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Steele LA, Mooney SS, Gilbee ES, Grover SR. When you see nothing at all: Outcomes following a negative laparoscopy. A systematic review. Aust N Z J Obstet Gynaecol 2024; 64:95-103. [PMID: 37737451 DOI: 10.1111/ajo.13749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/14/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Persistent pelvic pain (PPP) is a complex and often debilitating condition. While widely accepted to be multifactorial in nature, the precise aetiology of PPP remains elusive. In many cases, women who undergo laparoscopy for PPP will have no visible pathology identified (a 'negative' laparoscopy). Currently, there are no consensus guidelines which outline the recommended management following a negative laparoscopy, and the woman's experiences and outcomes are not widely known. AIMS This review aims to identify and summarise the literature surrounding the experiences of women with PPP who have a negative laparoscopy; specifically, their outcomes of pain, quality of life (QoL), satisfaction with care, and their overall management. MATERIALS AND METHODS A systematic search of the electronic databases Ovid Medline, PubMed and Embase was performed. Studies in English exploring the outcomes of women with PPP following a negative laparoscopy were included. RESULTS Four studies consisting of a total of 200 women were included. Results were inconsistent. Three studies concluded that the majority of women with PPP had persistent pain following a negative laparoscopy. A single study found that pain significantly improved after negative laparoscopy. QoL outcomes varied, with two studies reporting a positive impact and two studies reporting a deleterious impact on QoL following a negative laparoscopy. CONCLUSIONS The impact on pain outcomes and QoL following a laparoscopy that does not diagnose pathology remains unknown, and the available evidence is insufficient to guide evidence-based practice. This review highlights a significant gap in our understanding of surgical management for PPP.
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Affiliation(s)
- Lucy A Steele
- School of Medicine, Austin Hospital Clinical School, Victoria, Melbourne, Australia
| | - Samantha S Mooney
- Department of Endosurgery, Mercy Hospital for Women, Victoria, Melbourne, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ebony S Gilbee
- Department of Endosurgery, Mercy Hospital for Women, Victoria, Melbourne, Australia
| | - Sonia R Grover
- Department of Endosurgery, Mercy Hospital for Women, Victoria, Melbourne, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
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Knuttinen MG, Machan L, Khilnani NM, Louie M, Caridi TM, Gupta R, Winokur RS. Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2023; 221:565-574. [PMID: 37095667 DOI: 10.2214/ajr.22.28796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
Pelvic venous disorders (PeVD), previously known by various imprecise terms including pelvic congestion syndrome, have historically been underdiagnosed as a cause of chronic pelvic pain (CPP), a significant health problem associated with reduced quality of life. However, progress in the field has helped to provide heightened clarity with respect to definitions relating to PeVD, and evolution in algorithms for PeVD workup and treatment has been accompanied by new insights into the causes of a pelvic venous reservoir and associated symptoms. Ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for PeVD. Both treatments have been shown to be safe and effective for patients with CPP of venous origin, regardless of age. Current therapeutic protocols for PeVD exhibit significant heterogeneity owing to limited prospective randomized data and evolving understanding of the factors driving successful outcomes; forthcoming clinical trials are anticipated to improve understanding of CPP of venous origin as well as algorithms for PeVD management. This Expert Panel Narrative Review provides a contemporary update relating to PeVD, summarizing the entity's current classification, diagnostic workup, endovascular treatments, management of persistent or recurrent symptoms, and future research directions.
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Affiliation(s)
- M-Grace Knuttinen
- Department of Radiology, Division of Interventional Radiology, Mayo Clinic Arizona, 5777 Mayo Blvd, Phoenix, AZ 85255
| | - Lindsay Machan
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Neil M Khilnani
- Department of Radiology, Weill Cornell Medicine, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Michelle Louie
- Department of Medical and Surgical Gynecology, Mayo Clinic Arizona, Phoenix, AZ
| | - Theresa M Caridi
- Department of Radiology, Division of Interventional Radiology, UAB Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Ramona Gupta
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ronald S Winokur
- Department of Radiology, Weill Cornell Medicine, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY
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Kaftan BT. [Somatoform disorders-chronic pelvic pain in women]. UROLOGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00120-023-02087-4. [PMID: 37145155 DOI: 10.1007/s00120-023-02087-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 05/06/2023]
Abstract
Pelvic pain in women is a clinically common symptom and a frequent finding in general practitioner, urological, gynecological, and pediatric practice. The list of possible differential diagnoses is long and the clarification ranges from a visual diagnosis to technical and surgical examinations to complex interdisciplinary consultations. But when do we talk about chronic lower abdominal pain? What can be the cause of this and how can we approach it diagnostically and therapeutically? What should we pay attention to? The difficulty begins with the definition. If we look at the national and international guidelines and publications, we find different definitions for chronic pelvic pain. There are various causes of chronic pelvic pain. There is often a combination of physical and psychological factors, which is why it is often not possible to identify a single diagnosis behind chronic pelvic pain syndrome. The clarification of these complaints requires a biopsychosocial approach. Multimodal approaches should be considered in assessment and treatment, and experts from other disciplines should be consulted.
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Affiliation(s)
- Björn Theodor Kaftan
- Zentrum für Interstitielle Zystitis und Beckenschmerz (IC/BPS), Städtisches Klinikum Lüneburg gGmbH, Bögelstr. 1, 21335, Lüneburg, Deutschland.
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Tabaac AR, Chwa C, Sutter ME, Missmer SA, Boskey ER, Austin SB, Grimstad F, Charlton BM. Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States. J Sex Med 2022; 19:1012-1023. [PMID: 35508601 PMCID: PMC9149035 DOI: 10.1016/j.jsxm.2022.03.606] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/11/2022] [Accepted: 03/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sexual minority (lesbian, bisexual, mostly heterosexual) young women face many sexual and reproductive health disparities, but there is scant information on their experiences of chronic pelvic pain, including an absence of information on prevalence, treatment, and outcomes. AIM The purpose of this study was to describe the characteristics of chronic pelvic pain experiences of young women by sexual orientation identity and gender of sexual partners. METHODS The analytical sample consisted of a nationwide sample of 6,150 U.S. young women (mean age = 23 years) from the Growing Up Today Study who completed cross-sectional questionnaires from 1996 to 2007. OUTCOMES Age-adjusted regression analyses were used to examine groups categorized by sexual orientation identity (completely heterosexual [ref.], mostly heterosexual, bisexual, lesbian) and gender of sexual partner (only men [ref.], no partners, both men, and women). We examined differences in lifetime and past-year chronic pelvic pain symptoms, diagnosis, treatment, and quality of life outcomes. Sensitivity analyses also examined the role of pelvic/gynecologic exam history and hormonal contraceptive use as potential effect modifiers. RESULTS Around half of all women reported ever experiencing chronic pelvic pain, among whom nearly 90% had past-year chronic pelvic pain. Compared to completely heterosexual women, there was greater risk of lifetime chronic pelvic pain among mostly heterosexual (risk ratio [RR] = 1.30, 95% confidence interval [CI]: 1.22-1.38), bisexual (RR = 1.30, 95% CI: 1.10-1.52), and lesbian (RR = 1.23, 95% CI: 1.00-1.52) young women. Additionally, compared to young women with only past male sexual partners, young women who had both men and women as past sexual partners were more likely to report chronic pelvic pain interfered with their social activities (b = 0.63, 95% CI: 0.25-1.02), work/school (b = 0.55, 95% CI: 0.17-0.93), and sex (b = 0.53, 95% CI: 0.05-1.00). CLINICAL IMPLICATIONS Healthcare providers, medical education, and field-wide standards of care should be attentive to the way sexual orientation-based healthcare disparities can manifest into differential prognosis and quality of life outcomes for women with chronic pelvic pain (particularly bisexual women). STRENGTHS & LIMITATIONS Our study is the first to examine a variety of chronic pelvic pain outcomes in a nationwide U.S. sample across different outcomes (ie, past-year and lifetime). Though limited by sample homogeneity in terms of age, race, ethnicity, and gender, findings from this article provide foundational insights about chronic pelvic pain experiences of sexual minority young women. CONCLUSION Our key finding is that sexual minority women were commonly affected by chronic pelvic pain, and bisexual women face pain-related quality of life disparities. Tabaac AR, Chwa C, Sutter ME, et al. Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States. J Sex Med 2022;19:1012-1023.
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Affiliation(s)
- Ariella R Tabaac
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Cindy Chwa
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Megan E Sutter
- Department of Population Health, NYU School of Medicine, New York, NY, USA; Department of Obstetrics and Gynecology, NYU School of Medicine, New York, NY, USA
| | - Stacey A Missmer
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA; Channing Division of Network Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Elizabeth R Boskey
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Gender Surgery, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - S Bryn Austin
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Frances Grimstad
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA; Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Brittany M Charlton
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Brigham & Women's Hospital, Boston, MA, USA; Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Kaufman C, Little NA. Pelvic Congestion Syndrome: A Missed Opportunity. Indian J Radiol Imaging 2021; 31:539-544. [PMID: 34790295 PMCID: PMC8590552 DOI: 10.1055/s-0041-1735497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background/Aims Chronic pelvic pain (CPP) is pelvic pain for greater than 6 months with many potential causes one being pelvic congestion syndrome (PCS). PCS is diagnosed by clinical symptoms, exclusion of other etiologies, and imaging. Given the complex nature and diagnosis of CPP, we examined ordering and referral patterns in our local population to understand how the imaging findings of PCS correlate with patient symptoms and referral and treatment. Materials and Methods After IRB approval, we searched all 18 to 70-year-old females with CT of the pelvis between March 2015 and March 2018 with the terms "pelvic" plus "congestion," "varices," or "vein dilation" in the dictation. Via electronic medical record and image review we collected data regarding demographics, clinical presentation, symptoms, imaging findings, ordering provider, and any follow-up/referrals or interventions regarding PCS. Results A total of 96 patients were included of the 197 studies, with an average age of 47 years and average body mass index of 19.3 ( n = 93) at the time of imaging. The reason for imaging was often acute abdominal or flank pain ( n = 22) with 38% of cases ordered from the emergency room. Only 72 patients had documentation of clinical evaluation for symptoms of PCS. Notably, only 20 were referred for their symptoms, and only two patients were referred to IR. Both patients underwent successful endovascular intervention. Conclusion CPP is a common cause of morbidity with PCS representing an underdiagnosed cause. We demonstrate that while imaging findings may be incidental, we are failing to capture and triage patients with clinical symptoms of PCS. Radiologists can play a key role in the care of these patients.
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Affiliation(s)
- Claire Kaufman
- Department of Radiology, University of Utah, Salt Lake City, Utah, United States
| | - Nancy Ann Little
- Department of Radiology, University of Wisconsin, Madison, Wisconsin, United States
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Urits I, Callan J, Moore WC, Fuller MC, Renschler JS, Fisher P, Jung JW, Hasoon J, Eskander J, Kaye AD, Viswanath O. Cognitive behavioral therapy for the treatment of chronic pelvic pain. Best Pract Res Clin Anaesthesiol 2020; 34:409-426. [PMID: 33004156 DOI: 10.1016/j.bpa.2020.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 01/18/2023]
Abstract
Chronic pelvic pain (CPP) in women is defined as noncyclical and persistent pain lasting more than six months perceived to be related to the pelvis. There are many etiologies that can cause CPP, including gynecologic, urologic, gastrointestinal, musculoskeletal, neurologic, and psychosocial. There is a strong association between psychological factors and CPP. It has been noted that almost half of women being treated for CPP report a history of sexual, physical, or emotional trauma. Women with CPP have been noted to have higher rates of psychological disorders in comparison to their peers. For men, the most common etiology for CPP is chronic prostatitis and there are also correlations with psychological disorders. There are many different treatment options for CPP: surgical, pharmacological, and non-pharmacological (alternative therapies). Cognitive-behavioral therapy may be another option when treating chronic pelvic pain syndrome and should be considered.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA; Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.
| | - Jessica Callan
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
| | - Warner C Moore
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | | | - Jordan S Renschler
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Paul Fisher
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Jai Won Jung
- Georgetown University School of Medicine, Washington, DC, USA
| | - Jamal Hasoon
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Jonathan Eskander
- Portsmouth Anesthesia Associates, Anesthesiology and Pain Medicine, Portsmouth, VA, USA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Omar Viswanath
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA; Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA
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Jia X, Rana N, Crouss T, Whitmore KE. Gynecological associated disorders and management. Int J Urol 2019; 26 Suppl 1:46-51. [PMID: 31144734 DOI: 10.1111/iju.13974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic pelvic pain syndrome is complex and involves multiple organ systems. The gynecological aspects of chronic pelvic pain syndrome can be divided into four different areas: intra-abdominal, vaginal, pelvic floor muscles and sexual pain. This article provides an overview of gynecological evaluation in patients with chronic pelvic pain and reviews the most common gynecological diagnoses and their management. METHODS An extensive review of the literature including guidelines from the International Continence Society, the European Association of Urology, and the International Association for the Study of Pain was performed. RESULTS Gynecological evaluation of patients with chronic pelvic pain begins with a thorough history and physical examination. Laboratory tests, imaging studies and diagnostic procedures can be used as adjuncts to make a diagnosis. Treatment modalities include physical therapy, medications, trigger points injections, and surgery. CONCLUSION Common gynecological diagnoses of chronic pelvic pain include endometriosis, adenomyosis, vulvodynia, high tone pelvic floor dysfunction, and genitopelvic pain/penetration disorder. Gynecology is one of the many systems that can be associated with chronic pelvic pain. Managing patients with chronic pelvic pain requires a multimodal and multidisciplinary approach.
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Affiliation(s)
- Xibei Jia
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Neha Rana
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Tess Crouss
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Kristene E Whitmore
- Division of Female Pelvic Medicine and Reconstructive surgery and Urology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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Gynaecologists' view on diagnostic delay and care performance in endometriosis in the Netherlands. Reprod Biomed Online 2018; 37:761-768. [PMID: 30366841 DOI: 10.1016/j.rbmo.2018.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 11/21/2022]
Abstract
RESEARCH QUESTION To evaluate implementation of the key recommendations of the European Society of Human Reproduction and Embryology (ESHRE) guidelines on endometriosis, and to assess factors influencing diagnostic delay of endometriosis from Dutch gynaecologists' point of view. DESIGN Questionnaire study among gynaecologists from all hospitals in the Netherlands. The questionnaire consisted of 56 questions relating to implementation of the ESHRE guidelines, organization of endometriosis care and diagnostic delay. RESULTS Gynaecologists from 67 out of 85 hospitals completed the questionnaire. A total of 99-100% of respondents agree with, and 91-100% adhere to, the diagnosis-related recommendations in the guidelines. Diagnostic delay is estimated at 42 months. Main factors contributing to diagnostic delay according to gynaecologists are lack of knowledge and awareness of endometriosis in both patients and medical professionals, as well as limitations in diagnostics and late referral. Suggested interventions to reduce diagnostic delay are aimed at improving knowledge and awareness in both patients and medical professionals, as well as improving collaborations between medical professionals. CONCLUSIONS Overall familiarity with, and use of, the 2014 ESHRE guidelines among Dutch gynaecologists is high. Dutch gynaecologists agree with the recommendations relating to diagnosis and adhere to them closely. Diagnostic delay, however, is still considerable; therefore, efforts to reduce diagnostic delay of endometriosis should be aimed at improving knowledge and awareness in both patients and medical professionals, as well as improving collaboration.
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Brichant G, Denef M, Tebache L, Poismans G, Pinzauti S, Dechenne V, Nisolle M. Chronic pelvic pain and the role of exploratory laparoscopy as diagnostic and therapeutic tool: a retrospective observational study. ACTA ACUST UNITED AC 2018. [DOI: 10.1186/s10397-018-1045-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Forty percent of exploratory laparoscopies are performed for chronic pelvic pain (CPP). However, a final diagnosis is still unreported in 35% of the patients. We decided to evaluate the identification of pathological lesions and the improvement of painful symptoms in patients with CPP and normal physical examination and imaging and who are scheduled for exploratory laparoscopy. The prospective study was designed in a tertiary referral center for endometriosis. Forty-eight patients complaining of CPP and scheduled for exploratory laparoscopy were included. Pelvic pain intensity was assessed using the visual analogue pain scale (VAS), and at inclusion, negative clinical and imaging assessments were required. During exploratory laparoscopy, the recognized lesions were reported and different surgical treatment options were performed depending on the location of the lesion.
Results
In 98% of the cases, exploratory laparoscopy demonstrated the presence of pelvic anomalies that had not been diagnosed at the time of clinical and imaging examination. After surgery, a significant improvement of CPP has been demonstrated in 24 (59%) patients with VAS < 5 postoperatively.
Conclusions
Exploratory laparoscopy is reasonable in patients complaining of CPP, allowing a final diagnosis in a high percentage of patients and a significant improvement in pain symptom in 59% of the cases. This study was retrospectively registered by our local Ethics Committee on February 7, 2018 (B412201835729).
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Affiliation(s)
- R William Stones
- Community Clinical Sciences Research Division, University of Southampton
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Abstract
Peripheral generators and the central nervous system have a role in the production of visceral and somatic hypersensivities and hyperalgesias.More generalised symptoms often exist and efferent activity from the CNS may also be responsible for abnormal visceral and muscular function.It is important to dissect out the symptoms and as well as treating peripheral generators to consider interventions of the central mechanisms aimed at the cognitive behavioural aspects of the patients' condition.
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Chronic Pain Syndromes, Mechanisms, and Current Treatments. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2015; 131:565-611. [DOI: 10.1016/bs.pmbts.2015.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Berzuk K. The Pelvic Floor Muscle: the Link Between Bladder, Bowel, and…Sex? A Review of Current Pelvic Therapy Approaches for Diagnosis and Treatment of Sexual Disorders. CURRENT SEXUAL HEALTH REPORTS 2014. [DOI: 10.1007/s11930-014-0025-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Brawn J, Morotti M, Zondervan KT, Becker CM, Vincent K. Central changes associated with chronic pelvic pain and endometriosis. Hum Reprod Update 2014; 20:737-47. [PMID: 24920437 DOI: 10.1093/humupd/dmu025] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Chronic pelvic pain (CPP) is a significant public health problem with 1 million affected women in the UK. Although many pathologies are associated with CPP, the pain experienced is often disproportionate to the extent of disease identified and frequently no pathology is found (chronic pelvic pain syndrome). The central nervous system (CNS) is central to the experience of pain and chronic pain conditions in general are associated with alterations in both the structure and function of the CNS. This review describes the available evidence for central changes in association with conditions presenting with CPP. METHODS A detailed literature search was performed to identify relevant papers, however, this is not a systematic review. RESULTS CPP is associated with central changes similar to those identified in other pain conditions. Specifically these include, alterations in the behavioural and central response to noxious stimulation, changes in brain structure (both increases and decreases in the volume of specific brain regions), altered activity of both the hypothalamic-pituitary-adrenal axis and the autonomic nervous system (ANS) and psychological distress. CONCLUSIONS The evidence reviewed in this paper demonstrates that CPP is associated with significant central changes when compared with healthy pain-free women. Moreover, the presence of these changes has the potential to both exacerbate symptoms and to predispose these women to the development of additional chronic conditions. These findings support the use of adjunctive medication targeting the CNS in these women.
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Affiliation(s)
- Jennifer Brawn
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Matteo Morotti
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK Department of Obstetrics and Gynaecology, University of Genoa, Genoa 16100, Italy
| | - Krina T Zondervan
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Christian M Becker
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Katy Vincent
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
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Loving S, Thomsen T, Jaszczak P, Nordling J. Female chronic pelvic pain is highly prevalent in Denmark. A cross-sectional population-based study with randomly selected participants. Scand J Pain 2014; 5:93-101. [PMID: 29913678 DOI: 10.1016/j.sjpain.2013.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 12/24/2013] [Indexed: 11/25/2022]
Abstract
Background and purpose Female chronic pelvic pain is a significant clinical problem that burdens the health care services and work productivity, and leads to disability and reduced quality of life among the women affected. A recent systematic review reported worldwide prevalence rates for female chronic pelvic pain ranging from 2.1% to 24%. Our aim was to assess the prevalence, characteristics, and factors associated with chronic pelvic pain among women living in Denmark, and to compare these findings with a pain-free reference group. Secondly, we evaluated the impact of pain on daily life in women suffering from chronic pelvic pain. Methods A cross-sectional postal survey of the prevalence of chronic pelvic pain was undertaken in a randomly selected general female population in Denmark (N = 2500). Inclusion criteria were: (a) ≥18 years of age and (b) living in the Capital region or the region of Zealand in Denmark. Statistical analyses included prevalence percentage rates, chi-square tests, Mann-Whitney tests, and unpaired T-tests. Logistic regression analysis was used to identify the significant independent variables and to estimate their simultaneous impact on chronic pelvic pain. The results were expressed as odds ratio and 95% confidence intervals. All tests were two-tailed and significance levels were set at p < 0.05. Results 1179 (48%) women living in representative areas of Denmark responded. The prevalence of chronic pelvic pain was 11% (n = 130) in women ≥18 years with a prevalence of 13.6% (n = 87) in women of reproductive age; 6.2% (n = 73) women experienced at least moderate average pain intensity (numerical rating scale ≥4). Self-reported diagnosis of irritable bowel syndrome (20%), bladder pain syndrome/interstitial cystitis (3%), vulvodynia (9%), endometriosis (8%), and pelvic surgery in the preceding 6 months (5%) were more prevalent in cases compared to pain-free reference subjects (p = 0.00). Chronic pelvic pain interfered with daily life "all the time" in 5% of the women, "sometimes" in 72.3%, and "not at all" in 22.7%. Factors independently associated with chronic pelvic pain were age, country of birth, and former pelvic trauma or pelvic surgery (p < 0.05). No association was found between chronic pelvic pain and selected socio-demographic factors (residential area, educational level, cohabitation status and employment status). Conclusions Female chronic pelvic pain appears highly prevalent (11%) in Denmark (6.2% with moderate to severe pain). Women of reproductive age had a slightly increased prevalence (13.6%). Although the reported prevalence is based on 48% (N = 1179) of the invited sample, dropout analyses found that respondents did not deviate from non-respondents. Therefore, we considered the reported prevalence rate representative for the total sample and generalisable to the general female population in Denmark. This study was cross-sectional, and relied on association-based analyses. Consequently, causality between age groups, country of birth, former pelvic surgeries and pelvic traumas and experiences of chronic pelvic pain remains unknown. Implications In order to improve prevention and treatment of chronic pelvic pain in Denmark, high quality, population-based cohort studies and randomised clinical trials are essential. The demand for trustworthy chronic pelvic pain prevalence estimates might also inspire political attention and hereby facilitate funding for further development of treatment and research.
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Affiliation(s)
- S Loving
- Multidisciplinary Pain Centre, Department of Anaesthesiology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - T Thomsen
- Abdominal Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - P Jaszczak
- Department of Gynaecology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - J Nordling
- Department of Urology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
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Female chronic pelvic pain is common and complex. Scand J Pain 2014; 5:91-92. [DOI: 10.1016/j.sjpain.2014.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Pierce AN, Ryals JM, Wang R, Christianson JA. Vaginal hypersensitivity and hypothalamic-pituitary-adrenal axis dysfunction as a result of neonatal maternal separation in female mice. Neuroscience 2014; 263:216-30. [PMID: 24462609 DOI: 10.1016/j.neuroscience.2014.01.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/11/2013] [Accepted: 01/14/2014] [Indexed: 02/07/2023]
Abstract
Early life stress can permanently alter functioning of the hypothalamic-pituitary-adrenal (HPA) axis, which regulates the stress response and influences the perception of pain. Chronic pelvic pain patients commonly report having experienced childhood neglect or abuse, which increases the likelihood of presenting with comorbid chronic pain and/or mood disorders. Animal models of neonatal stress commonly display enhanced anxiety-like behaviors, colorectal hypersensitivity, and disruption of proper neuro-immune interactions in adulthood. Here, we tested the hypothesis that early life stress impacts vaginal sensitivity by exposing mice to neonatal maternal separation (NMS) for 3h/day during the first two (NMS14) or three (NMS21) postnatal weeks. As adults, female mice underwent vaginal balloon distension (VBD), which was also considered an acute stress. Before or after VBD, mice were assessed for anxiety-like behavior, hindpaw sensitivity, and changes in gene and protein expression related to HPA axis function and regulation. NMS21 mice displayed significantly increased vaginal sensitivity compared to naïve mice, as well as significantly reduced anxiety-like behavior at baseline, which was heightened following VBD. NMS21 mice exhibited significant thermal and mechanical hindpaw hypersensitivity at baseline and following VBD. NMS14 mice displayed no change in anxiety-like behavior and only exhibited significantly increased hindpaw mechanical and thermal sensitivity following VBD. Centrally, a significant decrease in negative regulation of the HPA axis was observed in the hypothalamus and hippocampus of NMS21 mice. Peripherally, NMS and VBD affected the expression of inflammatory mediators in the vagina and bladder. Corticotropin-releasing factor (CRF) receptor and transient receptor potential (TRP) channel protein expression was also significantly, and differentially, affected in vagina, bladder, and colon by both NMS and VBD. Together these data indicate that NMS affects both central and peripheral aspects of the HPA axis, which may drive changes in vaginal sensitivity and the development of comorbid chronic pain and mood disorders.
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Affiliation(s)
- A N Pierce
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - J M Ryals
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - R Wang
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - J A Christianson
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, KS 66160, United States.
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Thomeer MG, Steensma AB, van Santbrink EJ, Willemssen FE, Wielopolski PA, Hunink MG, Spronk S, Laven JS, Krestin GP. Can magnetic resonance imaging at 3.0-Tesla reliably detect patients with endometriosis? Initial results. J Obstet Gynaecol Res 2014; 40:1051-8. [DOI: 10.1111/jog.12290] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/09/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Anneke B. Steensma
- Divisions of Gynecology and Reproductive Medicine of the Department of Obstetrics and Gynecology; Erasmus MC; Rotterdam The Netherlands
| | - Evert J. van Santbrink
- Divisions of Gynecology and Reproductive Medicine of the Department of Obstetrics and Gynecology; Erasmus MC; Rotterdam The Netherlands
| | | | | | - Myriam G. Hunink
- Department of Radiology; Erasmus MC; Rotterdam The Netherlands
- Department of Epidemiology; Erasmus MC; Rotterdam The Netherlands
| | - Sandra Spronk
- Department of Epidemiology; Erasmus MC; Rotterdam The Netherlands
| | - Joop S. Laven
- Divisions of Gynecology and Reproductive Medicine of the Department of Obstetrics and Gynecology; Erasmus MC; Rotterdam The Netherlands
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Abstract
Endometriosis is an enigmatic disease and its fundamental cause is still unknown. Endometriosis-associated pain syndrome is a common problem; it is underdiagnosed and patients suffering from the syndrome are rarely seen in specialist pain clinics. The correlation between the extent of the disease and pain is weak. Endometriosis-associated pain syndrome may be cyclical or persistent and the pain may radiate to other pelvic organs. Optimum treatment is timely intervention using a multidisciplinary approach.
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Affiliation(s)
- Julia Cambitzi
- National Hospital for Neurology and Neurosurgery, University College Hospitals, London, UK
| | - Maya Nagaratnam
- National Hospital for Neurology and Neurosurgery, University College Hospitals, London, UK
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20
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Bartley JM, Carrico DJ, Gilleran JP, Sirls LT, Peters KM. Chronic pelvic pain in women: common etiologies and management approach recommendations. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/cpr.12.74] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Tsakova A, Surcheva S, Vlaskovska M. Ex Situ-En Blockand In VitroAnimal Models of Mechanosensory and Motor Equivalents of Pelvic and Urogenital Pain. BIOTECHNOL BIOTEC EQ 2013. [DOI: 10.5504/bbeq.2013.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Weijenborg PTM, Kuile MM, Gopie JP, Spinhoven P. Predictors of outcome in a cohort of women with chronic pelvic pain - A follow-up study. Eur J Pain 2012; 13:769-75. [DOI: 10.1016/j.ejpain.2008.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2008] [Revised: 07/30/2008] [Accepted: 09/07/2008] [Indexed: 01/22/2023]
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23
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Endometriosis: the consequence of uterine denervation–reinnervation. Arch Gynecol Obstet 2011; 284:1423-9. [DOI: 10.1007/s00404-011-2063-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 08/08/2011] [Indexed: 12/11/2022]
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Warren JW, Morozov V, Howard FM. Could chronic pelvic pain be a functional somatic syndrome? Am J Obstet Gynecol 2011; 205:199.e1-5. [PMID: 21620363 DOI: 10.1016/j.ajog.2011.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 03/14/2011] [Accepted: 04/04/2011] [Indexed: 12/18/2022]
Abstract
The cause of noncyclical chronic pelvic pain (CPP) in many women is unknown: 30% have no identifiable pelvic pathology, and in those who do the relationship of CPP and the pathology is often unclear. Moreover, epidemiologic studies demonstrate that the common findings of endometriosis and adhesions do not greatly increase the odds of having CPP. CPP and the functional somatic syndromes (fibromyalgia, irritable bowel syndrome, and others) share many characteristics including pain as a prominent symptom and comorbidity. For the functional somatic syndromes, the initial focus of etiologic investigations has been on local mechanisms and then on systemic pathogeneses. We believe that the research trajectories of the functional somatic syndromes and CPP are converging. Their juncture might reveal an important pathologic mechanism for CPP in some women that is primarily outside the pelvis. This observation would open up new areas of exploration and treatment of CPP.
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Affiliation(s)
- John W Warren
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Droz J, Howard FM. Use of the Short-Form McGill Pain Questionnaire as a diagnostic tool in women with chronic pelvic pain. J Minim Invasive Gynecol 2011; 18:211-7. [PMID: 21354067 DOI: 10.1016/j.jmig.2010.12.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 12/21/2010] [Accepted: 12/22/2010] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE To estimate the usefulness of the Short-Form McGill Pain Questionnaire (MPQ) pain descriptors in the diagnostic evaluation of chronic pelvic pain. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING University-based center specializing in chronic pelvic pain. PATIENTS Three hundred thirty-one consecutively evaluated women with chronic pelvic pain who had data sufficient for evaluation. INTERVENTIONS The relationships between MPQ pain descriptors and subsequent diagnoses were evaluated using odds ratios, sensitivity, specificity, and positive and negative predictive values. MEASUREMENTS AND MAIN RESULTS The most common diagnoses were endometriosis, interstitial cystitis and painful bladder syndrome, and irritable bowel syndrome. Seventy-one percent of the patients had more than one diagnosis. Relative risks for pain descriptors as diagnostic tools for specific diagnoses were most significant, with "cramping" for endometriosis (4.0), "cramping" for interstitial cystitis and painful bladder syndrome (2.0), "sickening" for irritable bowel syndrome (1.5), and "aching" for abdominal myofascial pain syndrome (4.27). CONCLUSION Several of the MPQ descriptors had high negative predictive values but not high positive predictive values, which suggests that they have diagnostic usefulness in excluding but not predicting pelvic pain-related diagnoses. This was especially the case with cramping as an MPQ descriptor in women with endometriosis. However, overall the MPQ descriptors were not robust as diagnostic tools, which suggests that inclusion of the MPQ descriptors in the evaluation of women with chronic pelvic pain is of limited diagnostic value.
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Affiliation(s)
- Jennifer Droz
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Butrick CW, Howard FM, Sand PK. Diagnosis and Treatment of Interstitial Cystitis/Painful Bladder Syndrome: A Review. J Womens Health (Larchmt) 2010; 19:1185-93. [DOI: 10.1089/jwh.2009.1702] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Charles W. Butrick
- Department of Obstetrics & Gynecology, The Urogynecology Center, Overland Park, Kansas, and Kansas University Medical Center, Kansas City, Kansas
| | - Fred M. Howard
- Department of Obstetrics & Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Peter K. Sand
- Department of Obstetrics & Gynecology, Northwestern University, Feinberg School of Medicine, Evanston, Illinois
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Abstract
The denervation-reinnervation view proposes that retrograde menstruation results from loss of normal, fundocervical polarity caused by injuries to uterine nerves. Injuries may be sporadic (following vaginal delivery) or recurrent (after persistent straining during defaecation) creating very different appearances at laparoscopy. Clinical symptoms of pelvic pain, menstrual problems, dyspareunia, and dysmenorrhoea result from aberrant reinnervation that may occur with, or without deposits of pelvic endometriosis. Endometrium, delivered by retrograde menstruation, adheres to any injured tissues in the lower pelvis. Classical 'endometriosis' is largely an epiphenomenon to underlying processes of denervation and reinnervation.
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30
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Weijenborg PTM, Ter Kuile MM, Stones W. A cognitive behavioural based assessment of women with chronic pelvic pain. J Psychosom Obstet Gynaecol 2009; 30:262-8. [PMID: 19922399 DOI: 10.3109/01674820903378742] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
From population-based surveys, chronic pelvic pain (CPP) in women is a common condition with a spectrum of associated disability and distress. Those seen by gynaecologists in a referral setting often have substantial impairment of function and mood disturbance. Because in most cases, the aetiology of CPP cannot be explained and the range of effective interventions remains limited, treatment of CPP might easily result in a sense of frustration not only for the patient but also for the gynaecologist. To avoid this situation in clinical practice, a structured assessment of women suffering from CPP using a cognitive behavioural model, is suggested. This type of assessment provides information about the impact of CPP on a particular patient's daily life. It also facilitates referral for pain management. Future studies are needed to show further evidence of benefit of this approach for women with CPP.
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31
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MAROUN P, COOPER MJW, REID GD, KEIRSE MJNC. Relevance of gastrointestinal symptoms in endometriosis. Aust N Z J Obstet Gynaecol 2009; 49:411-4. [DOI: 10.1111/j.1479-828x.2009.01030.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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32
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Seaman HE, Ballard KD, Wright JT, de Vries CS. Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease: findings from a national case-control study--Part 2. BJOG 2008; 115:1392-6. [PMID: 18715239 DOI: 10.1111/j.1471-0528.2008.01879.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate whether the increased chances of having a diagnosis of irritable bowel syndrome (IBS) and pelvic inflammatory disease (PID) in women with endometriosis is due to misdiagnosis or co-morbidity. DESIGN A case-control study of women aged 15-55 years with endometriosis and matched controls. SETTING Data from the UK's General Practice Research Database for the years 1992-2001. SAMPLE A total of 5540 women aged 15-55 years, diagnosed with endometriosis, each matched to four controls without endometriosis. The index date was defined as the date of diagnosis. METHODS Data were analysed to determine whether women with endometriosis were more likely to receive a diagnosis of PIDor IBS than women without endometriosis. Odds ratios were calculated for endometriosis associated with IBS and PID before and after the index date. MAIN OUTCOME MEASURES Diagnosis of IBS or PID before and after the index date. RESULTS Compared with the controls, women with endometriosis were 3.5 times more likely to have received a diagnosis of IBS (OR 3.5 [95% CI: 3.1-3.9]). Even after women had been diagnosed with endometriosis, they were still two and a half times more likely to receive a new diagnosis of IBS when compared with the controls (OR 2.5 [95% CI: 2.2-2.8]). Similarly, women with endometriosis were more likely than those without endometriosis to have been treated for PID both before (OR 5.9 [95% CI: 5.1-6.9]) and after (OR 3.8 [95% CI: 3.1-4.6]) being diagnosed with endometriosis. CONCLUSIONS Women with endometriosis are more likely to be diagnosed with IBS and PID than controls, even after a definitive diagnosis of endometriosis has been reached.
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Affiliation(s)
- H E Seaman
- Department of Pharmacoepidemiology, Postgraduate Medical School, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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33
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Ballard KD, Seaman HE, de Vries CS, Wright JT. Can symptomatology help in the diagnosis of endometriosis? Findings from a national case-control study--Part 1. BJOG 2008; 115:1382-91. [PMID: 18715240 DOI: 10.1111/j.1471-0528.2008.01878.x] [Citation(s) in RCA: 229] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the value of patient-reported symptoms in diagnosing endometriosis. DESIGN A national case-control study. SETTING Data from the UK General Practice Research Database for years 1992-2001. SAMPLE A total of 5540 women aged 15-55 years, diagnosed with endometriosis, each matched to four controls without endometriosis. METHODS Data were analysed to determine whether specific symptoms were highly indicative of endometriosis. Odds ratios for these symptoms were derived by conditional logistic regression analysis. MAIN OUTCOME MEASURES Symptoms associated with endometriosis. RESULTS The prevalence of diagnosed endometriosis was 1.5%. A greater proportion of women with endometriosis had abdominopelvic pain, dysmenorrhoea or menorrhagia (73%) compared with controls (20%). Compared with controls, women with endometriosis had increased risks of abdominopelvic pain (OR 5.2 [95% CI: 4.7-5.7]), dysmenorrhoea (OR 8.1 [95% CI: 7.2-9.3]), menorrhagia (OR 4.0 [95% CI: 3.5-4.5]), subfertility (OR 8.2 [95% CI: 6.9-9.9]), dyspareunia and/or postcoital bleeding (OR 6.8 [95% CI: 5.7-8.2]), and ovarian cysts (OR 7.3 [95% CI: 5.7-9.4]), and of being diagnosed with irritable bowel syndrome (IBS) (OR 1.6 [95% CI: 1.3-1.8]) or pelvic inflammatory disease (OR 3.0 [95% CI: 2.5-3.6]). Women with endometriosis were also found to consult the doctor more frequently than the controls and were twice as likely to have time off work. CONCLUSIONS Specific symptoms and frequent medical consultation are associated with endometriosis and appear useful in the diagnosis. Endometriosis may coexist with or be misdiagnosed as pelvic inflammatory disease or IBS.
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Affiliation(s)
- K D Ballard
- Department of Women's Health, Postgraduate Medical School, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.
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Riedl A, Schmidtmann M, Stengel A, Goebel M, Wisser AS, Klapp BF, Mönnikes H. Somatic comorbidities of irritable bowel syndrome: a systematic analysis. J Psychosom Res 2008; 64:573-82. [PMID: 18501257 DOI: 10.1016/j.jpsychores.2008.02.021] [Citation(s) in RCA: 169] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 02/05/2008] [Accepted: 02/07/2008] [Indexed: 02/07/2023]
Abstract
OBJECTIVE A large number of irritable bowel syndrome (IBS) patients are additionally afflicted with other somatic intestinal and/or extraintestinal comorbidities. The occurrence of one or more comorbidities is correlated with enhanced medical help seeking, worse prognosis, and higher rates of anxiety and depression-all resulting in a reduced quality of life. The aims of this study were, firstly, to review the literature on comorbidities of IBS and to assess gastrointestinal and extraintestinal comorbidities, and, secondly, to evaluate explanatory hypotheses and possible common pathophysiological mechanisms. METHODS We systematically reviewed the scientific literature in the past 25 years, as cited in MEDLINE. RESULTS IBS patients present with a twofold increase in somatic comorbidities compared to controls, possibly caused by common pathophysiological mechanisms. Nevertheless, to date, there has been no convincing evidence for a consolidated underlying pathophysiology or somatization. Gastrointestinal disorders, such as functional dyspepsia, gastroesophageal reflux disease, functional constipation, and anal incontinence, occur in almost half of the patients. In a broad variety of extraintestinal comorbidities, fibromyalgia, chronic fatigue syndrome, and chronic pelvic pain are best documented and appear in up to 65%. CONCLUSION The knowledge and structured assessment of comorbid somatic symptoms might allow to identify subgroups of IBS patients with special characteristics and lead to adaptation of the therapeutic concept.
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Affiliation(s)
- Andrea Riedl
- Division of Hepatology, Gastroenterology, and Endocrinology, Department of Medicine, Charité-University Medical Center, Campus Virchow, Berlin, Germany
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Abstract
Patterns of injury to the levator ani in parous women with laparoscopy-negative, chronic pelvic pain (CPP) are described. A consecutive series of 26 parous women with laparoscopy-negative CPP, had magnetic resonance imaging (MRI) in axial, coronal and sagittal planes. Similar imaging studies were performed in 32 parous women having MRI scans for other clinical indications and 20 asymptomatic, nulliparous women. Three patterns of injury/defect to the levator ani (LAd) were observed in 20/26 patients with unexplained pelvic pain: avulsion of the pubococcygeus from its origin at the pubis (LAd I, 3/20), avulsion of the pubococcygeus from its origin at the arcus tendineus levator ani (LAd II, 14/20), and, loss of shape and form of the pubococcygeus (LAd III, 6/20). Three patterns of injury to the levator ani have been described with MR imaging in parous women with unexplained CPP.
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Affiliation(s)
- M Quinn
- Department of Obstetrics and Gynaecology, Hope Hospital, Salford, UK.
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36
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Greene R, Stratton P, Cleary SD, Ballweg ML, Sinaii N. Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril 2008; 91:32-9. [PMID: 18367178 DOI: 10.1016/j.fertnstert.2007.11.020] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2007] [Revised: 11/08/2007] [Accepted: 11/09/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether first physician seen and symptoms beginning in adolescence have an impact on the diagnostic experience of endometriosis. DESIGN Cross-sectional study of self-reported survey data. SETTING Academic research. PATIENT(S) Four thousand three hundred thirty-four Endometriosis Association Survey respondents reporting surgical diagnosis of endometriosis. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Specialty of first physician seen, timing of onset of symptoms, time to seeking medical care and to diagnosis, number of physicians seen, and satisfaction with care. RESULT(S) Almost all respondents reported pelvic pain. Fifty percent first saw a gynecologist and 45% saw a generalist for symptoms related to endometriosis. Two thirds reported symptoms beginning during adolescence; they waited longer to seek medical care than adults did. Those seeing a generalist first took longest to get diagnosed; those seeing a gynecologist first saw fewer physicians. Sometime before diagnosis, 63% were told nothing was wrong with them. CONCLUSION(S) Women and girls who reported seeing a gynecologist first for symptoms related to endometriosis were more likely to have a shorter time to diagnosis, to see fewer physicians, and to report a better experience overall with their physicians. The majority reported symptoms beginning during adolescence, also reporting a longer time and worse experience while obtaining a diagnosis.
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Affiliation(s)
- Rebecca Greene
- Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-1871, USA
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Montenegro MLLS, Vasconcelos ECLM, Candido Dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract 2008; 62:263-9. [PMID: 18067562 DOI: 10.1111/j.1742-1241.2007.01530.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6 months, which occurs continuously or intermittently and is not associated exclusively with menstruation or intercourse. CPP is a highly prevalent debilitating disease with negative impact on the quality of life and productivity of women. The dilemma regarding the management of CPP continues to frustrate the health professionals, partly because its physiopathology is poorly understood. Consequently, the treatment of this condition is often unsatisfactory and limited to temporary symptom relief. In the present review, we discuss characteristics of the clinical history and physical examination associated with musculoskeletal involvement in women with CPP and possible treatments, especially in the area of physiotherapy. METHODS We evaluated data available in PubMed (1984-2006) and surveyed the reference list. Three reviewers analysed the data independently, considering a study to be of high quality if it had at least three of the following characteristics: prospective design, valid measurement instruments, and adequate sample estimate and response rate. Other studies such as retrospective investigations, reviews and expert opinions were also considered, but with decreasing emphasis. RESULTS There are evidences of musculoskeletal system disorders in most women with CPP. These musculoskeletal disorders can be the primary cause of CPP or postural changes and pelvic muscle contractures secondary to CPP. CONCLUSIONS Synchronised intervention by physicians and physiotherapists is becoming increasingly more necessary both in terms of a more refined diagnosis of the clinical situation and of the institution of effective and lasting treatment.
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Affiliation(s)
- M L L S Montenegro
- Department of Gynecology and Obstetrics, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Weijenborg PTM, Greeven A, Dekker FW, Peters AAW, Ter Kuile MM. Clinical course of chronic pelvic pain in women. Pain 2007; 132 Suppl 1:S117-S123. [PMID: 17689866 DOI: 10.1016/j.pain.2007.06.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 05/06/2007] [Accepted: 06/15/2007] [Indexed: 12/01/2022]
Abstract
A follow-up study on a cohort of women with chronic pelvic pain (CPP) was conducted, to evaluate the clinical course and to identify factors associated with outcome. Participants were over 18 years of age and had initially visited a multidisciplinary CPP-team of a Gynaecological Department of a University Hospital. The course of chronic pelvic pain was evaluated using the Life Chart Interview (LCI) method. All participants completed questionnaires covering demographic and clinical characteristics, pain (McGill) and psychological distress (SCL-90) at baseline and follow up. The response rate was 60%. A survival analysis was conducted. After a mean follow-up period of 3.4 years, 18 women (25%) of the study sample (N=72) reported recovery from pelvic pain (i.e. pelvic pain for less than 3 months per year). Eight of these 18 women (11% of the total sample) reported no pain at all at follow up. Relapse of symptoms was not encountered. Not any demographic, clinical or pain related variable measured at baseline, nor any intervention between baseline and follow up, was associated with outcome. Our results indicate that chronic pelvic pain in women in secondary care is a longstanding condition. Further research is recommended to identify risk factors for persistence of symptoms.
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Affiliation(s)
- Philomeen T M Weijenborg
- Department of Gynaecology, Leiden University Medical Centre (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands Department of Clinical and Health Psychology, Leiden University, The Netherlands Department of Clinical Epidemiology, Leiden University Medical Centre, The Netherlands
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Abstract
BACKGROUND Endometriosis is a common gynaecological condition which affects many women of reproductive age worldwide and is a major cause of pain and infertility. The modern oral contraceptive pill is widely used to treat pain occurring as a result of endometriosis, although the evidence for its efficacy is limited. OBJECTIVES To assess the effects of the oral contraceptive pill (OCP) in comparison to other treatments for painful symptoms of endometriosis in women of reproductive age. SEARCH STRATEGY We searched the Menstrual Disorders and Subfertility Group Specialised Register of controlled trials; Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2006); MEDLINE (January 1966 to September 2006); EMBASE (1980 to September 2006); National Research Register; and reference lists of articles. SELECTION CRITERIA All truly randomised controlled trials of the use of oral contraceptive pills in the treatment of women of reproductive age with symptoms ascribed to the diagnosis of endometriosis and made visually at surgical procedure were included. DATA COLLECTION AND ANALYSIS Study quality assessment and data extraction were carried out independently by two review authors. One of the assessors was an expert in the content matter. We contacted study authors for additional information. MAIN RESULTS Only one study met the inclusion criteria, in which a total of 57 women were allocated to two groups to compare an OCP to a GnRH analogue. Methods of randomisation and allocation concealment were unclear and the study was acknowledged by its authors to be underpowered. Women in the GnRH analogue group became amenorrhoeic during the treatment period of six months, whilst women in the OCP group reported a decrease in dysmenorrhoea. No evidence of a significant difference between the two groups was observed in terms of dysmenorrhoea at six months follow up after stopping treatment (OR 0.48; 95% CI 0.08 to 2.90). Some evidence for a decrease in dyspareunia was found at the end of treatment in women in the GnRH analogue group, although no evidence of a significant difference in dyspareunia was observed at the end of the six months follow up (OR 4.87; 95% CI 0.96 to 24.65). AUTHORS' CONCLUSIONS The limited data we found available suggests that this is no evidence of a difference in outcomes between the the oral contraceptive pill (OCP) studied and GnRH analogue was as effective as a GnRH analogue in treating for endometriosis-associated painful symptoms of endometriosis. However, the lack of studies with larger sample sizes, or focusing on other comparable treatments is concerning and further research is needed to fully evaluate fully the role of OCPs oral contraceptive pills in managing symptoms associated with ement of endometriosis.
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Affiliation(s)
- L Davis
- Picker Institute Europe, King's Mead House, Oxpens Road, Oxford, UK, OX1 1RX.
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Stratton P. The tangled web of reasons for the delay in diagnosis of endometriosis in women with chronic pelvic pain: will the suffering end? Fertil Steril 2006; 86:1302-4; discussion 1317. [PMID: 17070184 DOI: 10.1016/j.fertnstert.2006.06.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Revised: 06/16/2006] [Accepted: 06/16/2006] [Indexed: 11/29/2022]
Abstract
Understanding the woman's experience with chronic pelvic pain and endometriosis is critical to decreasing her suffering. Further investigation must continue to determine the relation between endometriosis and pain, despite empirical treatment with GnRH agonists becoming routine in the United States.
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Affiliation(s)
- Pamela Stratton
- Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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Atwal G, du Plessis D, Armstrong G, Slade R, Quinn M. Uterine innervation after hysterectomy for chronic pelvic pain with, and without, endometriosis. Am J Obstet Gynecol 2005; 193:1650-5. [PMID: 16260205 DOI: 10.1016/j.ajog.2005.05.035] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2005] [Accepted: 05/06/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Chronic pelvic pain is associated with a wide range of clinical conditions that include endometriosis. The precise cause, mechanisms of pain, and natural history are imprecise. Patterns of uterine innervation have been studied after hysterectomy for chronic pelvic pain with and without endometriosis. STUDY DESIGN Tissue blocks were taken from the lower one half of the uterus after hysterectomy for advanced endometriosis (n = 16 specimens; group 1) and for chronic pelvic pain without endometriosis (n = 15 specimens; group 2). The control group consisted of uteri that were removed for painless gynecologic conditions (n = 25 specimens; group 3). Tissue sections from the lower one half of the uterus were stained with anti-S100 to demonstrate patterns of innervation, and nerve fiber profiles were counted by standardized techniques; qualitative differences were also recorded. RESULTS In uteri from women with advanced endometriosis, there were increased numbers of nerve fiber profiles compared with control specimens (group 1 vs group 3; P = .0013, Mann Whitney U test). There were also increased numbers of nerve fiber profiles in uteri that were associated with chronic pelvic pain without endometriosis (group 2 vs group 3; P = .04, Mann Whitney U test). There were no differences in nerve fiber count in uteri from groups 1 and 2 (P = .35, Mann Whitney U test). Comparing both groups of uteri with controls (groups 1 and 2 vs 3) demonstrated marked differences in nerve fiber counts (P = .002, Mann Whitney U test). Two distinctive patterns of reinnervation that were observed: disruption of nerve bundles (collateral sprouting with microneuroma formation) and ingrowth around blood vessels (perivascular nerve fiber proliferation). There were increased numbers of microneuromas (groups 1 and 2 vs 3; P = .001, chi-squared test with Yates correction) and perivascular nerve fiber proliferation (groups 1 and 2 vs 3; P = .008, chi-squared test with Yates correction) in the myometrium in chronic pelvic pain with, and without, endometriosis compared with the control group. CONCLUSION Nerve fiber proliferation and other features of reinnervation have been observed in the isthmic regions of uteri that were removed at hysterectomy for chronic pelvic pain with and without endometriosis. There were no quantitative differences between the groups with chronic pelvic pain and endometriosis. These observations provide an alternative explanation for the source of pain and other clinical symptoms in these clinical settings.
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Affiliation(s)
- Gurprit Atwal
- Department of Histopathology, Hope Hospital, Manchester, UK
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Abstract
This review is based on a MEDLINE/PSYCHINFO search for all papers on psychological aspects of vulvar vestibulitis syndrome (VVS) published 1995-2002. VVS is a condition in which painful patches appear on the vulva which make intercourse painful. Causation, natural history and prevalence of VVS are unknown. Attempts to identify psychological characteristics typical of women with VVS have not yielded consistent results with some studies suggesting high levels of psychopathology and others not. It is suggested that inconsistencies in findings reflect not only decisions by women about whether and how to access health care but also the health care system acting to actively filter those reaching specialist services and selecting those with particular psychological characteristics. There is no compelling evidence that VVS per se is associated with any particular psychological or behavioural characteristics other than the sort of difficulties in sexual functioning which might be expected with chronic vulval pain. However there is evidence for high levels of psychological distress in some samples of women with VVS being seen in secondary care.
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Affiliation(s)
- J Green
- Department of Clinical Health Psychology, Clarence Wing, St. Mary's Hospital, London, UK.
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Prowse AH, Fakis G, Manek S, Churchman M, Edwards S, Rowan A, Koninckx P, Kennedy S, Tomlinson IPM. Allelic loss studies do not provide evidence for the “endometriosis-as-tumor” theory. Fertil Steril 2005; 83 Suppl 1:1134-43. [PMID: 15831286 DOI: 10.1016/j.fertnstert.2004.07.982] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2004] [Revised: 07/01/2004] [Accepted: 07/01/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To identify consistent genetic changes in endometriosis samples to determine whether endometriosis lesions are true neoplasms. DESIGN We analyzed ovarian endometriosis lesions for loss of heterozygosity (LOH) at 12 loci of potential importance (D9S1870, D9S265, D9S270, D9S161, D11S29, D1S199, D8S261, APOA2, PTCH, TP53, D10S541, and D10S1765), including some at which genetic changes were previously reported in endometriosis. SETTING Molecular biology laboratory in a university hospital department. PATIENT(S) Seventeen women with ovarian endometriosis. INTERVENTION(S) Laser capture microdissection to separate the endometriotic epithelium, the adjacent endometriotic stroma, and surrounding normal ovarian stromal tissue, followed by DNA extraction and polymerase chain reaction amplification of polymorphic microsatellite markers. MAIN OUTCOME MEASURE(S) Fluorescence-based quantitation for the LOH analysis. RESULT(S) We identified LOH in only one lesion at one locus (D8S261). CONCLUSION(S) Our data do not support the hypothesis that ovarian endometriosis is a true neoplasm.
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Affiliation(s)
- Amanda H Prowse
- Nuffield Department of Obstetrics and Gynaecology and Women's Centre, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
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Thielecke F, Maxion-Bergemann S, Abel F, Gonschior AK. Update in the pharmaceutical therapy of the irritable bowel syndrome. Int J Clin Pract 2004; 58:374-81. [PMID: 15161123 DOI: 10.1111/j.1368-5031.2004.00136.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The therapeutic management of the irritable bowel syndrome (IBS) is ineffective and not satisfying either patients or practitioners. Research in functions of the enteric nervous system and its interaction with the central nervous system is the basis for the development of emerging pharmaceuticals in therapy of the IBS. These pharmaceuticals include agents such as opioid agonists, psychotropic agents and particularly serotonin receptor modulators. These novel pharmaceuticals aim to provide a more comprehensive approach in the therapy of the IBS and will serve both patients and practitioners. So far, the US Food and Drug Administration has approved two agents specifically for the treatment of the IBS, both belonging to the group of serotonin receptor modulators. However, questions remain whether a single therapy is sufficient in the management of IBS because this disease is influenced by biological and psychological as well as cultural and social factors.
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Affiliation(s)
- F Thielecke
- Institute of Medical Outcome Research GmbH, Lörrach, Germany.
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Quinn M. Obstetric denervation-gynaecological reinnervation: disruption of the inferior hypogastric plexus in childbirth as a source of gynaecological symptoms. Med Hypotheses 2004; 63:390-3. [PMID: 15288354 DOI: 10.1016/j.mehy.2004.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2004] [Accepted: 03/01/2004] [Indexed: 11/25/2022]
Abstract
Difficult vaginal deliveries damage branches of the inferior hypogastric plexus as they are distributed to the pelvic viscera. The initial denervatory injury is often asymptomatic. Nerve fibre proliferation along the course of damaged nerve trunks results in chaotic reinnervation of the visceral stroma and subsequent sensory pelvic symptoms including chronic pelvic pain, painful heavy periods, painful intercourse, urinary frequency and urgency, irritable bowel symptoms and vulval pain. Each symptom may be described as pain, or discomfort, in response to light touch (allodynia). In other visceral sites allodynic syndromes are frequently associated with aberrant neural repair. Nerve fibre proliferation has now been reported in every viscus in the female pelvis though its antecedents have not been established. It is proposed that clinical presentations with one, or more, sensory pelvic symptoms occur some years after a difficult intrapartum episode; the initial denervatory injury is succeeded by nerve fibre proliferation in the affected organs. The precise pathoanatomy, mechanisms of intrapartum injury and clinical presentation remote from the intrapartum episode, may have obscured the common aetiology of many sensory pelvic syndromes.
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Affiliation(s)
- Martin Quinn
- Department of Obstetrics and Gynaecology, Hope Hospital, Stott Lane, Salford, Manchester M6 8HD, UK.
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Affiliation(s)
- Fred M Howard
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York 14642, USA.
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Gupta JK, More S, Clark TJ. Chronic pelvic pain and irritable bowel syndrome. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2003; 64:275-80. [PMID: 12789736 DOI: 10.12968/hosp.2003.64.5.1759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes the common association between chronic pelvic pain and irritable bowel syndrome. The aim of the diagnosis and management of chronic pelvic pain and irritable bowel syndrome is to improve the quality of life of the patient. Methods of diagnosis, treatment and overall management for these two challenging conditions are outlined in this article.
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Affiliation(s)
- Janesh K Gupta
- Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, Birmingham B15 2TG
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Tosetti C. A young girl with recurrent severe abdominal pain after appendicectomy. J Clin Gastroenterol 2003; 36:282. [PMID: 12590245 DOI: 10.1097/00004836-200303000-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Affiliation(s)
- R William Stones
- Community Clinical Sciences Research Division, University of Southampton, Princess Anne Hospital, Southampton SO16 5YA, UK.
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