Laparoscopic Treatment of Chronic Pelvic Pain in 100 Adult Women by James E. Carter, MD, Ph.D., OBGYN.net Editorial Advisor, Laparoscopy & Hysteroscopy and Chronic Pelvic Pain Medical Director, Women's Health Center of South Orange County, Inc.

Abstract

Study Objective. To evaluate the effectiveness of laparoscopic surgical treatment for women with chronic pelvic pain.
Design. Prospective evaluation of women treated consecutively between January 1, 1989, and December 31, 1992.
Setting. A private practice.
Patients. One hundred women with chronic pelvic pain.
Interventions. Laparoscopic treatment was performed in all patients. Pain level was rated on a scale of 1 to 10 (1 = no pain, 10 = severe, disabling pain). Patients recorded their pain levels before and 1 month, 3 months, and 6 months after surgery, as well as at intervals of 1, 2, and 3 years after surgery.
Measurements and Main Results. Preoperatively, the average pain level reported by the patients was 8.2. At 1 month after laparoscopic surgical therapy, it had dropped to 3.6, at 6 months to 1.9, and at 3 years to 2.2. Twenty patients reported pain levels of 5 or greater at the 6-month interval. Six of them proceeded to hysterectomy, and four of these six were found to have adenomyosis. Eleven of the 100 who had pain levels greater than 5 after the initial procedure had no further therapy, and 3 underwent repeat laparoscopy.
Conclusion. Extensive laparoscopic surgery to restore normal pelvic anatomy and remove all diseased tissue, including treatment of all endometriosis, resection of ovarian cysts, resection of adhesions, removal of the appendix, and treatment of hernias when indicated, together with laparoscopic uterosacral nerve vaporization or presacral neurectomy, results in significant improvement in reported pain levels.


Chronic pelvic pain can be defined as nonmenstrual pain of 3 or more months' duration that localizes to the anatomic pelvis, and is severe enough to cause functional disability and require medical or surgical treatment. ¹ Chronic dysmenorrhea or menstrual pain of 6 or more months' duration that causes functional disability to and requires medical or surgical treatment is also - appropriately included in the definition. Chronic pelvic pain is the reason for 10% of all office visits to a gynecologist² and for over 40% of laparoscopies.¹

Laparoscopic examination of women with chronic pelvic pain revealed endometriosis in 71%,~ 80%,~ and 83%~ of these patients. These patients also have adhesions, leiomyomas, appendiceal abnormalities, hernias, bowel adhesions, ovarian cysts of various types including endometriomas, and hydrosalpinges. ⁴ This study was performed to determine the effectiveness of laparoscopic surgical therapy for abnormal pelvic findings in women with chronic pelvic pain. The surgery was performed to reestablish normal pelvic anatomy, remove all abnormal or diseased tissue, and transect nerve tissue if indicated by the operative findings by either uterosacral nerve ablation⁶ or laparoscopic presacral neurectomy. ⁷


Materials and Methods

Between January 1, 1989, and December 31, 1992, operative laparoscopy was performed on 100 consecutive women age 18 to 54 years (average 40 yrs) for chronic pelvic pain. Patients were included in this study if they satisfied one of two criteria: nonmenstrual pain of 3 or more months' duration, localized to the anatomic pelvis, severe enough to cause functional disability, and requiring medical or surgical treatment; or menstrual pain of 6 or more months' duration that caused functional disability and required medical or surgical treatment.

Thirty-eight of these patients had had previous surgery. These were laparoscopic procedures in 17 patients, with 4 women having two procedures, 1 having three procedures, and 1 having four procedures. In addition, six patients had had laparoscopic tubal ligations. Exploratory surgery had been performed on 21 patients, with 8 having surgery on the ovary, 6 appendectomies, 5 cesarean sections, and 2 abdominal hysterectomies.

Data were collected prospectively. Pain levels were assessed by patient interviews before surgery, and 1, 3, and 6 months, and 1, 2, and 3 years postoperatively. The women rated their pain on a scale from 1 (no pain) to 10 (severe, disabling pain).^8'9 Activity levels were assessed by patient interviews preoperatively and at the six postoperative times from 1 (extremely limited activity) to 10 (no limits on activity). The scalar data on pain were analyzed statistically by Wilcoxon signed ranked test.

Laparoscopic surgery was designed to restore normal pelvic anatomy by the resection or vaporization of all endometriosis, treatment of ovarian cysts, lysis of pelvic adhesions, lysis of bowel adhesions, appendectomy where appropriate, myomectomy if indicated, and hernia repair as necessary. Endometriosis was diagnosed based on laparoscopic appearance as described by Martin et al¹⁰ and classified according to the revised American Fertility Society (AFS) system.¹¹ It was treated primarily by resection, and by laser vaporization for superficial lesions.

The uterosacral nerve was vaporized to 1 cm in depth and divided at its junction with the cervix, with destruction as well of the nerve plexus across the base of the utero-cervical junction between the two uterosacral ligaments.⁶ The contact-tip neodynium: yttrium-aluminum-garnet (Nd:YAG) laser (Surgical Laser Technologies, Oakridge, PA) with a GRP-6 sapphire-tip scalpel was used for this procedure.

For presacral neurectomy, the superior hypogastric plexus was identified and transected in the region just below the bifurcation of the aorta at a point where only two or three major branches of the hypogastric nerve exist.¹² Hernia repair was performed according to the procedure described by Schultz.¹³ Appendectomy was performed if right lower quadrant pain was a significant part of the patient's pain profile and if the appendix appeared abnormal, that is, involved in adhesions, thickened or discolored, or stiff when grasped. Appendectomy was performed according to the technique first described by Semm,¹⁴ modified by the use of bipolar coagulation on the appendiceal artery where Semm uses needle suturing.

When patients elected to have the uterus removed as a part of the procedure, vaginal hysterectomy together with laparoscopic treatment of disease in the pelvis was performed. Laparoscopic-assisted vaginal hysterectomy was performed when it became available, and was based on the earliest report. ¹⁵ The specific technique used the contact-tip Nd:YAG laser to dissect the anterior leaf of the broad ligament, perform the posterior colpotomy incision, develop the anterior bladder flap, and open the anterior vaginal space.¹⁶


Results

Laparoscopic evaluation of these 100 patients with chronic pelvic pain revealed endometriosis in 73%. By AFS classification," 27% had stage 1, 43% stage 2, 17% stage 3, and 13% stage 4 disease. Superficial lesions underwent laser vaporization either with the carbon dioxide or contact-tip Nd:YAG laser. Deep endometriotic lesions were treated by deep resection using either laser or electrosurgical energy. Lesions on the bowel were resected with general surgical assistance. Eight patients who had stage 3 or 4 endometriosis elected to receive medical therapy with gonadotropin-releasing hormone analogs (GnRHa) for 6 months after primary laparoscopic surgery.

Pelvic adhesions were found in 44 patients. They were treated by sharp dissection and resection using unipolar electrical scissors or contact-tip Nd:YAG laser. Bowel adhesions were present in 38 patients and were treated by sharp dissection with care taken to avoid thermal or traumatic damage to the bowel. Assistance from a general surgeon was obtained for extensive adhesiolysis involving the bowel. Resection of endometriosis from the surface of the bowel was required in 13 women. In two, the bowel was entered, one during enterolysis and one during resection of endometriosis, and in both laparoscopic repair was accomplished.

Fifty-five benign ovarian cysts were identified in 35 patients. Sixteen women had bilateral polycystic ovarian disease, 12 endometriomas (4 bilateral), 5 simple cysts of the ovary, and 2 benign teratomas.

Because of the chronicity of the pain and previous attempts at surgical therapy, 13 patients elected to have the ovary on the side of the pain removed. Polycystic ovaries were treated with laser drilling using the contact-tip Nd:YAG laser. Endometriotic cysts were resected from the ovary with either unipolar scissors or contact-tip Nd:YAG laser. The ovarian bed from which the cyst was resected was treated with either argon beam coagulation (Birtcher Medical, Irvine, CA) or contact-tip laser.

Appendectomy was performed in 14 patients. Pathology of six of these specimens was abnormal with fibrous obliteration in three and adhesions in three.

Leiomyomata were found in 11 patients, of whom 7 elected to undergo laparoscopic myomectomy. The myomas were subserosal to intramural and 2 to 4 cm in diameter. Four of these women underwent vaginal hysterectomy with laparoscopic assist, the largest uterus being 321 g. Two of the patients also had stage 2 endometriosis treated at the time of surgery.

Thirteen women who had previously had laparoscopic surgery for their complaints and who had completed childbearing elected to have a vaginal hysterectomy with bilateral salpingo-oophorectomy as their primary therapy, together with laparoscopic treatment of all disease present in the pelvis. In this group there were four patients with myomatous uteri, two of
whom had associated endometriosis. Serosal endometriosis of the uterus was present in four, adenomyosis in three, extensive adhesions in three, and one uterus had no pathology.

Two patients who had bilateral inguinal hernias underwent repair by a laparoscopic mesh procedure.

Laparoscopic uterosacral nerve vaporization was performed in 56 patients who complained of significant central dysmenorrhea. For four women in whom this pain was disabling, laparoscopic presacral neurectomy was performed.

The average pain level prior to surgery of 8.2 was significantly decreased to a relatively stable level of 2.4 by 3 months postoperatively (Wilcoxon signed rank test p <0.005; Table 1). The variation between reported levels from 3 months to 3 years after surgery was not statistically significant.

Preoperative activity levels were 3.4 and rose to 9.7 a year after surgery, a statistically significant level (Wilcoxon signed rank test p <0.005)

Twenty patients reported a pain level of 5 or greater at the 6-month interval. Of these, six proceeded to hysterectomy, and in four of them adenomyosis was found. Three underwent repeat laparoscopic surgery; 11 who reported pain levels greater than 5 at the 6-month interval did not elect further treatment. Eight of these 20 had undergone previous laparoscopies: one had three, three had two, and four had one procedure.

Table 1. Quality of Life Survey Before and After Laparoscopic Treatment for Pelvic Pain

	Pain Level a	Activity Level b
Before Surgery	8.2	3.4
1 month after surgery	3.6	7.4
3 months after surgery	2.4	9.0
6 months after surgery	1.9	9.6
1 year after surgery c	2.2	9.7
3 years after surgery d	2.2	9.7

^a On this scale, 1 = no pain, 10 = extreme pain
^b On this scale, 1 = extremely limited, 10 = no limits
^c Eight patients were lost to follow up.
^d Fifteen patients were lost to follow up.

Discussion

Extensive surgical therapy for the management of pelvic pain in adolescents resulted in improvement in 76% over a follow-up of 1 to 58 months.¹⁷ Pelvic pathology was present in 86%. Endometriosis was treated in 47% and adhesions in 13% of patients in this 1980 report.

Treatment of pelvic adhesions by laparoscopy was effective in relieving symptoms in patients with chronic pelvic pain. Cure or improvement was reported by 65% of patients whose chief complaint was chronic abdominal pain, and by 47% of those whose chief complaint was dysmenorrhea.¹⁸

In a similar study, 40% of patients with chronic pelvic pain or dyspareunia reported continued improvement or resolution of pain during daily activities, and of those without chronic pain syndrome, 75% were better.⁸ Another study reported that 84% of 65 patients with chronic lower abdominal pain who underwent laser laparoscopic adhesiolysis experienced symptomatic relief.¹⁹ In women with previous abdominal operations with significant pain, enterolysis and adhesiolysis resulted in improvement in 67%.²⁰ Of 35 patients undergoing adhesiolysis for chronic abdom-inal pain, 18 were asymptomatic and 10 had their symptoms lessened.²¹ In a prospective study of 58 patients treated for abdominal pain with adhesiolysis, 45% had complete remission of symptoms, 35% had substantial improvement, and 20% had persistence of the complaint.²²

The role of adhesions in chronic pelvic pain has been questioned, however. A retrospective study comparing asymptomatic infertile patients with women with chronic pelvic pain did not reveal a significant difference in the density or location of adhesions.²³ A randomized clinical trial on the benefits of adhesiolysis by laparotomy showed no benefit in patients with light or moderate pelvic adhesions. Patients with severe adhesions involving the intestinal tract benefited from this procedure.²⁴

When pain is persistent, a thoughtful examination is required and all potential causes of pain should be investigated.²⁵ However, endometriosis often is the sole finding in women with incapacitating pelvic pain.²⁶ A review of the role of laparoscopic surgery in the treatment of endometriosis concluded that laser laparoscopic cytoreduction of ectopic endometrial implants offers a reasonable degree of pain relief in mild, minimal, and moderate disease.²⁷

Twelve percent of patients who suffered from recurrent disease required repeat laparoscopic surgery. The recurrences arose de novo and rarely occurred at previously treated sites unless the surgeon failed to remove deeply infiltrating disease completely in the uterosacral ligaments or the rectovaginal septum.²⁸ These implants can infiltrate up to 15 mm in depth.²⁹ One surgeon routinely divides the uterosacral ligaments that carry many of the afferent sensory nerve fibers to the lower parts of the uterus by way of the Lee Frankenhauer plexus, which lies in and around the uterosacral ligaments as they insert into the posterior aspect of the cervix. This simple technique gave good results not only in retrospective studies^30,31 but also in a well-designed, randomized, double-blind prospective study.⁶

The efficacy of laparoscopic laser uterine nerve ablation (LUNA) for dysmenorrhea was demonstrated in an initial series of 14 women with dysmenorrhea and menorrhagia who had the procedure combined with transcervical resection of the endometrium. At 16- to 18-month follow-up, 93% of patients reported light or absent menses and improvement or absence of pain.³² Laparoscopic laser treatment of endometriosis with the Nd:YAG sapphire probe combined with LUNA was also effective in reducing or eliminating pain in 80% of patients.³³

Conservative resection of the uterosacral nerves was carried out in 15 women with a history of endometriosis and recurrent pelvic pain, whether or not involvement of the ligaments underwent presacral neurectomy. Histologic evaluation disclosed involvement of endometriosis in the uterosacral nerves in 54% of patients. Dysmenorrhea was relieved in 80% of patients, but in the subset who had histologic endometriosis of the uterosacral ligaments, all had relief of symptoms.³⁴ Finally, destruction of endometriosis by electrocoagulation was effective in the management of chronic pelvic pain.³⁵

The stage and location of endometriosis are not associated with the frequency and severity of dysmenorrhea, pelvic pain, and dyspareunia.³⁶ However, the total number of ectopic endometrial implants is associated directly with the intensity of dysmenorrhea experienced by patients. Patients with lower pain (dysmenorrhea) scores had significantly fewer implants than those with high scores.³⁷ Complete surgical eradication of the disease resulted in pain relief in 81% of patients whose pain was due to endometriosis.³⁸ However, 19% experienced recurrence of new disease in 5 years.

A 5-year prospective study used only treatment with GnRHa for patients with pelvic pain and laparoscopically confirmed endometriosis. At the end of 5 years, 63% of women with minimal disease were symptom free, compared with only 26% of those with severe disease. Overall, 47% of patients had no symptoms 5 years after a 6-month course of GnRHa.³⁹

A review of 11 published studies on laparoscopy and chronic pelvic pain showed that less than 50% of women were helped by diagnostic and operative laparoscopy.' This rate of relief is comparable to that achieved with ovarian suppression therapy. When the clinical index of suspicion is very high that endometriosis is related to chronic pelvic pain, a diagnostic-therapeutic trial of GnRHa may be considered and in fact may be as effective as laparoscopic therapy. Ovarian endometriomas are a source of severe chronic pain 27 and their removal by stripping techniques or laser photovaporization of the capsule provides gratifying results in terms of relief.⁴⁰

For patients with severe disabling central dysmenorrhea, presacral neurectomy was effective in a well-controlled prospective study.⁴¹ The effectiveness of laparoscopic presacral neurectomy m relieving pain has been demonstrated,^7,42 including when the pain is due to endometriosis.⁴³ However, an evaluation was undertaken of preoperative and postoperative pain assessments by patients who underwent laparoscopic ablation or excision of endometriosis, 76 of whom also underwent presacral neurectomy. Although significant improvement (by Wilcoxon signed rank test) over preoperative pain levels was found in both groups, degrees of pain relief were comparable.⁴⁴ In fact, presacral neurectomy was associated with a significant improvement in both dysmenorrhea and dyspareunia over other procedures.⁴⁵ In this study the procedure was performed only for women with severe dysmenorrhea or dyspareunia. Uterosacral nerves were also resected in all of these patients.
Success rates of 73% in relieving dysmenorrhea, 77% in relieving dyspareunia, and 63% in relieving other pelvic pains were achieved by presacral neurectomy in 50 patients treated for chronic pelvic pain after failing to respond to medical management.⁴⁶ Uterosacral ligament resection did not increase the success rate over presacral neurectomy alone. A 70% mean reduction in chronic cancer-related pelvic pain was achieved with neurolytic blockade of the superior hypogastric nerve plexus, confirming a role for presacral neurectomy in the treatment of pelvic pain.⁴⁷

Hysterectomy with bilateral oophorectomy was effective in women who failed to obtain long-term relief of pain with medical therapy.⁴⁸ These women were diagnosed with pelvic congestion syndrome, although pathology revealed that 25% had adenomyosis.

Of 99 women who underwent hysterectomy for chronic pelvic pain of at least 6 months' duration, and whose disease by symptoms and examination was confined to the uterus, 77.8% had significant improvement and 22.2% had persistent pain.⁴⁹

In 55 laparoscopic appendectomies performed for chronic right lower quadrant abdominal and pelvic pain the pathologic conditions included entrapping adhesions in 38, chronic appendicitis in 12, and endometriosis in 5. Forty-four of these patients had complete relief, nine satisfactory improvement, and two no relief.⁵⁰

Appendicopathy does exist and can be the cause of chronic lower abdominal pain. Sixty-three patients had appendectomy for chronic lower abdominal pain, 79% of whom had pain localized to the right lower quadrant. All of these women had had previous surgery for pain without relief, and 54% had sought psychologic intervention or pain clinic treatment to no avail. Histologically, 92% of the removed appendixes revealed abnormality, and 95% of these patients were completely cured.⁵¹

In 103 patients with chronic right lower quadrant pain appendiceal abnormality was noted laparoscop-ically in 62(60%), and these appendixes were removed. Histology was abnormal in 30 of them (48%). After pelvic reconstructive surgery and appendectomy, 60 (97%) of 62 of these women reported complete relief of symptoms.⁵²

Of 348 patients treated laparoscopically for generalized chronic pelvic pain, 72% reported complete or significant relief of pain for at least 6 months. Of these, 38 had visually abnormal appendixes, which were removed.⁵²

Visible pathology of the appendix may be less than histopathology. In 85 women undergoing laparoscopy for pelvic pain, pelvic adhesions, and endometriosis, pathology of the appendix was visible in 16.8%, and histopathologic examination revealed pathology in 42.4%. Because of the high frequency of pathology in patients with these conditions, appendectomy at the time of laparoscopy may be both a preventive and a therapeutic measure.⁵³

After laparoscopic evaluation and treatment in a series of 65 women with 1 month of chronic pelvic pain, 78% of patients had decreased pain and 45% were pain free.⁵⁴ Endometriosis was present in 38% and adhesions in 34% of these women. Neither uterosacral nerve ablation nor presacral neurectomy was performed in this group. No hernias were reported.

With application of all currently available laparoscopic modalities, 80% of women with chronic pelvic pain will report a decrease of pain to below S on a linear scale. A significant average reduction can be achieved and maintained for up to 3 years.

Individual factors contributing to pain cannot be determined, although the frequency of endometriosis dictates that its complete treatment be attempted. The beneficial effect of uterosacral nerve ablation may be as much due to treatment of occult endometriosis in the uterosacral ligaments as to transection of the nerve fibers themselves. The benefit of the presacral neurectomy appears to be definite but strictly limited to midline pain. Appendectomy, herniorraphy, and even hysterectomy are all appropriate therapies for patients with chronic pelvic pain.

Even with all laparoscopic procedures employed, fully 20% of patients experience unsatisfactory results. A diagnostic-therapeutic trial of GnRHa may in fact be warranted prior to laparoscopic intervention in women with clinically diagnosed pelvic pain related to endometriosis. In addition, these patients are often depressed.⁵⁵ Whether the pain contributes to the depression or the depression to the pain is irrelevant to them. Selected referrals to an integrated pain center with psychologic assistance together with judicious prescription of antidepressant drugs will likely benefit both women who respond to surgical intervention and those who do not.


Psychology versus Pathology

Women in whom a thorough exclusion work-up, including laparoscopy, does not disclose a likely etiology of pain, who have a history of major psychosexual trauma, or who have a history of consultation and therapy for several unrelated somatic symptoms should be referred for skilled psychologic evaluation and therapy.⁵⁶ Chronic pelvic pain does not constitute a single well-defined category of symptoms and findings. An integrated approach that devotes attention to somatic, psychologic, dietary, emotional, and physiotherapeutic factors will likely show improvement over simply surgical or medical intervention.⁵⁷ In that study however, no abnormalities were found in the laparoscopies on 65% of the patients in the surgical treatment arm, and in only four of these was endometriosis diagnosed. This multidisciplinary approach resulted in significant symptomatic improvement in approximately 75% of the patients with a mean duration of follow-up of 1.6 years.⁵⁸


Conclusion

A maximum surgical effort must be expended to resect all endometriosis, restore normal pelvic anatomy, resect nerve fibers, and treat surgically accessible disease. In addition, it is important to provide patients with chronic pelvic pain sufficient psychologic support to overcome the effects of the condition, and to assist them with underlying psychologic disorders.

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Reprinted with permission of the author.

For original publication, please see:
Carter JE. Laparoscopic treatment of chronic pelvic pain in 100 adult women. J Amer Assoc Gynecol Laparosc 2 (3): 255-62, 1995