Investigations for chronic pelvic pain

Chronic pelvic pain (CPP) is a common problem with a prevalence of about 38/1000 among women aged 20–50 years. The main gynaecological diagnoses include endometriosis, pelvic inflammatory disease and adhesions. The most common gastrointestinal diagnosis is irritable bowel syndrome and genitourinary diagnosis includes pathology such as interstitial cystitis. It is a challenge instigating the right investigations for patients with chronic pelvic pain because there is a considerable symptom overlap. They also have a higher prevalence for symptoms such as dysmenorrhea and dyspareunia. In this review, we aim to discuss the clinical consultation necessary to help us decide upon which investigative tools we need to use to help diagnose the cause(s) of CPP, although one needs to stress that a specific cause may not be found in patients with CPP and symptom focused multidisciplinary management of CPP is at least as important as diagnosis of specific pathology and disease focused treatment.     

Psychosocial factors and chronic pelvic pain: a comparison of women with endometriosis and with unexplained pain

Chronic pelvic pain is a common clinical problem, and physical investigation often fails to reveal its cause. For this reason, it has been argued that psychological and social factors contribute to such "unexplained" pain. Few studies to date using well-validated psychometric measures and adequate sample sizes have compared patients with unexplained pain and those with identified physical disease. The present study compared pain severity, mood symptoms, personality characteristics and social adjustment in women with unexplained pain and women with endometriosis. Women with endometriosis were more likely to come from upper socioeconomic groups. No differences in mood symptoms or personality characteristics were identified, but women with endometriosis had somewhat more severe pain and greater social dysfunction than those with unexplained pain. Mood disorder and social dysfunction appear to be at least as important in patients with proven endometriosis as in those with unexplained pain.     

Laparoscopy in chronic pelvic pain]

Levofloxacin bactericidal activity was compared to ciprofloxacin and ofloxacin against 10 strains of Moraxella catarrhalis. The cidal action (by kill-curve analysis) was slightly more rapid for levofloxacin, but all tested fluoroquinolones were considered bactericidal for all strains tested, including those producing BRO-1 and 2 beta-lactamases.     

Evidence-based management of chronic pelvic pain

Diagnosis and management of chronic pelvic pain are greatly facilitated by a multidisciplinary approach integrating medical intervention with identification and management of socioenvironmental problems, cognitive-behavioral pain strategies, and treatment of concurrent psychological morbidity. Available evidence suggests that outcomes, including pain severity, general health and functional status, and disability are more significantly improved after this approach than after isolated medical or surgical interventions. Because of the chronic nature of many of the underlying psychological and social factors predisposing to chronic symptom formation and maintenance, care of the patient with chronic pelvic pain must be continuous and longitudinal if recurrent adverse sequelae, including disability, inappropriate healthcare utilization, and recurrent depression, are to be prevented.     

Factors influencing outcome in consultations for chronic pelvic pain

We aimed to document the demographic and clinical characteristics of women referred by primary care physicians for investigation of chronic pelvic pain to a university hospital gynecology outpatient clinic and to test the hypothesis that specific patient features and the quality of doctor/patient communication at the initial consultation would influence pain outcomes. A clinical questionnaire, visual analog scales for pain, and instruments for hostility and the experience of the consultation were administered at the initial clinic attendance to 105 consecutive women. Follow-up pain scores were obtained 6 months later from 98 women. The mean hostility score was highly significantly elevated compared with normative data (p < 0.001). In a logistic regression model, a favorable patient rating of the initial consultation was associated with complete recovery at follow-up and interacted significantly with whether or not exercise was impaired (p < 0.005). For those in whom symptoms persisted, significant factors found by multiple regression models to predict continuing pain levels were the initial level of pain, the number of functions of daily life impaired, endometriosis, and the doctor who carried out the initial consultation. Patient hostility scores and the doctor's level of experience or gender were not significantly associated with continuing pain. This study highlights the importance of good communication as a basis for successful treatment of a group of hostile patients and indicates the influence in individual doctors of subtle attitudinal and personality factors that modify patients' experience of the medical consultation.     

Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer

A study was carried out into the hematological abnormalities of peripheral blood bone marrow in patients chronically exposed to benzene. The metabolic biotransformation and the mechanisms involved in toxicity are described. Hematological data are described and discussed. Macrocytosis and lymphopenia are the earliest hematological signs of benzene toxicity. Bone marrow abnormalities are demonstrated by the complementary methods of cytology and histology. Global hypocellularity was mainly due to the granulocytic series. Mastocytosis, eosinophilia and magakariocytic abnormalities are also presented. Inflammatory abnormalities and signs of dismyelopoiese could also be observed. The importance of peripheral blood abnormalities and the need for a critical approach to this important public health problem are emphasized.     

Chronicle of functional pain: chronic pelvic pains

Chronic pelvic pains are one of the most frequent complaints in our daily gynecological practice, motivating at least a quarter of our consultants. As it usually puts the practitioner ill at ease in a difficult situation, we will try to understand the meaning of those particular pains, thus defined: a duration outlasting 6 months and the absence or the ineffective suppression of any organic--somatic--substratum. But every alleged pain is real and true, and we must work on that. To validate such suffering, to accept such repetitive complaints, can also be a therapeutic medical approach, even if it is less gratifying for the gynecologist, and certainly less customary.     

Long-term administration of large doses of oral morphine for chronic pain

We here report a patient with chronic pain who was treated with large doses of oral morphine. A 37-year-old female was diagnosed as Lyme disease and lumbar disc hernia. When she received lumbar puncture for myelography, she fainted due to severe pain in the legs. After this incident, her pain increased markedly, and she visited our outpatient clinic in 1996. After confirming the temporary pain relieving effect of caudal block, we prescribed oral morphine tablets 60 mg daily. The dose of morphine necessary to relieve her pain increased gradually to 220 mg. But she did not develop dependence or side effects. However, when the daily dose of 300 mg was administered, she felt dizzy. We therefore performed lumbar sympathetic block with phenol. After the block, her conditions improved markedly at a dosage of 300 mg. In conclusion, our experience in this case has shown the effectiveness of long-term morphine use with non-cancer patients and the efficacy of nerve block to avoid increasing the morphine dosage.     

Long-term prognosis for tonsillectomy patients with IgA nephropathy

A retrospective study of 85 patients with IgA nephropathy was undertaken to determine the long-term effect of tonsillectomy. Forty-three patients (24 males and 19 females) had received tonsillectomies (Group A) and 42 patients (17 males and 25 females) had not (Group B). These patients had been followed up for more than 5 years after renal biopsy. The average age at the initial renal biopsy was 25.72 years in Group A, and 33.16 years old in Group B. The average period of renal biopsy to tonsillectomy in Group A was 10.47 months. The average follow-up period was 8 years and 9 months in both groups. At the beginning of treatment, the two groups were well matched in terms of creatinine clearance, urinalysis, and blood pressure. Six patients in Group A and eight patients in Group B were treated with steroids. The glomerular injury detected at the renal biopsy was more extensive in Group A than in Group B. Renal function in the two groups was compared. The clinical remission rate in Group A was significantly higher than in group B (P<0.05). The stable renal function rate in Group A was significantly higher than in Group B (P<0.05). The renal survival rate was 97.7% in Group A and 83.3% in Group B, but there was no significant difference between the two groups. Histologically, the rate of remission of the minor lesion in Group A was significantly higher than in Group B (P < 0.05). Our results showed that tonsillectomy for IgA nephropathy was clinically of great value.     

Role of laparoscopy in the management of chronic pelvic pain

OBJECTIVE: The pharmacokinetics of N(G)-nitro-L-arginine methyl ester (L-NAME), an inhibitor of nitric oxide (NO) synthesis, was investigated in patients with septic shock. METHODS: Blood was sampled at intervals before, during and after 12-h infusion of L-NAME 1 mg x kg(-1) x h(-1) in nine septic shock patients for determination of plasma concentrations by high-performance liquid chromatography (HPLC). In three patients the renal clearance of the drug was determined. RESULTS: Incubation of L-NAME with plasma and blood in vitro revealed hydrolysis to N(G)-nitro-L-arginine (L-NOARG), the active inhibitor of NO synthesis. L-NOARG did not undergo further degradation. Continuous intravenous infusion of 1 mg x kg(-1) x h(-1) of L-NAME for 12 h in patients with septic shock increased blood pressure and resulted in increasing plasma concentrations of L-NOARG (Cmax 6.2 microg x ml(-1) at 12 h) whereas L-NAME concentrations reached a plateau within 1.5 h (Cmax 1.0 microg x ml(-1)). After the infusion was stopped L-NAME disappeared from the plasma rapidly (half-life 19.2 min) whereas L-NOARG concentration declined slowly (half-life 22.9 h). The calculated volume of distribution for L-NAME was 0.451 x kg(-1) body weight and 1.961 x kg(-1) for L-NOARG. The renal clearance for L-NOARG was 3.5% of total body clearance for L-NOARG, whereas L-NAME could not be detected in urine. CONCLUSION: We conclude that vasoconstriction with L-NAME in septic patients may result from hydrolysis to L-NOARG, the active inhibitor of NO synthesis. The long plasma half-life and large volume of distribution for L-NOARG suggests extensive distribution to extravascular tissues. Since renal excretion is minimal, elimination of the metabolite L-NOARG follows other pathways.     

Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study

In 100 consecutive patients who were undergoing laparoscopy for infertility (group 1, n = 52), chronic pelvic pain (group 2, n = 18) or tubal sterilization (group 3, n = 30, asymptomatic fertile women), peritoneal biopsies were taken from areas of visually normal peritoneum of uterosacral ligaments. Twenty-six patients in group 1 (50%), eight patients in group 2 (44.4%) and 13 patients in group 3 (43.3%), were found to have laparoscopic evidence of endometriosis elsewhere in the pelvis. The majority of women (80.7% in group 1, 87.5% in group 2, and 100% in group 3) had stage I disease. The incidence of the distinctive appearances of the lesions was similar in the three groups of patients and 7% of all women or 15% (7/47) of those patients having endometriosis at laparoscopy had only subtle (non-?typical') endometriotic peritoneal lesions. Uterosacral biopsies showed the presence of endometriotic tissue in three cases (5.7%), two cases (11%) and three cases (10%) in groups 1, 2, and 3 respectively. One of the two patients in group 2 and two of the three patients in group 3 had no evidence of endometriosis at laparoscopy; thus histological study revealed the presence of endometriosis in normal peritoneum in 11% (5/47) of patients having macroscopic endometriosis and in 6% (3/53) of patients without endometriosis at laparoscopy. Previous oral contraceptive users were significantly higher among women having macroscopic and/or microscopic endometriosis than among women without the condition. In conclusion, our prospective study shows a high prevalence (45-50%) of endometriosis (including microscopic forms) in both patients with chronic pelvic pain and asymptomatic women (fertile and infertile), thus supporting the modern concept that in many women endometriosis may be a paraphysiological condition while probably only in some patients small amounts of endometriosis are an ?annoyance' with implications to their reproductive health and may produce symptoms (e.g. pelvic pain) and therefore should be defined as a ?dis-ease'. Previous use of oral contraceptives may increase the risk of developing endometriosis.     

Re: "Long-term prognosis of women after myocardial infarction"

Significant decrease of serum vitamin A (V.A) level in 4 out of 5 Japanese Black beef steers on day 7 after introduction was described in the present study. The feeder steers were fed the diets containing much more V.A than they required. In the farm where they were introduced, the productivity was high and the frequency was low in bovine cases of death and disease. The herd management; i.e. feeding method and environment of the farm were properly arranged. Results obtained from blood serum analyses revealed that health and nutritional status of the feeder steers were good on the day of introduction. The feeder steers, clinically healthy on the day of introduction, manifested mild bronchitis and diarrhea on days 2 and 10 after introduction, respectively, and slightly decreased dietary intake on both days. Serum V.A levels of the feeder steers were within the normal range. However, significantly decreased serum V.A level was detected in 4 feeder steers out of 5 on day 7 after introduction. This may be attributed to stress-increased V.A consumption rather than the decreased V.A intake.     

Pancreatic xanthomatous neuropathy associated with hyperlipidemia: a cause of abdominal pain mimicking chronic pancreatitis

"Hyperlipidemic crisis" is a term used to describe episodic abdominal pain in patients with hyperlipidemia. The morphologic correlates of this phenomenon have not been investigated and the etiology of the disorder is uncertain. We report a unique histologic finding in the pancreas of a 34-year-old woman with a 17-year history of episodic abdominal pain, sometimes accompanied by hyperamylasemia. At the age of 18 years, grossly elevated cholesterol and triglyceride levels were documented and type V hyperlipidemia was diagnosed. At the age of 34 years, subtotal pancreatectomy was performed for intractable abdominal pain. Histologic examination identified an increased number of enlarged pancreatic nerves that were infiltrated by foamy macrophages and encircled by fibrous tissue; endoneurial infiltration with macrophages occasionally split nerves into individual fascicles. Otherwise, the pancreas had only minimal fibrosis, nesidioblastosis, mucinous metaplasia of some pancreatic ducts, and scattered small collections of chronic inflammatory cells, subtle features suggesting very mild chronic pancreatitis. We propose that this novel xanthomatous neuropathy mimicked pancreatitis and was one of the underlying pathophysiologic mechanisms of abdominal pain in this patient. Further studies are necessary to document the prevalence of this new entity in patients with hyperlipidemia and to correlate its occurrence with "hyperlipidemic crisis" in those individuals.     

Mind/body dualism in medicine: The case of chronic pelvic pain without organic pathology: a critical review of the literature

Chronic pelvic pain in the absence of organic pathology identifiable in medical terms is considered one of the most perplexing conditions that gynecologists confront. A critical analysis of the medical, psychiatric, and psychological literature on chronic pelvic pain without organic pathology reveals that the dichotomous construct of mind and body underpinning medical research and understanding is a barrier to the successful diagnosis and treatment of this condition, and indeed to the productive engagement of the health professional with the patient. The strict duality of the condition's etiology being understood in either physiological or psychogenic terms has been questioned at times over the last 40 years, but only recently has an "integrative model" been proposed. However, it is argued here that although the development of a multidisciplinary approach is important, only a radical deconstruction of the medical paradigm will truly address the problem and enable a real change in practice.