Definitions for the level of evidence (1-4) and grade of recommendation (A-C) are provided at the end of the "Major Recommendations."
Assessment Recommendations (see table titled 'Psychological Factors in the Assessment of Chronic Pelvic Pain' below)
A psychologist (or equivalent) is not required for this level of assessment, but access to regular discussion with a psychologist enables the clinician to interpret better the results of assessment.
Anxiety
It is important to obtain the patient's view of what is wrong or of what the patient is worried might be causing pain and other symptoms. Investment in establishing a trusting therapeutic relationship with the patient pays off when these questions are asked. One suggestion is to ask the patient, 'What do you believe or fear is the cause of your pain'?
Investigations and results of examination should be explained clearly, in terms of what they can show, what they did or didn't show, and how this helps the investigations, attempts at diagnosis, or plans for treatment. This requires an adequate model of pain. Brief reassurance alone provides (at best) short-term relief of anxiety, after which the patient returns to seek help with the problem and the anxiety.
Depression
If the patient admits a depressed mood and attributes it to pain, it may be that the patient is interpreting information about and experience of pain and other symptoms in catastrophic ways. Good information can counteract this (as in anxiety). It may also be that the pain has had a serious impact on the patient's life; roles and satisfactions are lost because of pain, but can return with effective treatment. Encouragement to consider how to recover valued activities, with or without some pain relief, is helpful but the patient may require advice on how to do this from a pain management team.
Sexual and Physical Abuse in Childhood
It is important to consider the possibility of physical and sexual abuse when taking the history, but disclosure can be difficult before a therapeutic relationship is established. It is not clear that pain, which the patient attributes to childhood sexual or physical abuse, should be managed any differently. Any disclosure of current physical or sexual abuse should be referred immediately to appropriate health, social or welfare services.
Table: Psychological Factors in the Assessment of Chronic Pelvic Pain
| Assessment |
Level of Evidence |
Grade of Recommendation |
Comment |
Anxiety about cause of pain:
'Are you worried about what might be causing your pain?'
|
1a |
C |
Studies of women only: men's anxieties not studied |
Depression attributed to pain: ask 'How has the pain affected your life?'
'How does the pain make you feel emotionally?'
|
1a |
C |
Studies of women only: men's anxieties not studied |
| Multiple physical symptoms/general health |
1a |
C |
|
| History of sexual or physical abuse |
1a |
C |
Current/recent abuse may be more important |
Psychological Factors in Treatment of Pelvic Pain (see table titled 'Treatment Factors In the Management of Chronic Pelvic Pain' below)
Untreated, there is a significant likelihood of symptom improvement. A follow-up study of women with pelvic pain referred to a clinic showed that 25% reported recovery (nearly half of them total recovery) over the 3 to 4 intervening years. However, neither pain nor distress at baseline, nor intervention received, was found to be associated with recovery.
Other sections cover the various physical (surgical, pharmacological, physiotherapeutic) interventions for male and female pelvic pain, and their outcomes. Psychological interventions may be directed:
- At the pain itself, with the intended outcome of pain reduction and consequent reduction of impact of pain on life
- At adjustment to pain, with the intended outcome of improved mood and function and reduced healthcare use, with or without pain reduction
The first category of interventions includes relaxation and biofeedback methods of controlling and decreasing pain by reducing muscle tension. Such methods are being applied to pelvic floor retraining, both in men and women, sometimes alongside other physical therapies (see the National Guideline Clearinghouse (NGC) summary of the European Association of Urology (EAU) guideline Pelvic Floor Function and Dysfunction).
In the second category of interventions (see above), multicomponent pain management, involving education, physical retraining, behavioural change and increasing activity, relaxation, and cognitive therapy, is often applied to mixed groups of chronic pain patients, including those with pelvic pain, but there have been no randomized controlled trials of pelvic pain groups.
A meta-analysis concluded in favour of educational counselling combined with ultrasound scan, which improved pain and mood; and a multidisciplinary rehabilitative approach, including surgery, pharmacotherapy, physiotherapy, and psychosocial intervention, which improved function but not pain. A selective serotonin reuptake inhibitor antidepressant made no improvement in pain but improved function. Consultation using a photograph taken during laparoscopy had no effect; emotional disclosure (a stress reduction method) through writing brought about very small improvement in some pain scores.
Mood change is a particular issue since, intentionally or not, any intervention, and even a good consultation can bring about cognitive, emotional, and/or behavioural change. Enabling the patient to understand what is causing the pain, and therefore the implications of the pain for everyday life and longer-term life goals, can be a major influence on the patient's successful management of pain.
Table. Treatment Factors in the Management of Chronic Pelvic Pain
| Treatment |
Level of Evidence |
Grade of Recommendation |
Comment |
| Tension-reduction; relaxation, for pain reduction |
1b |
A |
Relaxation +/- biofeedback +/- physical therapy; mainly male pelvic pain |
| Multidisciplinary pain management for well-being |
(1a) |
(A) |
Pelvic pain patients treated within larger group: no specific pelvic pain trials |
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendations
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
