The role of laparoscopy and cystoscopy in the diagnosis and management of chronic pelvic and bladder painChapter 1
BACKGROUND
Chronic pelvic pain (CPP) in women has prevalence rates comparable to that of lower back pain and asthma, causing a huge impact on the quality of life of the individual patient and a large burden on the economy [1]. In this chapter, we explore the role of laparoscopy as a diagnostic and therapeutic tool in the management of CPP. We investigate bladder pain syndrome (BPS) as a manifestation of CPP and the role cystoscopy plays in its diagnosis and treatment. We also explore the causes of CPP and evaluate the most effective methods of diagnosis.
WHAT IS CHRONIC PELVIC PAIN?
Chronic pelvic pain is an intermittent or constant pain in the lower abdomen for at least 6 months, not associated with pregnancy and not occurring exclusively with menstruation or sexual intercourse [2]. The International Association for the Study of Pain and the European Association of Urology revised definition of CPP includes both men and women, with pain perceived in structures related to the pelvis, acknowledging its negative impact on cognition, behaviour, sexual and emotional well-being and noting the possible association with urinary, bowel, sexual, pelvic floor or gynaecological dysfunction [3, 4].
There is difficulty in delineating causes behind CPP as there are many possible causes for the pain and several pathologies may co-exist, making a single diagnosis sometimes impossible. A recent systematic review estimated the prevalence of CPP to range between 8–81% worldwide [5].
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Seema A Tirlapur MBChB, Women's Health Research Unit, Queen Mary, University of London, London, UK. Email: s.a.tirlapur@qmul.ac.uk (for correspondence)
Khalid S Khan MRCOG MMed MSc, Women's Health Research Unit, Queen Mary, University of London, London, UK.
The range of causes for CPP is extensive and the methods of diagnosis for each vary in terms of diagnostic accuracy and patient acceptability. The causes of CPP may be classified as gynaecological versus non-gynaecological or structural and non-structural. Gynaecological causes include endometriosis, adenomyosis, ovarian cysts, uterine fibroids, pelvic congestion syndrome, chronic pelvic inflammatory disease (PID) and adhesions, which may be gynaecological, secondary to endometriosis or PID or non-gynaecological after previous surgery or infection. Non-gynaecological causes include irritable bowel syndrome and BPS as well as musculoskeletal, neuropathic and psychological conditions.
THE ROLE OF LAPAROSCOPY
More than 250,000 laparoscopies are performed annually in the United Kingdom. Diagnostic laparoscopy has been regarded as the ‘gold standard’ investigation for CPP, after a careful preoperative work-up, which involves a thorough history, physical examination and imaging in the form of pelvic ultrasound or pelvic magnetic resonance imaging, if necessary [2]. However, depending on the preceding work-up, up to 40% of diagnostic laparoscopies fail to show any pathological cause for the patient's pain [6].
Table 1.1 shows the gynaecological causes of CPP and the accuracy of laparoscopy as a diagnostic tool. Laparoscopy can successfully diagnose adhesions and several types of endometriosis [6, 7], but its accuracy in diagnosing other pathologies associated with CPP is unproven. Nevertheless, diagnostic laparoscopy remains a popular test in the work-up of CPP and this may reflect its additional benefits. These include assessment of fertility by examining tubal patency, and evaluating the severity of disease to plan appropriate treatment, e.g. identifying the presence of severe endometriosis necessitating management in an experienced endometriosis centre.
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Laparoscopy requires insertion of instruments into the peritoneal cavity and is not without risk, highlighted by the fact that up to 57% of gynaecologists have reported major bowel and vascular injures, regardless of the entry technique used [8]. Whilst laparoscopy is more invasive than other testing modalities in CPP, the technique allows surgical treatments to be effected enhanced by advances in instrumentation. Thus, in an attempt to avoid multiple operations and their associated surgical and anaesthetic risks, ‘see and treat’ therapeutic laparoscopies are considered preferable [9]. To successfully achieve such an efficient approach to managing CPP requires good prior diagnostic work up. For example, in addition to thorough clinical assessment, a rigorously performed pelvic ultrasound scan may be useful. Feature suggestive of endometriosis or adhesions can be detected such as site-specific pain of the uterosacral ligaments, decreased ovarian mobility, presence of endometriomas and hydrosalpinges [10]. The surgeon can then more effectively plan the site and setting for surgery and ensure that the patient is well informed and that suitably skilled staff and surgical instruments are available [9].
Endometriosis
Endometriosis often affects areas of the pelvis, such as the uterosacral ligaments, pouch of Douglas and rectovaginal septum, which are difficult to assess clinically [11]. Laparoscopy can improve diagnostic accuracy but has limitations. One observational study noted that 42% of general gynaecologists failed to recognise rectovaginal endometriosis on visual inspection at primary laparoscopy [12]. A systematic review of the accuracy of laparoscopic visual inspection in the diagnosis of peritoneal endometriosis showed that a negative laparoscopy could accurately exclude endometriosis, whilst a positive laparoscopy needed to be followed by histological confirmation [13]. The technique of diagnostic laparoscopy is important such that a careful, systematic inspection of the abdomen and pelvis is undertaken and importantly adequate anteversion and anteflexion of the uterus is achieved to allow for thorough inspection of the pouch of Douglas. Despite these limitations, most gynaecologists view visual inspection at laparoscopy as the ‘gold standard’ method of diagnosing superficial endometriosis.
Superficial peritoneal endometriosis can be treated by cautery or excision. There is much debate over the optimal method of treating superficial endometriosis and often depends on the surgeons preference. Whilst excision is effective and enables a histological biopsy to be obtained for disease confirmation, it requires dissection skills and knowledge of underlying structures to avoid trauma. Excision also allows visualisation of possible invasion below diseased areas, especially of uterosacral ligament endometriosis. In contrast, ablative treatments may be inadequate due to the risk of thermal injury to nearby structures. A small randomised controlled trial (RCT) of 24 patients, compared ablation using monopolar diathermy versus excision using monopolar diathermy scissors in patients with mild endometriosis (stage 1 or 2 revised American Fertility Score). Both methods of treatment produced symptomatic relief with no difference between the treatments with regard to 6-month symptom questionnaire scores [14]. A large randomised trial is needed to compare diathermy versus excision to obtain more reliable results.4
Adhesions
Adhesions may be caused by endometriosis, exposure to infection or previous surgery and can cause pain by organ distension or stretching [2]. They can range from fine filmy adhesions to dense, vascular ones. The symptomatic benefits of laparoscopic adhesiolysis are uncertain. Whilst there is no clear evidence to support adhesiolysis in women with CPP, an RCT of 100 patients treated with adhesiolysis compared to no treatment during diagnostic laparoscopy for chronic abdominal pain, showed both groups reported substantial pain relief with no difference between the groups 1 year after surgery [15]. Similar results were noted in a small observational study, with 45% of patients reporting on-going symptomatic relief 2 years after laparoscopic adhesiolysis [16]. From these results, it can be argued that there may be a psychologically beneficial effect to surgery and the perceived improvement in pain [17].
Adenomyosis
Adenomyosis is a common benign gynaecological condition, often reported on imaging or identified during laparoscopy. It is defined by the presence of islands of ectopic endometrial tissue within the myometrium, causing smooth muscle hypertrophy [18A]. It can be associated with endometriosis and endometrial hyperplasia and is known to cause heavy menstrual bleeding and dysmenorrhoea. On laparoscopy, the clinician may observe the classical appearance of a bulky ‘boggy’ uterus, although the accuracy of laparoscopic diagnosis is unproven and final diagnosis rests upon histological confirmation, usually after hysterectomy. Imaging in the form of pelvic ultrasound or magnetic resonance imaging (MRI) may identify the condition with good accuracy (72% sensitivity for transvaginal ultrasound and 77% for MRI, compared against histology), allowing medical treatment to be initiated without the need for surgery [18B].
UNCERTAINTIES OF LAPAROSCOPY
A diagnostic laparoscopy can be a useful tool for evaluating the causes of CPP, but 40% of laparoscopies may show no pathology. Clinicians should therefore carefully weigh up the perceived surgical benefits of laparoscopy against the risks of surgery. Patients need to be informed about the limitations of this investigation and the implications of a ‘negative’ laparoscopy. CPP has many non-gynaecological and non-structural causes, which may not be identified by laparoscopy, e.g. functional and psychosomatic conditions which may benefit from alternative complementary therapies. The term chronic pelvic pain syndrome (CPPS) has been introduced by the International Association for the Study of Pain to describe the occurrence of CPP where pain may be focused around a single organ or multiple pelvic organs, and where there is no proven infection or other obvious local pathology to account for the pain [4]. Whilst a laparoscopy may not always be able to identify any cause of pain, sometimes this can have a beneficial, reassuring effect on the patient [19].
WHAT IS BLADDER PAIN SYNDROME?
Patients suffering from BPS may present with CPP. BPS is the condition formerly known as interstitial cystitis and painful bladder syndrome. It is defined as CPP, pressure or discomfort 5related to the bladder along with at least one other urinary symptom, such as urgency or frequency, in the absence of any other pathology [20]. The prevalence of BPS is estimated to be between 2 and 306 per 100,000 of the population, with lower prevalence in the Japanese population compared to European and American patients [21]. There is variation in the method of diagnosing BPS because patients may present with a wide spectrum of pain and urinary symptoms, which makes accurate prevalence rates difficult to record.
In 2008, The International Society for the Study of BPS suggested that BPS may be classified according to the findings at cystoscopy, hydrodistension and bladder biopsies with a normal cystoscopy equating to BPS grade 1, glomerulations (pin point sized areas of bleeding) equating to grade 2 and Hunner's lesions (distinctive areas of inflammation) were grade 3 with sub-classification a, b, or c depending on biopsy results [20]. Table 1.2 shows the classification of BPS according to cystoscopy and biopsy findings. In some previous guidelines, BPS has traditionally been defined and diagnosed through cystoscopy findings alone [21]. In 2011, the American Association of Urology (AUA) published guidelines on the diagnosis and management of BPS, which recommend that initial assessments should include a careful history, physical examination and laboratory tests to exclude infection. An important recommendation is that cystoscopy may be used as an aid in complex cases but it is not necessary to make a diagnosis or commence treatment [22]. Conservative first-line treatments, such as stress and pain management, patient education and and lifestyle modifications such as change in diet, avoidance of caffeine and limiting evening fluid intake, should be initiated without delays.
THE ROLE OF CYSTOSCOPY
Cystoscopy is often thought of as the investigation of choice to diagnose BPS. It can differentiate between BPS with normal bladder mucosal appearance from grade 2 and 3 disease with the presence of petechial bleeds, glomerulations and Hunner's lesions/ulcers [23]. The presence of Hunner's ulcers may lead the clinician to offer alternative treatments such as fulguration at an early stage, rather than persevering with conservative treatments. Hydrodistension during cystoscopy can allow visualisation of petechial haemorrhages. It can also provoke petechial bleeds that are thought to be pathognomonic.
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Cystoscopy with hydrodistension has a therapeutic effect. The hydropressure is believed to degenerate afferent nerves, leading to reduced bladder pain and increased bladder capacity [21]. If brief hydrodistension is performed, using 80–100 cm of water for 2–10 minutes, studies have shown variable symptomatic improvement but the effects decreased after 6 months post treatment [24]. Prolonged periods of hydrodistension are not recommended due to the adverse effect of bladder rupture [22].
THE UNCERTAINTIES OF CYSTOSCOPY
Cystoscopy and bladder biopsies have traditionally been used as the ‘gold standard’ to diagnose and classify BPS [20]. However, some studies show poor correlation between cystoscopy findings and diagnosis, because glomerulations may be seen in asymptomatic patients and bladder biopsies may not confirm disease in the presence of glomerulations [21, 25]. This has resulted in uncertainties in the diagnosis and management of the BPS. Some guidance ranks diagnosis by cystoscopy ahead of bladder biopsy when recommending evidence-based treatments [23]. Guidance from the AUA recognises the limitations of cystoscopy and bladder biopsy. It supports a clinical diagnosis, based upon symptoms and signs derived from the patient history and examination, on which to recommend treatment [22].
CONCLUSION
There are many causes for CPP. Several risk factors, such as a history of drug, alcohol and sexual abuse, PID, anxiety and depression have been associated with CPP [26]. In order to fully investigate a patient and possibly diagnose the cause of pain, invasive procedures like a laparoscopy and cystoscopy may be useful and can have therapeutic effects. The degree of sensitivity of each test varies with the target condition, and these procedures may not yield a cause of pain, which may reassure some patients but equally may cause distress if no obvious cause of pain can be identified [19]. Prior to surgery, a careful work-up of the patient with thorough history, examination and imaging is essential to correctly plan management. When a laparoscopy is performed, a ‘see and treat’ therapeutic laparoscopy is recommended rather than a purely diagnostic procedure, provided the surgeon is suitably trained and equipped.
CPP and BPS affect large numbers of people across the world, often with unknown etiology and overlapping symptoms and possibly co-existing disease pathology, which makes the management of such patients difficult [27, 28]. Both conditions may have non-specific symptoms with pain as the main complaint. In light of these considerations, it may be prudent to perform both laparoscopy and cystoscopy in cases of persistent CPP.7
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