dr sherif tawfeek ms ann johnson dr ingo kolossagpcme.co.nz/pdf/2017...
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Dr Sherif TawfeekConsultant Gynaecologist
Christchurch Gynaecology Associates
Christchurch
8:30 - 10:30 WS #5: Chronic Pelvic Pain - A Holistic Approach - Part 1
Ms Ann JohnsonWomen’s Health Physiotherapist
Christchurch Women’s Hospital
Christchurch
Dr Ingo KolossaColorectal and Gastrointestinal Surgeon
Intus Digestive and Colorectal Care
Christchurch
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Chronic Pelvic Pain – A Holistic Approach
Ingo Kolossa
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Prevalence of Chronic Pelvic Pain
• Numbers vary throughout literature
• 38 per 1000/ a, e.g. migraine, asthma and chronic back pain (UK GP database)
• 15% in the USA, 24% in the UK (Community surveys UK, USA)
• 2-27% worldwide (WHO 2004, Cochrane Library 2014)
• Up to 20% gynaecologic outpatient referrals for CPP
• 40% of laparoscopies performed for CPP
• 10%-15% of hysterectomies performed for CPP
• Obvious cause remains unknown in 35%-60% of patients
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Prevalence of Chronic Pelvic Pain
• 1,160 random sample from NZ Electoral Roll
• 25,4% aged between 18 and 50yrs in New Zealand
• 47,7% remained undiagnosed
• Maori women less likely than non Maori women 18,8% vs. 27,4%
• 55,2% dysmenorrhoea, 19,7% dyspareunia
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Healthcare Cost of Chronic Pelvic Pain
• 34,346 women 15-59yrs admitted between April1, 2008 and March 31, 2012
• $ 100.5 million with an average cost of $ 25mio per year
• 92.9% associated with surgical intervention
• Hysterectomy 47.1%, Laparoscopy 25.8%, Adnexal Surgery 6.8%, Others 11.6%
• Not accounting for Outpatient Treatment, Productivity, Impact on QoL
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Healthcare Cost of Chronic Pelvic Pain
• $6 billion/a direct cost of medical and surgical treatment for women with
endometriosis and CPP
• 11 working hours/women/week in absenteeism
• $200-$250/week/women to employer in absenteeism
• $34.3 billion cost for chronic pain in 2007 (Sydney Pain Management Research Institute)
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Characteristics of Chronic Pelvic Pain
• Longer than six months
• Unspecific
• Cyclic (Endometriosis)
• Trigger (Dyspareunia, Dyschezia, Voiding)
• Somatic, visceral, somato-visceral convergence, viscero-somatic convergence
• Neuropathic
• Sensitisation
• Psychological (78% childhood abuse)
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Causes of Chronic Pelvic Pain
• Endometriosis
• Adhesions
• Pelvic Organ Prolapse
• Myofascial dysfunction
• Irritable bowel syndrome, Chronic diverticulitis
• Interstitial cystitis (painful bladder syndrome)
• Fibromyalgia
• Neuropathic (pudendal neuralgia, post surgery, post trauma)
• Hernia
• Inflammatory bowel disease, Anal-/Bowel cancer, Chronic appendicitis
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Patient
Urologist
GP
Pain
Specialist
Physio-
therapist
Dietitian
Colorectal
Surgeon
Gynae-
cologist
Psycho-
therapist
Gastro-
entero-
logist
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Patient
Urologist
GP
Pain
Specialist
Physio-
therapist
Dietitian
Colorectal
Surgeon
Gynae-
cologist
Psycho-
therapist
Gastro-
entero-
logist
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Surgical vs. non-surgical management
• 23 studies with 1,847 patients
• No statistically significant difference in pain improvement between surgical and
medical treatment
“….this study may encourage clinicians to consider a less invasive
alternative for treating their patients’ chronic pelvic pain in the near future.”
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Surgical vs. non-surgical management
• 13 RCT with 750 patients
• High doses of Progestogen to improve pain by >50% (weight gain, bloatedness)
• Reassurance ultrasound scan plus counselling better than “wait and see”
• Writing therapy (disclosure of pain) more likely to improve pain
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Surgical vs. non-surgical management
Protocol for currently ongoing review
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Surgical vs. non-surgical management
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Surgical vs. non-surgical management
• Adequate time for the women to be able to tell her story
• Screening for infection (STIs, e.g. Chlamydia trachomatis, gonorrhoea)
• Transvaginal ultrasound and MRI
• Women with cyclical pain should be offered hormonal treatment 3-6 months
before having diagnostic laparoscopy
• IBS patients should be offered antispasmodics and dietary input
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Personal List Of Worries
• Length
• Previous Surgery
• Medication
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Surgical management
• Endometriosis, collaborative if transmural bowel invasion
• Adhesions, Chronic appendicitis
• Pelvic Organ Prolapse
• Neuropathic
• Digestive System ( Colonoscopy, Chronic diverticulitis, IBD, Neoplasia, Fistula)
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Surgical management
• Endometriosis, collaborative if transmural bowel invasion
• Adhesions, Chronic appendicitis
• Pelvic Organ Prolapse
• Neuropathic
• Digestive System ( Colonoscopy, Chronic diverticulitis, IBD, Neoplasia, Fistula)
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Adhesiolysis
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Adhesiolysis
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Adhesiolysis
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Adhesiolysis
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Adhesiolysis
• Pain caused by traction, twisting entrapment of bowel or pelvic structures
• Account for 30% of chronic pelvic and abdominal pain
• Aim to restore normal anatomy and prevent recurrence
• Success rates 17% - 97%
• CAVE: often short-term follow-up, not placebo controlled
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Adhesiolysis
Design: 52 pat. laparoscopic adhesiolysis
48 pat. laparoscopy alone (Placebo)
12 yrs follow-up
Outcome: pain relief, QoL, complications, analgesics, revisits, re-operations
Results:
• complete pain relief 19% adhesiolysis vs. 42% placebo
• Use of analgesics 62% adhesiolysis vs. 52% placebo
• Specialist visits 33% adhesiolysis vs. 19% placebo
• Re-operation 19% adhesiolysis vs. 3% placebo
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Adhesiolysis
• 13 studies included, only 2 randomized trials
• only 1 study with improved pain after adhesiolysis vs. laparoscopy alone
55,8% vs. 41,7% (not significant)
• only short-term follow-up 6-12months
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Adhesiolysis
• 13 studies included, only 2 randomized trials
• only 1 study with improved pain after adhesiolysis vs. laparoscopy alone
55,8% vs. 41,7% (not significant)
• only short-term follow-up 6-12months
“….there is little evidence for long-term efficacy of adhesiolysis for chronic
pain…At present there is little evidence to support routine use of
adhesiolysis in treatment for chronic pain.”
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Pelvic Organ Prolapse
Mesh in the pelvis?
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Transvaginal mesh for Pelvic organ prolapse
• 110 studies included, 11,785 patients
• 10% of women experienced mesh erosion within 12 months
• >50% with erosion required (partial) surgical excision
• Vaginal shortening, tightening, pain due to mesh contraction not uncommon
• Abdominal approach (sacralcolpopexy) results in lower erosion rate, < 4%
• Several non-absorbable mesh products withdrawn
• Transvaginal prolapse repair decreased by 40 - 50% in US
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Transvaginal mesh for Pelvic organ prolapse
• 30 RCT, 3414 patients
Authors conclusion:“ Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse
on examination, repeat surgery for prolapse, postoperative SUI and dyspareunia than a
variety of vaginal interventions.
The limited evidence does not support use of transvaginal mesh compared to native tissue
repair for apical vaginal prolapse. Most of the evaluated transvaginal meshes are no longer
available and new lighter meshes currently lack evidence of safety.”
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Transvaginal mesh for Pelvic organ prolapse
Design: multicentre (35 /65) parallel-group RCT
865 mesh group (430 standard vs. 435 mesh)
735 graft group (367 standard vs. 368 graft)
2 yrs follow-up
Outcome: Prolapse symptoms, QoL, complications (erosion, reoperation etc.)
Results:
• No difference for QoL, POP-SS, satisfaction rate, urogenital function
• No difference for serious complications <10%
• Mesh erosion in 12%, 9% required partial removal, 80 % asymptomatic
“no symptomatic or anatomical benefit for augmenting a primary transvaginal repair”
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So what?
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MDT Pelvic
Floor Meeting
Colorectal Surgeon
Gynaecologist
Physiotherapist
Psychotherapist
Urologist
Radiologist
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Mesh repair for Rectal Prolapse LVMR
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Mesh repair for Rectal Prolapse LVMR
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Mesh repair for Rectal Prolapse LVMR
D’Hoore A.
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Perineal levatorplasty
ResearchGate
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Perineal levatorplasty and
Laparoscopic proctocolposacropexy LVMR
D’Hoore A.
ResearchGate
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Patient A – Slide 1
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Patient A – Slide 2
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Patient A – Slide 3
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Patient A – Slide 4
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Patient A – Slide 5
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Patient A – Slide 6
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Patient B –Slide 1
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Patient B – Slide 2
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Patient B – Slide 3
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Patient B – Slide 4
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Patient B – Slide 5
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Patient B – Slide 6
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Patient B – Slide 7
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Patient B – Slide 9
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Patient C – Slide 1
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Patient C – Slide 2
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Patient C – Slide 3
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Patient C – Slide 4
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Patient C – Slide 5
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Patient C – Slide 6
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Patient C – Slide 7
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Patient C – Slide 8
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Patient C – Slide 9
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Patient D – Slide 1
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Patient D – Slide 2
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Patient D – Slide 3
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Patient D – Slide 4
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Patient D – Slide 5
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Mesh repair for Rectal Prolapse LVMR
• Samaranayake CB et al. 2010, 728 (4) patients, 0,55% erosion
• Smart et al. 2013, 866 (5) patients, 0,57% erosion
• Gouvas et al. 2014, 1316 (4), 0,3% erosion
• Mercer-Jones MA et al. 2014, panel of experts, 2-3% erosion
• Pelvic Floor Society Subgroup of ACPGBI, 2,4% erosion
• LVMR is a safe and effective operation with low erosion rates of 2-3%
• Polypropylene mesh 1,8% vs. Polyester mesh 6,5% risk of erosion
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Mesh repair for Rectal Prolapse LVMR
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Sacral Nerve Modulation
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Sacral Nerve Modulation
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Sacral Nerve Modulation
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Sacral Nerve Modulation
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Sacral Nerve Modulation
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Sacral Nerve Modulation
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Sacral Nerve Modulation
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Sacral Nerve Modulation
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• Scanty literature with variable success
• Mainly case series and small numbers
• Only short term follow-up 6-15 months
• Occasional significant reduction of pain scores and improvement of QoL
• Minimal invasive and reversible
• Should be considered before adopting more aggressive surgical procedures
• More RCT needed
Sacral Nerve Modulation
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Own experience:
Patient 1:
• 69yrs, abdominal and perineal pain >20 yrs
• Left oophorectomy aged 52 (1994)
• 5x laparoscopy
• Collagenous colitis
• Sigmoid + upper rectal resection for incontinence and pain( 2007)
• Colostomy and Hartmann’s procedure 2007
• Abdominoperineal proctectomy 2008
• SNM Test Trial 5/2011
“completely symptom free, new experience for more than eight years”
• Permanent Implantation 06//11, absolutely fine on review 6 weeks
• Symptom free until last review 9/13
• Adhesiolysis for recurrent abdominal pain, no pelvic pain, turned device off,
noticed ongoing relief
• 9/15 requested explantation as ongoing relief despite device off
Sacral Nerve Modulation
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Own experience:
Patient 2:
• 51yrs, pain since hysterectomy aged 28 in 1988 for uterovaginal prolapse
• numerous procedures
Sacral Nerve Modulation
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Own experience:
Patient 2:
• 51yrs, pain since hysterectomy aged 28 in 1988 for uterovaginal prolapse
• numerous procedures
• At Burwood Pain Clinic since late 90’s
• Test Trial 8/12 with 80% reduction of vaginal and deep pelvic floor pain
• Permanent Implantation 9/12, ongoing reduction of vaginal pain and dyspareunia
on 3 months follow-up “ more than I could have dreamed of”
• Review 2/13 lower abdominal pain recurred, pelvic floor still amazing
• Colostomy 7/13 after 3 months pain free on elemental diet
• Reversal procedure 1/15 due to recurrent abdominal pain
• Revision of anastomosis due to stricture 11/16
• Reversal of loop ileostomy 2/17
• No pain in abdomen or on bowel motions on last follow-up 4/17
Sacral Nerve Modulation
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Own experience:
Patient 3:
• 45yrs, pain since teenager, endometriosis
• HE aged 33 (2000)
• 8x laparoscopy
• Right hemicolectomy 2008 (for caecal bascule)
• Sigmoid + upper rectal resection + ovarian cystectomy 2009
• At Burwood Pain Clinic since 2003
• SNM Test trial 10/12 with 90% pain reduction, resumed back to normal activities
14hrs/d
“ concerned that she may wake up and realise this was just a dream”
• Permanent Implantation 12/12, absolutely fine on review 6 weeks
• Review 3/13 felt miserable, constipation better but felt poisoned by device with
constant toxic taste in mouth
• Explantation 4/13, felt much better, lost on follow-up since 7/13
Sacral Nerve Modulation
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Possible benefit for lower pelvic pain and pelvic floor pain
Trial and error approach in highly selected patients
Sacral Nerve Modulation
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• Prevalence of CPP in women aged 20 to 49 is 15%
• Aetiology unknown in 35% to 60% of patients
• Multifactorial (Endometriosis, Adhesions, IBS, POP, Neuropathic, Psychologic)
• Effective non-surgical interventions available
• Surgical role as multidisciplinary approach (Endometriosis, Prolapse, IBS)
• Sacral nerve Modulation, Adhesiolysis, Bowel resection with limited success
• Large number remain in pain despite treatment
• Effective integrated multidisciplinary care pathways crucial
Summary
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Thank you
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