on the management of these patients.
• Set realistic management goals and plan, and avoid unnecessary surgical interventions. Pain control might be the best option available rather than absolute cure in many cases. Patients should be made aware of this possibility.
• Carry all objective investigations as soon as possible to make a reliable diagnosis, bearing in mind that management of illness could be more important than identifying a single pathology which might not be the real cause of the problem.
• Intervene early when indicated to prevent the development of the chronic pelvic pain syndrome.
• Stick to the agreed protocols to avoid conflict of opinion within the multidisciplinary team which could send the wrong message to an already confused and stressed patient.
• The team should have regular meetings to discuss cases, and audit outcome.
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