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Chronic Pelvic Pain Resolved Best With Interdisciplinary Approach

February 7, 2018
Study authors set out to see changes in chronic pelvic pain severity after following patients for one year

Interviews with Paul Yong, MD, PhD, FRCSC, and Theresa Mallick-Searle, MSN, RN-BC, APN-BC

Chronic pelvic pain (CPP) is a type of pain that persists for more than three to six months, and is not solely attributed to menstruation, sexual activity, or bowel movements.1 This common condition, with prevalence estimates ranging between 5.7% and 26.6%2 of women worldwide, is complex and not well-understood.2

In a study published in the American Journal of Obstetrics & Gynecology, Paul Yong, MD, PhD, and colleagues at the University of British Columbia completed a prospective observational cohort trial of CPP treatment at an interdisciplinary center.3

Chronic pelvic pain is best managed with an interdisciplinary team approach.

The complexity of chronic pelvic pain makes it a vexing condition to manage. The intersection of gynecologic, urologic, gastrointestinal, musculoskeletal and psychosocial comorbidities that typically coincide in patients with chronic pelvic pain lends itself to a multifaceted care model.3 This approach incorporates physiotherapy, psychological therapies, and gynecological management.1,4

As such, the authors set out to determine the changes in chronic pelvic pain severity, functional quality of life and health utilization after following patients for one year. The researchers also examined whether certain comorbidities were associated with CPP severity.

Taking a Look at the Study Design

The study was performed at BC Center for Pelvic Pain and Endometriosis, a tertiary referral center in British Columbia. The center has gynecologists with specialized training in CPP and minimally invasive surgery, a clinical fellow, a registered nurse, a physiotherapist and a clinical counselor. Patients could choose their course of treatment, which included minimally invasive surgery, medical management and/or a pain program.3 A total of 296 patients (out of 535) completed the 1-year follow-up.

Patients completed an online questionnaire to rate different types of pelvic pain on a scale of 1-10.3 Functional quality of life was assessed, and physician and emergency room visits over the last 3 months were also disclosed. Comorbidities were determined based on questionnaire results, medical records and/or physical exam findings.3 Endometriosis, irritable bowel syndrome (IBS), painful bladder syndrome (PBS), abdominal wall pain, pelvic floor myalgia, depression, anxiety, and pain catastrophizing were also diagnosed.

CPP severity, the primary outcome, decreased 2 points on average from baseline to 1 year (P < 0.001).3 Also, the proportion of participants in the severe category (7-10 on the numeric scale) decreased from 49% to 27%, and the proportion in the none to mild category (0-3 on the scale) increased from 24% to 50% (P < 0.001).3 Significant improvement in functional quality of life and reduction in number of subjects with physician or emergency department visits were also observed. The number of patients who met the criteria for IBS, PBS, depression, anxiety, and catastrophizing decreased at 1 year.3

The authors identified factors associated with severity of chronic pelvic pain using ordinal logistic regression. Greater pain catastrophizing (P = 0.02) and abdominal wall pain (P = 0.02) were the comorbidities significantly associated with CPP severity.3 Also, the total number of comorbidities was associated with CPP severity (P = 0.02).

The demographic variables associated with CPP severity included rereferral (P = .008) and history of sexual assault (P = 0.04). Older age was associated with less CPP at 1 year (P = 0.006).3 Finally, among the interventions, only surgery at the center was associated with less CPP at 1 year (P = 0.008).

Lastly, in the final multivariable regression model, the factors that remained significantly associated with chronic pelvic pain severity at one year were greater baseline pain catastrophizing (P = 0.04), re-referral (P = 0.01), older age (P = 0.02) and surgery (P = 0.05).3

Responsiveness to Broad-based Care Proved More Efficacious

Following one year of treatment, patients with chronic pelvic pain experienced less pain severity, improved quality of life, and lower health care utilization having been managed in an interdisciplinary treatment center. Patients with higher pain catastrophizing initially exhibited greater chronic pelvic pain, suggesting these patients should be given special consideration during treatment.

In discussing the results, Dr. Yong told Practical Pain Management, “we were surprised that many patients who met standardized diagnostic criteria for irritable bowel syndrome and painful bladder syndrome no longer met these criteria at the end of the study.”

“This suggests that sensitization of the nervous system may underlie these conditions in some patients and that an interdisciplinary approach to CPP may change the nervous system and thus reverse bowel and bladder symptoms in some patients,” he said.

Improved Pain Outcomes Observed With Interdisciplinary Team Approach 

Dr. Yong hopes the strength of the findings from this research will be sufficient enough to urge clinicians to employ a team approach when treating patients for chronic pelvic pain.

“The study showed that an interdisciplinary approach not only improved CPP and quality of life, but also reduced emergency room visits as well as all other physician visits,” Dr. Yong said, “Practicing clinicians can take this information to their administrators to justify investment in interdisciplinary care (eg, provision of allied health care services), which ultimately may reduce health care costs down the line.”

Theresa Mallick-Searle, MSN, RN-BC of Stanford Health Care, who was not associated with the research, told Practical Pain Management that “the management of CPP in an interdisciplinary setting can result in improved outcomes and patients with catastrophizing behaviors may be more refractory to treatment.”

She added that the findings were significant for showing that patients would benefit from being treated in an interdisciplinary setting. “As with other chronic pain etiologies, these patients will achieve best outcomes in pain relief and improvement in quality of life when management focuses on their physical, functional and psychological needs,” Ms. Mallick-Searle said.

Dr. Yong agreed, concluding, “In many cases, CPP cannot be treated by just targeting one factor.  An interdisciplinary setting, ideally with different care providers integrated at a single site, allows for a holistic approach to the multiple factors involved in the patient's pain.”

Last updated on: April 29, 2020
Continue Reading:
Significance of Mental Health Indicators in Women with Chronic Pelvic Pain

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