Chronic pelvic pain: multifactorial influences

Journal of Evaluation in Clinical Practice ISSN 1365-2753 Chronic pelvic pain: multifactorial influences 1 jep_1485 1137..1139 2 Adriana Peterson Mariano Salata Romão, Ricardo Gorayeb PhD, Gustavo Salata Romão PhD,3 Omero Benedicto Poli-Neto PhD,4 Francisco José Cândido dos Reis PhD,5 Júlio César Rosa-e-Silva PhD,6 Hermes de Freitas Barbosa PhD7 and Antonio Alberto Nogueira PhD8 1 Psychologist, postgraduate student, Department of Gynecology and Obstetrics, University Hospital, Faculty of Medicine of Ribeirão Preto, SP, USP, Brazil 2 Professor, Department of Neurosciences and Sciences of Behavior, University Hospital, Faculty of Medicine of Ribeirão Preto, SP, USP, Brazil 3 Professor, Department of Medicine, Federal University of São Carlos, SP, Brazil 4 Professor, Department of Surgery and Anatomy, University Hospital, Faculty of Medicine of Ribeirão Preto, SP, USP, Brazil 5 Professor, Department of Gynecology and Obstetrics, University Hospital, Faculty of Medicine of Ribeirão Preto, SP, USP, Brazil 6 Doctor, Department of Gynecology and Obstetrics, University Hospital, Faculty of Medicine of Ribeirão Preto, SP, USP, Brazil 7 Doctor, Department of Gynecology and Obstetrics, University Hospital, Faculty of Medicine of Ribeirão Preto, SP, USP, Brazil 8 Professor, Department of Gynecology and Obstetrics, University Hospital, Faculty of Medicine of Ribeirão Preto, SP, USP, Brazil Keywords emotional aspects, chronic pelvic pain, depression, anxiety, quality of life Correspondence Ms Adriana Peterson Mariano Salata Romão Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto – USP Department de Ginecologia e Obstetrícia Av. Bandeirantes, 3900 – 8° andar – Bairro Monte Alegre CEP: 14048-900 Ribeirão Preto – São Paulo – Brasil E-mail: [email protected] Accepted for publication: 16 March 2010 doi:10.1111/j.1365-2753.2010.01485.x Abstract Rationale Chronic pelvic pain (CPP) is a common and complex disease whose cause is often clinically inexplicable, with diagnosis and treatment being more difficult. From a clinical viewpoint, CPP is defined as non-cyclic, non-menstrual pain lasting at least 6 months and sufficiently severe to interfere with habitual activities and requiring clinical or surgical treatment. Thus, CPP is a syndrome resulting from a complex interaction of the nervous, musculoskeletal and endocrine systems and also influenced by psychological and sociocultural factors. CPP is influenced by emotional aspects with an impact on quality of life, and involving high costs for health services. Its aetiology is not always clear and a cure or significant improvement of symptoms is not always obtained with the treatments employed, with constant frustration of the professionals involved. It can be seen that its treatment is often unsatisfactory, simply providing temporary relief of symptoms. Methods In the present study, we reviewed the bibliography regarding pelvic pain, with emphasis on emotional aspects and on the importance of a multidimensional approach to the care for these patients. Results and conclusions New investigations are needed to clarify these relations and interventions in a more effective manner. Interdisciplinary care can minimize the impact of the disease, helping the patients to cope with symptoms and improving their quality of life. Chronic pelvic pain Chronic pelvic pain (CPP) has been defined as non-exclusively menstrual pain lasting at least 6 months and sufficiently intense to interfere with habitual activities, requiring clinical and/or surgical treatment [1]. Its etiology is unclear and usually results from a complex interaction between the gastrointestinal, urinary, gynecological, musculoskeletal, neurologic, psychological and endrocrinologic systems, being also influenced by sociocultural factors [2]. CPP is a common and complex syndrome often of unidentified causes, with difficulty in diagnosis and treatment and has an important impact on the well-being of affected patients, with consequences for their marital, social, professional and sexual life. Chronic pain is not an alert to an aggression but corresponds to the disease itself and may be associated with psychopatho- logical processes such as depression, hypochondria, somatization and anxiety, and with environmental factors such as physical and sexual abuse in addition to a stressful milieu. The response to these aversive stimuli occurs by means of emotional stress which contributes to the maintenance of the painful signs and symptoms. Little is known about the pathogenesis of CPP and its treatment is not always simple or satisfactory [3]. Its prevalence is 3.8% among women aged 15–73 years (higher than the prevalence of migraine, asthma and backache) and ranges from 14 to 24% among women of reproductive age, with a direct impact on their marital, social and professional life [1,2,4–8], causing CPP to be a serious public health problem [8]. About 60% of women with the disease never received a specific diagnosis and 20% were never submitted to any investigation in order to elucidate the cause of pain [9]. © 2010 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 17 (2011) 1137–1139 1137 Chronic pelvic pain In an attempt to explain the mechanism of pain, Fordyce [10], reported that a chronic painful response may be associated and learned when there is a ‘gain’ represented by obtaining attention or discontinuing undesirable activities. Although several historical models have explained the mechanism of pain, the model most extensively accepted at present is the biopsychosocial one, which is the basis for multidisciplinary care for the diagnosis and treatment of CPP. This model postulates that painful stimuli are universal and that specific psychosocial conditions may contribute to the development and maintenance of chronic pain. CPP may be a great problem in terms of levels of suffering and stress for the affected person if we consider the large number of persons reporting this complaint in health services and the difficulties they experience for diagnosis and effective treatment. Psychological factors There is a strong association between anxiety and depression and CPP [11–14]. Individuals with chronic diseases are those most frequently presenting depressive symptoms within the medical context. The characteristics of the base diseases, their intensity and the degree of limitation they cause, together with the life history of the patients, their previous psychic functioning and the social and family network of support available are important to determine the social, emotional and cognitive implications for the life of the patients [15]. The loss of a healthy and active body may mean the loss of autonomy and independence for many persons. These persons also commonly suffer losses of their social circle because of the limitations imposed by the disease and its symptoms, with changes in the social and mainly in the affective dynamics. The loss of a job and of economic stability favours feeling of uselessness which generate anxious or depressive states. The cognitive perceptions are gradually altered as the disease occupies a central position in the life of these persons [16]. The prevalence of depression is estimated to be as high as 78%, with evidence indicating that depression is a consequence of chronic pain, although there is no consensus about which condition precedes the other. A recent review of the literature about the association of pain and depression mentioned a 12–17.2% prevalence of depression among patients submitted to gynecological laparoscopy required by the need for a diagnosis of CPP [17]. The pain-depression association may aggravate suffering, impair treatment compliance and the response to analgesics, and cause social isolation, despair and lack of care. The progression of the disease and the disappointing results of many treatments applied cause patient hostility towards the persons and professionals involved in their care [3]. These conditions may favour noncompliance with treatment, prolong pain and suffering, impair physical and psychic functionality, and cause a deterioration of quality of life [14]. With respect to chronic diseases, the role of health care regarding the improvement of quality of life has been increasingly emphasized as a means of relieving pain and suffering. In contrast to previous decades, when all efforts were directed at life gains in terms of number of years lived, improvement of the quality of life has been a constant topic in recent years [18]. Chronic disease may start as an acute, apparently nonsignificant condition which continues through episodes of exacerbation and remission. Although a control is possible, the accumulation of 1138 A.P.M.S. Romão et al. events and the restrictions imposed by treatment may lead to a drastic change in the life style of people [19]. Thus, individuals with chronic diseases have to face new tasks such as following a treatment regimen, learning about their disease and coping with physical discomfort; losses in their social and financial relations and in activities such as locomotion, work and leisure; threats to their physical appearance, to life and to the preservation of hope [20]. The complexity and extent of the problems inherent to the experience of chronic pain have led many investigators to study the impact of this condition on several aspects of the quality of life of persons with chronic pain [21–24]. In a recent study [25] evaluating a group of women with CPP compared with a control group, women presenting a worse quality of life were also found to present worse anxiety and depression. It is also important for the physician to be alert to the signs and symptoms of depression on which the psychotherapeutic and psychopharmacological conducts will be based in order to reestablish the mental, social and organic equilibrium of the patient. The signs and symptoms that characterize depression when they persist for more than 2 weeks and throughout most of the day are: sadness, lack of interest and/or pleasure, weeping crises, mood sleep and appetite variations, loss of libido, social isolation, loss or relaxation of productivity, despair, lack of interest in recreational or leisure activities, guilt feelings and suicidal thoughts. Conclusion Chronic pelvic pain can involve multiple aspects of a psychological, psychic and social nature, continuing to be a challenging disease. A full patient evaluation requires a search for physical causes and of psychological and social conditions. Interdisciplinary care can minimize the impact of the disease, helping the patients to cope with symptoms and improving their quality of life. The association of anxiety, depression and quality of life with chronic pain is already known. Regarding sexual life, it is not clear how chronic pain is associated with sexual relations, or whether complaints in this area are to be attributed to depression or to the factors involved in the experience of pain itself. An interdisciplinary approach to the care of these women and follow-up by psychoeducational groups are also scarce. Existing studies are still modest and require better confirmation. Thus, new investigations are needed to clarify these relations and interventions in a more effective manner. Further investigations will permit a better understanding of these patients and of their real needs for treatment. References 1. 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