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

Dr Sherif Tawfeek Ms Ann Johnson Consultant Gynaecologist Women s Health Physiotherapist Christchurch Gynaecology Associates Christchurch Women s Hospital Christchurch Christchurch Dr Ingo Kolossa Colorectal and Gastrointestinal Surgeon Intus Digestive and Colorectal Care Christchurch 8:30-10:30 WS #5: Chronic Pelvic Pain - A Holistic Approach - Part 1

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

Dietitian GP Urologist Patient Psychotherapist Gastroenterologist Physiotherapist Gynaecologist Colorectal Surgeon Pain Specialist

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.

Surgical vs. non-surgical management 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

Surgical vs. non-surgical management Protocol for currently ongoing review

Surgical vs. non-surgical management

Surgical vs. non-surgical management 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 Pelvic Organ Prolapse Neuropathic Digestive System ( Colonoscopy, Chronic diverticulitis, IBD, Neoplasia, Fistula)

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.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.

Mesh in the pelvis? Pelvic Organ Prolapse

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

Transvaginal mesh for Pelvic organ prolapse 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.

Transvaginal mesh for Pelvic organ prolapse 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?

Colorectal Surgeon Radiologist Gynaecologist MDT Pelvic Floor Meeting Urologist Physiotherapist Psychotherapist

Mesh repair for Rectal Prolapse LVMR

Mesh repair for Rectal Prolapse LVMR D Hoore A.

Perineal levatorplasty ResearchGate

Perineal levatorplasty and Laparoscopic proctocolposacropexy LVMR ResearchGate D Hoore A.

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Mesh repair for Rectal Prolapse LVMR 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

Mesh repair for Rectal Prolapse LVMR

Sacral Nerve Modulation

IIIXXXXXXII IIIXXXXXII Sacral Nerve Modulation

Sacral Nerve Modulation

Sacral Nerve Modulation 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: Sacral Nerve Modulation 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: Sacral Nerve Modulation Patient 2: 51yrs, pain since hysterectomy aged 28 in 1988 for uterovaginal prolapse numerous procedures

Own experience: Sacral Nerve Modulation 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: Sacral Nerve Modulation 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

Sacral Nerve Modulation Possible benefit for lower pelvic pain and pelvic floor pain Trial and error approach in highly selected patients

Summary 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

Thank you