�BERKELEY, CA (UroToday.com) - Organized by the Pain of Urological Origin (PUGO) especial interest group of the International Association for the Study of Pain (IASP), Glasgow, Scotland August 15-16, 2008.
PUGO held a 2 day meeting in Scotland prior to the IASP twelfth World Congress on Pain to regard the past, present and future of urogenital pain. The place was to outline current practice and have a look at what the future may hold. Speakers from North America and Europe gave invited lectures, and synergistic sessions with all coming together attendees were interspersed throughout the proceeding leading to very lively discussions. The organizing commission included: Andrew Baranowski from London, John Hughes from Middlesbrough, UK, Beverly Collett from Leicester, UK, Ursula Wesselmann from Birmingham, Alabama, Leroy Nyberg from Bethesda, MD, Richard Berger from Seattle, Curtis Nickel from Kingston, Ontario, and Paul Abrams from Bristol, UK. The meeting was attended by a broad range of specialists in pain medicine, anesthesiology, psychology, neurology, neurosurgery, urology, gynecology, physical therapy, and internal practice of medicine. Patient advocates were as well enthusiastic participants. Many fantabulous presentations were given, and this report can only highlight selected ones. The proceedings will be synthesized by the organizing citizens committee and faculty and a formal publication is planned.
Curtis Nickel set the stage for the meeting with a discussion on the failure of our traditional biomedical model to successfully understand and treat urogenital chronic pelvic pain syndrome (UCPPS). He proposed a raw schema in which an initiator leads to redness or tissue damage. In some patients this results in UCPPS and can go on to develop into a regional pain in the neck syndrome and/or become a part of a systemic pain syndrome. Likewise, a systemic or regional pain sensation syndrome potty result in UCPPS in some patients. He proposed a strategy in which we attempt to identify the initiators, ameliorate the pain, treat the pelvic consequences of pelvic storey dysfunction, and tackle the associated phenotypes if diagnosed (irritable bowel syndrome, inveterate fatigue syndrome, fibromyalgia, etc.). He stressed the want to name and treat cognitive modulators including slump and catastrophizing as well as helplessness.
Fred Howard from the University of Rochester rundle on the endometriosis painfulness syndrome. Chronic pelvic botheration in women is almost commonly of gastrointestinal origin followed by the urinary tract and finally the reproductive tract. Endometriosis is a histologic finding, non a syndrome per se. We don't know the percentage of patients with endometriosis wHO also make pelvic painfulness, nor do we know the pct of women with pelvic pain wHO have endometriosis. We don't understand how it causes pelvic nuisance, why removing lesions doesn't always end the pain, or why similar symptoms are seen in patients with and without endometriosis. The common chord of symptoms associated with endometriosis includes dysmenorrhea, dyspareunia, and inveterate pelvic painful sensation. This throne be referred to as the adenomyosis pain syndrome. Dr. Howard quoted Frank Ling's report (Obstetrics and Gynecology, 93:51-58, 1999) showing the efficacy of depot leuprolide for chronic pelvic botheration in women suspected of having endometriosis, whether or not the diagnosis was borne kayoed on subsequent laparoscopy, a rather curious finding. Work by Sutton, Jones, and Abbott powerfully suggests that endometriosis lesions can cause pain and that operative treatment is more efficient than symptomatic laparoscopy in randomized, controlled trials (Fertility and Sterility, 62:696-700, 1994) (JSLS, 5:111-115, 2001) (Fertility and Sterility, 82:878-884, 2004).
Thibault Riant from Nantes, France related ground breakage surgical work in the treatment of the pudendal nerve entrapment syndrome (PNE) and the development of the Nantes criteria. The main criteria for diagnosing include all of the following: annoyance in the sensory country supplied by the pudendal nerve, hurting never awakens the patients during the night, pain increases in the seated position, no sensory loss is establish, and an immediate decreasing of botheration is noted after a pudendal anesthetic block. Therapeutic blocks, aesculapian treatment, S2 transcutaneous electrical nerve stimulation, physical therapy, and surgery were all discussed as possible forms of therapy. A multidisciplinary approach was suggested.
Maria Adele Giamberardino from the University of Chieti in Italy presented her research on the part of viscero-visceral hyperalgesia. Her studies, some in collaboration with Karen Berkley in Tallahassee, Florida, addressed patients affected with urinary calculosis and igure in 20 year old South Korean males.
Bert Messelink from Groningen, the Netherlands, spoke on pelvic storey muscles and urogenital hurting. In patients with urogenital pain, the pelvic floor muscles should be interpreted into account when talking and thinking about causative factors and possible options for treatment. Pelvic floor muscle education, physical therapy, biofeedback, and treatment of myofascial trigger points were all discussed. Possible injection of botulinum-A toxin or lidocaine into trigger points was mentioned, but information is sparse.
Eija Kalso from Finland spoke on opioids and guidelines for use in chronic pelvic pain, followed by some other talk on drug therapy by Sam Chong from the United Kingdom. Dr. Kelso illustrious that at that place are no randomized trials or regular case reports regarding the use of opioids for chronic nonmalignant pelvic hurting. Strong opioids should not be victimized as monotherapy, but rather as a part of a multidisciplinary approach. Use in combination with nonsteroidals and gabapentinoids may check tolerance. An intravenous opioid trial may be a good negative predictor of whether to consider opioids in a particular patient role. Assessing quality of sprightliness is decisive in decision making whether to continue opioids, as particular patients crataegus oxycantha find the diminished quality of life they associate with the treatment is not balanced by whatsoever perceived infliction benefit. Dr. Chong agreed that victimization cocktails and combination pain pill therapy is usually better than monotherapy.
Tony Buffington from Columbus, Ohio opened the bit day of the meeting. His presentation covered comorbidities, vulnerability factors, and familial aggregation data. Specifically he discussed variable combinations of idiopathic chronic pain syndromes including bladder pain syndrome, fibromyalgia, testy bowel syndrome, chronic pelvic pain syndrome, chronic fatigue syndrome, as well as affective disorders such as post traumatic stress disorderliness, panic disorderliness, anxiety and depression. These are ordinarily seen together in patients. They consist MUS or medically unexplained symptoms, and may strike up to 1/3rd of people seeking medical care. One candidate underlying disorder is sensitizing of the central tenseness response system and an imbalance in its production in response to stressors. Enhanced sensitiveness may result from variable combinations of familial (transmitted and environmental) factors. He hypothesizes that sensitization creates a greater vulnerability to life stressors, putting certain individuals at greater risk of development disorders characterized by painful sensation and uncomfortableness.
Andrew Baranowski presented the IASP categorisation system as it pertains to continuing pelvic pain, and noted how it embeds description of many phenotypes that are currently felt to be critical in categorizing patients with chronic pain. A resilient discussion with the audience and Dr. Nickels in particular ensued. Jose De Andres from Valencia, Spain then gave a elaborated and gripping discussion on neuromodulation techniques, concentrating on the evolving field of sacral spunk root stimulation and spinal anaesthesia cord stimulation. He accented that the level of evidence in this sphere is "low" and we are "simply treating patients". He was followed by an elegant presentation from Dr. Karen Berkeley from the University of Florida detailing her research on mechanisms of pain in a gnawer model of endometriosis - and the relationship of pain from endometriosis to other conditions via pelvic cross-talk. Central sensitization, outside central sensitization, and central hormonal modulation require a deliberate multifactorial approach to assessment and diagnosis of chronic pelvic pain.
Psychology and gender were the next topics. Anna Mandeville gave a introductory talk on the psychology of managing pain in the pelvis, highlighted by shell presentations. She described several sexual "myths" including
a. sex is to be reserved for the thoroughgoing, or at least the healthy;
b. sex must be spontaneous;
c. sex activity always should lead to intercourse;
d. each partner should instinctively know what the other wants.
Melissa Farmer from McGill University in Montreal followed Dr. Mandeville with a fascinating treatment on "sexual pain". Dyspareunia is a pain syndrome, not a sexual dysfunction. It requires biopsychosocial assessment and treatment. The motion she posed is, "Is pain sexual, or is sex painful?" In other words, does the pain in the ass occur in nonsexual or presexual situations. We would not say that depress back pain is a "work disorder" simply because the patient says it interferes with work. Likewise, we should not limit dyspareunia as a "sex disorder" because it interferes with sex. It is a pain disorder.
Dr. Farmer used the term "provoked vestibulodynia" instead of vulvovestibulitis syndrome. She famed that thither are no effective pharmacologic treatments, and that cognitive/behavioral therapy, hurting management, pelvic floor physical therapy, and vestibulectomy are efficacious in selected patients. Biomedical intervention (gynaecologist, pain specialiser), psychosocial intervention (psychologist, sexual urge therapist, psychiatrist), and phsiotherapy are all parts of successful therapy. Reducing pain does non always beggarly restoring sexual activity, nor does it necessarily lead to restoration of a relationship. Be careful how you define success in these patients.
Amanda C de C Williams from University College in London reviewed result assessment. She noted that pain is rarely adequately measured by quality of life definitions, but tone of life often approximates more closely than bother, symptom, or function measures what matters most to the affected role, and moves the focus from disease or dysfunction to the patient. She recommended falling somatization as being conceptually problematic, culturally specific, and incompatible with pain science. Likewise, cope may seem valid just is conceptually flawed. It addresses behaviour but non its setting or outcome. In a similar fashion, pain control predicts small, and is too general. Control may be an unrealistic shoot for for some pain.
The European Society for the Study of Interstitial Cystitis diagnostic approach shot was related by Jorgen Nordling from Copenhagen, and served as a model for end organ specialist rating of a chronic pain syndrome. Tim Ness from Birmingham, Alabama illustrated how the pain in the neck specialist approaches diagnosis.
Tier 1: rule out ruinous processes;
Tier 2: evaluation that guides the pick of intervention;
Tier 3: evaluation to limit discourse toxicity (imagination, laboratory testing, behavioral assessment if controlled substances are to be employed);
Tier 4: longitudinal outcome assessment;
Tier 5: use therapeutical results to help determine diagnostic information.
This comprehensive meeting ended with a presentation by this correspondent on practical considerations and algorithms for chronic pelvic pain, and also with a give-and-take led by Drs. Nickel and Baronowski to bestow the comprehensive proceedings to a close. It was agreed by all attendance that some type of clinical phenotype management strategy may help to move the field of discussion for chronic pelvic pain forward.
The management of chronic urogenital pain is a complex, but evolving field. We need standardisation of classification and valuation. We also need targeted therapies through a multidisciplinary approach, and finally, bob Hope for future benefits from translational science.
Reported by UroToday.com Contributing Editor Philip M. Hanno, MD, MPH
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