Practical Training and Research in Gynecologic Endoscopy

 Chronic pelvic pain

J.F. Hulka
Department of Obstetrics and Gynecology
UNC School of Medicine
Chapel Hill N.C. 27514 USA

L. Wolf
University of North Carolina
School of Medicine
Chapel Hill, N.C. USA

I. Introduction

The field of chronic pelvic pain (CPP) is in its infancy as a clinical science. The clinical diagnoses most often made for which surgery is performed include pelvic adhesions (including chronic PID), ovarian cysts and endometriosis. The relative ease of laparoscopic surgery has encouraged compassionate physicians to re-operate in order to relieve recurrent pain. Although re-operative laparoscopy for relief of pelvic pain has been extensively reported in the literature, documentation of its efficacy is scant.

In recent years, the explosive emergence of operative laparoscopy for CPP has created new questions. At what point is surgery indicated? What is the incidence of recurrence or persistence? When dealing with recurrent or persistent disease, what is the efficacy of re-operation? Efficacy is dependent on basic biologic factors such as wound healing, natural history of diseases and neuro-psychiatric factors as well as surgical techniques. We will discuss the existing data concerning the need and efficacy of operation and re-operation in these conditions.

 

1. General Indications and Caveats

Chronic pelvic pain (CPP) is a major reason for patients undergoing surgical procedures, often multiple times. It is the diagnosis in

  • 10% of office visits to gynecologists2 and general clinics3

  • 10-20% of all hysterectomies in the United States 4, 5,6

  • 40% of diagnostic and operative laparoscopies 1,7

The patient with CPP may be a candidate for laparoscopy if 6 months have gone by during which more conservative forms of therapy (e.g., antibiotics, psychotherapy, endocrine suppression) have proved unsuccessful. Studies of pelvic findings in patients undergoing laparoscopy for chronic pain have revealed pathology in 70 to 80% of patients.8,9 However, comparisons of findings in patients with chronic pain to patients with infertility and no complaints of pain have generally shown no statistical difference between the nature or distribution of adhesions or other pathology found.10-13 In pain associated with endometriosis, deep infiltrating lesions are causally related to the symptoms and may require difficult excision.14,15 On the other hand, endometriosis does not consistently cause pain: it has been found in up to 45% of asymptomatic women.16

Chronic pain persisting over 1 year can alter the nerve pathways and the spinal pain "gate". In these patients, surgical management of adhesions found may not cause permanent relief: The pain can be re-established through the "open gate" pathways after about 6 months17 For example, hysterectomy for pain with documented pathology was found to result in recurrent pain in 23% of patients.18 Although some form of psychiatric pain management therapy is indicated, most patients undergo repeated, temporarily successful surgery.

The placebo effect of diagnostic laparoscopy alone in women with the absence of pathology on visualization has been reported.19 In this study women with no pelvic pathology and no intra-operative treatment were returned to their primary physicians with no psychiatric care or other interventions and remained free of pain 6 months post-operatively. Thus, we need to be intellectually cautious in the causal relationships between pathology and pain, as well as the causal relationships between surgery and cure.

A suggestion has been made that laparoscopy has no therapeutic value alone compared to total pain management programmes.10 Most pelvic pain is relieved after laparoscopy for 3 to 6 months, but pain of central nervous origin is re-established within one year in 60% of patients.17 These considerations should be taken into account by the operative laparoscopist before a second or third attempt is made at relieving chronic pain surgically.

2. Evaluation:

A. Prior procedures

All new CPP patients should bring all operative records, together with the pre-operative description of the indications and pathologic findings, if any, of previous laparotomies or laparoscopies. Some patients are given operative photographs or videotapes of prior findings. These can be time-consuming but rewarding in assessing prior procedures. During the history taking a note should be made of discrepancies of perception and fact the patient may have of her prior conditions.

B. History

A detailed history as to the time of onset of the pain, character, location, what made it better, what makes it worse, relation to functions (menses, coitus, motion) and life events (onset of coitus, job loss, marriage, divorce, childbirth) will reveal useful patterns to suggest diagnoses.

C. The physical examination

Since CPP may well be of non-gynaecological origin the physical examination should include brief examination of the costo-vertebral angle (for chronic pyelonephritis), spinal and lateral sacral tenderness (peripheral nerve compression or sympathetic tenderness), repeated abdominal tenderness evaluation (consistency of finding, association with a lateral abdominal scar) with and without distracting the patient, and leg motion range for hip or peripheral nerve pathology.

The gynecological examination is best begun with a gentle mono-manual examination, showing the patient that the abdominal hand is not being used. Introital tenderness or spasm (vaginismus), anterior vaginal wall tenderness (urethritis or cystitis) as well as uterine tenderness on motion of the cervix can all be detected without alarming the patient with bimanual pressure. Patients with long-standing CPP may not be able to tolerate a standard bimanual examination, and the examination should be discontinued when exceeding the patient's pain tolerance.

II. Lysis of Adhesions For Pain

Before the introduction of laparoscopic techniques to lyse adhesions and minimize their recurrence, many surgeons were reluctant to attempt therapy unless the adhesions caused bowel obstruction. Recent studies have indicted that adhesions tend to reform less frequently when lysed by laparoscopy than by open laparotomy.20-22 This is probably due to less direct trauma from swabbing during laparotomy which results in mechanical abrasion and desiccation of serosal surfaces. Studies of wound healing and adhesion reformation have been reviewed in detail.23,24 Peritoneal surfaces tend to heal from the "bottom up", by a process of peritoneal regeneration from underlying vasculature. Damage to this underlying vasculature during laparotomy results in cytokine release and alterations in plasminogen activator activity which is necessary for endogenous lysis of excess fibrinous attachments.24

In contrast, the ovarian surface is protected by loose cells derived from the peritoneal fluid and damage to these cells stimulates tubal, bowel and omental adhesions as the hypoxic cells on the ovary secrete angiogenic factors promoting "vascular grafts" from nearby viable tissue.25 As a result of this process, the ovary is the pelvic structure most likely to reform adhesions after attempts at lysis26 Further, the percentage of ovarian surface covered by adhesions is a major prognostic factor after adhesiolysis for infertility.27 Most recent animal and human observations suggest that the ovary heals best (with minimal adhesions) without attempts at re-approximation by suturing.28-30 The role of chemical and mechanical adjuvants to prevent adhesion re-formation such as Hyskon, corticosteroid, Interceed, or Goretex have yielded mixed results in clinical experience. Thus, the following four points are currently recommended in adhesiolysis by laparoscopy or laparotomy to minimize recurrence:

  1. Minimal use of absorbable sutures (they provoke an inflammatory and adhesive response)

  2. Sharp dissection to cause minimal cell destruction

  3. Less meticulous micro-haemostasis to allow normal clotting and vasoconstriction rather than tissue destruction by excess electro-desiccation or fulgaration

  4. Dilute the angiogenic factors by leaving 1000 to 2000 ml of lactated Ringers in the peritoneal cavity after surgery 31,32

Second Look Studies

Second look laparoscopy studies26,33,34 reveal a surprising amount of adhesion reformation despite good surgical technique. Since adhesions form immediately after surgery, postoperative adhesions causing pain usually do so within 1 or 2 months after surgery. Pelvic pain, especially chronic pain over 6 months' duration and arising months or years after surgery, is thus seldom causally related to post-surgical adhesions and more elusive psychological trauma and scars need to be sought and dealt with.

Adhesions from endometriosis or infection may be progressive over time and causally related to chronic pain, but these adhesions may also be incidental findings in a patient with deeper psychological origins of chronic pain. An emerging observation is that lysis of adhesions of bowel to the anterior abdominal wall 35 seem to be effective in relief of CPP. This may be due to the involvement of peritoneal branches of intercostal nerves in the adhesions on the anterior abdominal wall peritoneum. These nerves are able to localize parietal pain in fairly specific segmental distribution. In contrast, the bowel itself is essentially void of pain fibres, and bowel mesentery has visceral pain fibres of poorly localizing autonomic origin and distribution 36.

In a report of 30 re-operations for relief of chronic pelvic pain (defined as 6 months or more duration) due to adhesions,37 previous surgery included 25 laparotomies and 10 laparoscopies. No correlation between the severity of adhesions and pain was found. Pain was localized to the area of adhesions in 90% of patients. Although immediate post-operative pain relief was frequent, symptoms tended to recur in 6-12 months after surgery. This observation which is consistent with others, makes a follow-up period of observation of at least 6 months necessary to evaluate efficacy of treatment for pain. Re-operative adhesiolysis resulted in long-term improvement of daily pain in 63%, with no improvement in 37%. Among patients with the chronic pain syndrome (see below), dyspareunia was unchanged or worse in 4 out of 6 patients. Among these chronic pain patients with either pain and/or dyspareunia, 6 out of 10 showed no long-term improvement.

Confirmed by other studies, the re-lysis of adhesions for relief of recurrent pelvic pain emerges as a legitimate indication for operative laparoscopy. Most recently, Steege has explored the use of small diameter (2 mm) office laparoscopy with the placement of a Tenckhoff catheter in the umbilicus for re-lysis on four occasions during the first 2 post-operative weeks.29,37 The average interval between re-operation was 3-4 days. This interval was chosen to optimize outcome by lysing adhesions that were still filmy and had not been vascularized or collagenized. This study confirmed the feasibility and safety of re-lysis but appropriate applications of this particular procedure remain to be defined. Similarly, the development of miniscopes and office laparoscopy may be used for pain mapping procedures.

III. The Chronic Pain Syndrome

Evaluation of the efficacy of re-operation for chronic pelvic pain is confounded by the occurrence of important associated psychological conditions, termed by Steege "the chronic pain syndrome" with symptoms similar to those of chronic depression. This syndrome includes:

  • pelvic pain of 6 months or more that lacks apparent physical cause

  • previous treatments unsuccessful in relieving pain

  • significantly altered physical activity, including work, recreation, sexual activity, etc.,

  • disturbance of mood, mostly depression with at least one vegetative sign (sleep dysfunction, loss of appetite, psychomotor retardation)

  • altered role in the family38

These patients report less benefit from adhesiolysis. Again, careful preoperative selection, including duration of symptoms, recurrence of symptoms after previous surgery, and psychological and behavioral assessment are all important prognostic factors for both primary and re-operation for chronic pelvic pain. In a prospective study by Peters10 patients with chronic pelvic pain were divided into one group receiving routine laparoscopy and one group receiving an integrated approach giving attention to somatic psychological conditions. In the second group, laparoscopy was not routinely performed. The integrated approach appeared to improve pelvic pain significantly more than the standard laparoscopic approach.

The importance of evaluation of the emotional component in patients with chronic pain was summed up well by a gynecologist trained later as a psychiatrist who ruefully commented "I have done many laparoscopies for depression"39.

IV. Removal of Adnexal Mass

Ovarian cysts are often found in patients with acute or chronic pelvic pain. Although the cause and effect relationship between adnexal masses and acute pain is clear, this relationship is questionable in chronic pain. Nevertheless, cystectomies and oophorectomies are often performed for relief of pain, particularly if there are adhesions on the ovarian surface. Although the relief of acute pain with removal of adnexal masses has been well documented, there are no data concerning the efficacy of adnexal mass removal for chronic pelvic pain.

Recurrence of ovarian cysts after cystectomy has been studied. Hasson40 found that endometriomas recur in 50% of cases if not completely excised. Fayez and Vogel41 compared recurrence rates and adhesion formation for different laparoscopic treatments of endometriomas. They found stripping of the lining, laser ablation of the lining and drainage with irrigation, all had a recurrence rate of 20%. When complete excision was accomplished there were no recurrences but there was 100% adhesion formation compared to 30% with the other three methods. In contrast, more recent studies have indicated a rate as low as 2% for the recurrence of functional cysts after laparoscopic fenestration. However, when pelvic adhesions were seen at the time of laparoscopy, the recurrence rate increased to 11%. Post-operative hormonal therapy with a progestogen or combined oral contraceptive pill demonstrated no protective effect. Follicular cysts had a recurrence rate of 2%, while corpus luteum cysts recurred in 14%. With both functional cysts and endometriomas, caution must be exercised weighing the significance of the finding of an ovarian cyst and contemplating its removal for relief of chronic pelvic pain.42

V. Endometriosis

The patho-physiology of endometriosis is such that a significant percentage of patients treated for pain experience recurrence of symptoms. Success therefore can be defined as the length of the pain free interval and the percentage of patients that experience recurrence. The technical objectives of laparoscopic surgery are to restore normal pelvic anatomy and resect, coagulate or vaporize all endometriotic implants. These objectives can be accomplished with mechanical excision, thermal, electrical or laser energy and there are no objective data that one is better than another.43 The surgeon's knowledge, familiarity and competence with the energy sources are far more important than any differences between them1. Full depth resection of all implants including atypical lesions is necessary. Based on studies to date, approximately 67% of women treated laparoscopically for pain with documented endometriosis, will note an improvement in pelvic pain that will last for at least one year. There is no consensus on combined medical and surgical treatment of endometriosis in CPP.

The advantages suggested by other studies include:

  1. Suppression of ovulatory activity to eliminate the confusion of functional cysts with endometriomas.

  2. Decreased inflammation and size of endometriosis implants

  3. Decreased pelvic vascularity43,44

The disadvantages of medical therapy are:

  1. Decrease in size or change in appearance of implants may lead to sub-optimal excision or ablation.

  2. Cost and side effects

  3. n patients attempting conception, medical therapy results in time delay.43

Laparoscopic Uterine Nerve Ablation and Pre-Sacral Neurectomy

CPP may present as severe dysmenorrhoea and at laparoscopy the nerves to the uterus and pelvis can be interrupted by the LUNA procedure or pre-sacral neurectomy. The efficacy of LUNA was recently supported in a prospective study where 62% of patients undergoing LUNA (and ablation of endometriotic implants) had improvement of relief of symptoms, compared to 23% of non-surgical controls 45. The risk of venous or ureteric injury in this area can be reduced with relatively simple methods and the procedure should be abandoned if the position of the ureter is not completely visualized.

Pre-sacral neurectomy can be performed laparoscopically with more significant risks of injury to the vena cava, and though one study reported a significant improvement in midline dysmenorrhoea,46 a similar study showed no relief with endometriosis 47. The risk-benefit aspect of this procedure remains controversial and in areas where there is not immediate availability of a vascular surgeon to assist in the repair of an injured vessel, the greater risk is not justified by proven efficacy.

Pelvic Congestion

Since Howard C. Taylor,Jr. first proposed pelvic congestion (varicosities of the adnexal venous plexus) as a cause of CPP 48the theory has been met with indifference despite the wide respect for the author. Most recently Prof. Richard Beard in London has activated modern interest in the condition and has reported significant improvement in patients treated with medroxyprogesterone acetate 50 mg daily49 or 30mg50. Nevertheless, the existence of this cause of CPP or its medical management has again not yet been widely accepted. Surgical intervention with scarring of the overlying peritoneum has been suggested but there is significant risk of injury to the underlying vessels and this technique has not been studied.

When dyspareunia is the dominant component and retro-version of the uterus the only physical finding at laparoscopy, uterine suspension has been suggested. There are no published prospective studies documenting efficacy.

Conclusions

Sixty percent of women with CPP have a pathologic or anatomic abnormality. In patients with CPP with documented endometriosis or pelvic adhesions to the bowel or stretching the peritoneum, re-operation offers a minimally invasive method for treatment with clinical improvement afterwards in 65 to 80%. In patients with CPP and previously normal pelvis, CPP syndrome, or functional cysts, less than 50% will report improvement in pain following re-operation1. These patients require an integrated comprehensive pain management program to optimize their pain relief rather than re-operation alone.

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