Perioperative factors associated with persistent post-surgical pain after hysterectomy, cesarean section, prostatectomy, and donor nephrectomy: a systematic review and meta-analysis

The Impact of Diclofenac Suppositories on Post-Cesarean Section Pain: A Systematic Literature Review

Background: Managing postoperative pain after Cesarean section is imperative, as acute postoperative pain is considered a risk factor for chronic postoperative pain. We investigated the role of diclofenac suppositories in postoperative pain management after Cesarean section. Methods: For this systematic review, we searched PubMed, Scopus, the Cochrane Library, Google Scholar, and two other clinical trial registers from database inception up to July 23 to July 26, 2024. We included randomized controlled trials and other studies in which diclofenac suppositories were administered as an intentional intervention. We excluded studies not reported in English and without a focus on the principal medicine (diclofenac suppository). Two researchers independently chose studies and assessed the risk of bias using RoB-2, following the PRISMA-2020 guidelines. Primary outcomes included pain severity or intensity measured with validated clinical scales. We synthesized the studies narratively. The PICO was used to generate the research question: Population-Cesarean section patients, Intervention-diclofenac suppository, Comparison-opioids, Outcome-lower pain scores and a reduced need for more pain medications, Research question-the effectiveness of diclofenac suppositories in preventing postoperative pain and reducing the consumption of pain medicines in Cesarean section patients. Findings: From an initial pool of 203 records, 20 records were selected for review. Notably, discrepancies in the study design and reporting were observed. This raised concerns about the consistency and reliability of the results obtained from the different studies. The visual analogue scale (VAS) emerged as the frequently used pain assessment tool. Diclofenac suppository was compared against other treatments under three categories: placebo, other nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids or opioid-like medicines. The findings revealed that diclofenac suppository was effective in reducing pain compared to placebo and hence, minimized the need for opioids. The concept of combining pain medicines for postoperative management, known as multimodal analgesia, was central to most of the studies. Interpretation: Combination of diclofenac suppositories with other pain relief medicines reduces the need for rescue pain medicines, which are usually opioids such as morphine, meperidine, or pentazocine. Clinical Implications: Patient satisfaction can be improved with these enhanced pain management strategies. Also, reliance on opioids for postoperative pain management and its related side effects will be reduced. This research reinforces the importance of multimodal analgesia in postoperative pain management. The findings also open pathways for further clinical trials to explore the appropriate combinations, dosages, and administration of NSAIDs for specific surgical populations and settings. Future research should focus on standardizing methodologies and addressing risk of bias to enhance reliability of findings related to diclofenac suppository and multimodal analgesia.

Development and internal validation of a clinical risk tool to predict chronic postsurgical pain in adults: a prospective multicentre cohort study

ABSTRACT

Chronic postsurgical pain (CPSP) is a highly prevalent condition. To improve CPSP management, we aimed to develop and internally validate generalizable point-of-care risk tools for preoperative and postoperative prediction of CPSP 3 months after surgery. A multicentre, prospective, cohort study in adult patients undergoing elective surgery was conducted between May 2021 and May 2023. Prediction models were developed for the primary outcome according to the International Association for the Study of Pain criteria and a secondary threshold-based CPSP outcome. Models were developed with multivariable logistic regression and backward stepwise selection. Internal validation was conducted using bootstrap resampling, and optimism was corrected by shrinkage of predictor weights. Model performance was assessed by discrimination and calibration. Clinical utility was assessed by decision curve analysis. The final cohort included 960 patients, 16.3% experienced CPSP according to the primary outcome and 33.6% according to the secondary outcome. The primary CPSP model included age and presence of other preoperative pain. Predictors in the threshold-based models associated with an increased risk of CPSP included younger age, female sex, preoperative pain in the surgical area, other preoperative pain, orthopedic surgery, minimally invasive surgery, expected surgery duration, and acute postsurgical pain intensity. Optimism-corrected area-under-the-receiver-operating curves for preoperative and postoperative threshold-based models were 0.748 and 0.747, respectively. These models demonstrated good calibration and clinical utility. The primary CPSP model demonstrated fair predictive performance including 2 significant predictors. Derivation of a generalizable risk tool with point-of-care predictors was possible for the threshold-based CPSP models but requires independent validation.

Chronic pain after cesarean delivery: what do we know today? A narrative review

Childbirth is a major event in life, associated with both physical and psychological changes which may affect women's quality of life. Cesarean delivery (CD) is among the most frequent surgical procedures performed worldwide. Because of the high CD volume and patients' vulnerability (young age and female sex), for chronic postsurgical pain (CPSP), the societal impact of chronic pain after CD requires attention. According to the literature, the incidence of CPSP after CD is highly variable but reasonable evidence suggests a low incidence at six months (3-4%) and later (0.6-0.8%). The recent definition of CPSP in the ICD-11 coding system may not necessarily apply to the specific context of childbirth and CPSP after CD, suggesting that some modifications could be implemented. Interestingly, the incidence of chronic pain after CD is lower than that observed after gynecologic procedures performed in the similar body area. Consequently, since the risk factors do not really differ from those reported for other procedures, the existence of protective factors related to hormonal modulations secondary to pregnancy and lactation have been suggested. Such observations, in preclinical models, also question the pathophysiology of chronic pain after childbirth. Because severe acute postpartum pain is a striking risk factor of CPSP after CD, the preventive effect of different analgesic treatments, mainly regional analgesia techniques, has been evaluated but the results remain disappointing. In conclusion, many questions remain regarding the incidence, pathophysiology and potential prevention of CPSP after CD, and these questions warrant further research.

Changes in spatial bodily pain distribution one year after benign hysterectomy with emphasis on prevalence and risk factors for de novo and persistent pelvic pain- a prospective longitudinal multicenter study

BACKGROUND

The objectives were to determine the prevalence of de novo and persistent pelvic pain after benign hysterectomy and to assess risk factors.

METHODS

A Swedish prospective multicenter study of 440 women undergoing benign hysterectomy was conducted between October 2011 and March 2017. Measures of pain, the spatial extent of bodily pain, and pain sensitivity were assessed using a self-reporting questionnaire, Margolis's patient pain drawing, and quantitative sensory testing of pain thresholds for pressure, heat, and cold, respectively. Quality of life was evaluated by EQ-5D-3L and SF-36. Psychological distress was assessed by the Hospital Anxiety and Depression Scaleand the Stress-Coping Inventory. Logistic regression models were used to assess risk factors, and the outcome was presented as an adjusted odds ratio (aOR) and 95% confidence interval (CI).

RESULTS

Preoperatively, 18.0% of the women reported no bodily pain, 41.5% had pelvic pain, either as the only location (7.0%) or along with pain in other locations (34.5%), and 40.5% had non-pelvic pain only. Postoperatively, 6.2% developed de novo pelvic pain and 16.4% had persistent pelvic pain. De novo pelvic pain developed exclusively in women who preoperatively had non-pelvic pain only. Risk factors for de novo pelvic pain were a long hospital stay (aOR 1.50 (95%CI) 1.02-2.21)), high preoperative pain intensity (aOR 1.25 (95%CI 1.01-1.62)) and a high number of pain areas (aOR 1.15 (95%CI 1.05-1.27)), along with anxiety (aOR 10.61 (95%CI 1.84-61.03)) and low EQ-5D-3L health index (aOR 0.02 (95%CI 0.00-0.31)). Risk factors for persistent pelvic pain were lower age (aOR 0.89 (95%CI 0.81-0.97)), higher number of pain areas (aOR 1.08 (95%CI 1.02-1.14)), and a higher frequency of preoperative pain (aOR 12.75 (95%CI 2.24-72.66)).

CONCLUSION

Although hysterectomy appeared to be reasonably effective in curing pelvic pain, a non-negligible proportion of women developed de novo pelvic pain or had persistent pelvic pain. De novo pelvic pain seemed to affect only those who preoperatively had widespread bodily pain. Women at risk for de novo and persistent pelvic pain after hysterectomy could be identified preoperatively.

TRIAL REGISTRATIONS

The study was retrospectively registered in ClinicalTrial.gov (NCT01526668) on 01/27//2012.

Perioperative Risk Factors for Persistent Postsurgical Pain After Inguinal Hernia Repair: Systematic Review and Meta-Analysis

Persistent postsurgical pain (PPSP) is one of the most bothersome and disabling long-term complications after inguinal hernia repair surgery. Understanding perioperative risk factors that contribute to PPSP can help identify high-risk patients and develop risk-mitigation approaches. The objective of this study was to systematically review and meta-analyze risk factors that contribute to PPSP after inguinal hernia repair. The literature search resulted in 303 papers included in this review, 140 of which were used for meta-analyses. Our results suggest that younger age, female sex, preoperative pain, recurrent hernia, postoperative complications, and postoperative pain are associated with a higher risk of PPSP. Laparoscopic techniques reduce the PPSP occurrence compared to anterior techniques such as Lichtenstein repair, and tissue-suture techniques such as Shouldice repair. The use of fibrin glue for mesh fixation was consistently associated with lower PPSP rates compared to tacks, staples, and sutures. Considerable variability was observed with PPSP assessment and reporting methodology in terms of study design, follow-up timing, clarity of pain definition, as well as pain intensity or interference threshold. High or moderate risk of bias in at least one domain was noted in >75% of studies. These may limit the generalizability of our results. Future studies should assess and report comprehensive preoperative and perioperative risk factors for PPSP adjusted for confounding factors, and develop risk-prediction models to drive stratified PPSP-mitigation trials and personalized clinical decision-making. PERSPECTIVE: This systematic review and meta-analysis summarizes the current evidence on risk factors for persistent pain after inguinal hernia repair. The findings can help identify patients at risk and test personalized risk-mitigation approaches to prevent pain. PROSPERO REGISTRATION: htttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=154663.

The Utility of CO2 Laser Treatment of Pelvic Symptoms in Women with Previous Perineal Trauma during Delivery

This study aimed to examine the impact of fractional CO2 laser treatment of pelvic symptoms in women who have undergone perineal trauma from vaginal delivery. It was a retrospective, monocentric analysis that encompassed all women assessed for pelvic discomfort or signs of vulvovaginal atrophy following vaginal delivery between 2013 and 2018. The severity of symptoms was assessed using the Visual Analogue Scale (VAS). Twenty-seven patients met the inclusion criteria and were sorted into two groups: (1) women who had undergone episiotomies during labor (n = 11); and (2) women who had experienced spontaneous tears during vaginal delivery (n = 16). For women with episiotomies, each treatment and subsequent evaluation consistently showed a significant reduction in dyspareunia intensity. A similar positive trend was observed regarding pain at the introitus (7.5 vs. 6.5 after the first treatment, p = 0.03; 6.5 vs. 3 after the second treatment, p = 0.01; 3 vs. 1 after the third treatment, p = 0.01). Among women experiencing spontaneous perineal tears during delivery, there was a notable decrease in dyspareunia following all treatments (8 vs. 7 after the first treatment, p = 0.01; 8 vs. 4 after the second treatment, p = 0.02; 3 vs. 1 after the third treatment, p = 0.03). The impact of laser treatment did not exhibit significant differences between women who underwent episiotomies and those who experienced spontaneous perineal tears. In conclusion, fractional CO2 laser can be regarded as a non-pharmacological option for managing pelvic floor symptoms in women who encountered perineal trauma during delivery, independently from the nature, spontaneity, or iatrogenesis of the perineal laceration.

Intrathecal Morphine Injection for Postoperative Analgesia Following Gender-Affirming Pelvic Surgery: A Retrospective Case-Control Study

Background Gender-affirming pelvic surgery (GAPS) can be associated with significant postoperative pelvic pain. Given the lack of available peripheral nerve blocks to the perineum, intrathecal morphine (ITM) injection could offer a potent analgesic modality for this patient population. No prior studies to date have been performed examining the analgesic effects of intrathecal morphine for these patients. Methods This retrospective case-control study aims to understand the postoperative analgesic effects of intrathecal morphine for these patients with a historical comparison group of patients who did not receive intrathecal morphine. Results Fourteen patients presented for gender-affirming pelvic surgery over an eight-month period at a single institution and were offered intrathecal morphine for postoperative analgesia. Their analgesic results were compared to a similar historical group of 13 patients who were not offered or declined intrathecal morphine. Conclusions Intrathecal morphine injection is a potent analgesic modality for patients presenting for gender-affirming pelvic surgery.

Male gender, smoking, younger age, and preoperative pain found to increase postoperative opioid requirements in 592 elective colorectal resections

PURPOSE

With increased awareness of the opioid epidemic, understanding contributing factors to postoperative opioid use is important. The purpose of this study was to evaluate patient and perioperative factors that contribute to postoperative opioid use after colorectal resections and their relation to pre-existing pain conditions and psychiatric diagnoses.

METHODS

A retrospective review was conducted identifying adult patients who underwent elective colorectal resection at a single tertiary center between 2015 and 2018. Patient demographics, preoperative factors, surgical approach, and perioperative pain management were evaluated to determine standard conversion morphine milligram equivalents required for postoperative days 0 to 3 and total hospital stay.

RESULTS

Five hundred and ninety-two patients: 46% male, median age 58 years undergoing colorectal resections for indications including cancer, inflammatory bowel disease, and diverticulitis were identified. Less opioid use was found to be associated with female gender (β =  - 42), patients who received perioperative lidocaine infusion (β =  - 30), and older adults (equivalents/year) (β =  - 4, all p < 0.01). Preoperative opioid use, preoperative abdominal pain, epidural use, and smoking were all independently associated with increased postoperative opioid requirements.

CONCLUSIONS

In this study of patients undergoing elective colorectal resection, factors that were associated with higher perioperative opioid use included male gender, smoking, younger age, preoperative opioid use, preoperative abdominal pain, and epidural use. Perioperative administration of lidocaine was associated with decreased opioid requirements. Understanding risk factors and stratifying postoperative pain regimens may aid in improved pain control and decrease long-term dependency.

Chronic pain and infection: mechanisms, causes, conditions, treatments, and controversies

Throughout human history, infection has been the leading cause of morbidity and mortality, with pain being one of the cardinal warning signs. However, in a substantial percentage of cases, pain can persist after resolution of acute illness, manifesting as neuropathic, nociplastic (eg, fibromyalgia, irritable bowel syndrome), or nociceptive pain. Mechanisms by which acute infectious pain becomes chronic are variable and can include immunological phenomena (eg, bystander activation, molecular mimicry), direct microbe invasion, central sensitization from physical or psychological triggers, and complications from treatment. Microbes resulting in a high incidence of chronic pain include bacteria such as the Borrelia species and Mycobacterium leprae, as well as viruses such as HIV, SARS-CoV-2 and herpeses. Emerging evidence also supports an infectious cause in a subset of patients with discogenic low back pain and inflammatory bowel disease. Although antimicrobial treatment might have a role in treating chronic pain states that involve active infectious inflammatory processes, their use in chronic pain conditions resulting from autoimmune mechanisms, central sensitization and irrevocable tissue (eg, arthropathy, vasculitis) or nerve injury, are likely to cause more harm than benefit. This review focuses on the relation between infection and chronic pain, with an emphasis on common viral and bacterial causes.

Postoperative Pain Is Driven by Preoperative Pain, Not by Endometriosis

(1) Background: The aim of this study was to evaluate the impact of endometriosis on postoperative pain following laparoscopic hysterectomy; (2) Methods: A total of 214 women who underwent a laparoscopic hysterectomy between January 2013 and October 2017 were divided into four subgroups as follows: (1) endometriosis with chronic pain before the surgery (n = 57); (2) pain-free endometriosis (n = 50); (3) pain before the surgery without endometriosis (n = 40); (4) absence of both preoperative pain and endometriosis (n = 67). Postoperative pain was compared by using Visual Analog Scale (VAS) scores and by tracking the use of painkillers during the day of surgery and the first two postoperative days; (3) Results: Women with chronic pain before the surgery reported higher VAS scores during the first postoperative days, while the use of analgesics was similar across the groups. There was no difference in the postoperative pain when comparing endometriosis patients to non-endometriosis patients; (4) Conclusions: Women with chronic pelvic pain demonstrated increased postoperative pain after laparoscopic hysterectomy, which was independent of the presence or severity of endometriosis. The increased VAS scores did not, however, translate into equally greater use of painkillers, possibly due to the standardised protocols of analgesia in the immediate postoperative period. These findings support the need for careful postsurgical pain management in patients with pain identified as an indication for hysterectomy, independent of the extent of the surgery or underlying diagnosis.