Dr Sherif Tawfeek Ms Ann Johnson Dr Ingo Kolossagpcme.co.nz/pdf/2017 South/Thu_Room9_0830_KolossaIngo_CPP Talk.… · Dr Sherif Tawfeek Consultant ... • 51yrs, pain since hysterectomy

Dr Sherif TawfeekConsultant Gynaecologist

Christchurch Gynaecology Associates

Christchurch

8:30 - 10:30 WS #5: Chronic Pelvic Pain - A Holistic Approach - Part 1

Ms Ann JohnsonWomen’s Health Physiotherapist

Christchurch Women’s Hospital

Christchurch

Dr Ingo KolossaColorectal and Gastrointestinal Surgeon

Intus Digestive and Colorectal Care

Christchurch

Chronic Pelvic Pain – A Holistic Approach

Ingo Kolossa

Prevalence of Chronic Pelvic Pain

• Numbers vary throughout literature

• 38 per 1000/ a, e.g. migraine, asthma and chronic back pain (UK GP database)

• 15% in the USA, 24% in the UK (Community surveys UK, USA)

• 2-27% worldwide (WHO 2004, Cochrane Library 2014)

• Up to 20% gynaecologic outpatient referrals for CPP

• 40% of laparoscopies performed for CPP

• 10%-15% of hysterectomies performed for CPP

• Obvious cause remains unknown in 35%-60% of patients

Prevalence of Chronic Pelvic Pain

• 1,160 random sample from NZ Electoral Roll

• 25,4% aged between 18 and 50yrs in New Zealand

• 47,7% remained undiagnosed

• Maori women less likely than non Maori women 18,8% vs. 27,4%

• 55,2% dysmenorrhoea, 19,7% dyspareunia

Healthcare Cost of Chronic Pelvic Pain

• 34,346 women 15-59yrs admitted between April1, 2008 and March 31, 2012

• $ 100.5 million with an average cost of $ 25mio per year

• 92.9% associated with surgical intervention

• Hysterectomy 47.1%, Laparoscopy 25.8%, Adnexal Surgery 6.8%, Others 11.6%

• Not accounting for Outpatient Treatment, Productivity, Impact on QoL

Healthcare Cost of Chronic Pelvic Pain

• $6 billion/a direct cost of medical and surgical treatment for women with

endometriosis and CPP

• 11 working hours/women/week in absenteeism

• $200-$250/week/women to employer in absenteeism

• $34.3 billion cost for chronic pain in 2007 (Sydney Pain Management Research Institute)

Characteristics of Chronic Pelvic Pain

• Longer than six months

• Unspecific

• Cyclic (Endometriosis)

• Trigger (Dyspareunia, Dyschezia, Voiding)

• Somatic, visceral, somato-visceral convergence, viscero-somatic convergence

• Neuropathic

• Sensitisation

• Psychological (78% childhood abuse)

Causes of Chronic Pelvic Pain

• Endometriosis

• Adhesions

• Pelvic Organ Prolapse

• Myofascial dysfunction

• Irritable bowel syndrome, Chronic diverticulitis

• Interstitial cystitis (painful bladder syndrome)

• Fibromyalgia

• Neuropathic (pudendal neuralgia, post surgery, post trauma)

• Hernia

• Inflammatory bowel disease, Anal-/Bowel cancer, Chronic appendicitis

Patient

Urologist

GP

Pain

Specialist

Physio-

therapist

Dietitian

Colorectal

Surgeon

Gynae-

cologist

Psycho-

therapist

Gastro-

entero-

logist

Patient

Urologist

GP

Pain

Specialist

Physio-

therapist

Dietitian

Colorectal

Surgeon

Gynae-

cologist

Psycho-

therapist

Gastro-

entero-

logist

Surgical vs. non-surgical management

• 23 studies with 1,847 patients

• No statistically significant difference in pain improvement between surgical and

medical treatment

“….this study may encourage clinicians to consider a less invasive

alternative for treating their patients’ chronic pelvic pain in the near future.”


• 13 RCT with 750 patients

• High doses of Progestogen to improve pain by >50% (weight gain, bloatedness)

• Reassurance ultrasound scan plus counselling better than “wait and see”

• Writing therapy (disclosure of pain) more likely to improve pain


Protocol for currently ongoing review



• Adequate time for the women to be able to tell her story

• Screening for infection (STIs, e.g. Chlamydia trachomatis, gonorrhoea)

• Transvaginal ultrasound and MRI

• Women with cyclical pain should be offered hormonal treatment 3-6 months

before having diagnostic laparoscopy

• IBS patients should be offered antispasmodics and dietary input

Personal List Of Worries

• Length

• Previous Surgery

• Medication

Surgical management

• Endometriosis, collaborative if transmural bowel invasion

• Adhesions, Chronic appendicitis


• Neuropathic

• Digestive System ( Colonoscopy, Chronic diverticulitis, IBD, Neoplasia, Fistula)

Surgical management

• Endometriosis, collaborative if transmural bowel invasion

• Adhesions, Chronic appendicitis


• Neuropathic

• Digestive System ( Colonoscopy, Chronic diverticulitis, IBD, Neoplasia, Fistula)

Adhesiolysis

Adhesiolysis

Adhesiolysis

Adhesiolysis

Adhesiolysis

• Pain caused by traction, twisting entrapment of bowel or pelvic structures

• Account for 30% of chronic pelvic and abdominal pain

• Aim to restore normal anatomy and prevent recurrence

• Success rates 17% - 97%

• CAVE: often short-term follow-up, not placebo controlled

Adhesiolysis

Design: 52 pat. laparoscopic adhesiolysis

48 pat. laparoscopy alone (Placebo)

12 yrs follow-up

Outcome: pain relief, QoL, complications, analgesics, revisits, re-operations

Results:

• complete pain relief 19% adhesiolysis vs. 42% placebo

• Use of analgesics 62% adhesiolysis vs. 52% placebo

• Specialist visits 33% adhesiolysis vs. 19% placebo

• Re-operation 19% adhesiolysis vs. 3% placebo

Adhesiolysis

• 13 studies included, only 2 randomized trials

• only 1 study with improved pain after adhesiolysis vs. laparoscopy alone

55,8% vs. 41,7% (not significant)

• only short-term follow-up 6-12months

Adhesiolysis

• 13 studies included, only 2 randomized trials

• only 1 study with improved pain after adhesiolysis vs. laparoscopy alone

55,8% vs. 41,7% (not significant)

• only short-term follow-up 6-12months

“….there is little evidence for long-term efficacy of adhesiolysis for chronic

pain…At present there is little evidence to support routine use of

adhesiolysis in treatment for chronic pain.”

Pelvic Organ Prolapse

Mesh in the pelvis?

Transvaginal mesh for Pelvic organ prolapse

• 110 studies included, 11,785 patients

• 10% of women experienced mesh erosion within 12 months

• >50% with erosion required (partial) surgical excision

• Vaginal shortening, tightening, pain due to mesh contraction not uncommon

• Abdominal approach (sacralcolpopexy) results in lower erosion rate, < 4%

• Several non-absorbable mesh products withdrawn

• Transvaginal prolapse repair decreased by 40 - 50% in US


• 30 RCT, 3414 patients

Authors conclusion:“ Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse

on examination, repeat surgery for prolapse, postoperative SUI and dyspareunia than a

variety of vaginal interventions.

The limited evidence does not support use of transvaginal mesh compared to native tissue

repair for apical vaginal prolapse. Most of the evaluated transvaginal meshes are no longer

available and new lighter meshes currently lack evidence of safety.”


Design: multicentre (35 /65) parallel-group RCT

865 mesh group (430 standard vs. 435 mesh)

735 graft group (367 standard vs. 368 graft)

2 yrs follow-up

Outcome: Prolapse symptoms, QoL, complications (erosion, reoperation etc.)

Results:

• No difference for QoL, POP-SS, satisfaction rate, urogenital function

• No difference for serious complications <10%

• Mesh erosion in 12%, 9% required partial removal, 80 % asymptomatic

“no symptomatic or anatomical benefit for augmenting a primary transvaginal repair”

So what?

MDT Pelvic

Floor Meeting

Colorectal Surgeon

Gynaecologist

Physiotherapist

Psychotherapist

Urologist

Radiologist

Mesh repair for Rectal Prolapse LVMR



D’Hoore A.

Perineal levatorplasty

ResearchGate

Perineal levatorplasty and

Laparoscopic proctocolposacropexy LVMR

D’Hoore A.

ResearchGate

Patient A – Slide 1






Patient B –Slide 1

Patient B – Slide 2







Patient C – Slide 1









Patient D – Slide 1






• Samaranayake CB et al. 2010, 728 (4) patients, 0,55% erosion

• Smart et al. 2013, 866 (5) patients, 0,57% erosion

• Gouvas et al. 2014, 1316 (4), 0,3% erosion

• Mercer-Jones MA et al. 2014, panel of experts, 2-3% erosion

• Pelvic Floor Society Subgroup of ACPGBI, 2,4% erosion

• LVMR is a safe and effective operation with low erosion rates of 2-3%

• Polypropylene mesh 1,8% vs. Polyester mesh 6,5% risk of erosion


Sacral Nerve Modulation





IIIXXXXXXII

IIIXXXXXII




• Scanty literature with variable success

• Mainly case series and small numbers

• Only short term follow-up 6-15 months

• Occasional significant reduction of pain scores and improvement of QoL

• Minimal invasive and reversible

• Should be considered before adopting more aggressive surgical procedures

• More RCT needed


Own experience:

Patient 1:

• 69yrs, abdominal and perineal pain >20 yrs

• Left oophorectomy aged 52 (1994)

• 5x laparoscopy

• Collagenous colitis

• Sigmoid + upper rectal resection for incontinence and pain( 2007)

• Colostomy and Hartmann’s procedure 2007

• Abdominoperineal proctectomy 2008

• SNM Test Trial 5/2011

“completely symptom free, new experience for more than eight years”

• Permanent Implantation 06//11, absolutely fine on review 6 weeks

• Symptom free until last review 9/13

• Adhesiolysis for recurrent abdominal pain, no pelvic pain, turned device off,

noticed ongoing relief

• 9/15 requested explantation as ongoing relief despite device off


Own experience:

Patient 2:

• 51yrs, pain since hysterectomy aged 28 in 1988 for uterovaginal prolapse

• numerous procedures


Own experience:

Patient 2:

• 51yrs, pain since hysterectomy aged 28 in 1988 for uterovaginal prolapse

• numerous procedures

• At Burwood Pain Clinic since late 90’s

• Test Trial 8/12 with 80% reduction of vaginal and deep pelvic floor pain

• Permanent Implantation 9/12, ongoing reduction of vaginal pain and dyspareunia

on 3 months follow-up “ more than I could have dreamed of”

• Review 2/13 lower abdominal pain recurred, pelvic floor still amazing

• Colostomy 7/13 after 3 months pain free on elemental diet

• Reversal procedure 1/15 due to recurrent abdominal pain

• Revision of anastomosis due to stricture 11/16

• Reversal of loop ileostomy 2/17

• No pain in abdomen or on bowel motions on last follow-up 4/17


Own experience:

Patient 3:

• 45yrs, pain since teenager, endometriosis

• HE aged 33 (2000)

• 8x laparoscopy

• Right hemicolectomy 2008 (for caecal bascule)

• Sigmoid + upper rectal resection + ovarian cystectomy 2009

• At Burwood Pain Clinic since 2003

• SNM Test trial 10/12 with 90% pain reduction, resumed back to normal activities

14hrs/d

“ concerned that she may wake up and realise this was just a dream”

• Permanent Implantation 12/12, absolutely fine on review 6 weeks

• Review 3/13 felt miserable, constipation better but felt poisoned by device with

constant toxic taste in mouth

• Explantation 4/13, felt much better, lost on follow-up since 7/13


Possible benefit for lower pelvic pain and pelvic floor pain

Trial and error approach in highly selected patients


• Prevalence of CPP in women aged 20 to 49 is 15%

• Aetiology unknown in 35% to 60% of patients

• Multifactorial (Endometriosis, Adhesions, IBS, POP, Neuropathic, Psychologic)

• Effective non-surgical interventions available

• Surgical role as multidisciplinary approach (Endometriosis, Prolapse, IBS)

• Sacral nerve Modulation, Adhesiolysis, Bowel resection with limited success

• Large number remain in pain despite treatment

• Effective integrated multidisciplinary care pathways crucial

Summary

Thank you

Documents

Dr Sherif Tawfeek Ms Ann Johnson Dr Ingo Kolossagpcme.co.nz/pdf/2017 South/Thu_Room9_0830_KolossaIngo_CPP Talk.… · Dr Sherif Tawfeek Consultant ... • 51yrs, pain since hysterectomy