Chronic pelvic pain

Journal Club 17th 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

Research the evidence available for different management options of chronic pelvic pain

Improve evidence based practice skills Critically appraise a systematic review

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?

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)?

Chronic pelvic pain

Symptom, not a diagnosis 6 months + Constant or intermittent pain Not exclusively with dysmenorrhoea

or dyspareunia Not during pregnancy

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

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RCOG guidelines April 2005 – outdated?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)

Literature search

Search terms: chronic pelvic pain Limits: since 2005, female, trials,

reviews, case studies, guidelines

Databases searched: Cochrane and Pubmed

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

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)

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

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

Data collection and analysis

2 review authors working independently

3rd author as arbiter Detailed search methods Quality of trials assessed based on

Cochrane guidelines

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

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)

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

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)

Results

Ultrasound and counselling vs “wait and see”

Favours ultrasound – improvement in mood and pain scores

Large confidence intervals Available in primary care

Results

Adhesiolysis vs. no surgery No significant benefit in pain score

or self-rating Combines 2 trials (different surgical

methods)

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

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

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