Psychological Causes and Association

This is an area usually neglected by medical professionals, and denied by most patients and their families. This is despite of the well-known fact that pain perception is modulated by psychological factors [Eisendrath SJ. 1995], which may precede or follow the onset of chronic pelvic pain. In some cases, such pain has even been considered as a variant of depression [Blumer and Heilbronn, 1982]. In other cases, both of them were considered as an outcome of childhood sexual abuse, and past stressful experiences [Walker et al, 1988]. Such patients may have neuropsychiatric problems associated with low pain threshold. This was attributed to low serotonin level which is known to affect pain perception, mood and sleep regulation. Furthermore, they are more susceptible to pain producing impulses, and are less capable to deal with them. Women with the following problems are more susceptible to chronic pelvic pain:

  • History of physical or sexual abuse
  • Personality or somatization disorders
  • Anxiety state or depression
  • Marital or family disorders

All these factors may lead to psychosomatic problems and somatisation. In such cases symptoms can not be explained by any specific medical condition. Coexistence of somatisation and chronic pelvic pain has been reported in 70% of the cases [Ehlert et al, 1999]. On the other hand, the negative effect of chronic pelvic pain on the quality of life can lead to depression, and other psychological problems. At least it may tip the scale for those who are already predisposed. Furthermore, chronic pelvic pain may lead to difficulties with falling sleep [Nolan et al, 1992], going to work and maintaining normal social or marital relations. A recent report by Cox et al in 2007 showed that most of life quality parameters were affected by chronic pain. However, a direct ‘role limitation’ effect was only associated with pain due to sexual intercourse and bladder and bowel dysfunction.

It is also important to deal with the consequences of the diagnosis and treatment provided in these patients. Endometriosis and adhesions are almost synonymous to infertility in the minds of most patients and can create tension within the marital relationship. This is especially so if there is disagreement between a couple on when and how to start a family. Accordingly, the diagnostic work up and management and follow up plans should incorporate means to diagnose and deal with all these psychological problems. The initial questionnaire should include a section to deal with psychological issues. The International Pelvic Pain Society questionnaire is comprehensive and covers these areas well, and can be used for that purpose [http://www.pelvicpain.org]. As well, a psychologist with special interest in chronic pelvic pain can help with the assessment of these patients; provide counselling and effective pain coping techniques.

Chronic pelvic pain syndrome

The ultimate objective of treating pelvic pain is to prevent the development of the chronic pelvic pain syndrome, which is characterised by chronic pain, psychological problems, and behavioural changes. These points can be demonstrated by:

    • Hyperalgesia which is pain out of proportion to the painful stimulus.
    • Allodynia refers to pain produced by non-painful stimuli and is felt in healthy areas not involved in the original tissue injury;
    • Failure to respond to the standard or over the counter medication;
    • Signs of depression and impaired function;
    • Altered roles in marriage, family and career.

Early treatment of pain especially in teenagers can prevent patients sliding into this syndrome. Management should involve time contingent and pain rescue strategies, with the liberal use of combined medications. This should include analgesics, antidepressants and specific medication to deal with neuropathic pain (polypharmacy). Intelligent use of psychological help will deal with the predisposing problems, and relieve any distress caused by chronic pain. Liberal use of biofeedback techniques by a trained physiotherapist will go a long way in relieving pelvic floor pain.

It is very important to avoid pain-accentuating factors by both surgeons and patients alike. 

·     Patients should be encouraged to lead as normal life as possible, and should avoid negative pain behaviour. They should have adequate medical and psychological support to help them deal with their symptoms.

·     Surgeons, on the other hand, should avoid unnecessary surgical interventions and should use minimal access surgery to reduce tissue damage. They should use pre-emptive anaesthesia by injecting incision sites with local anaesthetics before making them. Moreover, they should avoid additional elective surgical procedures to reduce the extent of tissue damage.

·     Patients should be offered adequate postoperative analgesia; preferably a patient controlled-type while in hospital and adequate medication to use at home. They should be encouraged to mobilise early, dress normally and wear their usual make up to improve their morale.
 


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