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Chronic pelvic pain

Chronic pelvic pain. Journal Club 17 th June 2011 Dr Claire Hoxley (GPST1) Dr Harpreet Rayar (GPST2). Aims and Objectives. Know how to investigate and manage chronic pelvic pain in primary care and when to refer to secondary care

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Chronic pelvic pain

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  1. Chronic pelvic pain Journal Club 17th June 2011 Dr Claire Hoxley (GPST1) Dr Harpreet Rayar (GPST2)

  2. Aims and Objectives • Know how to investigate and manage chronic pelvic pain in primary care and when to refer to secondary care • Research the evidence available for different management options of chronic pelvic pain • Improve evidence based practice skills • Critically appraise a systematic review

  3. Case presentation • GP referral in GOPD • 28 year old woman • 4 year history of pelvic pain • No dysmenorrhoea or dyspareunia • Some improvement on OCP but wishes to conceive • Negative laparoscopy 2 years before (some pelvic vein congestion) • Negative triple swabs • What management options are there?

  4. The Clinical Question • What are the management options for chronic pelvic pain? • What guidelines are there for investigating and managing chronic pelvic pain in primary care (non-surgical management)?

  5. Chronic pelvic pain • Symptom, not a diagnosis • 6 months + • Constant or intermittent pain • Not exclusively with dysmenorrhoea or dyspareunia • Not during pregnancy

  6. Chronic pelvic pain • Presents to primary care as often as migraine, asthma or low back pain • Heavy economic and social burden • Limited understanding of pathophysiology • Affected by physical, social and psychological factors • Requires biopsychosocial model of management

  7. Guidelines • No NICE guidelines • RCOG guidelines – Chronic pelvic pain, Initial management (Green-top 41) • No BWH Guidelines • RCOG guidelines April 2005 – outdated? • Limited guidance for primary care management (non-surgical)

  8. Literature search • Search terms: chronic pelvic pain • Limits: since 2005, female, trials, reviews, case studies, guidelines • Databases searched: Cochrane and Pubmed

  9. Literature search results • Cochrane results: Systematic Review 2005, updated 2010 • 2 protocols November 2010 • Non surgical interventions for the management of chronic pelvic pain • Surgical interventions for the management of chronic pelvic pain in women • Limited Pubmed evidence

  10. Paper selected • Interventions for treating chronic pelvic pain in women (Review). Stones W, Cheong YC, Howard FM, Singh S The Cochrane Library 2010, Issue 11 • Highest level of evidence • Reviewed 2010 (more recent than guidelines)

  11. Criteria for selecting trials • Included: patients with diagnosis of pelvic congestion syndrome or adhesions. Any age • Excluded: patients with diagnosis of endometriosis, primary dysmenorrhoea, pain due to active chronic pelvic inflammatory disease or irritable bowel syndrome

  12. Criteria for selecting trials • Randomised controlled trials in women with chronic pelvic pain • Any intervention including lifestyle, physical, medical, surgical, psychological • Outcome measures: pain rating scales, quality of life measures, economic analyses, adverse events

  13. Data collection and analysis • 2 review authors working independently • 3rd author as arbiter • Detailed search methods • Quality of trials assessed based on Cochrane guidelines

  14. Results • 19 trials identified • 14 included (N = 6-286) • Included psychological, medical, surgical, lifestyle interventions • Excluded trials due to insufficient information re outcomes, non-comparable evaluation points, uncertainty re study design

  15. Risk of bias Allocation concealment: • 10 x A • 3 x B • 1 x C Quality of allocation concealment graded as A (adequate) B (unclear) or C (inadequate)

  16. Risk of bias • 13 had good follow-up rates • 9 had intention-to-treat analyses • Outcome assessment blinded to treatment allocation in all 14 • Participants aware of their treatment allocation

  17. Combining results • 2 studies on • Progestogen vs. placebo • Adhesiolysis vs. expectant management or diagnostic laparoscopy • Single studies for other interventions • Combined results with caution (different surgical methods)

  18. Results • Ultrasound and counselling vs “wait and see” • Favours ultrasound – improvement in mood and pain scores • Large confidence intervals • Available in primary care

  19. Results • Adhesiolysis vs. no surgery • No significant benefit in pain score or self-rating • Combines 2 trials (different surgical methods)

  20. Limitations • Different end points/follow up • Some trials used scales influenced by menstruation – those resulting in amenorrhoea score better • Excludes many causes of chronic pelvic pain • One study had male participants • Majority of outcomes subjective

  21. Implications for research • Limited range of interventions • Mainly single studies (underpowered conclusions) • Limited evidence available to base clinical practice on • High prevalence and healthcare costs • Complex causation and treatment – design of studies needs to reflect this

  22. Summary and Conclusion • Limited evidence for effective management options • Some options available in primary care • Need for further research – cochrane protocols in place, separate surgical/non-surgical management • Better understanding of complex psychosocial model of chronic pelvic pain

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