Chronic pelvic pain
Journal Club 17th June 2011
Dr Claire Hoxley (GPST1)
Dr Harpreet Rayar (GPST2)
Aims and Objectives
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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
Case presentation
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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
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What management options are there?
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The Clinical Question
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What are the management options
for chronic pelvic pain?
What guidelines are there for
investigating and managing chronic
pelvic pain in primary care (nonsurgical management)?
Chronic pelvic pain
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Symptom, not a diagnosis
6 months +
Constant or intermittent pain
Not exclusively with dysmenorrhoea
or dyspareunia
Not during pregnancy
Chronic pelvic pain
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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
Guidelines
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No NICE guidelines
RCOG guidelines – Chronic pelvic pain,
Initial management (Green-top 41)
No BWH Guidelines
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RCOG guidelines April 2005 – outdated?
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Limited guidance for primary care
management (non-surgical)
Literature search
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Search terms: chronic pelvic pain
Limits: since 2005, female, trials,
reviews, case studies, guidelines
Databases searched: Cochrane and
Pubmed
Literature search results
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Cochrane results: Systematic Review
2005, updated 2010
2 protocols November 2010
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Non surgical interventions for the management
of chronic pelvic pain
Surgical interventions for the management of
chronic pelvic pain in women
Limited Pubmed evidence
Paper selected
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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)
Criteria for selecting trials
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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
Criteria for selecting trials
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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
Data collection and analysis
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2 review authors working
independently
3rd author as arbiter
Detailed search methods
Quality of trials assessed based on
Cochrane guidelines
Results
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19 trials identified
14 included (N = 6-286)
Included psychological, medical,
surgical, lifestyle interventions
Excluded trials due to insufficient
information re outcomes, noncomparable evaluation points,
uncertainty re study design
Risk of bias
Allocation concealment:
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10 x A
3xB
1xC
Quality of allocation concealment
graded as A (adequate) B (unclear)
or C (inadequate)
Risk of bias
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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
Combining results
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2 studies on
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Progestogen vs. placebo
Adhesiolysis vs. expectant
management or diagnostic laparoscopy
Single studies for other
interventions
Combined results with caution
(different surgical methods)
Results
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Ultrasound and counselling vs “wait
and see”
Favours ultrasound – improvement
in mood and pain scores
Large confidence intervals
Available in primary care
Results
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Adhesiolysis vs. no surgery
No significant benefit in pain score
or self-rating
Combines 2 trials (different surgical
methods)
Limitations
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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
Implications for research
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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
Summary and Conclusion
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Limited evidence for effective
management options
Some options available in primary care
Need for further research – cochrane
protocols in place, separate surgical/nonsurgical management
Better understanding of complex
psychosocial model of chronic pelvic pain