Home Medicine Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?
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Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?

  • Cecilie Therese Hagemann EMAIL logo and Unni Merete Kirste
Published/Copyright: April 1, 2016
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 11 Issue 1

In this issue of the Scandinavian Journal of Pain, Satu Pokki-nen and coworkers report from a small prospective observational study of patients examined median 30 months after laparoscopic and vaginal hysterectomy for benign conditions in two hospitals in Tampere, Finland [1]. The authors included patients who previously had participated in a questionnaire study, where as many as 26% of the responders (59 out of 227) reported pelvic pain 6 months after surgery [2]. Those reporting pain were further invited to participate in this clinical follow-up study. However, only 16 patients were willing to be included.

The reported post-operative clinical assessment included a gynaecological examination and a sensory examination performed by two different physicians. The gynaecological examination included inspection of the vulva and vagina, as well as a bimanual palpation of the pelvic area. The sensory examination of the lower abdomen/groin and the vulvar/perineal area was then performed by an anaesthesiologist specialised in pain medicine. A cotton stick was first used for assessing dysfunction in the low-threshold mechanoreceptor system (touch). Furthermore, the nociceptors/thermoreceptor system were tested using a special thermal roller instrument, as well as a pin prick with a wooden tooth pick. In each case, the patient was asked to compare from one site to another and rate the change on a numerical rating scale (NRS).The results were drawn on an illustrative sketch.

Of the sixteen patients tested, 10 still reported pain in the questionnaire given before the examination. Eight patients had sensory changes (mostly hyperestesia) corresponding to the iliohypogastric, the genitofemoral or the ilioinguinal nerves verified by the different sensory tests performed, and equally distributed after vaginal and laparoscopic hysterectomy. A conclusion of probable neuropathic pain was drawn from five of these patients. Not surprisingly, the women in this cohort scored lower on health related quality of life scores than the average women in Finland.

1 Chronic pelvic pain and post-hysterectomy pain

Pain is subjective, and the IASP taxonomy working group has defined chronic pelvic pain (CPP) as chronic or persistent pain perceived in structures related to the pelvis [3]. Studies from the UK show a yearly prevalence of CPP in general practice of 4% for women aged 15-73 years, this means, as common as back pain and asthma [4].

Chronic, or persistent, post-surgical pain is originally defined as pain of at least two months duration, developed after a surgical procedure, and other causes of the pain and the possibility of a continuum of the pain from the preoperative period should have been excluded [5]. Studies have shown different prevalence of post-surgical pain depending on the procedure performed, with the highest prevalence of pain after amputations, thoracotomies and breast surgery [6]. In gynaecological surgery, hysterectomy is one of the major procedures performed [7], and Denmark, Sweden and Finland have their own hysterectomy-registers [8, 9, 10]. However, only a few studies have systematically studied post-hysterectomy pain, reported in 5-32% [11]. Norwegian population data from the Troms0 study have found a self-reporting rate of 14-17% after surgery on the urinary tract and reproductive organs [12]. One would believe that the introduction of minimal invasive surgery could spare nerves and decrease the prevalence of posthysterectomy pain, although this has not been found so far [11].

According to its definition, the phenomenon of post-surgical pain says nothing about the nature of the pain causing it: nociceptive or neuropathic or a combination of the two [13]. In addition, the pain could be a continuum of the two, starting as nociceptive, caused by tissue injury, an inflammatory response or visceral pain towards neuropathic pain initiated by a primary lesion in the peripheral or central nervous system, see (Fig. 1) [14].

Fig. 1 Post-surgical pain could be nociceptive or neuropathic or a combination of the two. (Kindly provided permission from Tony Dickenson to modify his figure [14].)
Fig. 1

Post-surgical pain could be nociceptive or neuropathic or a combination of the two. (Kindly provided permission from Tony Dickenson to modify his figure [14].)

2 Neuropathic versus nociceptive pain and peripheral and central sensitisation

Neuropathic pain is rather strictly defined by the IASP as pain caused by a lesion or disease of the somatosensory nervous system [15]. This kind of pain is usually accompanied by sensory abnormalities like hyperesthesia, which includes both the phenomenon or hyperalgesia and allodynia [16], as well as hypoesthesia.

Hypoesthesia is a symptom of nerve damage while hyperesthesia could also be due to sensitisation [13]. The phenomenon of peripheral and central sensitisation rather complicates the diagnosis of the type of pain. Nociceptive pain is initiated by tissue damage from harmful mechanical, thermal or chemical stimuli (Fig. 1) [14]. Sensitisation of the peripheral nervous systems occur when there is continuous stimulation of the nerve endings or accelerated nervous firing due to inflammation or continuous release of pain-inducing chemicals from the surroundings. On the other hand, visceral pain is characterised by a more diffuse sense of localisation and the phenomenon of “referred pain” [13,17,18]. The latter is due to the spinal segmental overlap with somatosensory innervation from skin/musculature. From viscera, a wind-up process from repeated neural firing (temporal summation of pain) could be responsible for peripheral visceral sensitisation [19].

Furthermore, the increased activity in the peripheral nerve and dorsal root ganglions could induce central sensitisation due to a state of increased excitability of neurons at several levels of the CNS. This phenomenon, together with decreased inhibitory inputs, results in an amplification of signalling that elicit a state of pain hypersensitivity [16].

3 Pain assessment and clinical quantitative sensory testing (QST)

Regarding post-hysterectomy pain, a thorough history of pain should be undertaken before any surgery. Preferably, validated questionnaires should be used before and after the operation, for diagnosing the prevalence, the severity (reported with the help of NRS/VAS scale), and the quality of the pain (in neuropathic typically described as burning, lancination, electrical). Symptoms of sensory disturbances (hypoesthesia, hyperesthesia, or both) in the pelvis or lower extremities should be recorded. The area of the body where pain is reported should undergo a clinical sensory examination (testing for loss or gain of sensory function in a neuroanatomical area) in order to differentiate between pre- and postoperative pain and to classify the pain as “probable” or “possible” neuropathic (to classify the pain as “definite” neuropathic necessitates e.g., skin biopsy, MRI or neurographic diagnostic tools) [20].

A standardised quantitative sensory testing (QST), evaluate pain thresholds (“the minimum intensity of the stimulus that is perceived as painful”), perceived pain intensity (NRS/VAS) and pain tolerance (“the maximum stimulus intensity tolerated”) to a variety of sensory stimuli [13], usually from cold/warm testing devices and/or mechanical testing devices (calibrated vonFrey filaments, vibrameter, brush and calibrated pins or algometer/palpometer, the latter testing sensitivity to blunt pressure and could be applied both abdominally or vaginally) [21]. In addition, the phenomenon of temporal summation (wind-up) could be tested by pin-prick stimulation repeatedly applied with a standardised frequency and time to the area of the body to be tested [21]. To our knowledge, only the two Nordic studies have reported similar sensory testing in the abdominal or vaginal/vulvar area after hysterectomy [1,21]. Even if the test tools used by Pokkinen and coworkers probably not qualify to be named a proper QST, the authors present valuable non-standardised sensory data which could be used by the clinicians in practice. It means that the Finnish study adds to our knowledge regarding the assessment of persistent pelvic pain after such surgery. However, available preoperative QST-like data would have helped in the assessment of the phenomenon.

4 Conclusion and implications

Diagnosing a neuropathic component of post-hysterectomy pain could be helpful for the patient, thereby guiding the physician in the medical treatment of the phenomenon. Pharmacological agents, such as gabapentin, pregabalin, amitriptylin and venlafax-ine could be tried in addition to topical lidocaine or capsaicin. In addition, nerve growth factor and similar agents could prove helpful in the future. Even if nerve dysfunction seems to be prominent in post-surgical pain, coexistent other pain conditions are prevalent and must be treated appropriately, for example in interdisciplinary teams. As already stated visceral and central sensitisation could complicate the picture of post-surgical pain. Promising animal experimental data also suggest that new pharmacological oral agents like ultramicronised palmitoylethanolamide (PEA) could influence at the level of mast cells and prove useful for managing visceral hyperalgesia, and that PEA alone or in combination with classic anti-inflammatory/analgesic treatments could be offered patients [22].

All surgical procedures have complications and should be kept under strict surveillance. The best way of gathering such information is through National and Multi-National health registers. We call for such a Nordic register. We gladly welcome the development of alternative treatment options to hysterectomy for heavy bleeding and uterine fibroids (hormonal intra uterine contraceptive, minimal invasive trans-cervical surgical procedures, uterine artery embolisation and pharmacological agents like progesterone receptor modulators) making hysterectomy superfluous.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.11.011.

Department for laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology (NTNU), P.O. Box 8905, Medisinsk teknisk forskningssenter, 7491 Trondheim, Norway. Tel.: +47 72573825/958 29490

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Published Online: 2016-04-01
Published in Print: 2016-04-01

© 2016 Scandinavian Association for the Study of Pain

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  2. Psychophysiological effects of threatening a rubber hand that is perceptually embodied in healthy human subjects
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https://doi.org/10.1016/j.sjpain.2016.01.006

Articles in the same Issue

  1. Editorial comment
  2. Psychophysiological effects of threatening a rubber hand that is perceptually embodied in healthy human subjects
  3. Original experimental
  4. A preliminary investigation into psychophysiological effects of threatening a perceptually embodied rubber hand in healthy human participants
  5. Editorial comment
  6. Analysis of C-reactive protein (CRP) levels in pain patients – Can biomarker studies lead to better understanding of the pathophysiology of pain?
  7. Clinical pain research
  8. Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders
  9. Editorial comment
  10. Importance of early diagnosis of complex regional pain syndrome (CRPS-1 and CRPS-2): Delayed diagnosis of CRPS is a major problem
  11. Clinical pain research
  12. Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)
  13. Editorial comment
  14. Associative learning mechanisms may trigger increased burden of chronic pain; unlearning and extinguishing learned maladaptive responses should help chronic pain patients
  15. Original experimental
  16. When touch predicts pain: predictive tactile cues modulate perceived intensity of painful stimulation independent of expectancy
  17. Editorial comment
  18. Low back pain among nurses: Common cause of lost days at work and contributing to the worldwide shortage of nurses
  19. Observational study
  20. Pain-related factors associated with lost work days in nurses with low back pain: A cross-sectional study
  21. Editorial comment
  22. Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?
  23. Clinical pain research
  24. Characterization of persistent pain after hysterectomy based on gynaecological and sensory examination
  25. Editorial comment
  26. Transmucosal fentanyl for severe cancer pain: Nasal mucosa superior to oral mucosa?
  27. Original experimental
  28. Facilitation of accurate and effective radiation therapy using fentanyl pectin nasal spray (FPNS) to reduce incidental breakthrough pain due to procedure positioning
  29. Editorial comment
  30. Why do we have opioid-receptors in peripheral tissues? Not for relief of pain by opioids
  31. Clinical pain research
  32. Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial
  33. Editorial comment
  34. Chronic pain and psychological distress among long-term social assistance recipients – An intolerable burden on those on the lowest steps of the socioeconomic ladder
  35. Clinical pain research
  36. The co-occurrence of chronic pain and psychological distress and its associations with salient socio-demographic characteristics among long-term social assistance recipients in Norway
  37. Editorial comment
  38. Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain
  39. Clinical pain research
  40. Patient reported outcome measures of pain intensity: Do they tell us what we need to know?
  41. Editorial comment
  42. Postoperative pain documentation 30 years after
  43. Topical review
  44. Postoperative pain documentation in a hospital setting: A topical review
  45. Editorial comment
  46. Aspects of pain attitudes and pain beliefs in children: Clinical importance and validity
  47. Observational study
  48. The Survey of Pain Attitudes: A revised version of its pediatric form
  49. Editorial comment
  50. The role of social anxiety in chronic pain and the return-to-work process
  51. Clinical pain research
  52. Social Anxiety, Pain Catastrophizing and Return-To-Work Self-Efficacy in chronic pain: a cross-sectional study
  53. Editorial comment
  54. Advances in understanding and treatment of opioid-induced-bowel-dysfunction, opioid-induced-constipation in particular Nordic recommendations based on multi-specialist input
  55. Topical review
  56. Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group
  57. Observational study
  58. Opioid-induced constipation, use of laxatives, and health-related quality of life
  59. Editorial comment
  60. Migraine headache and bipolar disorders: Common comorbidities
  61. Systematic review
  62. Migraine headache and bipolar disorder comorbidity: A systematic review of the literature and clinical implications
  63. Editorial comment
  64. The role of catastrophizing in the pain–depression relationship
  65. Clinical pain research
  66. The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: A longitudinal analysis
  67. Announcement
  68. May 26-27, 2016 Scandinavian Association for the Study of Pain, Reykjavik, Iceland May 25, 2016 PhD course
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