Medical Specialists Meet to Assess the Past Present and Future of by mirit35


									Medical Specialists Meet to Assess the Past Present and Future of
Description The Pain of Urological Origin (PUGO) special interest group of the International Association for the Study of Pain (IASP) held a 2 day
meeting in Scotland prior to the IASP 12th World Congress on Pain to consider the past, present and future of urogenital pain. The aim was to outline
current practices and have a look at what the future may hold.

Newswise Organized by the Pain of Urological Origin (PUGO) special interest group of the International Association for the Study of Pain (IASP)
Glasgow, Scotland, August 15-16, 2008.

PUGO held a 2 day meeting in Scotland prior to the IASP 12th World Congress on Pain to consider the past, present and future of urogenital pain. The
aim was to outline current practice and have a look at what the future may hold. Speakers from North America and Europe gave invited lectures, and
interactive sessions with all meeting attendees were interspersed throughout the proceedings leading to very lively discussions. The organizing
committee included: Andrew Baranowski from London, John Hughes from Middlesbrough, UK, Beverly Collett from Leicester, UK, Ursula Wesselmann
from Birmingham, Alabama, Leroy Nyberg from Bethesda, MD, Richard Berger from Seattle, Curtis Nickel from Kingston, Ontario, and Paul Abrams
from Bristol, UK. The meeting was attended by a broad range of specialists in pain medicine, anesthesiology, psychology, neurology, neurosurgery,
urology, gynecology, physical therapy, and internal medicine. Patient advocates were also enthusiastic participants. Many excellent presentations
were given, and this report can only highlight selected ones. The proceedings will be synthesized by the organizing committee and faculty and a formal
publication is planned.

Curtis Nickel set the stage for the meeting with a discussion on the failure of our traditional biomedical model to successfully understand and treat
urogenital chronic pelvic pain syndrome (UCPPS). He proposed a new schema in which an initiator leads to inflammation or tissue damage. In some
patients this results in UCPPS and can go on to develop into a regional pain syndrome and/or become a part of a systemic pain syndrome. Likewise, a
systemic or regional pain syndrome can result in UCPPS in some patients. He proposed a strategy in which we attempt to identify the initiators,
ameliorate the pain, treat the pelvic consequences of pelvic floor dysfunction, and tackle the associated phenotypes if diagnosed (irritable bowel
syndrome, chronic fatigue syndrome, fibromyalgia, etc.). He stressed the need to identify and treat cognitive modulators including depression and
catastrophizing as well as helplessness.

Fred Howard from the University of Rochester spoke on the endometriosis pain syndrome. Chronic pelvic pain in women is most commonly of
gastrointestinal origin followed by the urinary tract and finally the reproductive tract. Endometriosis is a histologic finding, not a syndrome per se. We

He noted that physicians can create the idea that a disease is present by observing a set of symptoms and informing the patient that he or she has a
specific disease. This labeling may or may not be based upon discernable pathology, but the patient knows only what the doctor has told him or her. It
is possible, therefore for the patient to believe and act as if a disease is present when , in fact, there is no relevant pathology. He quoted Meador
(NEJM, 272:92-95, 1965) who observed that latent non-disease is ubiquitous, whereas manifest non-disease is expensive, frustrating and
embarrassing. Over-interpretation of laboratory tests, imaging studies and physical findings change latent to manifest non-disease. Dr. Loeser
concluded that people do have pains without pathology where it hurts. Such pains are the result of neural activity in the peripheral and central nervous
system. Patients who have pain without pathology are just as deserving of care as those who have a fractured femur!

Dr. Magnus Fall from Gothenburg, Sweden presented on the use of cystoscopy, hydrodistention, and bladder biopsy under anesthesia in the diagnosis
and treatment of bladder pain syndrome. While a local cystoscopy can rule out confusable disorders, only the distention under anesthesia can
accurately diagnose a Hunner

Richard Berger from the University of Washington spoke on organ ablation for bladder pain syndrome (interstitial cystitis) and non bacterial prostatitis.
Ablative therapy should be undertaken with extreme caution in patients with pelvic pain. In the rare patient who undergoes cystectomy or
prostatectomy, careful studies should be performed to determine the extent of hypersensitivity in organs and tissues innervated by adjacent
dermatomes. Long term follow-up should be carefully obtained and findings reported in the literature. These procedures are unlikely to be successful
in patients with central sensitization.

Dean Tripp from Kingston, Ontario gave a well-received, data-driven discussion of the psychological consequences of chronic pelvic pain. Pain and
depressive symptomatology predict a poor quality of life. Catastrophic helplessness is a critical predictor of disability from pain. He showed data in
Canadian males aged 16-19 years, noting that up to 8% may have symptoms of chronic prostatitis/chronic pelvic pain syndrome (J Urol, 179 (suppl)
33-34, 2008). That this is not a cultural phenomenon is suggested by a similar 6% figure in 20 year old South Korean males.
Bert Messelink from Groningen, the Netherlands, spoke on pelvic floor muscles and urogenital pain. In patients with urogenital pain, the pelvic floor
muscles should be taken into account when talking and thinking about causative factors and possible options for treatment. Pelvic floor muscle
education, physical therapy, biofeedback, and treatment of myofascial trigger points were all discussed. Possible injection of botulinum-A toxin or
lidocaine into trigger points was mentioned, but data is sparse.

Eija Kalso from Finland spoke on opioids and guidelines for use in chronic pelvic pain, followed by another talk on drug therapy by Sam Chong from
the United Kingdom. Dr. Kelso noted that there are no randomized trials or even case reports regarding the use of opioids for chronic nonmalignant
pelvic pain. Strong opioids should not be used as monotherapy, but rather as a part of a multidisciplinary approach. Use in combination with
nonsteroidals and gabapentinoids may delay tolerance. An intravenous opioid trial may be a good negative predictor of whether to consider opioids in
a particular patient. Assessing quality of life is critical in deciding whether to continue opioids, as particular patients may find the diminished quality of
life they associate with the treatment is not balanced by any perceived pain benefit. Dr. Chong agreed that using cocktails and combination analgesic
therapy is usually better than monotherapy.

Tony Buffington from Columbus, Ohio opened the second day of the meeting. His presentation covered comorbidities, vulnerability factors, and familial
aggregation data. Specifically he discussed variable combinations of idiopathic chronic pain syndromes including bladder pain syndrome, fibromyalgia,
irritable bowel syndrome, chronic pelvic pain syndrome, chronic fatigue syndrome, as well as affective disorders such as post traumatic stress
disorder, panic disorder, anxiety and depression. These are commonly seen together in patients. They comprise MUS or medically unexplained
symptoms, and may affect up to 1/3rd of people seeking medical care. One candidate underlying disorder is sensitization of the central stress
response system and an imbalance in its output in response to stressors. Enhanced sensitivity may result from variable combinations of familial
(genetic and environmental) factors. He hypothesizes that sensitization creates a greater vulnerability to life stressors, putting certain individuals at
greater risk of developing disorders characterized by pain and discomfort.

Andrew Baranowski presented the IASP classification system as it pertains to chronic pelvic pain, and noted how it embeds description of many
phenotypes that are currently felt to be critical in categorizing patients with chronic pain. A lively discussion with the audience and Dr. Nickels in
particular ensued. Jose De Andres from Valencia, Spain then gave a detailed and fascinating discussion on neuromodulation techniques,
concentrating on the evolving field of sacral nerve root stimulation and spinal cord stimulation. He stressed that the level of evidence in this field is

He was followed by an elegant presentation from Dr. Karen Berkeley from the University of Florida detailing her research on mechanisms of pain in a
rodent model of endometriosis - and the relationship of pain from endometriosis to other conditions via pelvic cross-talk. Central sensitization, remote
central sensitization, and central hormonal modulation require a deliberate multifactorial approach to assessment and diagnosis of chronic pelvic pain.

Psychology and sex were the next topics. Anna Mandeville gave a introductory talk on the psychology of managing pain in the pelvis, highlighted by
case presentations. She described several sexual

She noted that there are no effective pharmacologic treatments, and that cognitive/behavioral therapy, pain management, pelvic floor physiotherapy,
and vestibulectomy are effective in selected patients. Biomedical intervention (gynecologist, pain specialist), psychosocial intervention (psychologist,
sex therapist, psychiatrist), and phsiotherapy are all parts of successful therapy. Reducing pain does not always mean restoring sexual activity, nor
does it necessarily lead to restoration of a relationship. Be careful how you define success in these patients.

Amanda C de C Williams from University College in London reviewed outcome assessment. She noted that pain is rarely adequately measured by
quality of life definitions, but quality of life often approximates more closely than pain, symptom, or function measures what matters most to the patient,
and moves the focus from disease or dysfunction to the patient. She recommended dropping somatization as being conceptually problematic,
culturally specific, and incompatible with pain science. Likewise, coping may seem valid but is conceptually flawed. It addresses behavior but not its
context or outcome. In a similar fashion, pain control predicts little, and is too general. Control may be an unrealistic aim for some pain.

The European Society for the Study of Interstitial Cystitis diagnostic approach was related by Jorgen Nordling from Copenhagen, and served as a
model for end-organ specialist evaluation of a chronic pain syndrome. Tim Ness from Birmingham, Alabama illustrated how the pain specialist
approaches diagnosis.

Tier 1: rule out catastrophic processes;
Tier 2: evaluation that guides the selection of intervention;
Tier 3: evaluation to limit treatment toxicity (imaging, laboratory testing, behavioral assessment if controlled substances are to be employed);
Tier 4: longitudinal outcome assessment;
Tier 5: use therapeutic results to help ascertain diagnostic information.

This comprehensive meeting concluded with a presentation by this correspondent on practical considerations and algorithms for chronic pelvic pain,
and also with a discussion led by Drs. Nickel and Baronowski to bring the comprehensive proceedings to a close. It was agreed by all attending that
some type of clinical phenotype management strategy may help to move the field of treatment for chronic pelvic pain forward.

The management of chronic urogenital pain is a complex, but evolving field. We need standardization of classification and evaluation. We also need
targeted therapies through a multidisciplinary approach, and finally, hope for future benefits from translational science.

Reported by Contributing Editor Philip M. Hanno, MD, MPH

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