Long-term outcomes after surgical and nonsurgical management of chronic pelvic pain: One year after evaluation in a pelvic pain specialty clinic

doi:10.1016/j.ajog.2006.03.081

American Journal of Obstetrics and Gynecology

Volume 195, Issue 2, August 2006, Pages 591-598

https://doi.org/10.1016/j.ajog.2006.03.081 Get rights and content

Objective

The purpose of this study was to describe long-term outcomes for women with chronic pelvic pain (CPP) after evaluation in a CPP specialty clinic.

Study design

This was a prospective observational cohort study of women treated for CPP at the UNC Pelvic Pain clinic between 1993 and 2000. The primary outcome was improvement in pain and the main exposure was treatment group: primarily medical (pharmacotherapy, psychotherapy, physical therapy, or combinations of the 3) or surgical (hysterectomy, resection or ablative procedures, oophrectomy, diagnostic surgery, pain mapping, vulvar or vestibular repair). Univariate, bivariate, and multivariable analyses were performed to look for relationships between background characteristics, treatment group, and improvement in pain.

Results

Of 370 participants; 189 had surgical treatment and 181 had medical treatment. One year after evaluation, 46% reported improvement in pain and 32% improvement in depression. Improvement in pain was similar in both treatment groups and odds of improvement were equal even after adjusting for background characteristics, psychosocial comorbidity, and previous treatments.

Conclusion

One year after evaluation in a CPP specialty clinic, women experienced modest improvements in pain and depression after recommended surgical or nonsurgical treatment.

Section snippets

Study setting and study population

Between June 1993 and December 2000, the UNC Pelvic Pain Clinic evaluated 987 women referred predominately from North Carolina. Patient evaluation and data collection methods have been previously published.9, 10 The UNC Institutional Review Board approved the use of clinical data for research purposes.

Before examination, patients answered self-administered written questionnaires including a general medical information form, a history of physical abuse survey, the Beck Depression Inventory, and

Results

Of the 987 women seen in our CPP clinic between 1993 and 2000, records were successfully abstracted in 970 (98%) cases. The data presented here are obtained from 370 (38%) women whose records were complete and who returned the questionnaires at 1 year. Baseline characteristics of questionnaire respondents (n = 370) and nonrespondents (n = 600), were statistically similar in age, racial distribution, marital status, annual income, education, duration of pain, number of pain sites, history of

Comment

Chronic pelvic pain is a complex disorder that often requires use of several treatment modalities. Although chronic pain centers and the “multidisciplinary” treatment approach is recommended by pain experts,⁷ little is published about long-term outcomes of women managed in tertiary settings.

Following evaluation at our institution, treatments recommended by physicians were evenly distributed between primarily medical treatments (49%) and surgical treatments (51%). At the 1-year follow-up,

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To follow up deep dyspareunia severity over a 1-year prospective cohort at an interdisciplinary center, and to identify baseline predictors of more persistent deep dyspareunia at 1 year.
Prospective 1-year cohort study at a tertiary referral center for pelvic pain and endometriosis, where a range of interdisciplinary treatments are provided at a single center (surgical, hormonal, physical, and psychological therapies). Exclusion criteria were menopause, age >50 years, and never previously sexually active. Primary outcome (deep dyspareunia severity) and secondary outcome (sexual quality of life) were followed up over 1 year. Ordinal logistic regression was performed, controlling for baseline severity of deep dyspareunia, to identify baseline predictors of deep dyspareunia severity at 1 year.
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Clinicians should consider employing an interdisciplinary approach for deep dyspareunia, and screening for and treating depression symptoms in these women.
Strengths of the study include its prospective nature, and assessment of deep dyspareunia specifically (as opposed to superficial dyspareunia). Limitations include non-randomized design, and the patients lost to follow-up over the 1 year.
Over 1 year in an interdisciplinary setting, improvements were observed in deep dyspareunia and sexual quality of life, but younger women and those with more severe depression at baseline had more persistent deep dyspareunia at 1 year.
Yong PJ, Williams C, Bodmer-Roy S, et al. Prospective Cohort of Deep Dyspareunia in an Interdisciplinary Setting. J Sex Med 2018;15:1765–1775.
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Chronic pelvic pain affects ∼15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus, an interdisciplinary approach has been proposed for chronic pelvic pain, where these multifactorial comorbidities can be addressed by different interventions at a single integrated center. Moreover, while cross-sectional studies can provide some insight into the association between these comorbidities and chronic pelvic pain severity, prospective longitudinal cohorts can identify comorbidities associated with changes in chronic pelvic pain severity over time.
We sought to describe trends and factors associated with chronic pelvic pain severity over a 1-year prospective cohort at an interdisciplinary center, with a focus on the role of comorbidities and controlling for baseline pain, demographic factors, and treatment effects.
This was a prospective 1-year cohort study at an interdisciplinary tertiary referral center for pelvic pain and endometriosis, which provides minimally invasive surgery, medical management, pain education, physiotherapy, and psychological therapies. Exclusion criteria included menopause or age >50 years. Sample size was 296 (57% response rate at 1 year; 296/525). Primary outcome was chronic pelvic pain severity at 1 year on an 11-point numeric rating scale (0-10), which was categorized for ordinal regression (none-mild 0–3, moderate 4–6, severe 7–10). Secondary outcomes included functional quality of life and health utilization. Baseline comorbidities were endometriosis, irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia, and validated questionnaires for depression, anxiety, and catastrophizing. Multivariable ordinal regression was used to identify baseline comorbidities associated with the primary outcome at 1 year.
Chronic pelvic pain severity decreased by a median 2 points from baseline to 1 year (6/10–4/10, P < .001). There was also an improvement in functional quality of life (42–29% on the pain subscale of the Endometriosis Health Profile-30, P < .001), and a reduction in subjects requiring a physician visit (73–36%, P < .001) or emergency visit (24–11%, P < .001) in the last 3 months. On multivariable ordinal regression for the primary outcome, chronic pelvic pain severity at 1 year was independently associated with a higher score on the Pain Catastrophizing Scale at baseline (odds ratio, 1.10; 95% confidence interval, 1.00–1.21, P = .04), controlling for baseline pain, treatment effects (surgery), age, and referral status.
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Chronic pelvic pain (CPP) is a prevalent, debilitating, and costly condition. Although national guidelines and empiric evidence support the use of a multidisciplinary model of care for such patients, such clinics are uncommon in Canada. The BC Women's Centre for Pelvic Pain and Endometriosis was created to respond to this need, and there is interest in this model of care's impact on the burden of disease in British Columbia.
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La douleur pelvienne chronique (DPC) est un trouble prévalent, débilitant et coûteux. Bien que des lignes directrices nationales et des données empiriques soutiennent l'utilisation d'un modèle de soins multidisciplinaires pour les patientes qui présentent des DPC, les cliniques canadiennes offrant un tel modèle sont peu nombreuses. Le BC Women’s Centre for Pelvic Pain and Endometriosis a été créé pour répondre à ce besoin et un intérêt a été manifesté à l'endroit des effets de ce modèle de soins sur le fardeau de la maladie en Colombie-Britannique.
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Rachel E. Williams presently works at Glaxo SmithKline (GSK) and owns stock in GSK, but her participation in this study occurred when she was affiliated with UNC and before she began working for GSK.

Presented at the Sixty-Eighth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Orlando, FL, January 29-February 1, 2006.

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Transactions from the 68th Annual Meeting of the South Atlantic Association of Obstetricians and GynecologistLong-term outcomes after surgical and nonsurgical management of chronic pelvic pain: One year after evaluation in a pelvic pain specialty clinic

Objective

Study design

Results

Conclusion

Section snippets

Study setting and study population

Results

Comment

Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Pain

Am J Obstet Gynecol

J Minim Invasive Gynecol

Lancet

Pain

Pain

Pain

Prog Brain Res

Lancet

The role of laparoscopy in chronic pelvic pain: promise and pitfalls

Obstet Gynecol Surv

Chronic pelvic pain in women

Am J Manag Care

Transactions from the 68th Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologist
Long-term outcomes after surgical and nonsurgical management of chronic pelvic pain: One year after evaluation in a pelvic pain specialty clinic