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					What Is The Evidence For Pain Mapping As A Helpful Tool?
Fred M. Howard, MS, MD
Professorof Obstetrics & Gynecology University of Rochester School of Medicine & Dentistry Rochester, New York fred_howard@urmc.rochester.edu

Laparoscopy for Chronic Pelvic Pain
• When H&P - labs reveal no clear diagnosis • A routine part of diagnostic evaluation • When operative treatment is planned • As an extension of the physical exam: “pain mapping”

Laparoscopy for Chronic Pelvic Pain
Study Renaer, 1981 Royal College, 1980 Cunanan , 1983 Liston , 1972 Bahary , 1987 Mahmood, 1991 TOTAL Total No. of No. for Laparoscopies CPP 200 108 21,000 10,857 3831 1268 1215 134 433 130 1200 156 28,679 12,653 Percent for CPP 54% 51% 33% 11% 30% 13% 44%

Howard FM. Obstet Gynecol Surv 1993;48:357

Pelvic Exam vs. Laparoscopy
Laparoscopic Findings Normal Abnormal Total Normal Physical Examination 300 (38%) 496 (62%) 796 (100%) Abnormal Physical Examination 94 (19%) 397 (81%) 491 (100%)

Howard FM. Obstet Gynecol Surv 1993;48:357

Pelvic Exam vs. Laparoscopy
Laparoscopic Findings Normal Abnormal Total Normal Physical Examination 300 (38%) 496 (62%) 796 (100%) Abnormal Physical Examination 94 (19%) 397 (81%) 491 (100%)

Howard FM. Obstet Gynecol Surv 1993;48:357

Laparoscopic Diagnoses
No visible path. Endometriosis Adhesions Chronic PID Total 11 Studies (1318) 1981-1991 39 % 28 % 25 % 6% 98% 3 Studies (281) 1994 4% 62 % 17 % 3% 86% Ling (95) 1999

82%

Howard FM. Obstet Gynecol Survey 1993;48:357 Howard FM. J Amer Assoc Gynecol Laparosc 1996;4:85 Ling FW. Obstet Gynecol 1999;93:51-8

Laparoscopic Diagnoses
With CPP Without CPP Number of Pts No visible pathology Endometriosis Adhesions Chronic PID Leiomyomas 1524 35% 33% 24% 5% <1% 1103 72% 5% 17% 1% 2% Rel. Risk 0.5 6.6 1.4 5.0 -

Howard FM. Obstet Gynecol Surv 1993;48:357

Laparoscopic Diagnoses
• The relationship to CPP of a laparoscopic diagnosis may be:
– – – – Unrelated Etiologic Associated Contributory

Laparoscopic Diagnoses
• The relationship to CPP of a laparoscopic diagnosis may be:
– – – – Unrelated Etiologic Associated Contributory

Epidemiologic Evidence of Causation
• • • • • • • • Strength of association Consistency of association Cause precedes effect Dose-response gradient Biologic plausibility Coherence Experimental evidence Analogy

Epidemiologic Evidence of Causation
• • • • • • • • Strength of association Consistency of association Cause precedes effect Dose-response gradient Biologic plausibility Coherence Experimental evidence Analogy

Conscious Laparoscopic Pain Mapping
• Laparoscopy under local anesthesia as a diagnostic modality to localize areas of tenderness potentially responsible for chronic pelvic pain • First published description in 1996
– Palter and Olive – REI at Yale

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP • May more specifically direct surgical treatment • May avoid unneeded surgical treatment in those patients who do not map their pain to a specific lesion
1.2 mm minilaparoscope

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP • May more specifically direct surgical treatment • May avoid unneeded surgical treatment in those patients who do not map their pain to a specific lesion
1.2 mm minilaparoscope

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP • May more specifically direct surgical treatment • May avoid unneeded surgical treatment in those patients who do not map their pain to a specific lesion
1.2 mm minilaparoscope

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Accuracy of Microlaparoscopy
• Comparison of small diameter to conventional laparoscopy
– SDL followed by CL

• 37 patients with infertility, CPP, or sterilization • Procedures under general anesthesia • Observational, non-blinded study
Karabacak et al. Human Reprod 1997;12:2399-401

Accuracy of Microlaparoscopy
• Sensitivity of sm. diam. laparoscopy for dx of:
– – – – – Endometriosis: 71% Adhesions: 58% Ovarian lesions: 81% Uterine lesions: 89% Cul-de-sac lesions: 73%

• Specificity of sm. diam. laparoscopy for dx of:
– – – – – Endometriosis: 100% Adhesions: 96% Ovarian lesions: 100% Uterine lesions: 100% Cul-de-sac lesions: 100%

Karabacak et al. Human Reprod 1997;12:2399-401

Accuracy of Microlaparoscopy
• Study of 10 patients
– 6 with CPP – 3 with endometriosis – 1 with infertility & abnormal uterus

• 2 mm vs. 10 mm laparoscope • General anesthesia • 2 surgeons
– Not blinded
Faber BM, Coddington CC. Fertil Steril 1997;67:952-4.

Accuracy of Microlaparoscopy

Endometriosis
• Surgeon A
– Microlaparoscopy
• Diagnosed in 4 of 10 • Not diagnosed in 6 of 10

• Surgeon B
– Microlaparoscopy
• Diagnosed in 4 of 10 • Not diagnosed in 6 of 10

– Standard laparoscopy
• Diagnosed in 5 of 10 • Not diagnosed in 5 of 10

– Standard laparoscopy
• Diagnosed in 4 of 10 • Not diagnosed in 6 of 10

– Consistent diagnoses & scores in 9 of 10

– Consistent diagnoses & scores in 7 of 10

Faber BM, Coddington CC. Fertil Steril 1997;67:952-4.

Accuracy of Microlaparoscopy

Adnexal Adhesions
• Surgeon A
– Microlaparoscopy
• Diagnosed in 5 of 10 • Not diagnosed in 5 of 10

• Surgeon B
– Microlaparoscopy
• Diagnosed in 5 of 10 • Not diagnosed in 5 of 10

– Standard laparoscopy
• Diagnosed in 5 of 10 • Not diagnosed in 5 of 10

– Standard laparoscopy
• Diagnosed in 5 of 10 • Not diagnosed in 5 of 10

– Consistent diagnoses & scores in 10 of 10

– Consistent diagnoses & scores in 9 of 10

Faber BM, Coddington CC. Fertil Steril 1997;67:952-4.

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Safety & Reliability
No. Pts. Successful Complications

Palter et al
Almeida et al

11
74

9
74

0
0

Demco
Almeida et al

100
50

88
50

0
0

Howard et al

50

35

8

Conscious Laparoscopic Pain Mapping

Reasons for Failures
• Demco - 12%
– Adhesions
• 3%

• Howard - 30%
– Adhesions
• 12%

– Reaction to CO2
• 5%

– Pain intolerance
• 14%

– Pt intolerance
• 2%

– Unreliable findings
• 4%

– Unable to enter peritoneum
• 3%
Demco LA. J Soc Laparoendosc Surg 1997;1:319-21. Howard FM, et al. Obstet Gynecol 2000; 96: 934-9.

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Evaluation Of Patients Without CPP
• 20 infertile women evaluated
– No pathology

• No pain with touch or grasp of ovary, omentum, bowel or stretch of tuboovarian ligament • Pain with tubal distention
Zupi E et al. J Amer Assoc Gynecol Laparosc 1999;6:51-4.

Conscious Laparoscopic Pain Mapping

Evaluation Of Patients Without CPP
• “Generalized visceral hypersensitivity”
– CPP – Infertility – CPP – Infertility
– CPP – Infertility

10 of 11 pts 0 of 16 pts

• Intraoperative pain levels
7.0 5.0

• Postoperative pain levels
3.2 0.5
Palter SF, Olive DL. J Amer Assoc Gynecol Laparos 1996;3:359-64.

Conscious Laparoscopic Pain Mapping

Evaluation Of Patients Without CPP
• 41 infertile patients
– – – – – – Placement of foley Local infiltration Insertion of trocar Pneumoperitoneum Manipulation of pelvic organs Chromotubation

VAS
4.5 5.0 5.0 1.8 4.0 5.0

Takeuchi H et al. J Amer Assoc Gynecol Laparosc 1999;6:453-7.

Conscious Laparoscopic Pain Mapping

Evaluation Of Patients Without CPP
• 41 infertile patients
– – – – – – Placement of foley Local infiltration Insertion of trocar Pneumoperitoneum Manipulation of pelvic organs Chromotubation

VAS
4.5 5.0 5.0 1.8 4.0 5.0

Takeuchi H et al. J Amer Assoc Gynecol Laparosc 1999;6:453-7.

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Pain Orientation
Normal Patients Movement of left ovary Movement of right ovary Sensation on Left 71% Sensation on Right 15.5% Sensation in Midline 13.5%

2.2%

88.3%

9.5%

Demco LA. J Amer Assoc Gynecol Laparos 2000;7:181-3.

Conscious Laparoscopic Pain Mapping

Pain Orientation
Pain Patients Palpation of lesion on left Palpation of lesion on right Pain on Left 66% Pain on Right 13% Pain in Midline 21%

1.5%

73%

25.5%

Demco LA. J Amer Assoc Gynecol Laparos 2000;7:181-3.

Conscious Laparoscopic Pain Mapping

Endometriosis
Type of Lesion Clear Red White Black Painful (no.) 38 42 22 11 Not Painful Not Painful (no.) (%) 12 24 8 28 39 16 56 78

Demco LA. J Amer Assoc Gynecol Laparos 1998;5:241-5

Diagnosis of Endometriosis
• Endometriosis is "the presence of ectopic tissue which possesses the histological structure and function of the uterine mucosa"
– Sampson (1921)

• A histological definition
– It requires a tissue specimen – Ectopic endometrial glands and stroma must be present

Visual Diagnosis
Description of Lesion Black Brown White Red Clear papules Glandular Peritoneal defects Superficial yellow-brown Adhesions (ovarian) Carbon Adhesions (non-ovarian) Cribriform peritoneal defects Confirmation of Diagnosis 90% 78% 76% 67% 67% 67% 41% 40% 40% 17% 12% 9%

Conscious Laparoscopic Pain Mapping University of Rochester Series

Endometriosis
• Endometriosis diagnosed visually in 20 patients
– Histologically confirmed in 13 (65%) – 15 of cases had successful mapping & visual diagnosis

• Endometriotic lesions mapped in 7
– All 7 had histological confirmation of the diagnosis

• Endometriotic lesions not mapped in 8 cases
– Only 2 had histological confirmation of the diagnosis

Conscious Laparoscopic Pain Mapping University of Rochester Series

Endometriosis
• 7 of 9 cases with successful CPM & histologically-confirmed endometriosis mapped pain to endometriotic lesions • 0 of 6 cases with successful CPM in which the visual diagnosis of endometriosis was not histologically confirmed mapped their pain to “endometriotic” lesions
– P = 0.007, Fischer's exact test

Conscious Laparoscopic Pain Mapping

Distance of Pain from Endometriosis
10 9 8 7 6 5 4 3 2 1 0 0 4 8 12 16 mm mm mm mm mm 20 24 28 mm mm mm

No. Patients

Demco LA. J Amer Assoc Gynecol Laparos 1998;5:241-5

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Does It Result In Pain Relief?
• Case report
– Pain for 12 yrs with 14 laparoscopies – Old suture site painful – Fulguration of site resulted in pain relief at 6 mos follow up

The feasibility of an operation is not the best indication for its performance
Henry, Lord Cohen of Birkenhead, 1950

• Case reports (2)
– Sup. hypogastric block at CLPM – 1 pt with PSN, 1 not done – Pain relief in both

Almeida OD Jr. J Soc Laparoendosc Surg 2002;6:81-3. Steege JF. J Amer Assoc Gynecol Laparos 1998;5:265-7.

Conscious Laparoscopic Pain Mapping

Does It Result In Pain Relief?
“Forty-five of the 48 who underwent operative microlaparoscopy after conscious pain mapping had a significant amelioration of pelvic pain as measured by both improvement of symptom and physical examination.”
Almeida OD Jr, Val-Gallas JM. J Amer Assoc Gynecol Laparos 1997;4:587-90.

Conscious Laparoscopic Pain Mapping University of Rochester Series

Outcomes
Non-CLPM series (65) • Endometriosis 38% • Adhesions 34% • Decreased pain 78% • Pain-free 45% CLPM series (50) • Endometriosis 40% • Adhesions 54% • Decreased pain 44% • Pain-free 16%

Howard FM, et al. Obstet Gynecol 2000; 96: 934-9.

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP
– Can make diagnoses accurately with small laparoscopes – Can safely and reliably perform CLPM under conscious sedation and local anesthesia – Can show that mapping is not painful in non-CPP patients – Can show that identified lesions cause the patient’s pain

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP • May more specifically direct surgical treatment • May avoid unneeded surgical treatment in those patients who do not map their pain to a specific lesion
1.2 mm minilaparoscope

Conscious Laparoscopic Pain Mapping

Specifically Direct Surgical Treatment
• CLPM would have changed procedure or clarified diagnosis for Gyns
– Patient 1: 68% – Patient 2: 84%

• CLPM would have changed procedure for Gyns
– Patient 1: 73%
Steege JF. J Amer Assoc Gynecol Laparosc 2001;8:23-6

Conscious Laparoscopic Pain Mapping

Rationale
• May allow specific identification of lesions causing CPP • May more specifically direct surgical treatment • May avoid unneeded surgical treatment in those patients who do not map their pain to a specific lesion
1.2 mm minilaparoscope

Conscious Laparoscopic Pain Mapping University of Rochester Series

Chronic Visceral Pain Syndrome
• Specific viscera
– ~1/3 of positive sites

• Diffuse visceral-peritoneal tenderness
– ~1/6 of successful mappings

• Chronic visceral pain syndrome
– 45% of those successfully mapped
Howard FM, et al. Obstet Gynecol 2000; 96: 934-9.

Conscious Laparoscopic Pain Mapping University of Rochester Series

Avoid Unnecessary Surgical Procedures
• Specific viscera
– ~1/3 of positive sites

• Diffuse visceral-peritoneal tenderness
– ~1/6 of successful mappings

• Chronic visceral pain syndrome
– 45% of those successfully mapped
Howard FM, et al. Obstet Gynecol 2000; 96: 934-9.

Conscious Laparoscopic Pain Mapping

Published Series & Case Reports
1. Palter SF, Olive DL. Office microlaparoscopy under local anesthesia for chronic pelvic pain. J Amer Assoc Gynecol Laparos 1996;3:359-64. 2. Almeida OD et al. A protocol for conscious sedation in microlaparoscopy. J Amer Assoc Gynecol Laparos 1997;4:591-4. 3. Almeida OD Jr, Val-Gallas JM. Conscious pain mapping. J Amer Assoc Gynecol Laparos 1997;4:587-90. 4. Demco LA. Effect on negative laparoscopy rate in chronic pelvic pain patients using patient assisted laparoscopy. J Soc Laparoendosc Surg 1997;1:319-21. 5. Faber BM, Coddington CC. Microlaparoscopy: a comparative study of diagnostic accuracy. Fertil Steril 1997;67:952-4. 6. Karabacak O, et al. Small diameter versus conventional laparoscopy: a prospective, self-controlled study. Human Reproduction. 1997;12:2399401.

Conscious Laparoscopic Pain Mapping

Published Series & Case Reports
7. Love BR, McCorvey R. No scalpel, no IV, no stitch, microendoscopic office laparoscopy under local anesthesia. J Soc Laparorosc Surg 1997;227-9. 8. Almeida OD Jr, Val-Gallas JM. Office microlaparoscopy under local anesthesia in the diagnosis and treatment of chronic pelvic pain. J Amer Assoc Gynecol Laparos 1998;5:407-10 9. Demco LA. Mapping the source and character of pain dut to endometriosis by patient-assisted laparoscopy. J Amer Assoc Gynecol Laparos 1998;5:241-5. 10. Steege JF. Superior hypogastric block during microlaparoscopic pain mapping. J Amer Assoc Gynecol Laparos 1998;5:265-7. 11. Zupi E, et al. Pain mapping during minilaparoscopy in infertile patients without pathology. J Amer Assoc Gynecol Laparos 1999;6:51-4. 12. Demco LA. Pain referral patterns in the pelvis. J Amer Assoc Gynecol Laparos 2000;7:181-3.

Conscious Laparoscopic Pain Mapping

Published Series & Case Reports
13. Howard FM, et al. Conscious pain mapping by laparoscopy in women with chronic pelvic pain. Obstet Gynecol 2000; 96: 934-9. 14. Zupi E et al. Is local anesthesia an affordable alternative to general anesthesia for minilaparoscopy? J Amer Assoc Gynecol Laparos 2000;7:111-4. 15. Moore ML, Cohen M. Diagnostic and operative transvaginal hydrolaparoscopy for infertility and pelvic pain. J Amer Assoc Gynecol Laparos 2001;8:393-97 16. Steege JF. Clinical utility of pelvic pain mapping. J Amer Assoc Gynecol Laparosc 2001;8:263-6 17. Almeida OD Jr. Microlaparoscopic conscious pain mapping in the evaluation of chronic pelvic pain: a case report. J Soc Laparoendosc Surg 2002;6:81-3

What Is The Evidence For Pain Mapping As A Helpful Tool?

Conclusion
Those who are enamored of practice without science are like a pilot who goes into a ship without rudder or compass and never has any certainty where he is going
Leonardo da Vinci (1452-1519)

The egotistical surgeon is like a monkey; the higher he climbs the more you see of his less attractive features

You cannot cure everyone


				
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