by Jules S. Black, MB,BS,FRCOG,FRANZCOG, ... history such as incest, which
are reflected as pelvic pain in adulthood within an otherwise normal pelvis. ..... (9)
WINSTON, R.M.L. Microsurgery of the fallopian tube: From fantasy to reality. Fertil
...
CHRONIC PELVIC PAIN WITHOUT PATHOLOGY by
Jules S. Black, MB,BS,FRCOG,FRANZCOG, 2 Rae Street, Randwick, Sydney,N.S.W., AUSTRALIA 2031. ******************************************************************** ABSTRACT: Pain is the most common symptom which brings the patient to a doctor. Not all pain is indicative of disease. Even where disease does exist pain does not always require specific therapy. Women with chronic pelvic pain form a group of patients which engenders much frustration in many practising gynaecologists. There are many potential reasons for a woman to perceive pain in her pelvis and the most frequent events Mittelschmerz and dysmenorrhoea - are predominantly physiological. The doctor who investigates pelvic pain and pronounces, "I can find nothing wrong with you," creates a very ambivalent and confused patient as a consequence. She goes away thinking that this doctor, and often several beforehand, all believe she is imagining the pain. Nothing could be further from the truth The pain is very real to that person, and what the doctor really meant to say was, "There is no pathology that I could detect which requires medication or surgery." Causes for pelvic pains in the normal pelvis include the dyspareunias, vaginismus, pelvic congestion, Mittelschmerz and menses-related conditions. The primary approach in managing such problems should not be with the scalpel, and an impassioned plea is made to avoid surgery if at all possible. A high threshold for making a decision to operate is recommended. To perform a laparotomy on such a woman is merely pandering to her possible abnormal illness behaviour and in so doing the doctor may be displaying abnormal treatment behaviour. The consequences of such retrospectively unnecessary surgery can be of immense significance. Reduction in fertility is frequently found subsequently and resultant adhesions may produce long-term effects. Where a specific "illness" exists unfortunately it is less demanding, easier and quicker to treat an illness than to communicate with patients. The importance of taking a thorough history including personal history to establish what is going on in the person's life at or around the time of an attack of pain must be stressed. The clinician should be alerted to the high incidence of significant factors in the woman's past history such as incest, which are reflected as pelvic pain in adulthood within an otherwise normal pelvis. Ultimately, never be afraid to say, "I don't know." Great reassurance can be generated by saying, "I don't know what the pain is, but I can definitely tell you what it isn't." ******************************************************************** INTRODUCTION Pain is the most common symptom which brings the patient to a doctor. Defined as suffering or distress of body or mind, pain even if functional can give rise to vascular responses "which may complicate the pain in either a functional or physical mode."(1) Chronic pelvic pain without pathology (CPPWOP) can be a difficult, time consuming issue in gynaecology which engenders much frustration in many practising gynaecologists,(2) and even 'burn out' in some. The complexity of the issues has led to CPPWOP being described as enigmatic, but it is an enigma only when unexplained by demonstrable disease.(3) It will be shown that often there is no single 'pain', that CPPWOP can be multifaceted in aetiology. Because there is pain, and if as a result the patient perceives she has an illness, illness must be differentiated from disease.(4) Illness is an altered state of the patient's perception of self whereas disease is a biological concept, which may in fact not be associated with illness at all. (For example, gynaecologists occasionally find large endometriomata at laparotomy or laparoscopy which have been clinically silent. Conversely similar investigation of women with severe pelvic pain may only reveal a few tiny specks of endometriosis in the pelvis.) Thus even where disease does exist pain does not always require specific therapy since the pathology may not be a sufficient cause for the pain.(5) Gynaecology can be an ambiguous field and it is particularly difficult to define the normality or abnormality of the female genital organs with their anatomical variations and fluctuating functions and mechanisms.(1) Trying to manage women with CPPWOP can at times be like trying to hit a moving target because at any one time we are only seeing a 'freeze frame' as it were of the entire clinical picture.
THE FOUR DIMENSIONS OF CPPWOP CPPWOP can be considered as having four dimensions, each requiring individual attention. First Second Third Fourth
Dimension Dimension Dimension Dimension
THE PATIENT THE DOCTOR THE PAIN TIME
1. TIME Since the chronology of CPPWOP is the framework into which the entire clinical picture must be fitted, time, the fourth dimension is discussed first. (a) (b) (c)
Time since symptom first began Time of pain in relation to activity Time of pain in relation to cycle
(d)
Time spent in doctor-patient contact
(a) Time since symptom first began For pelvic pain to be classed as chronic, it is usually defined as a pain of at least six months' duration.(5) (b) Time of pain in relation to activity The onset, return or exacerbation of the pain may follow in the wake of what the patient was doing at the time, or what was going on in her life at the time. The pelvis may be that individual woman's 'shock organ' and her somatic response to stress may be manifested as pelvic pain. Problems with immediate or close family and friends, with marriage, sexuality, employment and life in general can trigger or exacerbate her pain. (c) Time of pain in relation to cycle There are many potential reasons for a woman to perceive pain in her pelvis and the most frequent diagnoses are due to physiological events such as Mittelschmerz and dysmenorrhoea. For example, after years of taking oral contraceptives many women have never previously perceived or may have forgotten the sensations associated with these events. The rebound hyperstimulation of the ovaries and increased menstrual flow which may follow cessation of anovulant therapy which has also suppressed the endometrium can result in quite a good deal of pain, although normally only for 1-2 cycles. (d) Time spent in doctor-patient contact Adequate management of CPPWOP requires a good deal of time. It is important to take a thorough medical and personal history in order to elucidate (a), (b) & (c), above for example. Where a specific "illness" exists, unfortunately, "it is less demanding, easier and quicker to treat an 'illness' by giving symptomatic treatment than to communicate with patients and deal with the issues in a situational crisis."(6) 2. THE PATIENT The personality type of the patient has a big influence on her problem. "The pelvis, seat of femininity and eroticism, will become for certain patients a favourite instrument of expression, giving rise to all kinds of affects such as guilt feelings and a need for punishment, which may or may not be conscious."(1) When we consider the psychosomatic aspects of CPPWOP, many patients who were psychologically well adjusted prior to the onset of pain will become debilitated and depressed by the chronicity of the pain. This change in affect itself may decrease their tolerance for pain.(2) The patient invariably describes her subjective experience of pain in a way that leads to the conclusion that it must have an organic cause.(7) Patients consider themselves and their illnesses to be important. They need to know the doctor thinks so too.(8) The doctor who investigates pelvic pain and pronounces, "I can find nothing wrong with you," creates a very ambivalent and confused patient as a consequence. She goes away thinking that this doctor, and often several beforehand all believe she is imagining the pain. Nothing could be further from the truth, the pain is very real to that person and the doctor must affirm this with her. What the doctor really meant to say was, "There is no pathology that I could detect which requires medication or surgery." If the patient returns home with the so-called 'nothing wrong' syndrome, she still has her symptoms but now without any respectable condition to pin them on.(8) When the average patient presents, she comes along complaining of pain because: (i) She doesn't understand the origin or nature of the pain or... (ii) She understands that the pain is more severe or prolonged than can reasonably be expected. It is recognized that patients exhibit 'illness behaviour' in that they react to aspects of their own functioning which they evaluate in terms of 'health' and 'illness.'(4) Pilowsky has become widely quoted in the psychiatric and psychological literature for a concept he described, 'abnormal illness behaviour' (AIB).(4) His observations would do well to appear in the gynaecological literature. Most patients react with relief or resignation to the physician's explanation. The AIB patient on the other hand does not respond in this way and it is the persistence of complaints and demands, on the basis of a view of one's own health status at variance with that of the physician, which characterizes AIB.(8) AIB can be neurotic or psychotic, conscious or unconscious, illness affirming or illness denying and it can be somatically or psychologically focussed. Examples of these conditions in which CPPWOP can be the presenting complaint include malingering, compensation neurosis, Munchhausen's Syndrome and hypochondriasis. AIB may be more precisely defined as "the persistence of an inappropriate or maladaptive mode of perceiving, evaluating and acting in relation to one's own state of health, despite the fact that a doctor (or other appropriate social agent) has offered a reasonably lucid explanation of the nature of the illness and the appropriate course of management to be followed, based on a thorough examination and assessment of all parameters of functioning (including special investigations where necessary), and taking into account the individual's age, educational and sociocultural background."(4) The diagnosis of hypochondria or conversion reaction is made on the basis of a perceived discrepancy between the nature of the somatic pathology observed and the patient's reaction to it. Such diagnoses are invoked when the doctor does not consider that the sick role the patient adopts or seeks to adopt is appropriate to the objective pathology detected.(4) The question of AIB arises when an individual complains of physical symptoms and discomforts in the apparent absence of adequate somatic pathology. Thus it is not only important to diagnose what kind of pelvic pain is present in the patient along traditional lines, but also what kind of pelvic pain is present in what kind of patient?
3. THE DOCTOR
If what kind of pelvic pain and what kind of patient are important, then the other essential dimension in management of CPPWOP is what kind of doctor treats the patient? Sick people want their doctors to take charge.(8) When pain is the chief complaint, the gynaecologist tends to look for a somatic explanation. "He is not concerned if the same organs are painless or numb, and characterized by a distortion or an absence of erotic reaction."(1) The difficulties encountered in the medical management of CPPWOP are engendered by the attempt to apply traditional medical and surgical techniques to a problem which requires mental health expertise beyond the capacities of the general gynaecologist.(2) What Pilowsky has done for patients by describing AIB, one of his colleagues, Singh has done for doctors. He has described 'abnormal treatment behaviour' (ATB)(6), which may manifest as: (1) (2) (3) (4) (5)
Over / underdiagnosis Over / underinvestigation Over / underreferring Over / underprescribing or...... Prolonged illness behaviour (by the doctor)
Singh talks about the 'reasonable doctor' in the same way we have the 'reasonable patient' and her illness behaviour in Medicine and the 'reasonable man' and his behaviour in legal parlance. Like AIB, ATB can be neurotic or psychotic, conscious or unconscious, illness affirming or illness denying and it can be somatically or psychologically focussed. The doctor may have unconscious neurotic factors stemming from his own personality such as dependency needs, identification with patient, narcissism, lack of professional self-esteem, countertransference and obsessional behaviour. Naturally the problem of the doctor's behaviour just like that of the patient becomes more bizarre if s/he is psychotic.(6) Those who treat CPPWOP should see the re-education of our colleagues as a major function of our clinical activity.(2) It is possible to be compassionate yet be objective in our management. In CPPWOP it really helps to accentuate the positive.(8) If there is a residuum of pain following disease, trauma or surgery which results in dyspareunia in certain positions for example, the author has always helped these patients to try and explore new strategies. This is done by describing alternative, painless coital postures and techniques in order to circumvent the pain which may have made the couple baulk at any sexual activity whatever. 'Chain reactions' can occur in gynaecology. Vaginitis, urethritis or cervicitis can lead to vaginismus; pelvic congestion can lead to dyspareunia. All of these are sequences that are commonly misunderstood by the practising gynaecologist.(2) The primary approach to treating CPPWOP should not be with the scalpel, and 'those who treat pelvic pain should develop a very high threshold for deciding to operate'.(2) The consequences of such retrospectively unnecessary surgery can be of immense significance. Reduction in fertility is frequently found subsequently and resultant adhesions may produce long term effects. Robert Winston reported on women attending the infertility clinic at Hammersmith in the 3 months between April and June, 1979.(9) There were 108 new patients with laparoscopically proven tubal damage. Seventy six percent (82/108) of these patients had some previous pelvic surgery. This included appendicectomy at the time of adnexal or uterine surgery; attempted tuboplasty at the time of ectopic pregnancy; ovarian cystectomy or wedge resection; tuboplasty by conventional techniques or myomectomy, which resulted in severe tubal damage. He felt that many of the women suffered iatrogenic damage. He concluded that, "much more care is required when operating on young women who have problems directly unrelated to fertility." To perform a laparotomy on a patient with CPPWOP may merely be pandering to her AIB and in so doing the doctor may be displaying ATB. There are few clinical situations in which reassurance is impossible.(8) One of our functions is to dispel apprehension. If possible, we try and restore the patient to a former state of health. We are unlikely to come up with a single explanation for all the problems. We are more likely to arrive at a list of suggestions which will hopefully improve the pain. With CPPWOP total and complete cure should not be the criterion for success in the patient's or the family's mind. We should set realistic goals.(2)
4. THE PAIN (a) Aetiology: Approximately 2/3 of women presenting with pelvic pain may have no obvious organic pathology and are therefore classed as having C.P.P.W.O.P..(5) Furthermore, sexual dysfunctions are a very frequent concomitant of the pain, and can either be a cause or an effect. Mills from Birmingham was President of the Section of Obstetrics and Gynaecology of the Royal Society of Medicine when he concluded, "In the absence of demonstrable pathology many cases are due to a state of vascular congestion that affects primarily the uterus," and that, "the cause of this congestion is usually some form of stress."(3) In a multidisciplinary study of chronic pelvic pain from the University of Washington in Seattle, the following findings and conclusions were reported.(10) Twenty five gynaecological patients with chronic pelvic pain attended a pain clinic. In 15 women (60%) the pelvic examination revealed no abnormality. Psychiatric evaluation showed all the patients had significant psychopathology (there was no control group). A significant incidence of early childhood family dysfunction and incest (9/25 or 36%) was found. [The incestuous relationships involved 1 brother; 2 fathers & 6 stepfathers for up to 8 years.] An incidence for incest of 36% is considerably higher than the estimated incidence of incest in the general population, (between 1:1,000,000 and 1:20). The 25 patients were managed with 'crisis intervention' techniques and at follow up, the pain was gone in 53%, lessened in 21% and unchanged in 26%. These patients with chronic pelvic pain appeared to have significant problems with dependency, relationships and trust. The significant finding of a 36% incidence of incest in the past history underlines the need for prolonged doctor-patient contact, the taking of a good history and keeping surgical intervention to a minimum. Also, one must keep in mind that "factors which are maintaining the pain behaviours may not be the same as those which started the problem in the first place."(5) As already mentioned, in considering CPPWOP there often is no single explanation in such patients who may have several of the facets of CPPWOP spread out over the
given history of the present illness or spread over the menstrual cycle. One has to construct a list of these various pains and analyse them in order. Ovulation: Mittelschmerz may occur 14 days before the next period is due to commence or up to several days either way. There may be associated secretion of ovulation mucus to the exterior. For some reason which is not understood, the pain is felt predominantly on the right side each month by most women. Rarely is it perceived on alternate sides every other month and rarely is it found purely on the left side. Usually lasting seconds, minutes or hours, it can occasionally last for 2-3 days. [Since ovulation is a random process dependent upon where the ovum bursts through the ovarian capsule, not infrequently one sees at operation that the most recent active corpus luteum has burst out to the surface and caused some localized bleeding. It is this blood which is very irritating to the surrounding peritoneum, which I believe is the cause of the pain for 2-3 days when it is cleared away.] Resumption of ovulation after pregnancy and lactation or combined oral contraception will often result in a rebound hyperstimulation of the ovaries with resultant increase in severity of Mittelschmerz. Since many patients commence taking anovulants for dysmenorrhoea as young teenagers and continue into adulthood and marriage, Mittelschmerz may be perceived for the first time when embarking upon the first pregnancy. It is little wonder such a pain causes anxiety, especially if magnified by hyperstimulation. Dysmenorrhoea: The variability in timing of this pain either from a few days prior to menses until the first few days of menses or its appearance only in certain cycles (?ovulatory), combined with its variability in severity can lead to patient anxiety. A patient diary will prove very useful in the management of such pain as it provides retrospective examination of ovulation and dysmenorrhoea. Pain with tampons: The woman with too narrow a vaginal barrel or too narrow an hymenal opening is an anatomical rarity. Gynaecologists would all agree one's fifth finger at least can be inserted with ease into even the young virgin. Therefore when a woman complains of pain inserting a tampon, some types of which are even slimmer than the little finger, the cause is usually lack of experience and ignorance of her own body. However, the pain experienced and her feelings of failure help contribute to a poor self-image. All these can be triggers in a 'chain reaction' leading to CPPWOP. Introital dyspareunia: When vulval or introital pathology have been excluded, the majority of cases are due to inadequate arousal and 1o or 2o vaginismus.(11,12) When a dry, tight introitus is penetrated, local tissue trauma in the form of minute abrasions will occur and finally heal until the next occasion. If these tiny 'lesions' are presented to many gynaecologists, therapy will consist of local excision. The problem persists or recurs because the underlying sexual dysfunction was not considered or diagnosed. I have seen patients who have had up to four operations to excise these 'lesions' before the patient has realized that this therapy is not effective. This type of surgery is contraindicated and indicates ATB. Deep dyspareunia during intercourse: Any man can appreciate that if his partner keeps kicking him in the testicles during coitus this would prove both off-putting and painful. An equivalent painful assault of a woman's gonads and internal reproductive organs is not as readily appreciated as her organs are not visible. Just because such kicks induce testicular pain, this does not connote testicular disease, merely that it is a painful occurrence. Reverse the sexes and deep dyspareunia generates anxiety that something is wrong. The commonest cause of deep dyspareunia is merely the upward displacement of the uterus by the penis or finger and the resultant stretching of the supporting ligaments.(11,12) In addition, some ovarian compression can occur if the penis negotiates one of the lateral fornices, especially if the ovary is enlarged and tender around the time of ovulation. Deep pelvic pain after intercourse when no orgasm has been experienced: This pain can appear several hours after intercourse. It is dull, throbbing and is described as being similar or identical to a premenstrual pelvic ache. The mechanism is the same and signifies the Pelvic Congestion Syndrome (PCS). Partial arousal will cause the congestion, and if the woman does not climax, the congestion lingers for hours, not minutes and can be so far removed from the time of the sexual act itself that the woman may not correlate the two events. (Once again, the male is conversant with pelvic congestion when he is aroused strongly to erection which does not culminate in orgasm and ejaculation.) Women can also experience PCS if partially aroused as a result of nocturnal dreams or daydreams. Deep pelvic pain after intercourse when orgasm has been experienced: PCS can still be present after orgasm if the arousal was high and the orgasm too mild to drain away all the congestion. (Its resolution with further orgasm, either partner- or self-induced is diagnostic and constitutes therapy.) A reasonable proportion (>20%) of orgasmic women experience either very strong single or multiple orgasms which produce prolonged, strong contractions of the pelvic floor muscles and uterus. At the end of such a strongly satisfying sexual encounter, pelvic pain can be felt. It feels akin to the muscular pain in arms or legs after vigorous sporting activities. The mechanism is the same and will settle down with rest. It is a good example of pain associated with pleasure and if it is seen in that context, the patient is reassured. (After all, we can come home burnt to a crisp after a wonderful summer's day at the beach and can hardly move. Nonetheless we know that pain will be gone in a few hours and we are still able to say, "I can hardly move, but wasn't that a great day!") Colpalgia fugax: A rare cause of pain, it is found in women with underlying sexual anxieties which may be associated with preorgasmia and dyspareunia.(12) (The male equivalent is proctalgia fugax which is commonly found in males with underlying homosexual anxieties.) It is described as a vague, intermittent, fleeting pain which the patient localizes to the external vulva or perineal region. I find a useful diagnostic clue in this condition is the fact that the patient has previously been to numerous general practitioners and gynaecologists to no avail. They have all said, "Nothing wrong!"
Inadequate hygiene: Many women with CPPWOP have vulval and vaginal itchiness, soreness and odour. A simple examination will reveal vulval erythema, smegma and possible invasion of the vagina by intestinal microorganisms which have been wiped forward after urination or defaecation. Since ignorance of anatomy and physiology is such a significant factor in female sexual dysfunction, it is very likely that such a patient may not know the basic rudiments of personal hygiene.(13) The sequelae of such ignorance will affect her body image and her sexuality, thus in turn her pelvic pain. In relation to stress: As previously stated, the pelvis can be a woman's 'shock organ'. Pain can appear during or after stressful events in her life. The stress may not necessarily be induced by negative factors such as death or disease in the family, but by what I call 'happy stress' (eustress). The excitement, all the work and arranging which which has to be done before an overseas trip or a daughter's wedding, for example, can be enough to induce pelvic pain which will dissipate after the event. Genital prolapse: The presence of genital prolapse can be a source of pelvic pain, especially in the age group when prolapse is more common. One can argue that prolapse constitutes pathology, but at least it is benign. Having excluded serious pathology such as malignancy, especially in view of the usual age group of such women, patients may choose not to undergo surgery, having been reassured about the non-malignant nature of the pain. Miscellaneous factors: This list is not intended to be exhaustive. We have all experienced cases of CPPWOP in which the cause seemed to be an unusual factor unique to that person. The main causes and common factors have been listed, but it should be remembered that the female pelvis contains three major organ systems and that pelvic pain may be caused by or contributed to by problems with: - the gastrointestinal tract or... - the urinary tract. Furthermore, the pain may be radiating to the pelvis from a musculo-skeletal source in the patient's back. (b) Management - HELP (a less medical, more friendly term??) History, physical examination and special tests: When the patient's history has been taken, a critical gynaecological examination is important and the use of a mirror by the patient to observe this examination is of great assistance.(11,12) The demonstration of the vulva, interlabial folds, clitoris, introitus, urethra, vaginal barrel and cervix to the patient gives many permission to look for the first time and dispels ignorance or anxiety concerning normality and function. Microbiological tests including chlamydia and viral swabs may be indicated at this stage. Deep, critical palpation of the pelvis to exclude pathology can be followed by an upward displacement of the uterus if deep dyspareunia is a symptom. This usually reproduces the pain. If the deep dyspareunia is perceived laterally, and if palpation of a lateral fornix confirms tenderness in the absence of palpable pathology, this is another guide to management. Gynaecological ultrasound can be a useful and reassuring non-invasive adjunct to support one's clinical examination. Specific suggestions: Surgery such as ventrosuspension for deep dyspareunia should be avoided. Therapy involves counselling the couple concerning modification (not relinquishing) of favourite coital postures in the same way the male partner would modify his position to avoid being kicked in the scrotum. It is bad advice to tell couples to give up certain coital postures because of pain. A good example is the 'astride' or 'female superior' position. This group of positions is terribly important for a lot of women capable and desirous of climaxing in intercourse. For them it may be the only position in which they can climax as they are in control of the stimulation in terms of speed, angle and depth of penetration. To deny these women such a pleasurable position, (which is the advice often given), when all the woman has to do to avoid pain is to bend one knee slightly more than the other, is a further example of abnormal treatment behaviour. If deep dyspareunia is perceived laterally, the patient can be counselled regarding coital postures designed to avoid her partner's penis reaching that fornix. The message to the patient is, "I don't know why that area is hurting now, but here is the way to avoid it so you can both get on with your lives." If Pelvic Congestion is a component in the pain and the patient is capable of achieving orgasm, arousal during sexual encounters with her partner not culminating in orgasm per se should be followed by orgasm either partner- or self-induced. If pelvic congestion is a component in a woman's dysmenorrhoea, and if she is embarrassed by partner stimulation during menses, then self-induced orgasm relieves much if not all of this congestive pain. The preorgasmic (formerly 'anorgasmic') woman requires sexual counselling to be able to arouse to orgasm. Once this breakthrough is achieved, the way to curing introital dyspareunia and the PCS is paved. Patients with vaginismus need separate sexual counselling, (not a Fenton's operation), for its resolution. If the pain is thought to be related to ovulation, and it is appropriate for the woman to practise oral contraception, anovulants should resolve this component of the pain, and possibly dysmenorrhoea as well. Antispasmodics alone or in combination with analgesics may be more useful than analgesics alone, and can therefore be a diagnostic as well as a therapeutic aid. Since the pain is likely to be multifactorial, and since CPPWOP may be different in site and timing due to a 'chain reaction', the patient should be urged to keep a diary after the first consultation to pinpoint the onset, site, radiation and duration of the pain and to correlate these symptoms with the events in her life. Advice can be given at the initial visit to help 'weed out' the more readily understood pains in order to see which, if any are left or are still proving troublesome. The above approach to management may appear simplistic, but often CPPWOP is merely the end product of either a single, initial triggering factor or the congruence of various factors which have just gone on for too long without relief or resolution. Even a 'reasonable woman' will ultimately develop secondary anxiety or
depression which disproportionately magnifies the original condition. Things not to do - Treatments to be avoided. Since CPPWOP can be an ambiguous and enigmatic problem, specific treatment apart from traditional pain relief can be difficult to define in general terms. However, it is much easier to define many treatments which should not be used except after full consideration of all possible factors. *
SURGERY:
-
Laparotomy 'just in case' Ventrosuspension Posterior Colpo-perineorrhaphy for preorgasmia Fenton's operation or other plastic repairs to widen the introitus unless the hymen is
genuinely rigid. - Excision of benign (infective or granulomatous) 'lesions' of the introitus. * UNOPPOSED BROAD SPECTRUM ANTIBIOTICS: If indicated without simultaneously covering the vagina against 2o moniliasis which will cause another link in the 'chain reaction' of pain. * ARTIFICIAL LUBRICANTS: These agents are unsuitable as a substitute for adequate precoital arousal or to overcome vaginismus. * LOCAL ANAESTHETIC: Creams, gels and sprays will 'mask' the original problem and also numb any possible pleasurable sensations. * "I CAN FIND NOTHING WRONG WITH YOU." (This phrase only refers to visible and palpable pathology or that confirmed by tests.)
CPPWOP is a very real condition and we must convince the woman that we think so too. This will help her in the quest to elucidate its cause/s, thence its relief.
DISCUSSION Pain is frightening to a patient until its nature and aetiology can be explained. Frequently, once a cause for chronic pelvic pain is established, even if one finds benign pathology such as an enlarged fibroid uterus or genital prolapse, the patient is no longer as worried about the pain. The giving of permission to have the pain, by establishing some reasonable explanation with a reasonable woman, we do not banish the pain, but the patient now lives with it comfortably. Total relief of the pain is not the end-point of cure. Much pelvic pain is an enigma only because the receptors involved in the pelvis have not yet been identified. On the other hand, pain due to pleurisy, trigeminal neuralgia or a torn muscle tendon for example, have some precision in the presentation and in the anatomical disturbance.(14) Whether the suffering is functional or associated with an anatomical lesion, the emotions which cause or accompany it belong to the patient alone, and there is no way of measuring their intensity. It is impossible to draw a line between pain and pleasure since the two can be simultaneous, intermingled and linked always by a common phenomenon - emotion.(1) If only we could take accurate, measurable psychic biopsies!(15) The one constant in the successive stages of a woman's life is that they are all painful experiences which may be transformed into sources of pleasure provided they are mastered with success. To evoke pleasure and ignore pain is to forget one of the fundamental truths of human nature, the bipolarity of all feelings and sensations, the alternation of suffering and joy.(1) As Myriam de Senarclens states, "the dialogue between gynaecologist and patient has a specific quality and through her physical problems, she is really seeking for understanding of the intimate feelings she is incapable of putting into words. Pain, desire, lack of desire and pleasure in spite of their fundamental difference are undoubtedly related and may sometimes be interchangeable. This is illustrated commonly in the field of gynaecology, often in the form of a caricature: - pleasure in pain - indifference in desire - pain without pleasure - pleasure without desire"(1) This group of patients can generate much frustration among most gynaecologists. In patients presenting with CPPWOP, one must be wary of possible abnormal illness behaviour (AIB), and one must in turn not fall into the trap of pandering to symptoms which are merely a 'ticket of admission' to discuss problems further afield. To do so, the doctor may be displaying abnormal treatment behaviour (ATB). I find that one of the most difficult groups of patients to convince they have a causal or resultant sexual dysfunction is the formerly sexually uninhibited, active and responsive woman who now has CPPWOP. An episiotomy can be all that it has taken to set off a 'chain reaction' of 2o orgasmic dysfunction, 2o vaginismus and pain. I have been referred literally hundreds of women with this problem who have somatized their CPPWOP to the perineal scar. In every case the patient has had an adequate primary repair or revision. These women remain difficult to convince that a sexual dysfunction underlies their CPPWOP. A doctor is not omnipotent, and in the management of CPPWOP, or any other condition for that matter, s/he must never be afraid to say, "I don't know." However, great reassurance can be generated by saying, "I
don't know what the pain is, but I can definitely tell you what it isn't." ---***oooOooo***--REFERENCES (1) de SENARCLENS, Myriam Genital pain and sexuality. In: Handbook of Sexology. John Money, Herman Musaph, eds. Amsterdam: Elsevier/North Holland Biomedical Press, (1977): P. 901-907. (2) STEEGE, J.F. The assessment and treatment of chronic pelvic pain. Proc. 9th. Annual Congress Aust. Soc. Psychosom. Obstet. Gynaec. (1982), Ed. Dennerstein, L. & Burrows, G.D., P. 63-68 (3) MILLS, W.G. The enigma of pelvic pain. J. Roy. Soc. Med. (1978) 71: 257-260 (4) PILOWSKY, I. A general classification of abnormal illness behaviours. Br. J. med. Psychol. (1978) 51: 131-137 (5) PEARCE, Shirley & BEARD, R.W. Chronic Pelvic Pain. In: Psych- ology and Gynaecological problems. Annabel K. Broome, Louise Wallace, eds. London: Tavistock; Sydney: Menthuen (1984): P. 95-116. (6) SINGH, K., NUNN, K., MARTIN, J. et al. Abnormal treatment behaviour. Br. J. med. Psychol. (1981) 54: 67-73 (7) BOND, M.R. Psychological aspects of pain. Update (1983) 1: 41-51 (8) KESSEL, N. Reassurance. Lancet (1979) 1: 1128-1133 (9) WINSTON, R.M.L. Microsurgery of the fallopian tube: From fantasy to reality. Fertil. Steril. (1980) 34: 521-530 (10) GROSS, R.J., DOERR,H., CALDIROLA,D. et al. Borderline syndrome and incest in chronic pelvic pain patients. Int. J. Psychiatr. Med. (1980) 10: 79-96 (11) BLACK, J.S. Sex and the gynaecologist. Aust. N.Z. J. Obstet. Gynaec. (1974) 14: 238-240 (12) BLACK, J.S. Sexuality and the gynaecologist. Patient Management (NZ) (1976) (September) 57-61 (13) BLACK, J.S. The medical consequences of unorthodox sexual behaviour. Aust. Fam. Physician (1986) 15: 20-24 (14) PHILIPP, E. Pelvic pain. J. Roy. Soc. Med. (1978) 71: 244-245 (15) BLACK, J.S. Book Review: "Psychology and Gynaecological Problems" [See Ref. (5)] Med. J. Aust. (1985) 143: 473
