| Medical experts put chronic pelvic pain on the map in Denver, April 3-4, 1998 |  |
A special OBGYN.net report
By Joel R. Cooper
OBGYN.net writer/reporterDENVER, Colorado -- To say that chronic pelvic pain is a poorly understood problem in medical practice, Ob/Gyn or otherwise, is a huge understatement.
But the group of experts that converged on the Brown Palace Hotel in Denver, April 3 - 4, for the Chronic Pelvic Pain Symposium would like nothing better than to unravel the mysteries of this devastating and enigmatic disease, step by step, layer by layer, and give patients new hope for a life free from the crippling pain.
And they're making important headway, judging from the high caliber of presentations and lively panel discussions at this symposium, presented by the Department of Obstetrics and Gynecology/University of Colorado School of Medicine, Denver, and the International Pelvic Pain Society, Birmingham, Alabama.
C. Paul Perry, MDChronic pelvic pain is a big problem. Estimates vary as to how many women suffer from chronic pelvic pain syndrome. But C. Paul Perry, M.D., president of The International Pelvic Pain Society, pegs it at somewhere between 200,000 and two million women in the United States alone.
"I realize that's a large span," he said, "but you have to realize that there have been so many individuals with the problem who have either been undiagnosed or who have just withdrawn. We know that 200,000 is a minimum figure, because at least that many women have vulvodynia. And that's only one component of chronic pelvic pain."Speakers at the Denver symposium included such well-known names in the field of pelvic pain as John C. Slocumb, M.D., Professor and Chief, General Gynecology and Obstetrics, Department of Obstetrics and Gynecology, University of Colorado Health Sciences Center; David L. Olive, M.D., Professor and Chief, Reproductive Endocrinology, Department of Obstetrics and Gynecology, Yale University; John Steege, M.D., Chief, Division of Gynecology and Professor, Obstetrics and Gynecology, University of North Carolina; Andrea Rapkin, M.D., Professor of Obstetrics and Gynecology, UCLA Medical Center; Mark Elliott Ph.D., Department of Anesthesiology, Ohio State University; and Fred Marion Howard, M.D., Chair and Professor, Department of Obstetrics and Gynecology, Rochester General Hospital.
Presentations were also given by a physical therapist, a urologist, a nurse practictioner, an anesthesiologist, a pharmacologist, and even a Ph.D. candidate in psychology. The symposium was truly multidisciplinary, bringing together a wide range of clinical perspectives all focused on the problem of pelvic pain. And that's what made it much more dynamic and exciting than the standard, garden variety subspecialty CME conference.
"The importance of this symposium is that it brings together health professionals from a wide diversity of fields, all of whom are interested in pelvic pain," said David Olive, M.D. "In that respect, it's fairly unique -- there is no other group in the country, or perhaps in the world, that brings together this kind of diversity to address a single problem like pelvic pain. By doing so, it really offers us a fresh perspective that we can take back to our respective clinical practices. I think it's an invaluable experience for those of us who are involved clinically in pelvic pain."
David Olive, MD
"I've been working in the chronic pelvic pain field for 10 years," said Deborah A. Metzger, Ph.D., M.D., Director of the Reproductive Medicine Institute of Connecticut, Associate Professor at Yale University, and Chairperson of The International Pelvic Pain Society's Research Committee. "I've learned an incredible amount by coming to this symposium because I'm learning from other specialists who are also learning. It doesn't matter if it's chronic backaches, chronic headaches, or any other chronic pain problem. They all have common characteristics, such as the disability, the depression, and all of the other things that go along with it."
Deborah Metzger,
MD, PhDDr. Metzger believes that chronic pelvic pain is one of those disorders that can really throw physicians for a loop.
"Most Ob/Gyns think that once the uterus is removed and the ovaries are out, their job is over with," she stated. "But if a woman is continuing to have pain, their job is really just beginning. There are treatment options, however. And there are people who know about these options and are actively seeking additional options for women with chronic pelvic pain. So there is hope for these patients."
Mapping out new territory in pelvic pain treatment
One of the highly publicized techniques addressed at the symposium was laparoscopic pain mapping. Presentations by both Dr. Olive and Dr. Steege and a subsequent panel discussion dealt specifically with pain mapping techniques, which are performed with the patient awake, using local anesthesia and light sedation, in an attempt to zero in on the peritoneal 'hot spots.'
One of the big clinical problems with chronic pelvic pain is that laparoscopic findings often do not correlate highly with reported symptomatology. For example, a woman with a small endometriosis lesion detected laparoscopically may report excruciating, unremitting pain, whereas another woman with more extensive endometriosis may report little or no pain at all. What you see is usually not what you get with chronic pelvic pain, and what you visualize may not be the actual source of pain at all. Pain mapping developed in response to this problem.
The objective of pain mapping, explained Dr. Olive during his presentation, is to try to make the patient hurt to isolate the exact source or sources of the pain, while keeping the pain at an absolute minimum.
According to Dr. Olive, microlaparoscopic pain mapping can be effectively performed in the Ob/Gyn office with a few additions, including a microlaparoscope, video camera, high-output light source, insufflator, accessory instruments, a table capable of getting the patient into Trendelenburg's position, a crash cart, suction, IV and tubing, and a trained assistant. In his experience, the procedure is well-tolerated by most patients, allows patients to leave the office approximately one hour after the procedure, and yields high rates of patient satisfaction compared to hospital-based laparoscopy. It is also significantly less expensive than hospital-based laparoscopy.
The first phase of research into this procedure was presented by Dr. Steege at the symposium.
A partial finding: laparoscopic pain mapping does seem to influence the surgical decision-making process when its results are viewed after patient history, physical examination, and conventional laparoscopy have been considered. Stated somewhat differently, doctors who have access to information gleaned from endoscopic pain mapping (over and above the information gleaned from patient history and physical exam and conventional laparoscopy) sometimes change their minds about the surgical treatment indicated.
This suggests that laparoscopic pain mapping may add a new branch of information to the treatment decision tree. What is less clear at this point is if the branch is solid, and how it might ultimately affect outcomes in cases of intractable pelvic pain.
And since women with chronic pelvic pain are among the most frequently laparoscoped patients, it makes sense to ask under which conditions pain mapping is appropriate. The data are far from all in, and the pain mapping procedure itself must first undergo some form of standardization.
"Clearly, laparoscopic pain mapping is not indicated for everyone," said Ted Belleza, vice president of marketing at InnerDyne, Inc., Sunnyvale, California. His company, which makes the Step™ non-trocar radially-expanding dilation system used in laparoscopic surgery, helped to sponsor the first-phase of research into pain mapping. InnerDyne is now seeking industry partners to help move the research further along.
"We need to find out for whom it is indicated and the proper way of doing it," he continued. "We need to answer the questions, 'Will it work like we hope it will work? Will it be effective?' The results are equivocal right now, and we certainly don't want endoscopic pain mapping to be over-hyped or oversold. We want it to be used by the appropriate physicians with patients who have the appropriate indications."
A brighter day coming for doctors and their pelvic pain patients
The symposium demonstrated that some of the brightest minds in the field of chronic pelvic pain have made a strong commitment to share information and work together for the benefit of patients collectively.
There is also a willingness among the Ob/Gyns involved to be open to the findings and clinical wisdom of other disciplines. And there is a growing consensus that chronic pelvic pain is a problem that won't likely be solved by Ob/Gyns in isolation, but through creative collaboration transcending specialties and geographic borders.
New hope for women suffering from chronic pelvic pain appears closer at hand, thanks largely to the pioneers in the field of pelvic pain and their patients, and The International Pelvic Pain Society. This organization is fostering a new level of productive networking among all health professionals working in this highly challenging field.
"Chronic Pelvic Pain is certainly a ubiquitous problem in general gynecological practice," said Dr. Steege, who serves on the board of directors of The International Pelvic Pain Society. "Some of the techniques that have been developed in multidisciplinary pain clinics and centers can be applied by the practicing gynecologist, and may be useful in helping the gynecologist understand which patients are appropriate for referral and which patients may be treated within their own practices. I think, ideally, collaborative relationships will develop between referral centers and practicing gynecologists, and we certainly welcome attendance by anyone interested at our twice-yearly pelvic pain conferences."
Editor's note: The next major conference and educational program of The International Pelvic Pain Society is slated for November 4, 1998 in San Diego, California. The registration fee for physicians is $300.00; for other professionals, $150.00; and for medical residents, $100.00. For conference or membership information, call 1-800-624-9676 or surf to the IPPS on the Web.
To reach Mr. Belleza, contact:
InnerDyne, Inc.
1244 Reamwood Avenue
Sunnyvale, CA 94089 USA
(800) 378-4733
(408) 745-6010
FAX: (408) 745-6570
e-mail: TedBelleza@aol.com
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